[Patient safety in differentiated (in-hospital) activation of the resuscitation room for severely injured patients]. / Patientensicherheit bei differenzierter (innerklinischer) Schockraumaktivierung für Schwerverletzte.

BACKGROUND AND OBJECTIVE: Providing trauma services demands high personnel resources and structural costs. The goal of this study was to show if the assignment of trauma patients to a defined A or B resuscitation room treatment as a modified management concept is safe and feasible. MATERIAL AND METHODS: Between May 2020 and January 2021, all resuscitation room trauma patients were included in this single center prospective observational study. All patients admitted to the resuscitation room underwent a classification according to the German S3 guidelines grade of recommendation GoR A and GoR B in polytrauma and the status of the ABCDE sequence to an A and B resuscitation room. The classification was performed by the senior consultant on call via telephone after consultation and discussion of clinical findings. RESULTS: All 135 resuscitation room patients were included in the study of whom 42 trauma patients were assigned to the A resuscitation room (A-SR) and 93 were assigned to the B resuscitation room (B-SR). The comparison of the two groups showed that patients in the A­SR group are more likely to be accompanied by a prehospital emergency physician (80.5%) than patients in the B­SR group (55.5%). Patients in the B­SR group showed a significantly higher Glasgow coma scale (GCS). Using the eFAST emergency ultrasound protocol, 2.4% of the A­SR and 4.3% of the B­SR patients had trauma-associated pathologies, 26% of the A­SR and only 3.2% of the B­SR patients had to be admitted to the ICU, 21.4% of the A­SR and 1% of the B­SR patients died within 30 days after trauma. The injury severity scores (ISS) of the A­SR patients were significantly higher than in the B­SR group (ISS 28.3 vs. 6.8). CONCLUSION: The study confirmed that the assignment by the emergency department consultant according to the German S3 guideline in combination with the ABCDE sequence into resuscitation room A or B treatment is feasible, does not compromise the quality of care and is efficient in the use of the personnel resources.

Counteracting age-related VEGF signaling insufficiency promotes healthy aging and extends life span.

Aging is an established risk factor for vascular diseases, but vascular aging itself may contribute to the progressive deterioration of organ function. Here, we show in aged mice that vascular endothelial growth factor (VEGF) signaling insufficiency, which is caused by increased production of decoy receptors, may drive physiological aging across multiple organ systems. Increasing VEGF signaling prevented age-associated capillary loss, improved organ perfusion and function, and extended life span. Healthier aging was evidenced by favorable metabolism and body composition and amelioration of aging-associated pathologies including hepatic steatosis, sarcopenia, osteoporosis, "inflammaging" (age-related multiorgan chronic inflammation), and increased tumor burden. These results indicate that VEGF signaling insufficiency affects organ aging in mice and suggest that modulating this pathway may result in increased mammalian life span and improved overall health.

Physics at the [Formula: see text] linear collider.

A comprehensive review of physics at an [Formula: see text] linear collider in the energy range of [Formula: see text] GeV-3 TeV is presented in view of recent and expected LHC results, experiments from low-energy as well as astroparticle physics. The report focusses in particular on Higgs-boson, top-quark and electroweak precision physics, but also discusses several models of beyond the standard model physics such as supersymmetry, little Higgs models and extra gauge bosons. The connection to cosmology has been analysed as well.

Musculoskeletal effects of 5 days of bed rest with and without locomotion replacement training.

