Reliability and validity of the dynamic risk outcome scales-short version for clients with mild intellectual disabilities or borderline intellectual functioning.

INTRODUCTION: This study investigated the reliability and validity of the dynamic risk outcome scales-short version (DROS-SV). This instrument is developed to monitor treatment progress using dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning and behavioural and/or mental health problems. METHOD: Data were collected from 264 clients who received Flexible Assertive Community Treatment (FACT), a form of intensive outpatient treatment. RESULTS: A principal component analysis showed that there were six components explaining 73.9% of the variance. Furthermore, the DROS-SV showed good internal consistency of its subscales and total score (α > 0.78). Correlating the DROS-SV with the Historical and Clinical subscales of the Historical, Clinical and Future-30 indicated convergent and divergent validity. DISCUSSION: The DROS-SV has good psychometric properties for measuring dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning in FACT teams.

Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper.

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.

Funnel plots a graphical instrument for the evaluation of population performance and quality of trauma care: a blueprint of implementation.

BACKGROUND: Using patient outcomes to monitor medical centre performance has become an essential part of modern health care. However, classic league tables generally inflict stigmatization on centres rated as "poor performers", which has a negative effect on public trust and professional morale. In the present study, we aim to illustrate that funnel plots, including trends over time, can be used as a method to control the quality of data and to monitor and assure the quality of trauma care. Moreover, we aimed to present a set of regulations on how to interpret and act on underperformance or overperformance trends presented in funnel plots. METHODS: A retrospective observational cohort study was performed using the Dutch National Trauma Registry (DNTR). Two separate datasets were created to assess the effects of healthy and multiple imputations to cope with missing values. Funnel plots displaying the performance of all trauma-receiving hospitals in 2020 were generated, and in-hospital mortality was used as the main indicator of centre performance. Indirect standardization was used to correct for differences in the types of cases. Comet plots were generated displaying the performance trends of two level-I trauma centres since 2017 and 2018. RESULTS: Funnel plots based on data using healthy imputation for missing values can highlight centres lacking good data quality. A comet plot illustrates the performance trend over multiple years, which is more indicative of a centre's performance compared to a single measurement. Trends analysis offers the opportunity to closely monitor an individual centres' performance and direct evaluation of initiated improvement strategies. CONCLUSION: This study describes the use of funnel and comet plots as a method to monitor and assure high-quality data and to evaluate trauma centre performance over multiple years. Moreover, this is the first study to provide a regulatory blueprint on how to interpret and act on the under- or overperformance of trauma centres. Further evaluations are needed to assess its functionality. LEVEL OF EVIDENCE: Retrospective study, level III.

Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up.

INTRODUCTION: This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period. METHODS: Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS). RESULTS: In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

Right atrial and ventricular strain detects subclinical changes in right ventricular function in precapillary pulmonary hypertension.

Right ventricular (RV) ejection fraction (EF) by cardiac magnetic resonance (CMR) correlates to outcome in precapillary pulmonary hypertension (pPH) patients, but is insensitive to early changes. Strain might provide incremental information. In this study, we compare right atrial (RA) and RV strain in pPH patients to healthy controls, and evaluate the prognostic value of strain in pPH. In this cross-sectional study, 45 pPH patients and 20 healthy controls underwent CMR, and feature-tracking derived RA and RV strain were evaluated. pPH patients had impaired RA reservoir and conduit strain, and RV longitudinal strain (LS), compared to healthy controls. In pPH patients with preserved RVEF (≥ 50%, n = 18), RA reservoir (35% ± 9 vs. 41% ± 6, p = 0.02) and conduit strain (16% ± 8 vs. 23% ± 5, p = 0.004), and RV-LS (-25% ± 4 vs. -31% ± 4, p < 0.001) remained impaired, compared to healthy controls. The association of strain with the primary endpoint (combination of all-cause death, lung transplantation, and heart failure hospitalization) was evaluated using a multivariable Cox regression model. RV-LS (HR 1.18, 95%-CI 1.04-1.34, p = 0.01) and RA strain (reservoir: HR 0.87, 95%-CI 0.80-0.94, p = 0.001; conduit: HR 0.85, 95%-CI 0.75-0.97, p = 0.02, booster: HR 0.81, 95%-CI 0.71-0.92, p = 0.001) were independent predictors of outcome, beyond clinical and imaging features. In conclusion, pPH patients have impaired RA strain and RV-LS, even when RVEF is preserved. In addition, RA strain and RV-LS were independent predictors of adverse prognosis. These results emphasize the incremental value of RA and RV strain analyses, to detect alterations in RV function, even before RVEF declines.

