[AKTIN - The German Emergency Department Data Registry - real-time data from emergency medicine : Implementation and first results from 15 emergency departments with focus on Federal Joint Committee's guidelines on acuity assessment]. / Das AKTIN-Notaufnahmeregister ­ kontinuierlich aktuelle Daten aus der Akutmedizin : Ergebnisse des Registeraufbaus und erste Datenauswertungen aus 15 Notaufnahmen unter besonderer Berücksichtigung der Vorgaben des Gemeinsamen Bundesausschusses zur Ersteinschätzung.

BACKGROUND: Emergency care in Germany is in transition. Emergency departments (EDs) treat their patients based on symptoms and acuity. However, this perspective is not reflected in claims data. The aim of the AKTIN project was to establish an Emergency Department Data Registry as a data privacy-compliant infrastructure for the use of routine medical data. METHODS: Data from the respective documentation systems are continuously transmitted to local data warehouses using a standardized interface. They are available for several applications such as internal reports but also multicentre studies, in compliance with data privacy regulations. Based on a 12-months period we evaluate the population with focus on acuity assessment (triage) and vital parameters in combination with presenting complaints. RESULTS: For the period April 2018 to March 2019, 436,149 cases from 15 EDs were available. A triage level is documented in 86.0% of cases, and 70.5% were triaged within 10 min of arrival. Ten EDs collected a presenting complaint regularly (82.3%). The respective documentation of vital signs shows plausible patterns. CONCLUSIONS: The AKTIN registry provides an almost real-time insight into German EDs, regardless of the primary documentation system and health insurance claims data. The Federal Joint Committee's requirements are largely met. Standardized presenting complaints allow for symptom-based analyses as well as health surveillance.

[Even low-acuity patients prefer hospital-based emergency care : A survey of non-urgent patients in an emergency department with unique regional position]. / Der Notfall "geht" ins Krankenhaus : Eine Befragung von Patienten mit niedriger Dringlichkeit in einer Notfallaufnahme mit regionaler Alleinstellung.

BACKGROUND: Besides increasing numbers of cases in German emergency departments (ED), the spectrum of attending patients is also changing. Patients with acute illnesses tend to prefer EDs to ambulatory care as primary contact point. This study examines the motives for use and use behavior of low-urgent ED-patients. METHODS: Anonymous patient survey in the ED of Wolfsburg Hospital between 12/2015 and 03/2016 with descriptive analysis. All patients with low urgency (Manchester-Triage-System (MTS), levels blue and green) were eligible. RESULTS: 81.5% of respondents (729 evaluable out of 7000 questionnaires distributed) attended the ED between 8:00 a. m. and 5:00 p. m., 70.1 % of them were walk-in patients. The motive most frequently cited was that they would receive better care in the ED (48.3 %). Contrary to acuity assessment, 67.8 % of respondents considered themselves a medium to life-threatening emergency. As alternative option, 49.2 % would choose a nearby clinic in the region for their complaints. CONCLUSION: Self-assessed urgency differs with acuity assessment according to MTS. Patients who fear an acute threat to their health do not use services provided in the ambulatory sector such as the emergency practice of the Association of Statutory Health Insurance Physicians in the immediate proximity sufficiently. Previous approaches for patient navigation do not seem to be successful in this setting. Strengthening of EDs as a single 24/7 access point for emergency care with simultaneous abolition of parallel care structures should be discussed.

[Intraoperative neurolysis of the celiac plexus in patients with unresectable pancreatic cancer]. / Intraoperative Neurolyse des Plexus celiacus bei Patienten mit nichtresektablem Pankreaskarzinom.

