Frequency and Characteristics of Non-Neurological and Neurological Stroke Mimics in the Emergency Department.

BACKGROUND: Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke. METHODS: This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city's Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups. RESULTS: Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics. CONCLUSIONS: Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.

Antibody responses elicited by mRNA vaccination in firefighters persist six months and correlate inversely with age and directly with BMI.

Knowledge regarding the sustainability of immune responses after COVID-19 vaccination is important, e.g., to decide whom and when to booster. Thus, we analyzed antibody titers in firefighters six months after vaccination with the mRNA-based vaccine Comirnaty. SARS-CoV-2 spike-binding antibodies (bAb) were quantified and compared to peak responses determined in healthcare workers (HCW). For the firefighters, neutralizing antibodies (nAb) were also analyzed. Six months after the second vaccine dose, all analyzed firefighters had detectable bAb, and 91% exhibited nAb titers above 1:16. However, actual titers six months after vaccination were over 12-fold lower than in the HCW control group four weeks after vaccination. bAb and nAb responses showed a significant correlation, and age correlated inversely with antibody responses. Unexpectedly, participants with a body mass index over 25 had higher neutralization titers after six months. All participants with very low neutralization titers were offered booster vaccination. The booster vaccination improved the extent and sustainability of antibody responses.

[Position of trauma surgery in emergency medicine]. / Stellung der Unfallchirurgie in der Notfallmedizin.

BACKGROUND: The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established. AIM: The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine. METHODS: A web-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine. RESULTS: Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40 years of age (n = 62, 63%), and in a professional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be a trauma surgeon (mean 87.9; SD: 19.7). DISCUSSION: A high volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in a central emergency department. Senior positions should also be sought to ensure high quality standards.

[Preliminary and Final Postmortem Examination and Death Certificate in the Emergency Medical Services in Germany: Heterogeneous Process Flows and Inadequate Standards]. / Vorläufige und endgültige Leichenschau und Todesbescheinigung im Rettungsdienst in Deutschland ­ uneinheitliche Prozessabläufe und mangelnde Standards.

BACKGROUND: Inconsistent regulations and laws can lead to misunderstandings and incorrect procedures. In this study we would like to evaluate the heterogeneity of the different processes of postmortem examination and death certification in the German emergency medical services. METHODS: An e-mail with a survey link was sent to 212 medical directors of emergency services. The questions were answered online. RESULTS: The response rate was 47%. Regulated procedures were evident in 58% of the cases. Issue of provisional death certificate comprised 64%, postmortem examination 45%; 19.4% of emergency physicians were required to do the final post-mortem. In 41% of the cases, the application protocol was considered sufficient as a form of documentation. 45% of the participants evaluated the respective legal regulation as sufficient. Questions and concerns arose, especially when medical directors of EMS believed that the state-specific regulations were not sufficient (p<0.001). CONCLUSION: The results show that the obligatory post-mortem examination in Germany is heterogeneous in its processing procedures. More than half of the participants rate the existing legal regulations as inadequate. As a result, it is not uncommon for queries and complaints to arise, but above all for uncertainties to arise in everyday practice. Our results suggest that uniform legislation and clearly defined processes are desirable.

COVID-19: Vaccination Side Effects and Sick Leave in Frontline Healthcare-Workers-A Web-Based Survey in Germany.

(1) Background: The COVID-19 vaccination has caused uncertainty among employees and employers regarding vaccination reactions and incapacitation. At the time of our study, three vaccines are licensed in Germany to combat the COVID-19 pandemic (BioNTech/Pfizer (Comirnaty), AstraZeneca (Vaxzevria), and Moderna (Spikevax). We aim to assess how often and to what extent frontline healthcare workers had vaccination reactions after the first and second vaccination. The main focus is on the amount of sick leave after the vaccinations. (2) Methods: We create a web-based online questionnaire and deliver it to 270 medical directors in emergency medical services all over Germany. They are asked to make the questionnaire public to employees in their area of responsibility. To assess the association between independent variables and adverse effects of vaccination, we use log-binomial regression to estimate prevalence ratios (PR) with 95% confidence intervals (95%CI) for dichotomous outcomes (sick leave). (3) Results: A total of 3909 individuals participate in the survey for the first vaccination, of whom 3657 (94%) also provide data on the second vaccination. Compared to the first vaccination, mRNA-related vaccine reactions are more intense after the second vaccination, while vaccination reactions are less intense for vector vaccines. (4) Conclusion: Most vaccination reactions are physiological (local or systemic). Our results can help to anticipate the extent to which personnel will be unable to work after vaccination. Even among vaccinated HCWs, there seems to be some skepticism about future vaccinations. Therefore, continuous education and training should be provided to all professionals, especially regarding vaccination boosters. Our results contribute to a better understanding and can therefore support the control of the pandemic.