Management of lactating breast abscesses by ultrasound-guided needle aspiration and continuation of breastfeeding: A pilot study.

INTRODUCTION: Needle aspiration of breast abscesses during lactation are currently recommended as an alternative to surgery only for moderate forms. In case of breast abscess, many patients stop breastfeeding on the advice of a health professional. We reviewed our experience of treatment of lactating breast abscesses by ultrasound-guided aspiration and suggest an algorithm of their management. We also analyzed the continuation of breastfeeding of these patients after advices from trained teams. MATERIEL AND METHODS: We conducted a retrospective study from April 2016 to April 2017, including 28 patients referred for a breast abscess during lactation at the Duroc Breast Imaging Center. A management by ultrasound-guided aspiration was proposed to each patient. We collected data about the breastfeeding between October 2018 and January 2019. RESULTS: A single aspiration was sufficient in 64.3% of cases. The delay between the occurrence of the abscess and the indication for drainage was significantly higher for patients who have needed finally surgical drainage (p = 0,0031). There were no difference of size of abscesses between patients receiving needle aspiration alone and those who have undergone surgery (p = 0,97). All patients who had been managed by needle aspiration continued breastfeeding after the treatment and 40% of the patients were still breastfeeding at 6 months. CONCLUSION: The management of lactating breast abscess by ultrasound-guided needle aspiration is an effective alternative to surgery. It appears to be effective regardless of the size of the abscess and is compatible with the continuation of breastfeeding. Our study has indeed shown that if they are well advised, the majority of patients continue breastfeeding so that it is essential that health professionals be better trained regarding the management of breastfeeding complications.

The Dutch nationwide trauma registry: The value of capturing all acute trauma admissions.

INTRODUCTION: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany. METHODS: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft für Unfallchirurgie (DGU) were applied on 2018 DNTR data. RESULTS: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS≥16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS≤ 15were treated at non-RTCs in 80% of cases. Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS≥16 and 68% of the fatal cases did not meet DGU inclusion criteria CONCLUSION: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,000 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals.

Complications of implant removal after healed hip fractures.

INTRODUCTION: Osteosynthesis of pertrochanteric fractures is one of the most frequently performed procedures in orthopaedic trauma care. Auto-dynamization during fracture healing can lead to lateralization of the screw or blade. This can cause debilitating complaints, which sometimes necessitate the removal of the screw or blade. After removal of the implant, we observed spontaneous femoral neck fractures in five patients. This article presents an evaluation of these cases with reference to literature. MATERIALS AND METHODS: Five cases of spontaneous femoral neck fracture (SFNF) after cephalomedullary nail removal are described. A literature search was performed on the incidence of chronic pain and gait impairment associated with auto-dynamization, and on risk factors for dynamization and complications after implant removal. Based on these findings recommendations are made for the prevention of SFNF. RESULTS: Over a 2-year period, we observed five cases of SFNF after cephalomedullary nail removal. In literature, reduced mobility, gait impairment and chronic pain are associated with screw or blade dynamization. Pertrochanteric fractures with AO-type 2 classification were associated with more dynamization and screw lateralization and henceforth more trochanteric pain and gait disturbances. SFNF after cephalomedullary nail removal occurs with an incidence of at least 15%, affecting mostly elderly patients. This severe complication mostly occurs within 3 weeks after implant removal. Risk factors associated with SFNF are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant and nail removal of the cephalomedullary implant. CONCLUSION: The clinical indications for implant removal in healed pertrochanteric fractures are not well established and should be restricted to specific cases. After removal of these implants without replacement partial weight-bearing should be advised strictly. Based on our findings it is recommended to replace the cephalomedullary nail with a shorter one, ideally combined with implant augmentation.

Validation of aortic valve 4D flow analysis and myocardial deformation by cardiovascular magnetic resonance in patients after the arterial switch operation.

