Competitive advantage gained from the use of helicopter emergency medical services (HEMS) for trauma patients: Evaluation of 1724 patients.

OBJECTIVES: The aim of the study was to analyze helicopter emergency medical service (HEMS) in comparison to EMS, in respect to patient's mortality and morbidity. DESIGN: From a cohort of traumatized patients (n = 1724) prospectively enrolled in the German trauma registry (DGU-R) at Frankfurt University Hospital from 2009 to 2013, 1646 could be analyzed for in-hospital mortality and short-term outcome (GOS) at discharge and compared between HEMS and EMS. MEASUREMENTS AND MAIN RESULTS: 129 patients (7.8%) died in the hospital. Unadjusted mortality was significantly lower in the HEMS group compared to EMS (p = 0.001). In a multiple logistic regression analysis after adjustment of variables including reanimation and age as the strongest predictors, in-hospital mortality was significantly reduced in HEMS (p = 0.014, OR = 0.21). Further predictors in the multiple logistic regression analysis were GCS > = 8 (p = 0.001), RRsys (p < 0.001), ISS at Head/Neck > = 3 (p = 0.003), and total ISS > = 9 (p < 0.001). Total rescue time and on scene time were associated with mortality (p < 0.001) but not included in the multiple logistic regression model. Without adjustment, short-term outcome (GOS) was significantly improved (p = 0.014). In a linear model, after adjusting for multiple variables including age, ISS Head/Neck > = 3, ISS Extremities > = 3, GCS > = 8, and RRsys as the strongest predictors (p < 0.001), the association remained significant (p = 0.043). Further predictors in the multiple linear regression analysis were total ISS > = 9 (p = 0.002), ISS abdomen (p = 0.001), and ISS Chest (p = 0.011). CONCLUSIONS: A significant improvement for in-hospital survival for HEMS could be demonstrated. Especially in Germany, with a high number of secondary call outs (about 44%) after EMS has already reached the traumatized patient, HEMS must be the first choice for severely injured trauma patients. Dispatch criteria for immediate alarm of HEMS are recommended under practical considerations.

Glycerol significantly decreases the three hour efficacy of alcohol-based surgical hand rubs.

BACKGROUND: Glycerol in alcohol-based hand rubs has positive effects on skin condition and user acceptability, but, to the authors' knowledge, its effect on the bactericidal effect of alcohol-based pre-operative hand rubs has not been reported. AIM: To investigate the impact of glycerol on the reduction of resident hand flora by ethanol 80% (w/w), isopropanol 75% (w/w) and n-propanol 60% (V/V). METHODS: In three series of in-vivo laboratory tests on volunteers hands, the efficacy of each of three alcohol-based formulations was tested concurrently with and without added glycerol 1.45% (V/V) according to European Norm EN 12791 for testing pre-operative hand rubs. Formulations were allotted at random to 24 volunteers to rub on to their hands for 3 min. Viable counts from fingertip samples were compared with the respective pretreatment counts immediately after treatment and 3 h later. FINDINGS: The 3-h bactericidal effects of the three pure alcoholic formulations were significantly greater than those of formulations containing glycerol (P < 0.01). With ethanol, this was also true for the immediate effect. CONCLUSION: Glycerol 1.45% (V/V) inhibits the bactericidal efficacy of alcohol-based surgical hand rubs, especially sustained efficacy.

[Mandatory elective course in emergency medicine with instructions by paramedics improves practical training in undergraduate medical education]. / Praktikum im Rettungsdienst mit Anleitung durch Rettungsassistenten.

BACKGROUND: Due to the complexity of medical emergencies undergraduate medical training in the integrative course on emergency medicine requires education combining knowledge, practical skills, algorithm-driven behavior and soft skills. New State board regulations on education and licensing of physicians demand a practical implementation of these objectives. MATERIALS AND METHODS: The medical faculty of Frankfurt medical school has implemented an obligatory prehospital elective course. A retrospective questionnaire assessed the organization, instructional competence of the paramedics and integration of students in the emergency medical teams. RESULTS: Out of a total of 486 students the majority rated the longitudinal curriculum as positive (66% very good and 28% good). The practical experience at a scene was evaluated to be reasonable by 86% and 95% of the students stated that integration into the emergency team was rendered without any difficulties. CONCLUSION: A prehospital experience supported by paramedics can serve as a valuable tool in an emergency medicine curriculum.

Surgical hand disinfection using alcohol: the effects of alcohol type, mode and duration of application.