OBJECTIVES: The present study evaluated the effectiveness of a short and versatile daily exercise regime, named locomotion replacement training (LRT), to maintain muscle size, isometric strength, power, and endurance capacity of the leg muscles following 5 days of head-down tilt (HDT) bed rest. METHODS: 10 male subjects (age 29.4 ± 5.9 years; height 178.8 ± 3.7 cm; body mass 77.7 ± 4.1 kg) performed, in random order, 5 days of 6° head-down tilt bed rest (BR) with no exercise (CON), or BR with daily 25 min of upright standing (STA) or LRT. RESULTS: Knee extensor and plantar flexor cross-sectional area (CSA) were reduced by 2-3 % following bed rest (P < 0.01) for CON and STA, yet maintained for LRT. Knee extensor isometric strength (MVC) decreased by 8 % for CON (P < 0.05), was maintained for STA, and increased with 12 % for LRT (P < 0.05). Plantar flexor MVC remained unaltered during the study. Maximum jump height declined (~1.5 cm) for all conditions (P < 0.001). Neural activation and knee extensor fatigability did not change with bed rest. Bone resorption increased during BR and neither LRT nor STA was able to prevent or attenuate this increase. CONCLUSION: LRT was adequate to maintain muscle size and to even increase knee extensor MVC, but not muscle power and bone integrity, which likely requires more intense and/or longer exercise regimes. However, with only some variables showing significant changes, we conclude that 5 days of BR is an inadequate approach for countermeasure assessments.

Prevailing effectiveness of the 2009 influenza A(H1N1)pdm09 vaccine during the 2010/11 season in Sweden.

Sixty per cent of the Swedish population received the monovalent AS03-adjuvanted pandemic influenza vaccine in the autumn of 2009. We assessed the age-specific effectiveness of this pandemic vaccine against hospitalisation with laboratory-confirmed influenza A(H1N1)pdm09 during the season 2010/11, in the age group from six months to 64 years in Sweden. The screening method was applied to available surveillance data. Our results suggest a prevailing effectiveness of 72% (95% confidence interval (CI): 63­80%) with the highest effectiveness among children, six months to nine years-old (92%, 95%CI: 80­97%). However, there were limitations in data quality and study design due to the lack of systematic recording of administered vaccinations, which underline the importance of preparing for an evaluation when planning for large public health actions. Despite these limitations, we believe the results reflect true, high prevailing vaccine effectiveness. Indeed, there were fewer deaths caused by influenza and the impact of influenza on intensive care units was less severe during the 2010/11 season in Sweden than in countries with lower pandemic vaccination coverage. The association between the pandemic vaccine and narcolepsy has increased the importance of assessing the risks and benefits of the vaccination; studies on the effectiveness and the duration of protection are needed for this.

[eLearning-radiology.com--sustainability for quality assurance]. / eLearning-radiology.com - Nachhaltigkeit im Sinne der Qualitätssicherung.

PURPOSE: The aim of the study was to analyze the availability of published radiological e-learning tools and to establish a solution for quality assurance. MATERIALS AND METHODS: Substantial pubmed research was performed to identify radiological e-learning tools. 181 e-learning programs were selected. As examples two databases expanding their programs with external links, Compare (n = 435 external links) and TNT-Radiology (n = 1078 external links), were evaluated. A concept for quality assurance was developed by an international taskforce. RESULTS: At the time of assessment, 56.4 % (102 / 181) of the investigated e-learning tools were accessible at their original URL. A subgroup analysis of programs published 5 to 8 years ago showed significantly inferior availability to programs published 3 to 5 years ago (p < 0.01). The analysis of external links showed 49.2 % and 61.0 % accessible links for the programs Compare (published 2003) and TNT-Radiology (published 2006), respectively. As a consequence, the domain www.eLearning-radiology.com was developed by the taskforce and published online. This tool allows authors to present their programs and users to evaluate the e-learning tools depending on several criteria in order to remove inoperable links and to obtain information about the complexity and quality of the e-learning tools. CONCLUSION: More than 50 % of investigated radiological e-learning tools on the Internet were not accessible after a period of 5 to 8 years. As a consequence, an independent, international tool for quality assurance was designed and published online under www.eLearning-radiology.com .

[How to cope with the demands of the new "Approbation Regulation" (AR) by radiology-related interdisciplinary courses. The Erlangen model]. / Wie wir die Herausforderungen der neuen Approbationsordnung (AO) durch neue computergestützte radiologisch-interdisziplinäre Programme bewältigen können. Das Erlanger Modell.