BACKGROUND: The analgetic treatment of inoperable pancreatic cancer patients is of paramount importance. The relative ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. However, the assessment of the results and the effectiveness of the block carried out during laparotomy have been unclear. PATIENTS AND METHODS: After 41 intraoperative celiac neurolytic blocks pain intensity was retrospectively analysed in 38 patients suffering from unresectable pancreatic carcinoma. The mean age of the patients was 59 years, the observation period after neurolysis ranged to 6 months. All patients underwent definitive neurolysis using 50 % ethanol in 0.5 % prilocaine. Immediate and long-term efficacy, analgetic consumption and mortality were evaluated at follow-up. The calculated parenteral equivalent morphine dosage (mg per day) was evaluated before as well as at different time points after treatment as an objective parameter to describe pain intensity. RESULTS: 7 to 34 days (at discharge from the hospital) after block pain intensity was statistically highly significant reduced (p=0.016). Long-term results were obtained from 17 (10 to 12 weeks after intervention) and 9 (up to 20 weeks after intervention) patients respectively, demonstrating a long-lasting effect of the neurolysis. A statistical analysis was not possible because of the small patient 's number. CONCLUSIONS: Intraoperative celiac neurolytic block is a safe and effective method of pain treatment in patients with unresectable pancreatic carcinoma. However, it alone provides complete pain relief until death only in a few cases. Therefore, it should be considered as an adjuvant treatment in the analgesic strategy. Combined palliative therapy is necessary in most of the cases.

Procalcitonin following elective partial liver resection--origin from the liver?

BACKGROUND: The origin of the inflammatory peptide procalcitonin (PCT) is still unknown. In the present study PCT concentrations in arterial and hepatic-venous blood were examined in patients undergoing elective partial liver resection (LR) using a fiberoptic pulmonary arterial catheter placed in a liver vein to obtain further information on the origin of PCT. METHODS: In 28 patients (21 male/7 female; average age of 58.8+/-8.8 years) undergoing LR, arterial and hepatic venous PCT concentrations were measured during 24 h perioperatively. The parallel blood withdrawals occurred immediately before the Pringle maneuver (Hx), 2 min, 1, 2, 6, 12, and 24 h after Hx. Over the whole period, the oxygen saturation in hepatic venous blood (ShvO2) was monitored. PCT concentrations were assayed by immunoluminometry. RESULTS: We observed a significant increase in PCT concentration already 6 h after Hx compared to the values before Hx. Twenty-four hours after Hx we found the highest plasma concentrations. It was conspicuous that hepatic venous PCT concentrations were always higher than the arterial ones (significantly from the 6th hour after Hx). There was no correlation between the courses of ShvO2 and PCT rise. A significant correlation was verified between Hx duration and PCT concentration measured 24 h after Hx both in the hepatic venous and arterial blood. CONCLUSIONS: The results of our investigation can be interpreted as evidence that liver (or the hepatosplanchnicus?) is a source of PCT. The mechanism of PCT induction cannot be clarified by our study: whether the induction of PCT was caused by an endotoxin translocation during the impeded splanchnic outflow or by the direct surgery-induced lesion (hypoxia) of the liver remains unclear. However, the latter appears more probable because of the observed correlation between Hx duration and PCT concentration rise.

[Intraoperative diagnosis of pheochromocytoma preoperative symptoms in a case of Recklinghausen's disease]. / Intraoperative Diagnose eines präoperativ symptomlosen Phäochromozytoms bei Morbus Recklinghausen.

Phaechromocytoma is a rare catecholamine secreting tumor, which occasionally presents as a life threatening crisis in association with surgery and anesthesia. We report a 58-year-old women with known Recklinghausen's disease who was admitted for elective resection of a pancreas tail cystadenoma. A cystadenocarcinoma was taken into account differential diagnostically. No clinical symtoms or signs pointing to a hormone active tumor were found preoperatively. After opening of the abdomen and palpation of the tumor, a hypertensive crisis occurred accompanied by considerable tachycardia, leading to the tentative diagnosis of a phaeochromocytoma in connection to the known phacomatosis. The hypertensive crisis was treated with nitroglycerin and esmolol. The putative tumor of the pancreas represented itself as an adrenal tumor without relationship to the pancreas. Following ligature of the suprarenal vein, antihypertensive therapy could be finished. For stabilization of blood pressure a noradrenaline application was necessary in descending dosage over a period of two days. The further postoperative course was without complications. The results of the urine catecholamine measurements and histological examinations confirmed the intraoperative diagnosis. An unidentified phaeochromocytoma is a vital threat for patients during surgery and anesthesia. Phaeochromocytomas are observed in patients suffering from Recklinghausen's disease (and other phacomatoses) in an above average incidence. Therefore, such a tumor should be excluded in these patients before elective surgery even if the patient does not show symptoms (asymptomatic phaeochromocytomas occur). The determination of catecholamines in 24 hour urine collections is an easy and specific diagnostic procedure and should be used in patients suffering from phacomatoses before elective surgery.

