[Optimizing radiological diagnostic management via mobile devices in trauma surgery]. / Anforderung von radiologischer Diagnostik in der Unfallchirurgie mittels mobiler Endgeräte.

BACKGROUND: Time is a scarce resource for physicians. One medical task is the request for radiological diagnostics. This process is characterized by high administrative complexity and sometimes considerable time consumption. Measures that lead to an administrative relief in favor of patient care have so far been lacking. AIM OF THE STUDY: Process optimization of the request for radiological diagnostics. As a proof of concept the request for radiological diagnostics was conducted using a mobile, smartphone and tablet-based application with dedicated voice recognition software in the Department of Trauma Surgery at the University Hospital of Würzburg (UKW). MATERIAL AND METHODS: In a prospective study, time differences and efficiency of the mobile app-based method (ukw.mobile based Application = UMBA) compared to the PC-based method (PC-based application = PCBA) for requesting radiological services were analyzed. The time from the indications to the completed request and the time required to create the request on the device were documented and assessed. Due to the non-normal distribution of the data, a Mann-Whitney U test was performed. RESULTS: The time from the indications to the completed request was significantly (p < 0.05) reduced using UMBA compared to PCBA (PCBA: mean ± standard difference [SD] 19.57 ± 33.24 min, median 3.00 min, interquartile range [IQR] 1.00-30.00 min vs. UMBA: 9.33 ± 13.94 min, median 1.00 min, IQR 0.00-20.00 min). The time to complete the request on the device was also significantly reduced using UMBA (PCBA: mean ± SD 63.77 ± 37.98 s, median 51.96 s, IQR 41.68-68.93 s vs. UMBA: 25.21 ± 11.18 s, median 20.00 s, IQR 17.27-29.00 s). CONCLUSION: The mobile, voice-assisted request process leads to a considerable time reduction in daily clinical routine and illustrates the potential of user-oriented, targeted digitalization in healthcare. In future, the process will be supported by artificial intelligence.

Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial.

BACKGROUND: Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU. METHODS: Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models. RESULTS: At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels. CONCLUSION: Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

Machine learning-based classification of Alzheimer's disease and its at-risk states using personality traits, anxiety, and depression.

BACKGROUND: Alzheimer's disease (AD) is often preceded by stages of cognitive impairment, namely subjective cognitive decline (SCD) and mild cognitive impairment (MCI). While cerebrospinal fluid (CSF) biomarkers are established predictors of AD, other non-invasive candidate predictors include personality traits, anxiety, and depression, among others. These predictors offer non-invasive assessment and exhibit changes during AD development and preclinical stages. METHODS: In a cross-sectional design, we comparatively evaluated the predictive value of personality traits (Big Five), geriatric anxiety and depression scores, resting-state functional magnetic resonance imaging activity of the default mode network, apoliprotein E (ApoE) genotype, and CSF biomarkers (tTau, pTau181, Aß42/40 ratio) in a multi-class support vector machine classification. Participants included 189 healthy controls (HC), 338 individuals with SCD, 132 with amnestic MCI, and 74 with mild AD from the multicenter DZNE-Longitudinal Cognitive Impairment and Dementia Study (DELCODE). RESULTS: Mean predictive accuracy across all participant groups was highest when utilizing a combination of personality, depression, and anxiety scores. HC were best predicted by a feature set comprised of depression and anxiety scores and participants with AD were best predicted by a feature set containing CSF biomarkers. Classification of participants with SCD or aMCI was near chance level for all assessed feature sets. CONCLUSION: Our results demonstrate predictive value of personality trait and state scores for AD. Importantly, CSF biomarkers, personality, depression, anxiety, and ApoE genotype show complementary value for classification of AD and its at-risk stages.

Interaction of panic and episodic breathlessness among patients with life-limiting diseases: a cross-sectional study.

BACKGROUND: Episodic breathlessness is often accompanied by panic. A vicious cycle of breathlessness-panic-breathlessness leads to emergencies with severe breathlessness and/or fear of dying. However, the interaction between episodic breathlessness and panic is poorly understood. Thus, the aim is a better understanding of the interaction between panic and episodic breathlessness to develop appropriate support for patients suffering from this symptom. METHODS: Patients suffering from episodic breathlessness due to life-limiting diseases answered questions on the characteristics of episodic breathlessness and panic-spectrum psychopathology, including underlying mechanisms. Using the Patient Health Questionnaire and the Structured Clinical Interview for DSM-IV Diagnoses (SCID), patients were screened for panic disorder. An open-ended question captured the patients' descriptions of panic during breathlessness episodes. RESULTS: Forty-six patients [52% women, mean age =66 years; standard deviation (SD) 7.3 years] provided information: 61% suffered from panic during the entire breathlessness episode, 39% experienced panic in every episode, and 25% were diagnosed with panic disorder. Exploratory data analysis was conducted. Patients with high scores in breathlessness catastrophizing thoughts experienced more panic in a breathlessness episode (P<0.001) and considered themselves more panic than low-scorers (P=0.024). There was a significant indirect effect of episodic breathlessness intensity on the panic experienced in an episode, and this effect was mediated by catastrophizing thoughts regarding breathlessness (b=0.164; 95% CI: 0.105, 0.222). Patients described in the open-ended question experiencing only panic or breathlessness, or a combination of both. Some patients managed to differentiate panic from episodic breathlessness, and used strategies to avoid panic in an episode. CONCLUSIONS: Research on treatment options for episodic breathlessness should not only focus on panic in breathlessness episodes, but also on underlying mechanisms such as catastrophizing thoughts, as they aggravate the burden.

Retroperitoneal arterial bleeding caused by an undisplaced conservatively treated hyperextension injury of the lumbar spine - A case report.

