[Screening for 4MRGN in German emergency departments]. / Screening auf 4MRGN in deutschen Notaufnahmen.

BACKGROUND: Multiresistant Gram-negative bacteria (MRGN) are a growing clinical problem. The practical implementation of the recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) for screening according to 4MRGN (MRGN resistant to all four categories of antibiotics), however, varies considerably between emergency departments. OBJECTIVES: This study is intended to give an overview of the status quo and the quality assurance of 4MRGN screening and to show possibilities for process optimization. MATERIALS AND METHODS: In 2018, a web-based survey was conducted among emergency room directors and directors of clinics in the Association of Hospital Directors in Germany (VKD). RESULTS: The response rate of the 267 clinics surveyed was 31.1%. In all, 83.4% of the emergency rooms surveyed routinely screen for multiresistant pathogens. In 71.8% a standard procedure (SOP) is defined and 82.0% of the test criteria refer to the KRINKO recommendation. Only 39.7% of the clinics follow it without in-house adaptation. No clinic can give an exact number of actual risk patients per year. According to the median, 55 patients in an emergency room met the KRINKO screening criteria in 2017. Only 40 patients were screened for suspected 4MRGN. Quality assurance of the screening was performed by 41.0% of emergency departments. The responsibility lies mainly with the hygiene department. CONCLUSIONS: Even if screenings are carried out as far as possible, there is a lack of standardization in the recording of case numbers and quality assurance. Therefore, it can be assumed that there are numerous individuals with undetected 4MRGN. As a quality indicator, SOPs could clearly assign responsibilities and improve infection hygiene.

Ultrasonographic examination reduces the percentage of unsuccessful inseminations in dairy cows.

The objective of this study was to investigate whether confirmation of suitability for service by traditional methods, observation and transrectal palpation, is improved in cattle by additional ultrasonographic examination of the uterus and ovaries. The data from 600 lactating cows from Southern Germany submitted for the first service and alternately assigned to manual (group M, n = 301) and manual and sonographic examination (group S, n = 299) were evaluated. Cows of group M with a large, soft follicle with an estimated diameter of 12.0 to 22.5 mm, without a palpable CL (>10 mm), and with a contractile uterus without palpable content were considered suitable for service and inseminated. Cows of group S with a soft follicle measuring 12.0 to 22.5 mm, without a CL (>10 mm), and with a contractile uterus and no echoic content were inseminated. Pregnancy was determined by ultrasonography at 28 to 35 days after the first service. In group S, 10.9% fewer cows (P = 0.003) were considered suitable for service than in group M. The main reason (29.6%) for exclusion from service in group S was the presence of a CL greater than 10 mm in addition to a preovulatory follicle (12.0-22.5 mm), which was diagnosed less frequently in group M (4.5%; P < 0.0001). The first-service conception rate tended to be higher in group S than in group M (62.7% vs. 54.9%; P = 0.10), and the percentage of open cows, based on all cows submitted for service, was higher in group M than in group S (35.2% vs. 25.1%; P = 0.007). We concluded that sonographic examination of cows submitted for service facilitates the exclusion from service of proestrous and diestrous cows and reduces the number of pointless services.

Assessment of solutions from the consistently linearized eigenproblem by means of finite difference approximations.

The consistently linearized eigenproblem (CLE) plays an important role in stability analysis of structures. Solution of the CLE requires computation of the tangent stiffness matrix [Formula: see text] and of its first derivative with respect to a dimensionless load parameter λ, denoted as [Formula: see text]. In this paper, three approaches of computation of [Formula: see text] are discussed. They are based on (a) an analytical expression for the derivative of the element tangent stiffness matrix [Formula: see text], (b) a load-based finite difference approximation (LBFDA), and (c) a displacement-based finite difference approximation (DBFDA). The convergence rate, the accuracy, and the computing time of the LBFDA and the DBFDA are compared, using the analytical solution as the benchmark result. The numerical investigation consists of the analysis of a circular arch subjected to a vertical point load at the vertex, and of a thrust-line arch under a uniformly distributed load. The main conclusion drawn from this work is that the DBFDA is superior to the LBFDA.

[Chest pain units or chest pain algorithm?]. / Chest Pain Units oder Chest-Pain-Algorithmus?

BACKGROUND: A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. OBJECTIVES: What are current options to improve chest pain evaluation in Germany? METHODS: A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". RESULTS AND DISCUSSION: A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.

[Health care situation of patients with suspected sepsis in a German emergency department]. / Versorgungsprozesse von Patienten mit Verdacht auf Sepsis in einer deutschen Notaufnahme.