BACKGROUND: To create radiology-related interdisciplinary programs for the undergraduate education in terms of the new "Approbation Regulation". MATERIAL AND METHODS: Medical students developed in collaboration with radiologists and clinical partners virtual, radiology-related interdisciplinary training courses for different fields. Students and teachers evaluated the acceptance of the programs' structure and content as well as the possibility to replace the radiologist partly during interdisciplinary lessons. RESULTS: Six target group oriented virtual, radiology-related interdisciplinary training courses were developed which will relieve the implementation of the new AR's demands for more interdisciplinary education in small groups and the dreaded shortage of personnel. CONCLUSION: By the use of web- and CDRom-based interdisciplinary course models different fields of medicine and diagnostic radiology can be bridged in the sense of the new AR's demands as well as manpower in radiology can be saved.

[An expert system neurology--possibilities and limitations]. / Ein Expertensystem für das Fachgebiet Neurologie--Möglichkeiten und Grenzen.

We present an expert system Neurology, which was developed completely on basis of the commercial available data base program Filemaker-7.0. At present it covers approximately 400 diagnoses of neurological and psychiatric diseases. After the input of cardinal symptoms, course and localisation of the disease the program calculates a first set of possible differential diagnoses and asks for additional symptoms or the performance of apparative diagnostics to investigate the final diagnose. At first, the performance of the expert system was tested with 15 predetermined neurological case reports. Users with different previous knowledge of Neurology performed the input. In this test the program was able to identify the correct diagnose in nearly all cases and the diagnostic proposals were superior to those of the users with minor neurological training. In a second test with real patient data, the rate of correct diagnoses was approximately 80%. In summary, the used computer algorithms proved as appropriate for the aim of giving Neurological diagnoses. Possible additional applications could be student training or the use as interdisciplinary reference work.

[Orthorad--the online reference database of skeletal plain film radiography]. / Orthorad--die Referenzdatenbank zur Skelettradiographie im Internet.

PURPOSE: It is evident that there is a growing need for Internet-based reference databases for reasons of practicability and due to the increasing use of reporting on digital workstations. The main advantages of online databases are expected with respect to plain film radiography and cross-sectional imaging. A reference database of skeletal plain film radiography was to be created using the Orthorad program. MATERIALS AND METHODS: The most important standard settings and special images of young and healthy adults in plain film radiography were collected over one year. All samples were approved for the Orthorad database by a board qualified radiologist. Based on the workflows of radiographers and radiologists, the records were organized by body part ( http://www.idr.med.uni-erlangen.de/orthorad/orthorad.htm ). This logical data structure will ensure that the tool serves as a source of information in two ways: On the one hand, the radiographer can access information on positioning, tube voltage and cassette format. On the other hand, the radiologist receives important knowledge regarding X-ray anatomy, reference data regarding the human skeleton, and information about the correct reporting for an image. RESULTS AND CONCLUSION: Orthorad is used as an online reference database for traumatologic plain film radiography to support radiographers and radiologists in their daily working routines. To date, user feedback has been positive.

Coagulation factor XIII reduces postoperative bleeding after coronary surgery with extracorporeal circulation.

BACKGROUND: One cause of diffuse bleeding after cardiac operations may be a low plasma concentration of coagulation Factor XIII, which is essential for coagulation but is not covered by standard coagulation monitoring. PATIENTS AND METHODS: In a prospective, randomized, double blinded study, 2500 units, 1250 units, and a placebo were administered in groups of 25 patients each, immediately after administration of protamine. Postoperative amount of blood loss and blood transfusion was recorded. RESULTS: Patients were not statistically different with respect to the course of plasma levels of Factor XIII until administration of the study drug. In all groups Factor XIII fell from preoperative normal values to subnormal values after extracorporeal circulation. After administration of the study drug, Factor XIII increased to 71 %, 85 %, 103 % in the placebo, 1250 units, and 2500 units group, respectively, and these differences were statistically significant ( p < 0.05). Postoperative blood loss was lowest in the 2500 units group and highest in the placebo group, however this was not significantly different. There was also no significant difference in the amount of blood transfusion. After differentiating all patients according to their post medication Factor XIII level into two groups with levels of < 70 % and > or = 70 %, postoperative blood loss was found to be significantly higher in the < 70 % group as was the amount of blood transfusions. CONCLUSIONS: Factor XIII administration reduces postoperative blood loss and the extent of blood transfusion after coronary surgery, however administration is only helpful if plasma levels are below the normal value. Measurement of plasma levels is recommended before Factor XIII substitution.