Due to their strong antimicrobial activity, rapid action, good dermal tolerance and ease of application, alcohol-based hand rubs are recommended for pre-operative preparation of the surgical team's hands. Using the EN 12791 protocol, three commercial products containing either mixtures of propan-1-ol and propan-2-ol or ethanol at total alcohol concentrations (w/w) between 73% (propanols) and 78.2% (ethanol), as the main active agents, were tested with a shortened application of 1.5 min rather than the usual 3 min. Preparation A containing 30% propan-1-ol and 45% propan-2-ol not only passed the test at this short application but even exceeded, though not significantly, the efficacy of the reference disinfection procedure in EN 12791 when applied for 3 min. Preparation B containing 45% propan-1-ol and 28% propan-2-ol fulfilled the required standard whereas the ethanol (78.2%)-based product C did not (P<0.1). This demonstrates that some, but not all, alcohol-based hand rubs pass the test even within 1.5 min, emphasising the importance of validation before a product is introduced into clinical practice. In another series with both preparation A and 60% v/v propan-1-ol, it was demonstrated that the additional inclusion of the forearms into the disinfection procedure, not required by EN 12791 but normal practice in surgical hand disinfection, does not significantly interfere with the antimicrobial efficacy of either hand rub. Therefore, the mode of test procedure in EN 12791 does not need specific adaptation for hand disinfection by surgical teams.

Prehospital ultrasound imaging improves management of abdominal trauma.

BACKGROUND: Blunt abdominal trauma with intra-abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding. METHODS: Six rescue centres took part in the study from December 2002 to December 2003, including 230 patients with suspected abdominal injury. The accuracy of physical examination at the scene and PFAST were compared. Later examinations in the emergency department (ultrasonography and/or computed tomography) were used as the reference standard. RESULTS: The complete protocol and follow-up was obtained in 202 patients. The sensitivity, specificity and accuracy of PFAST were 93 per cent, 99 per cent and 99 per cent, respectively, compared with 93 per cent, 52 per cent and 57 per cent for physical examination at the scene. Scanning with PFAST occurred a mean(s.d.) 35(13) min earlier than ultrasound in the emergency department. Abdominal bleeding was detected in 14 per cent of patients. Using PFAST led to a change in either prehospital therapy or management in 30 per cent of patients, and a change to admitting hospital in 22 per cent. CONCLUSION: In this study, PFAST was a useful and reliable diagnostic tool when used as part of surgical triage at the trauma scene.

[Chemoembolization of hepatocellular carcinomas: which factors determine therapeutic response and survival?]. / Chemoembolisation des hepatozellulären Karzinoms: Welche Faktoren bestimmen Therapieansprechen und Uberleben?

PURPOSE: To determine independent prognostic factors influencing the survival of patients with hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: Ninety-one patients with unresectable HCC were treated with 269 repetitive TACE. The dosages of epirubicin (40-60 mg) and ethiodized oil (8-20 ml) were adjusted to tumor size and liver function. The impact of tumor size, macroscopic tumor type, tumor location, portal vein infiltration, capsular infiltration, tumor vascularization, uptake of ethiodized oil within the tumors, Child-Pugh-Class and Okuda-Stage on patient survival were evaluated by means of univariate and multivariate regression analysis. RESULTS: The following independent prognostic factors were found: tumor type (nodular vs. infiltrating, p = 0 008), tumor size (p = 0.01), Child-Pugh-Class (A vs. B; p = 0.02) and grade of tumor vascularization (p = 0.04). In 57 patients with HCC of the nodular type, the median survival time was significant longer than in 32 patients with HCC of the infiltrating type (17.0 months vs. 7.9 months; p < 0.003; 2 tumors could not be classified). The 1-, 2- and 3-year-survival rates were significantly higher in 57 patients with Okuda-Stage I disease, compared to 34 patients with Okuda-Stage II and III disease (73%, 31% and 8% vs. 23%, 6% and 4% p < 0.0001). CONCLUSIONS: Tumor type, tumor size and grade of liver cirrhosis have an independent impact on prognosis of patients with HCC treated by TACE. An appropriate selection of patients is necessary to improve patients survival.

[Innovative training for enhancing patient safety. Safety culture and integrated concepts]. / Neue Trainingsformen und Erhöhung der Patientensicherheit. Sicherheitskultur und integrierte Konzepte.

INTRODUCTION: Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article. METHOD: Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed. RESULTS: The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising. CONCLUSION: As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

[Legal aspects in early defibrillation by trained lay respondents]. / Rechtliche Aspekte bei der Frühdefibrillation durch geschulte Laienhelfer.