BACKGROUND: The in-hospital mortality of patients with severe sepsis and septic shock (ssss) is high. Of note, little is known about the health care situation of patients with sepsis in German emergency departments. The aim of the study was to analyze whether sepsis patients are treated according to current guidelines, to identify the treatment sites within the hospital and to evaluate the death rate of affected patients during index hospitalization. PATIENTS AND METHODS: In this single-centre, prospective and observational trial we analyzed consecutive patients with complaints of sepsis during August and September 2012. RESULTS: During the study period 151 patients presented with complaints of sepsis (age 68.3 ± 18 years, 54.3% men, 45% with ssss, in-hospital mortality of the overall cohort: 14.6%). The Surviving Sepsis Campaign three hour bundle (lactate, blood cultures, broad spectrum antibiotics, and volume) was carried out in 54.2% of patients with ssss. In case of ssss, broad spectrum antibiotics were initiated in the emergency department in 85.4%. Patients with ssss were admitted to wards with usual care in 67.2%, in 32.8% they were admitted to an intensive or intermediate care unit. The in-hospital mortality of patients with ssss during their index hospitalization was 27.8%. CONCLUSION: Despite the high in-hospital mortality rate, more than two thirds of the patients with ssss were admitted to wards with usual care. We call for action 1) to early identify affected patients, 2) to provide adequate risk stratification tools and 3) to realize an early disposition of patients to the appropriate care units.

Mathematical conditions for and physical meaning of a maximum of the determinant of [Formula: see text] in the prebuckling regime.

It is shown that the determinant of the tangent stiffness matrix has a maximum in the prebuckling regime if and only if the determinant of a specific linear combination of the first and the third derivative of this matrix with respect to a dimensionless load factor vanishes. The mathematical tool for this proof is the so-called consistently linearized eigenproblem in the frame of the Finite Element Method. The physical meaning of the mentioned maximum is the one of a minimum of the percentage bending energy of the total strain energy. The paper provides mathematical and physical background knowledge on numerical results that were obtained 35 years ago.

Equipment for pre-hospital airway management on Helicopter Emergency Medical System helicopters in central Europe.

BACKGROUND: For advanced out-of-hospital airway management, skilled personnel and adequate equipment are key prerequisites. There are little data on the current availability of airway management equipment and standards of medical staff on Helicopter Emergency Medical System (HEMS) helicopters in central Europe. METHODS: An internet search identified all HEMS helicopters in Austria, Switzerland and Luxembourg. We identified 15 HEMS helicopter bases in Switzerland, 28 in Austria and three in Luxembourg. A questionnaire was sent to all bases, asking both for the details of the clinical background and experience of participating staff, and details of airway management equipment carried routinely on board. RESULTS: Replies were received from 14 helicopter bases in Switzerland (93%), 25 bases in Austria (89%) and all three bases in Luxembourg. Anaesthesiologists were by far the most frequent attending physicians (68-85%). All except one bases reported to have at least one alternative supraglottic airway device. All bases had capnometry and succinylcholine. All bases in the study except two in Austria had commercial pre-packed sets for a surgical airway. All helicopters were equipped with automatic ventilators, although not all were suitable for non-invasive ventilation (NIV; Switzerland: 43%, Austria: 12%, Luxembourg: 100%). Masks for NIV were rarely available in Switzerland (two bases; 14%) and in Austria (three bases; 12%), whereas all three bases in Luxembourg carried those masks. CONCLUSION: Most HEMS helicopters carry appropriate equipment to meet the demands of modern advanced airway management in the pre-hospital setting. Further work is needed to ensure that appropriate airway equipment is carried on all HEMS helicopters.

[Airway management in the German air rescue service]. / Atemwegsmanagement im deutschen Luftrettungsdienst.

BACKGROUND: The equipment carried in rescue helicopters concerning airway management is not standardized in Germany. The current DIN/EN equipment regulations are not detailed for every single item resulting in differences between the various rescue bases. The aim of this survey was to show existing differences in airway management equipment. METHODS: All 72 German air rescue helicopters listed in the ADAC air rescue stations atlas 2006/2007 received a questionnaire. RESULTS: A total of 64 bases returned the questionnaire (88.9%). The most frequent types of supraglottic airway equipment were laryngeal masks (67.2%), Combitubes (32.8%) and laryngeal tubes (29.7%). Cricothyrotomy sets were more frequent (68.8%) than tracheostomy sets (35.9%). Of the bases 18.8% had masks suitable for non-invasive ventilation (NIV). All helicopters were equipped to carry out capnometry. CONCLUSIONS: The rescue helicopters were found to have differences with respect to the equipment carried for airway management. Medical treatment according to current guidelines is possible on almost all bases.

