Effects of emergency medical service transport on acute stroke care.

BACKGROUND AND PURPOSE: Since early treatment of acute stroke is associated with an improved outcome, emergency medical service (EMS) transport of stroke patients is recommended. It remains unclear, however, whether EMS transport leads to faster treatment. The impact of the transport mode on pre- and in-hospital processes of care was therefore investigated. METHODS: The present study was based on a prospective database of 158 hospitals of the Stroke Register of Northwestern Germany, which included 162,511 stroke patients admitted between January 2010 and December 2011. Main outcome measures were the baseline characteristics associated with EMS transport and process-of-care indicators according to the transport mode. RESULTS: Overall, 101,850 (72.0%) patients were transported by EMS and 39,324 (28.0%) by self-transport. The baseline characteristics showing the strongest associations with EMS use were the care situation [institutional care, adjusted odds ratio (OR) 7.81; 95% CI 6.86-8.90], a disturbed level of consciousness (adjusted OR 3.00; 95% CI 2.59-3.48) and having a subarachnoid (adjusted OR 2.79; 95% CI 2.24-3.49) or intracerebral hemorrhage (adjusted OR 2.26; 95% CI 1.92-2.67). For self-transport patients the probability of being in a higher onset-to-door time category was 4.36 (95% CI 4.26-4.47) and the probability of being in a higher door-to-imaging time category was 1.32 (95% CI 1.28-1.36). Compared with self-transport, EMS transport was independently associated with thrombolysis (adjusted OR 1.95, 95% CI 1.77-2.15). CONCLUSIONS: Patient transport with EMS was independently associated with faster hospital arrival and shorter time periods from hospital admission to brain imaging and to the frequency of thrombolysis.

[Length of hospital stay of patients with ischemic brain infarction: trends over 10 years and analysis of influencing factors]. / Liegezeit von Patienten mit ischämischem Hirninfarkt: 10-Jahres-Trends und Analyse der Einflussfaktoren.

BACKGROUND: The length of the acute hospital stay (LOS) is an indicator of efficiency in the treatment of ischemic brain infarctions (ICD I63). The aim of this study was to describe the development of the LOS over 10 years and to analyze influencing factors with a focus on the structural level of hospitals. METHODS: Routine treatment data for the years 2000 to 2009 generated within the quality assurance project "Stroke Register Northwest Germany" formed the basis of our analyses (n = 175,149). Additionally, the infrastructure and equipment of the hospitals were documented. Information regarding the bed density on county level was provided by the statistical offices of the federal German states. The median LOS was calculated for each year. Moreover, a linear multilevel analysis of the influencing factors stratified by hospital specialty was performed. RESULTS: The LOS after an ischemic brain infarction decreased by several days over the years 2000 to 2009. The difference between the specialties neurology vs. internal and geriatric medicine diminished. A small part of variation in LOS was explained by the factors measured on the three levels patient, hospital and county. The biggest proportion of variance was explained by socio-demographic and clinical factors measured on patient level. Hospital equipment contributed somewhat additionally to the explanation of variance for hospitals specializing in internal and geriatric medicine. There were differences between the medical specialties both with regard to the associations observed and the distribution of variance on the three levels. CONCLUSION: There was a reduction of the LOS in patients with ischemic brain infarction. A stratified analysis according to medical specialty seems necessary. Single features of the hospital infrastructure are associated with the LOS. However, the interpretation of these associations is in part difficult.

[Working conditions and health of general practitioners in Rhineland-Palatinate, Germany: first results of a state-wide survey]. / Arbeitssituation und Gesundheit von Hausärzten in Rheinland-Pfalz: Erste Ergebnisse einer landesweiten Befragung.

AIM: The present study was designed to assess work stress and strain of German general practitioners as well as their health situation by means of standardised and validated instruments. A further objective was to investigate potential means to systematically prevent stress in the target population. METHODS: The Institute of Occupational, Social and Environmental Medicine of the University Medical Centre of Mainz carried out a state-wide anonymous survey between June and July 2009. Altogether, 2 092 practice-based GPs in the federal German state of Rhineland-Palatinate were asked to take part in the cross-sectional study via postal mail. RESULTS: 808 GPs participated (response rate 38.6%), n=790 of these were eligible for the analysis. We found high levels of work strain and perceived stress. The estimated weekly workload was 54.4 h, about one quarter of which (13.4 h) was dedicated to administrative work. 86.8% of the GPs exceeded the cut-off >1 of the ERI-Q (short version) indicating a high stress level. In the preceding year, participants had kept up their work on an average of 8 days on which they actually felt too sick to work. Measures to prevent stress, as suggested by the general practitioners themselves aim at a reduction of administrative work, an improvement of the financial situation - especially in terms of a higher financial security - and a decrease of the workload. Users of professional supervision and systematic relaxation techniques rated these as helpful regarding stress reduction. CONCLUSION: The present study is an important first step to systematically assess the working situation and health of GPs in Germany. The results reported here indicate an urgent need for actions to prevent stress.

Evaluation of branched-chain amino acid intake in children with maple syrup urine disease and methylmalonic aciduria.

The biochemical and growth responses to dietary branched-chain amino acid (BCAA) intake were studied in two children; one with a disorder of branched-chain amino acid metabolism, maple syrup urine disease (MSUD) (McKusick 24860), and another with methylmalonic aciduria (MMA) (McKusick 25100). Biochemical control of MSUD focussed on plasma leucine levels while measurement of plasma ammonia levels was used in MMA. From 0 to 2.75 years both patients exhibited five episodes of toxicity. In each case toxicity was associated with dietary indiscretion or infection. The quantity of protein tolerated was always less in the MMA patient and was approximately 1 g/kg/day. From 1 to 2.75 years each patient's growth velocity approximated their predicted growth channel except during periods of toxicity. In both cases leucine intake, which gave normal growth without toxicity, was always judged to be less than the FAO/WHO recommendations. The BCAA intake of the MMA patient was remarkably stable from 0.5 to 2.75 years and at 2 years of age isoleucine and valine intake approximated the FAO/WHO recommendations. From 2 to 2.75 years BCAA intake (mg/kg/day) of the MSUD patient was less than that of the MMA patient and well below FAO/WHO recommendations. Neuromotor development in both patients is normal.