[Initiation of lipid peroxidation (LPO) in blood during intraoperative mechanical autotransfusion--is hepatotoxicity of lipid peroxidation products of clinical significance?]. / Initiation der Lipidperoxidation (LPO) im Blut während der intraoperativen maschinellen Autotransfusion--Ist die Hepatotoxizität von LPO-Produkten klinisch von Bedeutung?

Machine autotransfusion using cell-saver is a well-established method of saving homologous blood during extensive surgical procedures. The processing of blood may induce the initiation of lipid peroxidation (LPO) with the release of hepatotoxic products. A series of 42 patients undergoing primary (n = 20) or revision (n = 22) hip arthroplasty comprised the study group. Patients received an average of 1,260 ml of autologous blood and 2.2 units of homologous packed cells. The concentration of thiobarbituric acid reactive substances (TBARS) as LPO metabolites was measured in the patients' plasma, in the autologous packed cells as well as in the supernatants of the cell-saver-processed blood. Additionally, parameters of iron metabolism, haemoglobin levels, haematocrit as well as the activities of so-called liver enzymes aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltranspeptidase and cholinesterase were determined. An initiation of LPO was detectable during the process of machine autotransfusion, but this took place mainly ex vivo. High concentrations of TBARS were detectable in the supernatants after cell-separation processing. We observed a decline in haemoglobin concentration and haematocrit during the perioperative period. Postoperatively, we found a significant iron deficiency as a consequence of the perioperative blood loss. There was not sufficient evidence of a postoperative liver disorder induced by toxic metabolites of LPO. To sum up, there is only a low contamination of the organism with LPO products during the process of machine autotransfusion. Therefore, an induction of liver damage seems to be improbable.

Plasma levels of glutathione, alpha-tocopherol and lipid peroxides in polytraumatized patients; evidence for a stimulating effect of TNF alpha on glutathione synthesis.

Prognosis and outcome of polytraumatized patients are determined by the possible development of multiple organ failure (MOF). Among the direct traumatic organ damage, it is caused by a systemic inflammatory reaction. This might be triggered by an activation of the inflammatory mediator cascade following hemorrhagic-traumatic shock as well as by oxygen-derived free radicals (ROS). The aim of our present study was to answer the following questions: 1. Is the "oxidative stress" measurable during the development of MOF after polytraumatic injury? 2. Is there a relation between the activation of the inflammatory mediator cascade and changes of the organism's antioxidative system? The study group included 26 patients (15 survivors, 11 non-survivors) suffering from severe polytraumatic injury (Hannover Polytrauma Score 12-63 points). Plasma levels of reduced (GSH) and oxidized (GSSG) glutathione alpha-tocopherol (TOC), lipid peroxides (expressed in terms of thiobarbituric acid reagible substances = TBARS), and tumor necrosis factor alpha (TNF) were measured each day from the point of admission on the ICU until the discharge or death of the patients. The following results were obtained: Independent from the outcome, we observed a continuous loss of plasma sulfhydryl groups and TOC. In the patients developing a MOF score > 5 on 10th day after injury (n = 6), a significant increase in plasma GSSG level was measurable. Additionally, a total loss of plasma GSH was seen in some of these patients indicating the collapse of the GSH-dependent antioxidative system. Similar changes were never observed in patients with MOF score < or = 5 on 10th day after injury (n = 15). In this group, a significant correlation between plasma TNF peaks and short time GSH boosts was obtained as a possible indicative for a stimulating effect of TNF on GSH synthesis. It can be concluded that processes of oxidative stress in connection with a consumption of endogenic antioxidants might be able to promote the development of MOF after polytraumatic injury.