Ventricular fibrillation is the main reason for cardiac arrest. The probability for survival decreases by 10% every minute, therefore immediate resuscitation is necessary. Cardiopulmonary Resuscitation (CPR) by trained first responders is already established, when a doctor is not available. Today automated external defibrillators (AED) are available to first responders for an effective therapy of ventricular fibrillation. Thanks to the high reliability of today's automated external defibrillators they can be used by trained first responders without any legal reservations. If a defibrillator is available, a trained first responder is obliged to use it in an emergency.

Simultaneous detection of cell volume and intracellular pH in isolated rat duodenal cells by confocal microscopy and BCECF.

The combination of confocal laser scan microscopy and the pH-sensitive fluorescent dye BCECF allowed us to record simultaneously intracellular pH, cell viability and relative cell volume. pH was measured by using the pH-sensitive excitation wavelength at 488 nm and the pH-independent excitation wavelength at 442 nm to obtain ratio images. Cell volume was traced by measuring fluorescence dye concentration at 442 nm. Isolated villus tip rat duodenal enterocytes were exposed to 20 mM NH4Cl, sodium free, or 1 mM amiloride buffer. Sodium free buffer and amiloride buffer acidified the cells. Cell volume did not change in sodium free buffer, or NH4Cl exposure, but amiloride led to an increase in cell volume of 20%. After acidification of the duodenal cells, amiloride buffer increased cell volume by almost 50%. These studies revealed that cell volume regulation during pH changes in short-living cells could easily be detected by confocal microscopy and BCECF.

BCECF in single cultured cells: inhomogeneous distribution but homogeneous response.

Using confocal laser scanning microscopy with a dual-wavelength laser system, the behaviour of BCECF [(2',7'-bis-2-carboxyethyl)-5-(and-6)carboxyfluorescein] was investigated in a variety of cell lines. Selection of a small area for monitoring allowed discrimination between various intracellular organelles, whose identity was established by vital staining. It was found that, after loading the cells with BCECF, both the nucleus and the mitochondria showed a higher level of fluorescence than the cytoplasm. Calibration of the pH-sensitivity of these fluorescence signals using the nigericin method yielded identical curves, as did exposure of the cells to NH4Cl. These studies suggest that BCECF, despite its inhomogeneous intracellular distribution, reports the pH of only one cellular compartment, the cytosol.

Intracellular pH-measurements in rat duodenal mucosa in vitro using confocal laserscan microscopy.

An improved technique was developed to measure intracellular pH-changes in in vitro duodenal mucosa. A confocal laserscan microscope was equipped with a second laser to permit dual wavelength excitation measurements employing BCECF (2'7'-bis-2-carboxyethyl-5-(and-6)carboxyfluorescein), a pH-sensitive fluorescent dye. Intact rat duodenal epithelium was mounted in a microperfusion chamber and loaded with BCECF via submucosal injection. Viability of the epithelial cells could be directly monitored by estimating the nucleus-to-cytoplasm ratio of the fluorescence intensity of BCECF. A calibration procedure using isolated duodenal cells, allowed estimation of the apparent intracellular pH. Initial apparent intracellular pH was 7.32 +/- 0.12, identical to that of isolated duodenocytes. Exposure of the duodenal epithelium to 60 mM NH4Cl led to a steady increase in apparent intracellular pH of 0.46 units within 2 min. Luminal application of 0.01 N HCl led to a steady decrease in apparent intracellular pH of 0.53 pH units within 1 min and was followed by a slow increase to baseline level after acid removal. Thus, confocal laserscan microscopy in combination with BCECF allowed noninvasive monitoring of intracellular pH-changes in single cells of an intact duodenal epithelium.

[Magnetic resonance imaging in perianal Crohn's disease]. / Kernspintomographie bei perianalem Morbus Crohn.

Magnetic resonance imaging (MRI) was undertaken in a prospective study of 34 consecutive patients (21 women, 13 men; median age 31 [18-53] years) suspected of having active perianal Crohn's disease. The results of the investigation were compared with those obtained by independent observers on proctological and intraoperative examination (n = 31). A total of 58 fistulas and 21 abscesses were noted intraoperatively, 47 fistulas and all 21 abscesses by MRI, and 40 fistulas and 13 abscesses proctologically. The proctological examination proved to be more sensitive in demonstrating short subcutaneous or anovaginal fistulas (three of four subcutaneous and two of five anovaginal fistulas were not shown by MRI). Intersphincteric, ischiorectal and supralevator involvement was shown better by MRI. These results indicate that in perianal Crohn's disease MRI is a useful addition to proctological examination.