BACKGROUND: Aortic regurgitation (AR) and subclinical left ventricular (LV) dysfunction expressed by myocardial deformation imaging are common in patients with transposition of the great arteries after the arterial switch operation (ASO). Echocardiographic evaluation is often hampered by reduced acoustic window settings. Cardiovascular magnetic resonance (CMR) imaging provides a robust alternative as it allows for comprehensive assessment of degree of AR and LV function. The purpose of this study is to validate CMR based 4-dimensional flow quantification (4D flow) for degree of AR and feature tracking strain measurements for LV deformation assessment in ASO patients. METHODS: A total of 81 ASO patients (median 20.6 years, IQR 13.5-28.4) underwent CMR for 4D and 2D flow analysis. CMR global longitudinal strain (GLS) feature tracking was compared to echocardiographic (echo) speckle tracking. Agreements between and within tests were expressed as intra-class correlation coefficients (ICC). RESULTS: Eleven ASO patients (13.6%) showed AR > 5% by 4D flow, with good correlation to 2D flow assessment (ICC = 0.85). 4D flow stroke volume of the aortic valve demonstrated good agreement to 2D stroke volume over the mitral valve (internal validation, ICC = 0.85) and multi-slice planimetric LV stroke volume (external validation, ICC = 0.95). 2D flow stroke volume showed slightly less, though still good agreement with 4D flow (ICC = 0.78) and planimetric LV stroke volume (ICC = 0.87). GLS by CMR was normal (- 18.8 ± 4.4%) and demonstrated good agreement with GLS and segmental analysis by echocardiographic speckle tracking (GLS = - 17.3 ± 3.1%, ICC of 0.80). CONCLUSIONS: Aortic 4D flow and CMR feature tracking GLS analysis demonstrate good to excellent agreement with 2D flow assessment and echocardiographic speckle tracking, respectively, and can therefore reliably be used for an integrated and comprehensive CMR analysis of aortic valve competence and LV deformation analysis in ASO patients.

Clinical ethics consultations in psychiatric compared to non-psychiatric medical settings: characteristics and outcomes.

BACKGROUND: In the recent years clinical ethics consultations (CEC) received an increasing attention not only in patients with medical conditions but also in those with mental disorders. However, the systematic and empirical knowledge is still small. The aim of this observational study was to investigate whether CECs differ between psychiatric and medical hospital inpatients regarding ethical issues, goals, characteristics, processes, and outcomes. METHODS: This is a retrospective and in parts prospective analysis of a semi-structured CEC approach provided by the CEC service at a large German general hospital between January 2006 and June 2015. RESULTS: A total of 259 CECs in three inpatient settings were investigated, i.e. intensive care units (ICU, 43.6%), low care units (LCU, 33.6%), and psychiatric care units (PCU, 22.8%). In all groups, most ethical issues addressed treatment intensity (80.6%) and resulted in over 93% in participants' agreement on final ethical recommendations as well as in high implementation rates (>89%). However, we found significant group differences: In PCUs patients participated more often in the CEC (p < .001), the number of all participants was higher (p < .001), CECs were more time expensive (p < .001), and more recommendations focused on interventions against the patients' declared intention (37.7% versus 0%) than in the other groups. DISCUSSION: In spite of different clinical characteristics and ethical issues between patients and settings, consensus and implementation of the CEC recommendation could be achieved at a high rate in all groups. There are substantial differences regarding goals, participation of patients, and processes. It is worth considering adapting the CEC to the special needs in psychiatric settings, especially under the aspect of the patients' perspective and involvement.

Correction to: Cost-effectiveness analysis of umeclidinium bromide/vilanterol 62.5/25 mcg versus tiotropium/olodaterol 5/5 mcg in symptomatic patients with chronic obstructive pulmonary disease: a Spanish National Healthcare System perspective.

Following publication of the original article [1], we have been notified of the below corrections to the 5th paragraph in the Discussion section.

Evaluation of Left Ventricular Function Long Term After Arterial Switch Operation for Transposition of the Great Arteries.

Long-term after arterial switch operation for transposition of the great arteries, abnormal coronary anatomy and altered loading conditions could compromise ventricular function. The current study investigates whether left ventricular function, measured with echocardiographic bi-plane ejection fraction and deformation imaging, in patients long term after arterial switch operation for transposition of the great arteries differs from healthy peers. A cross-sectional cohort study of patients at least 12 years after arterial switch operation was analyzed with bi-plane Simpson's left ventricular ejection fraction (LVEF) and deformation (speckle tracking) echocardiography. 81 patients, median age 20.6 (interquartile range 13.5-28.4) years, were included. LVEF was normal on average at 55.5 ± 6.1%. Global longitudinal strain (GLS) was lower in patients compared to healthy peers throughout all age groups and on pooled average (- 15.4 ± 1.1% vs. - 23.2 ± 0.9%). Although LVEF is normal on average in patients after arterial switch operation for transposition of the great arteries, GLS is impaired compared to healthy peers. The reduced GLS could indicate sub-clinical myocardial dysfunction.

Cost-effectiveness analysis of umeclidinium bromide/vilanterol 62.5/25 mcg versus tiotropium/olodaterol 5/5 mcg in symptomatic patients with chronic obstructive pulmonary disease: a Spanish National Healthcare System perspective.