[Quality improvement of resources in radiology on the internet]. / Qualitätsverbesserung radiologischer Lehrressourcen im Internet.

PURPOSE: Categorization and evaluation of online teaching files in radiology by representative members of the target group to make the specific search for adequate programs more effective. MATERIALS AND METHODS: A representative team of board qualified radiologists, residents and medical students performed a basic search for radiology teaching files on the Internet using search machines, international mailing lists and link lists to collections of national and international radiological societies and departments. The programs were categorized by language, modality, target group and special features, such as qualification for CME-accreditation. For final evaluation and ranking of the detected files, a questionnaire was developed to assess completeness, image quality, page loading time, layout, orientation, interactivity, annotation and maintenance. The results were stored in an Access database on a web server. A query form in HTML format, including the parameters described above, was made accessible to the online user. RESULTS: A search machine for radiological teaching files (RadList/Entity-link List) was made available online ( www.tnt-radiology.de/radlist and www.tnt-radiology.de/entitylinklist ). A submitted request calls a cgi script that searches the database for the appropriate sites according to the individual search parameters selected by the user. The list of matching URLs is returned to the user as HTML page. Evaluating the single sites by applying the criteria listed above contributed to the quality assurance of the radiological teaching resources on the Internet. CONCLUSION: Adapting a new Internet interface to the particular needs of the user allows a more effective access to specific radiological teaching files online. RadList/Entity-link List ( www.tnt-radiology.de/radlist and www.tnt-radiology.de/entitylinklist ) is conducive to quality improvement and benefits users as well as authors of radiological teaching files on the Internet.

[HNORAD]. / HNORAD. Eine interdisziplinäre interaktive Fallsammlung zu bildgebenden Verfahren in der Hals-Nasen-Ohren-Heilkunde im Internet.

BACKGROUND: New media are gaining importance in undergraduate as well as postgraduate and continued medical education. We aimed to create an interactive educational program for imaging diseases of the ear, nose and throat (ENT). MATERIALS AND METHODS: Cases and images representing clinical routine were collected, arranged by content and graphically presented according to instructional criteria. Undergraduate students participating in the project used an authoring system to generate case studies, which were then published at http://www.HNORAD.de. RESULTS: HNORAD is an interdisciplinary teaching program offering more than 100 classical disease presentations. Three systematic indices offer a choice of instructional approach. Apart from typical images, the information presented includes patient history, clinical findings, imaging findings as described by a board-qualified radiologist, diagnosis, differential diagnosis and internet links. Elements of the radiologist's report are linked with the images in such a way that the structure or finding described can be interactively highlighted. An evaluation index allows proficiency testing in self study and as a part of taught courses. CONCLUSION: HNORAD is a valuable resource for students, ENT surgeons and radiologists at the undergraduate, postgraduate and CME level for self study as well as for course work.

[Web-based training in radiology - student course in the Virtual University of Bavaria]. / Web-basiertes Training in der Radiologie - Studentenkurs in der Virtuellen Hochschule Bayern (VHB).

PURPOSE: The ninth version of the licensing regulation for medical doctors (Approbation Regulation (AR)) sets a benchmark in terms of practical experience, interdigitation of preclinical and clinical studies, interdisciplinary approach, economic efficiency, independence of students, added new teaching and learning modalities, and ongoing evaluation of the progress of the medical students. It is the aim to implement these major points of the AR in a model course for diagnostic radiology and radiation protection within the scope of the Virtual University of Bavaria and test them in practice. MATERIALS AND METHODS: In cooperation with residents and board certified radiologists, students developed the virtual course "Web-Based Training (WBT) Radiology" in diagnostic radiology and radiation protection for students in the first clinical semester. A representative target group taken from the student body was asked about the options to get access to the World Wide Web (Internet), and the satisfaction concerning configuration and content of the newly developed program. A comparison was made between the results of the final examination taken by students who made use of the virtual course in addition to conventional lessons and taken by students who did not subscribe to the virtual course and exclusively relied on conventional lessons. In addition, a pilot study was conducted in the winter semester 2002/03, which compared students taking either the traditional lessons or the new virtual course on the Internet. RESULTS: The virtual course-model had test results with a positive trend. All targeted students had Internet access. Constructive criticism was immediately implemented and contributed to rapid optimization. The learning success of the additive or alternative virtual course was in no way less than the learning success achieved with the conventional course. CONCLUSION: The learning success as measure of quality in teaching and the acceptance by students and teachers justify the continuation of this course model and its expansion. Besides enabling the learning in small study groups; the course "WBT Radiology" might not only help implementing the major points of the new AR but might also complement any deficiencies in the current education. Economic aspects may encourage their implementations.