Reduction of ischemia-reperfusion syndrome after abdominal aortic aneurysmectomy by N-acetylcysteine but not mannitol.

BACKGROUND: Abdominal aortic aneurysmectomy results in a general ischemia-reperfusion syndrome accompanied by an acute rise in mean pulmonary artery pressure (MPAP). Severe and sometimes fatal postoperative cardiopulmonary complications have been described. METHODS: This pilot study examined whether N-acetyl-cysteine (NAC), a precursor of the most important physiological antioxidant glutathione (reduced form: GSH; oxidized form: GSSG), or the hydroxyl radical scavenger mannitol (MAN) modifies these events. The patients received 150 mg/ kg b.m.NAC (n = 9) 30 minutes before infrarenal aortic clamping or 500 mg/kg b.m. MAN (n = 10) 10 minutes before declamping. 11 patients had no additional treatment (control). RESULTS: In the control group, a significant increase in plasma levels of oxidized glutathione and lipid peroxides was observed after declamping. Additionally, a significant increase in plasma levels of the stable metabolites of thromboxane (TXB2) and prostacyclin (6-keto-PGF1 alpha) was measureable after declamping. There was a transient increase in MPAP and pulmonary vascular resistance (PVR), both of which returned to normal values within 20 minutes. Six hours after surgery, pulmonary dysfunction was manifest by increase in the intrapulmonary shunt fraction. Relative to the control group, NAC pretreatment led to a complete lack of changes in plasma lipid peroxide, thromboxane and prostacyclin levels after declamping; there was a significant increase in plasma GSH concentration persisting over a period of 12 hours. MPAP, PVR and Qs/QT values were unchanged. MAN pretreatment showed similar effects on the parameters obtained in the acute phase after declamping like the control group. CONCLUSIONS: Pretreatment with NAC, but not mannitol, may help prevent ischemia-reperfusion syndrome following aortic clamping.

[Endotoxinemia and multiple organ failure after polytrauma]. / Endotoxinämie und Multiorganversagen nach Polytrauma.

Despite successful management of early complications in polytraumatized patients and obvious reduction of early death, lethality in the late course of the disease--frequently as a result of multiple organ failure (MOF)--remains generally unaffected. Concerning the pathogenesis of sepsis and MOF, there is some evidence that a central role is played by endotoxin. A series of 32 patients with severe polytraumatic injury (Hannover Polytrauma Score > 20 points) comprised the study group. Endotoxin was measured hourly over the first 24 hours. The first measuring point was four hours after injury at the latest. Endotoxin levels were determined by a quantitative turbidimetric limulus assay. The Goris MOF score reached between the 8th and 10th day after injury was used for evaluation of the severity of MOF. Thirty of the 32 patients showed episodes of endotoxemia during the measuring period. There was a strong correlation between observed endotoxin peak concentrations, on the one hand, and outcome as well as positive predictive value (PPV) concerning development of MOF, on the other hand. If the peak concentration was greater than 10 pg/ml, the PPV reached 100%. No patient survived a peak concentration greater than 12 pg/ml. Endotoxemia during the early phase after polytraumatic injury is a frequent phenomenon. It appears to be possible that measurement of endotoxin peak concentration during the early phase gives some indication of the development of MOF and the outcome of these patients.

[Severe course of ornithosis and its intensive care and diagnostic problems--a case report]. / Schwerer Verlauf einer Ornithose und ihre intensivmedizinische und diagnostische Problematik--eine Kasuistik.