Intracellular pH in renal tubules in situ: single-cell measurements by confocal laserscan microscopy.

Confocal laserscan microscopy with a dual-excitation device was used to record intracellular pH (pHi) regulation in rat proximal convoluted tubules microperfused in vivo. Cells were loaded with the pH-sensitive, fluorescent dye 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein (BCECF). Single cells could be distinguished within the tubules and separate measurements were possible. Application of an NH4Cl pulse by peritubular perfusion caused an immediate increase in intracellular pH. Intraluminal injection of NH4Cl led to a slower increase in intracellular pH. In both cases, cessation of perfusion led to an immediate acidification. Peritubular perfusion with 300 microM 4,4'-diisothiocanatodihydrostilbene-2,2'-disulphonic acid (H2DIDS) caused an intracellular alkalinisation. Microperfusion, pH-sensitive dyes and confocal laserscan microscopy provide a new non-invasive method to measure intracellular pH effectively in individual cells of near-surface structures of the intact kidney.

[Intracellular pH regulation in human SW-620 colon cancer cells]. / Intrazelluläre pH-Regulation in humanen SW-620-Kolonkarzinomzellen.

Intracellular pH (pHi) regulation is essential for basic functioning of the cell and activation of pHi regulatory mechanisms appears to be involved in the initial stage of cell division. Little is known about pHi regulation in human colonic carcinoma cells. We investigated SW-620 (CCL 227) cells, a cell-line derived from a human colonic adenocarcinoma. pHi changes were recorded by computer-assisted spectrofluorimetric monitoring of the pH-sensitive, fluorescent dye BCECF (2',7'-bis(carboxyethyl)- 5(6)carboxyfluorescein). Resting pHi in HEPES (N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid) buffered solution was 7.53 +/- 0.01. Intracellular acidification after an ammonium prepulse produced a pHi decline of 0.5 units and pHi returned to normal value in NaCl Ringer's. Both 1 mM amiloride and Na-free solution completely inhibited recovery for 8 minutes. This inhibition was reversible in NaCl Ringer's. Na-free solution led to a pHi decrease to 7.39 +/- 0.04 after 16 min, pHi was also lowered by 8 minute incubation of cells with 1 mM amiloride (7.40 +/- 0.02). In HCO3/CO2-buffered solution resting pHi was 7.42 +/- 0.01 (n = 35). Recovery from an acute acid load, induced by NH4 prepulse or switching from HEPES- to bicarbonate-buffered solution, was Na dependent, Cl independent, reversible and only partially blocked by 1 mM amiloride - pHi slowly recovered from 6.83 +/- 0.03 to 7.00 +/- 0.06 in 8 minutes. In the presence of amiloride and 200 microns H2DIDS (dihydro-4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid) pHi recovery was completely inhibited for 8 minutes. In Na-free solution pHi decreased from 7.44 +/- 0.04 to 7.29 +/- 0.03 within 8 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Regulation of intracellular pH by Na+/H+ exchange in human lymphocytes]. / Die Regulation des intrazellulären pH durch einen Na+/H+-Austauscher in humanen Lymphozyten.

Spectrofluorimetry and the pH-sensitive fluorescent dye 2',7'-bis(carboxyethyl)-5(6)carboxyfluorescein (BCECF) was used to measure the intracellular pH (pHi) of suspended human lymphocytes. A linear relationship exists between pHi and the fluorescent spinal-ratio (I490nm/I435nm, emission 526 nm) between pH 6.5 and pH 7.8. At the end of each experiment the ratio was calibrated using the high [K+] nigericin technique. All solutions were HEPES buffered. The pHi in resting cells was 7.27 +/- 0.02 (n = 37) at 25 degrees C. Na+ free solution caused a pHi decrease to 6.81 +/- 0.08. The ammonium prepulse technique (25 mM NH4Cl) dropped the pHi to pH 6.80. A rapid recovery of the pHi after this acidification was observed in NaCl Ringer solution. Na+ free solution completely blocked the recovery. 1 mM amiloride led to a partial block of recovery. pHi was restored to the basal value after readdition of Na+. We conclude that in HEPES buffered solutions human lymphocytes recover pHi via a mechanism dependent on extracellular Na+ and largely accomplished by an amiloride inhibitory Na+/H+ exchanger.