Prehospital airway management on rescue helicopters in the United Kingdom.

Adequate equipment is one prerequisite for advanced, out of hospital, airway management. There are no data on current availability of airway equipment on UK rescue helicopters. An internet search revealed all UK rescue helicopters, and a questionnaire was sent to the bases asking for available airway management items. We identified 27 helicopter bases and 26 (96%) sent the questionnaire back. Twenty-four bases (92%) had at least one supraglottic airway device; 16 (62%) helicopters had material for establishing a surgical airway (e.g. a cricothyroidotomy set); 88% of the helicopters had CO(2) detection; 25 (96%) helicopters carried automatic ventilators; among these, four (15%) had sophisticated ventilators and seven (27%) helicopters carried special face masks suitable for non-invasive ventilation. We found a wide variation in the advanced airway management equipment that was carried routinely on air ambulances. Current guidelines for airway management are not met by all UK air ambulances.

Stereometric assessment of TMJ space variation by occlusal splints.

Occlusal splints are used for the management of temporomandibular disorders, although their mechanism of action remains controversial. This study investigated whether insertion of an occlusal splint leads to condyle-fossa distance changes, and to mandibular rotation and/or translation. By combining magnetic resonance images with jaw tracking (dynamic stereometry), we analyzed the intra-articular distances of 20 human temporomandibular joints (TMJs) before and after insertion of occlusal splints of 3 mm thickness in the first molar region. For habitual closure, protrusion, and laterotrusion in the contralateral joint, occlusal splints led to minor--yet statistically significant--increases of global TMJ space and to larger increases at defined condylar areas. Condylar end rotation and translation in habitual closure were reduced. Hence, the insertion of a 3-mm-thick occlusal splint led to a change in the topographical condyle-fossa relationship, and therefore to a new distribution of contact areas between joint surfaces.

[German Refined-Diagnosis Related Groups 2008 version. What is new for anaesthesia and intensive care medicine?]. / German Refined-Diagnosis Related Groups, Version 2008. Was ist neu für Anästhesie und Intensivmedizin?

The present article reviews improvements in the 2008 version of the German Refined - Diagnosis Related Groups (G-DRG) which are relevant for anaesthesia and intensive care medicine. The focal points of further developments and the data base of the updated DRG version are presented. The efforts of the InEK, the institution which is responsible for the design and development of the G-DRG system, to provide a transparent system driven by rules are also explained, followed by a description of changes in coding of diagnoses (e.g. new diagnosis codes, revised complication and comorbidity level matrix, new specifications of individual diagnosis-related groups such as acute paraplegia) and procedures (e.g. new procedure codes, modifications for complex procedures). Furthermore, some new developments concerning the functions "complicating procedure" (increase in number of G-DRGs concerned and enlarged coverage of complex intensive care procedures) as well as changes in the demographic attribute "mechanical ventilation" (modification of G-DRGs for prolonged mechanical ventilation) are discussed. Finally, the legal requirements for supplemental revenues in 2008 (e.g. new additions, movements between different catalogues of services, transitions from the catalogue of innovative diagnostic and therapeutic methods to the official catalogue) are updated. The present contribution is an update of previous articles on this topic published in this journal in 2007. Therefore, knowledge of these previous publications is a prerequisite for the understanding of the current article. Readers who are not familiar with the complex material should refer to the publications from 2007.

[Diagnosis-related groups. Safeguarding and distribution of revenues from the perspective of anaesthesiology]. / Diagnosis Related Groups. Sicherung und Aufteilung von Erlösen aus anästhesiologischer Perspektive.

After 30 years of belt-tightening in the health care system and the mandatory implementation of the German diagnosis-related groups (DRG) system in 2004, the cost pressure on German hospitals has increased again. Cases break even only if prime costs fall below DRG revenues. On the one hand it is required from hospitals that prime costs are evaluated in terms of effectiveness, but on the other hand they have to allow for generation of adequate revenues and performance-oriented distribution of profits. This article first presents the political background of the German DRG system and then systematically assesses the different types of reimbursement. Aspects in the field of anaesthesia which are relevant to the generation of adequate revenues are: documentation of intraoperatively occurring diagnoses, documentation of intraoperative procedures, the grouper function "complicating procedure", the demographic attribute "hours on mechanical ventilation" and the issue of supplemental revenues. Following comments on the generation of adequate revenues, the alternative means of internal budgeting, the German DRG case-costing and the percentage of sales method, are discussed. The present contribution is intended to assist readers in the prevailing discussion about economic awareness of the health care market.