Ornithosis is still a life-threatening illness unless diagnosed early and adequately treated with antibiotics. Diagnosis, however, is difficult because often no direct contact with birds is obvious. We report on the course of a severe case of ornithosis in a 45-year-old man who had no previous health problems. Infection with Chlamydia psittaci probably occurred by inhaling of contaminated dust produced by flocks of wild pigeons. A special feature of the case is that commonly used serological tests (complement fixation reaction, CFR; ELISA) failed to yield clear results. Since propagation of Chlamydia psittaci requires special biological laboratory containment facility no. 3, we were able to detect the pathogen in faeces, blood, and urine using the direct immunofluorescence antibody technique (DIFT) and a modified peroxidase antiperoxidase technique (PAP). A lot of Chlamydia psittaci was found. These results were verified by electron microscopy. As a result, the treatment could be quickly adjusted to the application of doxycyclin, which led to a rapid improvement in the patient's condition. This direct detection of Chlamydia psittaci by DIFT, the PAP technique or electron microscopy, also in faeces, blood and urine specimens, represents a useful addition to the usual microbiological methods for the diagnosis of this pathogen.

Selenium in serum and whole blood in patients with surgical interventions.

Selenium values of serum and whole blood were determined for two groups of patients undergoing large surgical interventions (e.g., gastrectomy) and receiving a total parenteral nutrition (TPN). All patients showed low selenium values at the beginning of TPN. The first group received a supplementation of selenium, and it was established that selenium levels normalized after 6-7 d. The balances of selenium turned out to be positive in all cases. The second group, which was not administered selenium supplementation, showed significantly lower values of selenium. It can, therefore, be concluded that a substitution of selenium prior to large surgical interventions following TPN clearly helps patients combat the increase in the oxidant stress reactions.

[Selenium and antioxidant status in various diseases]. / Der Selen- und Antioxidanzienstatus bei verschiedenen Krankheitsbildern.

All healthy mammalian organisms are characterized by an equilibrium between the occurrence of highly reactive oxygen species and their destruction by anti-oxidants. Numerous diseases go hand in hand with a disturbance of the homoeostatis. In order to avoid or minimize the destructive effect of the oxidant stress on biological structures, therapies utilizing drugs with anti-oxidant effects are increasingly being applied. Preconditions for these therapies are a characterisation and a follow-up of the anti-oxidant status in the diseased organism. In the course of the present study selenium, glutathione peroxidase and malondialdehyde were determined in patients with various clinical pictures (terminal renal insufficiency, septic shock, high-risk gravidieties, arterioscleroisis, pulmonary carcinoma, acute myocardial infarction, test patients taking the contraceptive pill). Patients with terminal renal insufficiency and those suffering from septic shock syndromes clearly show a selenium decrease in serum and whole blood as well as a drop in the GSH-Px-activity, and increased malondialdehyde concentrations in the serum. Both are a reflection of an increased lipid peroxidation. First results of a selenium therapy are available for patients with therminal renal insufficiency and post-traumatically induced renal failure. The interpretation of the findings in the categories "high-risk gravidity" and "women on the contraceptive pill", which show a normal GSH-Px-activity and significantly increased malondialdehyde concentrations, seems problematic. The organism counteracts an increased lipid peroxidation with a normal plasma-GSH-Px-activity, clearly a sign of a still normal anti-oxidant potential.

Glutathione homeostasis in rats chronically treated with ethanol. Evidence for an increased hepatic GSH export in vivo.

The influence of chronic ethanol feeding to rats on the hepatic glutathione (GSH and GSSG) system (synthesis, catabolism, export) and on the GSH and GSSG concentrations in extrahepatic tissues was investigated. Histological examination of livers from ethanol pretreated rats revealed a minor dilatation of the hepatic sinusoids. After ethanol administration the distribution pattern of gamma-glutamyltranspeptidase (enzymehistochemistry) was nearly unchanged, but the hepatic activity of this enzyme was increased. The ethanol pretreatment led to a decrease in hepatic GSH content. The hepatic activity of the GSSG-reductase were increased after ethanol treatment whereas the activities of the GSH synthesizing enzymes (gamma-glutamyl-cysteinyl-synthetase and GSH-synthetase) were not affected. A strong increase in sinusoidal GSH export was found in the ethanol-pretreated rats. The GSH- and GSSG concentrations of brain, lung, kidney and skeletal muscle were unchanged. It can be concluded that the ethanol-induced alteration of the hepatic GSH metabolism is caused mainly by changes of the sinusoidal membrane of the hepatocytes (direct effect of ethanol on the sinusoidal GSH carrier) leading to an increased GSH export into plasma. This effect should not due to an increased extrahepatic requirement for GSH.