Impact of DST (Daylight Saving Time) on Major Trauma: A European Cohort Study.

(1) Background: Approximately 73 countries worldwide implemented a daylight saving time (DST) policy: setting their clocks forward in spring and back in fall. The main purpose of this practice is to save electricity. The aim of the present study was to find out how DST affects the incidence and impact of seriously injured patients. (2) Methods: In a retrospective, multi-center study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) between 2003 and 2017 from Germany, Switzerland, and Austria. We compared the included cases 1 week before and after DST. (3) Results: After DST from standard time to summertime, we found an increased incidence of accidents of motorcyclists up to 51.58%. The result is consistent with other studies. (4) Conclusion: However, our results should be interpreted as a tendency. Other influencing factors, such as time of day and weather conditions, were not considered.

FAST-ED scale smartphone app-based prediction of large vessel occlusion in suspected stroke by emergency medical service.

BACKGROUND AND PURPOSE: Considering the highly time-dependent therapeutic effect of endovascular treatment in patients with large vessel occlusion-associated acute ischemic stroke, prehospital identification of large vessel occlusion and subsequent triage for direct transport to a comprehensive stroke center offers an intriguing option for optimizing patient pathways. METHODS: This prospective in-field validation study included 200 patients with suspected acute ischemic stroke who were admitted by emergency medical service to a comprehensive stroke center. Ambulances were equipped with smartphones running an app-based Field Assessment Stroke Triage for Emergency Destination scale for transmission prior to admission. The primary measure was the predictive accuracy of the transmitted Field Assessment Stroke Triage for Emergency Destination for large vessel occlusion and the secondary measure the predictive accuracy for endovascular treatment. RESULTS: A Field Assessment Stroke Triage for Emergency Destination ⩾4 revealed very good accuracy to detect large vessel occlusion-related acute ischemic stroke with a sensitivity of 82.4% (95% confidence interval = 65.5-93.2), specificity of 78.3% (95% confidence interval = 71.3-84.3), and an area under the curve c-statistics of 0.89 (95% confidence interval = 0.85-0.94). Field Assessment Stroke Triage for Emergency Destination ⩾4 correctly identified 84% of patients who received endovascular treatment [73.5% specificity (95% confidence interval = 66.4-79.8)] with an area under the curve c-statistics of 0.82 (95% confidence interval = 0.74-0.89). In a hypothetical triage model of an urban setting, one secondary transportation would be avoided with every fifth patient screened. CONCLUSION: A smartphone app-based stroke triage completed by emergency medical service personnel showed adequate quality for the Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusion-associated acute ischemic stroke. We demonstrate feasibility of the use of a medical messaging service in prehospital stroke care. Based on these first results, a randomized trial evaluating the clinical benefit of such a triage system in an urban setting is currently in preparation.Clinical Trial Registration: https://clinicaltrials.gov Unique identifier: NCT04404504.

Validation of a shortened FAST-ED algorithm for smartphone app guided stroke triage.

BACKGROUND AND PURPOSE: Large vessel occlusion (LVO) recognition scales were developed to identify patients with LVO-related acute ischemic stroke (AIS) on the scene of emergency. Thus, they may enable direct transport to a comprehensive stroke centre (CSC). In this study, we aim to validate a smartphone app-based stroke triage with a shortened form of the Field Assessment Stroke Triage for Emergency Destination (FAST-ED). METHODS: This retrospective validation study included 2815 patients with confirmed acute stroke and suspected acute stroke but final diagnosis other than stroke (stroke mimics) who were admitted by emergency medical service (EMS) to the CSC of the Neurological University Hospital Essen, Germany. We analysed the predictive accuracy of a shortened digital app-based FAST-ED ( 'FAST-ED App') for LVO-related AIS and yield comparison to various other LVO recognition scales. RESULTS: The shortened FAST-ED App had comparable test quality (Area under ROC = 0.887) to predict LVO-related AIS to the original FAST-ED (0.889) and RACE (0.883) and was superior to Cincinnati Prehospital Stroke Severity (CPSS), 3-Item Stroke Scale (3-ISS) and National Institute of Health Stroke Scale (NIHSS). A FAST-ED App ⩾ 4 revealed very good accuracy to detect LVO related AIS (sensitivity of 77% and a specificity 87%) with an area under the curve c-statistics of 0.89 (95% CI: 0.87-0.90). In a hypothetical triage model, the number needed to screen in order to avoid one secondary transportation in an urban setting would be five. CONCLUSION: This validation study of a shortened FAST-ED assessment for a smartphone-app guided stroke triage yields good quality to identify patients with LVO.