BACKGROUND: A head-to-head study demonstrated the superiority of once-daily umeclidinium bromide/vilanterol (UMEC/VI) 62.5/25 mcg on trough forced expiratory volume in 1 s (FEV1) versus once-daily tiotropium/olodaterol (TIO/OLO) 5/5 mcg in symptomatic patients with chronic obstructive pulmonary disease (COPD). This analysis evaluated the cost effectiveness of UMEC/VI versus TIO/OLO from a Spanish National Healthcare System perspective, using data from this study and Spanish literature. METHODS: This analysis was conducted from the perspective of the Spanish National Healthcare System with a 3-year horizon as base case. A disease progression model using a linked risk equation approach was used to estimate disease progression and associated healthcare costs, and quality-adjusted life years (QALYs). The Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was used to develop the statistical risk equations for clinical endpoints, and costs were calculated using a health state approach (by dyspnea severity). Utilities for QALY calculation were estimated using patient baseline characteristics within a regression fit to Spanish observational data. Treatment effect, expressed as change from baseline in FEV1 was obtained from the head-to-head study and used in the model (UMEC/VI minus TIO/OLO difference: + 52 mL [95% confidence interval: 28, 77]). Baseline patient characteristics were sourced from Spanish literature or the head-to-head study if unavailable. A scenario analysis using only the intent-to-treat (ITT) population from the head-to-head study, and sensitivity analyses (including probabilistic sensitivity analyses), were conducted. Direct healthcare costs (2017 Euro) were obtained from Spanish sources and costs and benefits were discounted at 3% per annum. RESULTS: UMEC/VI was associated with small improvements in QALYs (+ 0.029) over a 3-year time horizon, compared with TIO/OLO, alongside cost savings of €393/patient. The ITT scenario analysis and sensitivity analyses had similar results. All probabilistic simulations resulted in UMEC/VI being less costly and more effective than TIO/OLO. CONCLUSION: UMEC/VI dominated TIO/OLO (more effective and less expensive). These results may aid payers and decision-makers in Spain when making judgements on which long-acting muscarinic antagonist/long-acting ß2-agonist (LAMA/LABA) treatments can be considered cost effective in Spain.

[Specialist Training in Psychiatry and Psychotherapy : Evaluation of the East Westphalia-Lippe Academy curriculum]. / Facharztweiterbildung Psychiatrie und Psychotherapie : Evaluation des Curriculums eines Weiterbildungsverbunds in Ostwestfalen-Lippe.

BACKGROUND: Despite of the undisputed impact of education quality on becoming a specialist in psychiatry and psychotherapist, systematic studies in this field do not exist in Germany, apart from the evaluation of practical education by the medical councils. MATERIALS AND METHODS: The Akademie-OWL, an education union of psychiatric clinics in the East Westphalia region of Germany, has provided 12-item questionnaire-based routine evaluations of theoretical education seminars since 2009. Seminars are held by consultants of psychiatry and psychotherapy within six separate weeks over a period of four years. All lecturers receive feedback from the evaluation. The results of this ongoing evaluation are presented using a typical example and in an aggregated format as a time series on the basis of one global item. RESULTS: The data show that (1) the full range of a five-point Likert scale is used by the candidates, (2) psychiatric competences of the lecturers are more positively evaluated than their didactic competences, (3) neither within the four-years period of psychiatric education nor between different generations of candidates are systematic changes of evaluation results observed, and (4) minor to moderate differences of evaluation were observed between the different thematic fields of psychiatry and psychotherapy. DISCUSSION: These results indicate the need of more systematic education research on establishing valid and reliable specific instruments as well as the need of systematic training of didactic competences of teaching consultants.

[System-immanent incentives in the remuneration for psychiatry and psychosomatics : Analysis exemplified by treatment of alcohol-related disorders]. / Systemimmanente Anreize im PEPP : Analyse am Beispiel der Behandlung alkoholbezogener Störungen.

BACKGROUND: The German fixed rate remuneration system in psychiatry and psychosomatics (PEPP) has been criticized by many specialty associations because negative effects on mental healthcare are expected through economic incentives. OBJECTIVE: Through analysis of performance data in the treatment of alcohol dependency at the Evangelical Hospital Bielefeld (Evangelisches Krankenhaus Bielefeld, EvKB) from 2014 and various simulations, the incentives of the PEPP (version 2015) were analyzed and its potential impact on patient care was evaluated. METHODS: Groups of cases were created based on the clinical data. Various parameters were evaluated, such as duration of treatment, PEPP coding, loss of income by merging cases and case remuneration. Additionally, changes in the duration of treatment, the intensity of treatment and the intensity of care were simulated. RESULTS: In the simulations a reduction in the duration of treatment by 16.1 % led to additional revenues of 1.9 % per treatment day. The calculated additional costs of 1:1 care and intensive nursing care were not completely covered by the additional revenues, whereas psychotherapeutic inpatient treatment programs showed positive profit contributions. Complicated cases with increased merging of cases showed lower revenues but with above average expenditure of efforts. CONCLUSION: The current version of the PEPP leads to misdirected incentives in patient care. This is caused, for example, by the fact that higher profit contributions can be realized in some patient groups and intensive nursing care of patients is insufficiently represented. It is not clear whether these incentives will persist or can be compensated in subsequent versions of the system.