Absence of compensatory platelet activation in patients with severe haemophilia, but evidence for a platelet collagen-activation defect.

Severe haemophilia is a serious, haemorrhagic disorder of the plasmatic coagulation system. In this study we investigated, whether 'compensatory' activation of the platelet coagulation system occurs in this situation. Platelet function was investigated with aggregation, adhesion and flow cytometric assays. In addition, we performed clot and platelet plug formation tests and determined endogenous thrombin potentials in patients with severe haemophilia A or B; results were compared to those of healthy controls. Platelet aggregation in response to stimulation with ADP, ristocetin and epinephrine was similar in patients and controls; aggregation in response to collagen was reduced significantly in haemophiliacs. Flow cytometric analysis of P-selectin (CD 62P) and CD 63, of the conformationally changed GP IIb/IIIa with PAC 1 and of thrombospondin bound to CD 36 (GP IV) was performed at baseline and post stimulation. Baseline expression of all markers was similar in haemophiliacs and controls. After stimulation of the platelet thrombin receptors with the thrombin receptor activating peptide (TRAP) 6, the surface expression of all markers increased significantly; again, the expression was similar in haemophiliacs and controls. With thrombelastography and PFA 100 analysis, clot formation under low shear and platelet plug formation under high shear is measured. Both test results revealed a significantly reduced clot and platelet plug formation capacity in severe haemophiliacs. Our results did not reveal signs of enhanced platelet preactivation in haemophiliacs, indicating that baseline platelet reactivity in severe haemophilia remains in a neutral state, despite the severely haemorrhagic condition. As expected, both thrombin and clot formation capacities were impaired significantly in severe haemophilia. The reduced response to collagen-based platelet stimulation tests is indicative of a concomitant platelet function defect. This defect probably contributes to the intensity of bleeding events in patients with severe haemophilia.

Paradoxical hyperfibrinolysis is associated with a more intensely haemorrhagic phenotype in severe congenital haemophilia.

To elucidate potential causes for differing bleeding phenotypes of haemophilic patients of identical degree of coagulation factor deficiency, we investigated 21 male patients with severe haemophilia. Median annual coagulation factor demand and the extent of haemophilic arthropathy were used to discriminate between intensely and less intensely haemorrhagic phenotypes. Haemophiliacs with a median annual coagulation factor demand of 800 IU per kg bodyweight or more and with three or more joints affected by haemophilic arthropathy represented the intensely haemorrhagic phenotype group; all other patients comprised the less intense group. The discriminator values represent the respective medians of the overall group. The results of activated partial thromboplastin time, endogenous thrombin potential, pro- and anticoagulant factor analysis did not differ between the two groups. Median tissue-type plasminogen activator concentration (TPA) was elevated significantly in haemophiliacs with an intensely haemorrhagic phenotype, as was the activity of the thrombin-activatable fibrinolysis inhibitor. Median activity of the plasminogen activator inhibitor 1 (PAI 1) and the concentration of TPA-PAI 1 complexes were increased to approximately double those in nonsevere haemophiliacs. Coexistent congenital thrombophilia was found significantly more often in the less intensely haemorrhagic group. Thus, increased stimulation of the fibrinolytic system was associated with a more intensely haemorrhagic phenotype in our patients. We hypothesize that ineffective haemophilic haemostasis in response to trauma evokes a protracted stimulation of the entire haemostatic system, including costimulation of fibrinolysis. The absence of coexistent congenital thrombophilia predisposes to excess stimulation of fibrinolysis, which cannot be downregulated effectively due to the dysfunctional intrinsic pathway. The association of a more intensely haemorrhagic phenotype with a paradoxical hyperstimulation of the fibrinolytic system resembles a vicious circle, where bleeding seems to cause predisposition to more bleeding.