[German Refined-Diagnosis Related Groups, version 2007. The depiction of intensive care medicine]. / German Refined-Diagnosis Related Groups, Version 2007. Die Abbildung der Intensivmedizin.

Since the G-DRG system was introduced in Germany in 2004, attempts have been made to model medical services performed in the intensive care units on a performance-oriented system by capitation. Based on this background the InEK, the institution which is responsible for design and development of the G-DRG system, has implemented several new issues into the version for 2007 which will be presented in this article. On the one hand the changes concerning the coding rules of diagnosis and procedures will be described and on the other hand important topics, such as "multimodal intensive care" or "complex treatment of patients with severe infections by multi-resistant pathogens", will be focused on. Furthermore, some new developments concerning the global functions ("complex procedures", "complex intensive treatment") as well as the changes in the coding rule for the demographic factor "mechanical ventilation" will be discussed. Finally, the regulations for additional remuneration are updated. In general, the attempts of the InEK to improve the G-DRG mapping for intensive care medicine are welcome and constructive. The regulations provided seem to be beneficial, but at the same time complicating the instructions. Hence, standardisation of intensive care medicine via diagnosis-related-groups still remains inadequate and therefore unsatisfactory in 2007.

Rho-kinase regulates myosin II activation in MDCK cells during recovery after ATP depletion.

Alterations in the actin cytoskeleton of renal tubular epithelial cells during periods of ischemic injury and recovery have important consequences for normal cell and kidney function. Myosin II has been demonstrated to be an important effector in organizing basal actin structures in some cell types. ATP depletion in vitro has been demonstrated to recapitulate alterations of the actin cytoskeleton in renal tubular epithelial cells observed during renal ischemia in vivo. We utilized this reversible cell culture model of ischemia to examine the correlation of the activation state and cellular distribution of myosin II with disruption of actin stress fibers in Madin-Darby canine kidney (MDCK) cells during ATP depletion and recovery from ATP depletion. We found that myosin II inactivation occurs rapidly and precedes dissociation of myosin II from actin stress fibers during ATP depletion. Myosin II activation temporally correlates with colocalization of myosin II to reorganizing stress fibers during recovery from ATP depletion. Furthermore, myosin activation and actin stress fiber formation were found to be Rho-associated Ser/Thr protein kinase dependent during recovery from ATP depletion.

Pressure-release tracheal gas insufflation reduces airway pressures in lung-injured sheep maintaining eucapnia.

Although tracheal gas insufflation (TGI) has proved to be a useful adjunct to mechanical ventilation, end-inspiratory as well as end-expiratory pressures may increase. We investigated the ability of continuous-flow TGI to maintain eucapnia while reducing airway pressure (Paw) and tidal volume (VT). Seven sheep (36 +/- 2 kg) were ventilated using the Dräger Evita 4 in the pressure control plus mode where flow is released via the expiratory valve to maintain constant inspiratory pressure. To avoid TGI-generated positive end-expiratory pressure (PEEP), a prototype reverse flow TGI tube was used. Two TGI flows (5 and 10 L/min) were investigated pre- and postsaline lavage-induced lung injury. Inspiratory pressures and VT were significantly reduced as TGI flow increased. At 10 L/min TGI flow the carinal pressures (Pcar) and VT were reduced pre- and postinjury by 15% and 20%, and by 28% and 34%, respectively. Tidal volume to dead space ratio (VD/VT) decreased preinjury from 0.49 +/- 0.1 to 0.18 +/- 0.2 and postinjury from 0.62 +/- 0.1 to 0.33 +/- 0.1 at a TGI flow of 10 L/min. The combination of the reverse flow TGI tube and a ventilator with an inspiratory pressure relief mechanism kept set end-inspiratory and end-expiratory pressures constant. This TGI system effectively reduced set Paw and VT while maintaining eucapnia.

Inhalation of nitric oxide in acute lung injury: results of a European multicentre study. The European Study Group of Inhaled Nitric Oxide.