[Circular intrathoracic tracheal replacement by a devitalized artery in the dog]. / Zirkulärer intrathorakaler Trachealersatz mit devitalisierter Arterie beim Hund.

Prepared artery (origin: human, calf, dog) with external or internal teflon-spiral-supporting was implanted in dogs (n = 10) as a circular intrathoracic tracheal substitute after cross-resection. Human arteries were rejected (n = 2). Calf arteries (n = 5) and dog arteries (n = 3) were incorporated fibrously. Central granulations appeared. The longest survival time was 36 days.

[Behavior of respiratory tract, esophagus and pulmonary artery pressure in bronchoscopies in normofrequent jet ventilation in comparison with Friedel's ventilation technics]. / Zum Verhalten von Atemwegs-, Osophagus- und Pulmonalisdruck während Bronchoskopien unter normofrequenter Jetventilation im Vergleich zur Friedelschen Beatmungstechnik.

The dynamics of selected physiological respiratory parameters were studied in a total of 29 patients. During slight hyperventilation and good oxygenation by both Friedel's and jet ventilation (driving pressure 0.3 and 0.4 MPa, respectively), comparably low respiratory tract pressures were observed. Transmission to intrathoracic (44-46%) and mean pulmonary artery pressure (11-13%) indicates only a low-grade ventilation-induced hemodynamic influence. By contrast, clear increases in pulmonary artery pressure due to intubation were recorded. Thus, the employed normofrequent jet ventilation with its continuous open-tube ventilation which is independent of the undisturbed bronchological examination possesses beneficial properties from a cardiorespiratory view.

[Toe transfer]. / Der Zehentransfer.

Today toe-to-hand transfer by micro-anastomoses is one of the most important methods in reconstructing severely injured hands. An experienced surgeon will obtain a survival rate of the transplant in about 94 to 96% of cases. All measures required can be performed by only one operation. The free toe-to-hand transfer guarantees the best functional and aesthetic results so far known.

Studies on the hypertriglyceridemia in the pregnant rat.

The in vivo tracer method and in vitro incorporation experiments were used to obtain information on the mechanism responsible for the hypertriglyceridemia found in 21 days pregnant rats. The results indicate that the uptake of plasma free fatty acids (FFA) by liver triglycerides of pregnant rats (2.0 mumoles FFA/min/300 g) did not differ from that of non-pregnant rats (2,1 mumoles FFA/min/300 g). The rate of liver fatty acid synthesis in pregnant rats (0,4 mumoles fatty acids/min/liver) is higher than that of non-pregnant rats (0,05 mumoles fatty acids/min/liver). In non-pregnant female and pregnant rats the turnover rates of plasma chylomicron and VLDL triglycerides were almost identical (about 2.8 mumoles triglyceride fatty acids/min/300 g, and about 2.3 mumoles triglyceride fatty acids/min/300 g, respectively). These various observations, when taken together, strongly suggest that increased hepatic triglyceride production cannot be the mechanism responsible for the hypertriglyceridemia in pregnant rats.

Maternal plasma triglycerides as a source of fetal fatty acids.

The transfer of plasma triglyceride fatty acids from mother to fetus was studied in rats. Following i.v. injection of labelled chylomicron and very low density lipoprotein (VLDL) triglycerides into the mother, the time courses of the plasma triglycerides, free fatty acids, and fetal radioactivity were determined. The data were analysed using a mathematical model. From the results the following conclusions were drawn: To cover the need of fetal fatty acids, the placenta utilizes only VLDL triglycerides but not chylomicron triglycerides. Comparison of the amount of VLDL triglyceride fatty acids (0.04 micromoles/min/litter) and of maternal plasma free fatty acids (0.08 micronmoles/min/litter) transferred into the fetus indicates that the maternal plasma triglycerides are a source of fetal fatty acids, that cannot be neglected.