Echocardiographic findings associated with mortality ortransplant in patients with pulmonary arterial hypertension:A systematic review and meta-analysis.

BACKGROUND: Identification of patients at risk of deterioration is essential to guide clinical management in pulmonary arterial hypertension (PAH). This study aims to provide a comprehensive overview of well-investigated echocardiographic findings that are associated with clinical deterioration in PAH. METHODS: MEDLINE and EMBASE databases were systematically searched for longitudinal studies published by April 2015 that reported associations between echocardiographic findings and mortality, transplant or clinical worsening. Meta-analysis using random effect models was performed for echocardiographic findings investigated by four or more studies. In case of statistical heterogeneity a sensitivity analysis was conducted. RESULTS: Thirty-seven papers investigating 51 echocardiographic findings were included. Meta-analysis of univariable hazard ratios (HRs) and sensitivity analysis showed that presence of pericardial effusion (pooled HR 1.70; 95 % CI 1.44-1.99), right atrial area (pooled HR 1.71; 95 % CI 1.38-2.13) and tricuspid annular plane systolic excursion (TAPSE; pooled HR 1.72; 95 % CI 1.34-2.20) were the most well-investigated and robust predictors of mortality or transplant. CONCLUSIONS: This meta-analysis substantiates the clinical yield of specific echocardiographic findings in the prognostication of PAH patients in day-to-day practice. In particular, pericardial effusion, right atrial area and TAPSE are of prognostic value.

[Trauma-focused psychotherapy: Technique, area of application, and treatment outcome]. / Traumaorientierte Psychotherapie : Technik, Anwendungsmöglichkeiten und Ergebnisse.

Traumatic events may lead to trauma-related disorders such as the posttraumatic stress disorder (PTSD) and constraints in quality of life. Meanwhile, there are different trauma-focused psychotherapies that aim to prevent PTSD shortly after experiencing a traumatic event and interventions that aim to treat PTSD. In Germany, cognitive-behavioral and psychodynamic trauma-focused approaches are commonly applied. While cognitive-behavioral programs aim at early exposure with the traumatic event, psychodynamic approaches emphasize the need of a period of stabilization before undergoing exposure. With regard to empirical evidence, cognitive-behavioral programs were able to prove their efficacy most often and are recommended in national and international guidelines. The German S3 guideline PTSD is currently under revision.

Assessment of LV ejection fraction using real-time 3D echocardiography in daily practice: direct comparison of the volumetric and speckle tracking methodologies to CMR.

AIMS: This study is the first to directly compare two widely used real-time 3D echocardiography (RT3DE) methods of cardiac magnetic resonance imaging (CMR) and assess their reproducibility in experienced and less experienced observers. METHODS: Consecutive patients planned for CMR underwent RT3DE within 8 h of CMR with Philips (volumetric method) and Toshiba Artida (speckle tracking method). Left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured using RT3DE, by four trained observers, and compared with CMR values. RESULTS: Thirty-five patients were included (49.7 ± 15.7 years; 55 % male), 30 (85.7 %) volumetric and 27 (77.1 %) speckle tracking datasets could be analysed. CMR derived LVEDV, LVESV and LVEF were 198 ± 58 ml, 106 ± 53 ml and 49 ± 15 %, respectively. LVEF derived from speckle tracking was accurate and reproducible in all observers (all intra-class correlation coefficients (ICC) > 0.86). LVEF derived from the volumetric method correlated well to CMR in experienced observers (ICC 0.85 and 0.86) but only moderately in less experienced observers (ICC 0.58 and 0.77) and was less reproducible in these observers (ICC = 0.55). Volumes were significantly underestimated compared with CMR (p < 0.001). CONCLUSION: This study demonstrates that both RT3DE methodologies are sufficiently accurate and reproducible for use in daily practice. However, experience importantly influences the accuracy and reproducibility of the volumetric method, which should be considered when introducing this technique into clinical practice.