[SARS-CoV-2 IgG seroprevalence in personnel of the extraclinical fight against the COVID-19 pandemic]. / SARS-CoV-2-IgG-Antikörperseroprävalenz bei Personal in der außerklinischen Bekämpfung der COVID-19-Pandemie.

BACKGROUND AND OBJECTIVES: The SARS-CoV­2 pandemic and the different manifestations of the coronavirus disease 2019 (COVID-19) are a major challenge for health systems worldwide. Medical personnel have a special role in containing the pandemic. The aim of the study was to investigate the SARS-CoV­2 IgG antibody prevalence in extraclinical personnel depending on their operational area in the fight against the COVID-19 pandemic. METHODS: On May 28 and 29, 2020, serum samples were taken from 732 of 1183 employees (61.9%) of the professional fire brigade and aid organizations in the city area and tested for SARS-CoV­2 IgG antibodies. The employees were divided into four categories according to their type of participation. category 1: decentralized PCR sampling teams, category 2: rescue service, category 3: fire protection, category 4: situation center. Some employees participated in more than one operational area. RESULTS: SARS-CoV­2 IgG antibodies were detected in 8 of 732 serum samples. This corresponds to a prevalence of 1.1%. A previous COVID-19 infection was known in 3 employees. In order to make a separate assessment of the other employees possible and to diagnose unknown infections, a corrected collective of 729 employees with 6 SARS-CoV­2 antibody detection was considered separately. The prevalence in the corrected collective is 0.82%. After subdividing the collective into areas of activity, the prevalence was low (1: 0.77%, 2: 0.9%, 3: 1.00%, 4: 1.58%). CONCLUSIONS: The seroprevalence of SARS-CoV­2 in the study collective is low at 1.1% and 0.82%, respectively. There is an increased seroprevalence in operational areas with a lower risk of virus exposure in comparison to operational areas with a higher risk.

Excess mortality due to Covid-19? A comparison of total mortality in 2020 with total mortality in 2016 to 2019 in Germany, Sweden and Spain.

INTRODUCTION: Excess mortality is a suitable indicator of health consequences of COVID-19 because death from any cause is clearly defined contrary to death from Covid-19. We compared the overall mortality in 2020 with the overall mortality in 2016 to 2019 in Germany, Sweden and Spain. Contrary to other studies, we also took the demographic development between 2016 and 2020 and increasing life expectancy into account. METHODS: Using death and population figures from the EUROSTAT database, we estimated weekly and cumulative Standardized Mortality Ratios (SMR) with 95% confidence intervals (CI) for the year 2020. We applied two approaches to calculate weekly numbers of death expected in 2020: first, we used mean weekly mortality rates from 2016 to 2019 as expected mortality rates for 2020, and, second, to consider increasing life expectancy, we calculated expected mortality rates for 2020 by extrapolation from mortality rates from 2016 to 2019. RESULTS: In the first approach, the cumulative SMRs show that in Germany and Sweden there was no or little excess mortality in 2020 (SMR = 0.976 (95% CI: 0.974-0.978), and 1.030 (1.023-1.036), respectively), while in Spain the excess mortality was 14.8% (1.148 (1.144-1.151)). In the second approach, the corresponding SMRs for Germany and Sweden increased to 1.009 (1.007-1.011) and 1.083 (1.076-1.090), respectively, whereas results for Spain were virtually unchanged. CONCLUSION: In 2020, there was barely any excess mortality in Germany for both approaches. In Sweden, excess mortality was 3% without, and 8% with consideration of increasing life expectancy.