OBJECTIVE: To determine whether inhalation of nitric oxide (INO) can increase the frequency of reversal of acute lung injury (ALI) in nitric oxide (NO) responders. DESIGN: Prospective, open, randomised, multicentre, parallel group phase III trial. SETTING: General ICUs in 43 university and regional hospitals in Europe. PATIENTS: Two hundred and sixty-eight adult patients with early ALI. INTERVENTIONS: NO responders were patients whose PaO(2) increased by more than 20 % when receiving 0, 2, 10 and 40 ppm of INO for 10 min within 96 h of study entry. Responders were randomly allocated to conventional treatment with or without INO. INO, 1-40 ppm, was given at the lowest effective dose for up to 30 days or until an end point was reached. The primary end point was reversal of ALI. Clinical outcome parameters and safety were assessed in all patients. RESULTS: Two hundred and sixty-eight patients were recruited, of which 180 were randomised NO responders. Frequency of reversal of ALI was no different in INO patients (61 %) and controls (54 %; p > 0.2). Development of severe respiratory failure was lower in the INO (2.2 % ) than controls (10.3 %; p < 0.05). The mortality at 30 days was 44 % for INO patients, 40 % for control patients (p > 0.2 vs INO) and 45 % in non-responders. CONCLUSIONS: Improvement of oxygenation by INO did not increase the frequency of reversal of ALI. Use of inhaled NO in early ALI did not alter mortality although it did reduce the frequency of severe respiratory failure in patients developing severe hypoxaemia.

Expiratory phase tracheal gas insufflation and pressure control in sheep with permissive hypercapnia.

Tracheal gas insufflation (TGI) has been shown to be a useful adjunct to mechanical ventilation, decreasing PaCO2 during permissive hypercapnia. While TGI can be used either with pressure (PCV) or volume-controlled ventilation and continuously or only during the expiratory phase (Ex-TGI), there are no controlled studies evaluating the effects of Ex-TGI with PCV in acute lung injury when the direction of the insufflated flow or the inspiratory:expiratory (I:E) ratio are varied. We evaluated the effect that Ex-TGI with PCV would have on CO2 removal during both direct and reverse insufflated flow direction with varied I:E ratios when peak airway pressure, total positive end-expiratory pressure (PEEP), and tidal volume (VT) were kept constant. In addition we examined the effect that insufflation flow directed toward the mouth (reverse flow) would have on the generation of PEEP compared with flow directed toward the carina (direct flow). After saline lavage, nine sheep were ventilated with PCV to a baseline PaCO2 of 80 mm Hg. Ex-TGI (10 L/min) was then randomly applied in the reverse and direct direction with I:E set at 1:2 or 2:1. During 1:2 I:E PaCO2 decreased from 78 +/- 4 mm Hg to 60 +/- 7 mm Hg (23.5 +/- 8.9%) with direct flow and to 64 +/- 5 mm Hg (18.5 +/- 5.5%) with reverse flow (p < 0.05), whereas during 2:1 I:E PaCO2 decreased from 80 +/- 4 mm Hg to 69 +/- 8 mm Hg (13.7 +/- 9.2%) with direct flow and to 66 +/- 4 mm Hg (17.2 +/- 4.4%) with reverse flow (p < 0.05). Greater PEEP was developed with direct flow (2.8 cm H2O I:E 1:2 and 4.0 cm H2O I:E 2:1) than with reverse flow (-0.9 cm H2O I:E 1:2 and -0.4 cm H2O I:E 2:1), p < 0.05. There was no difference in the PaCO2 change between I:E with reverse flow, but the PaCO2 decrease was greater (p < 0.05) during 1:2 versus 2:1 I:E with direct flow. CO2 removal during PCV and Ex-TGI is more consistent with reverse flow than with direct flow and PEEP level is less affected by TGI with reverse flow than with direct flow.

[Contra: noninvasive ventilation in acute respiratory insufficiency]. / Kontra: Nichtinvasive Beatmung bei akuter respiratorischer Insuffizienz.

Mechanical ventilation via a tracheal tube is an invasive measure whose complications may prevent recovery from respiratory failure. Today, noninvasive positive pressure ventilation via mouthpiece or mask is an economically and medically successful alternative for the treatment of chronic respiratory failure and acute exacerbation of COPD, respectively. Within certain limits, noninvasive ventilation may take over inspiratory work of breathing as well as elevate mean airway pressure and inspiratory oxygen concentration. This does not at all question the absolute indications to maintain a patent airway by tracheal intubation. Clinical applications of noninvasive ventilation within these limits are acute exacerbation of COPD, congestive heart failure with pulmonary edema or atelectasis. Respiratory muscle fatigue, cardiogenic and septic shock, severe pneumonia and ARDS are still absolute indications for invasive ventilation. Table 1 specifies 12 disadvantages and endpoints of noninvasive mechanical ventilation.