Current treatment practice for essential thrombocythaemia in adults.

Essential thrombocythaemia (ET) is a relatively benign chronic myeloproliferative disorder that occurs primarily in middle-aged patients. Its clinical course is characterised by thomboembolic and, less frequently, by haemorrhagic complications. Life expectancy of ET is generally of normal length and progression to acute leukaemia is a rare event. About one third of all patients are asymptomatic at diagnosis and many of them remain without complications for years. Therefore, the main challenge for treating patients with ET is to select patients who will benefit from a cytoreductive or antiplatelet therapy, because it is doubtful whether the beneficial effects of therapy outweigh the potential hazards in all cases. For this reason a risk stratification in high and low risk ET patients is essential. The treatment of ET has evolved from alkylating agents to hydroxyurea (HU) or pipobroman and more recently to agents such as IFN-alpha and anagrelide. Aspirin as an antiplatelet therapy is also expected to play a part in the treatment of ET. HU is first-line therapy for elderly patients with high risk ET. In young ET patients without ET related complications and a platelet count << 1000 - 1500 x 10(9)/l abstention from cytoreductive therapy or therapy with low-dose aspirin alone seems to be appropriate. The aim of this review is to address the current treatment practice for ET in adults.

Acquired haemophilia: experiences with a standardized approach.

Acquired haemophilia is a rare, life-threatening, acquired bleeding diathesis. No general consensus exists on the best therapeutic approach. We report on the standardized approach at our institution evaluated in ten patients with acquired haemophilia. Factor VIII inhibitors were found in all patients, activities ranging from 1 to 648 Bethesda units (BU). Eight of the ten patients presented with severe bleeding. Two patients died during the acute phase, one from intracranial bleeding and one due to Mycoplasma pneumonia. One patient with mild bleeding was treated with immunosuppression alone. Two patients with factor VIII inhibitor activities below 5 BU were started on factor VIII concentrate therapy. Therapy was successful in one and was changed to recombinant human activated factor VII infusion (rFVIIa) in the other, owing to insufficient factor VIII recovery. Six patients with factor VIII inhibitor activities above 5 BU were started on activated prothrombin complex concentrate (APCC) therapy. APCC treatment was successful initially in all six patients and was changed to rFVIIa infusion in one for rebleeding. One patient did not receive any specific therapy. Immunosuppression with prednisolone (2 mg kg(-1)) was begun in nine patients and was continued with cyclophosphamide (2 mg kg(-1)) in six. A complete remission of the acquired haemophilia was found in seven of the eight patients surviving the acute phase, one had a partial remission. All patients with acquired haemophilia could be managed effectively following our standardized approach. Routine administration of immunosuppression was associated with high inhibitor elimination rates.

[Pseudoaneurysm of the hepatic artery--a rare complication after orthotopic liver transplantation]. / Pseudoaneurysma der A. hepatica--eine seltene Komplikation nach orthotoper Lebertransplantation.

INTRODUCTION: Pseudoaneurysm of the hepatic artery is a rare complication of liver transplantation, the most common cause of which--apart from technical surgical problems--is an infection. The most common symptoms are rupture and hemorrhage. METHOD: The present case report describes an asymptomatic pseudoaneurysm of the hepatic artery following liver transplantation, and its treatment. RESULTS: In this patient, an pseudoaneurysm involving an eroded branch of the hepatic artery was found. Surgical treatment consisted in the excision of the aneurysm and oversewing of the branch of the hepatic artery. CONCLUSION: The potential for rupture and hemorrhage makes surgical intervention mandatory even in asympotomatic patients with pseudoaneurysm of the hepatic artery. The surgical procedure depends on the local situation and the time elapsed since transplantation. Preservation or reconstruction of the arterial perfusion is essential.