[COVID-19: acceptance and compliance of PPE (personal protective equipment) and rules for hygiene and reducing contacts in German emergency medical services-a nationwide survey]. / COVID-19: Akzeptanz und Compliance von persönlicher Schutzausrüstung (PSA) und AHA-L-Regeln (Abstands- und Hygieneregeln) im deutschen Rettungsdienst ­ eine bundesweite Umfrage.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has also significantly burdened and challenged the German emergency medical services (EMS). In this regard, the personal protective equipment (PPE) and rules like wear a mask, stay 6 feet away from others, avoid crowds and poorly ventilated spaces, wash your hands often (called AHA­L rules in Germany) play an important role in reducing the spread of COVID-19 infections. OBJECTIVE: The aim of this study is to evaluate the acceptance and compliance of PPE and protective measures among rescue service personnel in Germany during pandemic periods. METHOD: More than 270 medical directors of EMS were contacted. They were asked to forward a web-based online survey to the rescue stations. Participants were asked about acceptance and compliance in everyday life, in the rescue station, during missions without COVID-19, during missions with COVID-19. RESULTS: There were n = 1295 participants. Overall acceptance and compliance of PPE and protective measures is high. The lowest acceptance and compliance is found in the questions acceptance (mean = 4.16; ±1.01) and compliance (mean = 4.26; ±0.89) in the rescue station. CONCLUSION: We recommend targeted training regarding PPE in pandemics and the provision of appropriate premises for conflict-free compliance with AHA­L rules.

Acceptance of COVID-19 Vaccination among Front-Line Health Care Workers: A Nationwide Survey of Emergency Medical Services Personnel from Germany.

INTRODUCTION: The aim of this study was to evaluate the COVID-19 vaccination acceptance of emergency medical services (EMS) personnel as front-line health care workers (HCW) in Germany. Several studies have shown low willingness for vaccination (e.g., seasonal influenza) among HCWs and EMS personnel. METHODS: We created a web-based survey. The questions were closed and standardized. Demographic data were collected (age, sex, federal state, profession). Experience with own COVID-19 infection, or infection in personal environment (family, friends) as well as willingness to vaccinate was queried. RESULTS: The sample includes n = 1296 participants. A willingness to be vaccinated exists in 57%, 27.6% participants were undecided. Our results show a higher propensity to vaccinate among the following groups: male gender, higher medical education level, older age, own burden caused by the pandemic (p < 0.001). CONCLUSIONS: Due to the low overall acceptance of vaccination by HCWs, we recommend that the groups with vaccination hesitancy, in particular, be recruited for vaccination through interventions such as continuing education and awareness campaigns.

Calculating the number of undetected active SARS-CoV-2 infections from results of population-wide antigen tests.

Current European research estimates the number of undetected active SARS-CoV-2 infections (dark figure) to be two- to 130-fold the number of detected cases. We revisited the population-wide antigen tests in Slovakia and South Tyrol and calculated the dark figure of active cases in the vulnerable populations and the number of undetected active cases per detected active case at the time of the population-wide tests. Our analysis follows three steps: using the sensitivities and specificities of the used antigen tests, we first calculated the number of test-positive individuals and the proportion of actual positives in those who participated in the antigen tests. We then calculated the dark figure in the total population of Slovakia and South Tyrol, respectively. Finally, we calculated the ratio of the dark figure in the vulnerable population to the number of newly detected infections through PCR tests. Per one positive PCR result, another 0.15 to 0.71 cases must be added in South Tyrol and 0.01 to 1.25 cases in Slovakia. The dark figure was in both countries lower than assumed by earlier studies.

Excess mortality due to COVID-19 in Germany.

OBJECTIVES: The first wave of the SARS-CoV-2 pandemic in Germany lasted from week 10 to 23 in 2020. The aim is to provide estimates of excess mortality in Germany during this time. METHODS: We analyzed age-specific numbers of deaths per week from 2016 to week 26 in 2020. We used weekly mean numbers of deaths of 2016-2019 to estimate expected weekly numbers for 2020. We estimated standardized mortality ratios (SMR) and 95% confidence intervals. RESULTS: During the first wave observed numbers of deaths were higher than expected for age groups 60-69, 80-89, and 90+. The age group 70-79 years did not show excess mortality. The net excess number of deaths for weeks 10-23 was +8,071. The overall SMR was 1•03 (95%CI 1•03-1•04). The largest increase occurred among people aged 80-89 and 90+ (SMR=1•08 and SMR=1•09). A sensitivity analysis that accounts for demographic changes revealed an overall SMR of 0•98 (95%CI 0•98-0•99) and a deficit of 4,926 deaths for week 10-23, 2020. CONCLUSIONS: The excess mortality existed for two months. The favorable course of the first wave may be explained by a younger age at infection at the beginning of the pandemic, lower contact rates, and a more efficient pandemic management.