Background: Hyperextension fractures of the thoracolumbar spine are commonly seen in ankylotic disorders due to the rigidity of the spine. The known complications include instability, neurological deficits and posttraumatic deformity but there is no report of a hemodynamic relevant arterial bleeding in undisplaced hyperextension fractures. An arterial bleeding poses a life-threatening complication and may be difficult to recognize in an ambulatory or clinical setting. Case presentation: A 78-year-old male was brought to the emergency department after suffering a domestic fall with incapacitating lower back pain. X-rays and a CT scan revealed an undisplaced L2 hyperextension fracture which was treated conservatively. 9 days after admission, the patient complained about unprecedented abdominal pain with a CT scan disclosing a 12 × 9 × 20 cm retroperitoneal hematoma on grounds of an active arterial bleeding from a branch of the L2 lumbar artery. Subsequently, access via lumbotomy, evacuation of the hematoma and insertion of a hemostatic agent was performed. The therapy concept of the L2 fracture remained conservatively. Conclusions: A secondary, retroperitoneal arterial bleeding after a conservatively treated undisplaced hyperextension fracture of the lumbar spine is a rare and severe complication that has not been described in literature yet and may be difficult to recognize. An early CT scan is recommended in case of a sudden onset of abdominal pain in these fractures to fasten treatment and hence decrease morbidity and mortality. Thus, this case report contributes to the awareness of this complication in a spine fracture type with increasing incidence and clinical relevance.

[Ultrasound diagnostics: Differentiated vision - upgrading - better reimbursement]. / Ultraschalldiagnostik: Differenziert sehen ­ aufwerten ­ besser vergüten.

Ultrasonography is an imaging modality of great importance in everyday clinical practice. Technical innovations continuously expand the diagnostic and therapeutic possibilities of ultrasonography requiring continuous upskilling of sonographers. Only a small number of practitioners, in hospital and practice settings in Germany, currently have the required level of skills. Therefore, these techniques are not as readily available as would be desirable. A modern high-end ultrasound scanner in the hands of a qualified sonographer is a diagnostic high-tech precision instrument, which can compete with any other imaging modality.In conclusion, basic sonography, as it is currently practised should be separated from high-end sonography, requiring extensive training and better remuneration. In this context the introduction of a new medical board speciality for ultrasonography, "Advanced Ultrasonography", with corresponding upgrading should be recommended for high-end sonography.

Selective Effects of Cold Atmospheric Plasma on Bone Sarcoma Cells and Human Osteoblasts.

BACKGROUND: The use of cold atmospheric plasma (CAP) in oncology has been intensively investigated over the past 15 years as it inhibits the growth of many tumor cells. It is known that reactive oxidative species (ROS) produced in CAP are responsible for this effect. However, to translate the use of CAP into medical practice, it is essential to know how CAP treatment affects non-malignant cells. Thus, the current in vitro study deals with the effect of CAP on human bone cancer cells and human osteoblasts. Here, identical CAP treatment regimens were applied to the malignant and non-malignant bone cells and their impact was compared. METHODS: Two different human bone cancer cell types, U2-OS (osteosarcoma) and A673 (Ewing's sarcoma), and non-malignant primary osteoblasts (HOB) were used. The CAP treatment was performed with the clinically approved kINPen MED. After CAP treatment, growth kinetics and a viability assay were performed. For detecting apoptosis, a caspase-3/7 assay and a TUNEL assay were used. Accumulated ROS was measured in cell culture medium and intracellular. To investigate the influence of CAP on cell motility, a scratch assay was carried out. RESULTS: The CAP treatment showed strong inhibition of cell growth and viability in bone cancer cells. Apoptotic processes were enhanced in the malignant cells. Osteoblasts showed a higher potential for ROS resistance in comparison to malignant cells. There was no difference in cell motility between benign and malignant cells following CAP treatment. CONCLUSIONS: Osteoblasts show better tolerance to CAP treatment, indicated by less affected viability compared to CAP-treated bone cancer cells. This points toward the selective effect of CAP on sarcoma cells and represents a further step toward the clinical application of CAP.

Usability of a mHealth Solution using Speech Recognition for Point-of-care Diagnostic Management.

The administrative burden for physicians in the hospital can affect the quality of patient care. The Service Center Medical Informatics (SMI) of the University Hospital Würzburg developed and implemented the smartphone-based mobile application (MA) ukw.mobile1 that uses speech recognition for the point-of-care ordering of radiological examinations. The aim of this study was to examine the usability of the MA workflow for the point-of-care ordering of radiological examinations. All physicians at the Department of Trauma and Plastic Surgery at the University Hospital Würzburg, Germany, were asked to participate in a survey including the short version of the User Experience Questionnaire (UEQ-S) and the Unified Theory of Acceptance and Use of Technology (UTAUT). For the analysis of the different domains of user experience (overall attractiveness, pragmatic quality and hedonic quality), we used a two-sided dependent sample t-test. For the determinants of the acceptance model, we employed regression analysis. Twenty-one of 30 physicians (mean age 34 ± 8 years, 62% male) completed the questionnaire. Compared to the conventional desktop application (DA) workflow, the new MA workflow showed superior overall attractiveness (mean difference 2.15 ± 1.33), pragmatic quality (mean difference 1.90 ± 1.16), and hedonic quality (mean difference 2.41 ± 1.62; all p < .001). The user acceptance measured by the UTAUT (mean 4.49 ± 0.41; min. 1, max. 5) was also high. Performance expectancy (beta = 0.57, p = .02) and effort expectancy (beta = 0.36, p = .04) were identified as predictors of acceptance, the full predictive model explained 65.4% of its variance. Point-of-care mHealth solutions using innovative technology such as speech-recognition seem to address the users' needs and to offer higher usability in comparison to conventional technology. Implementation of user-centered mHealth innovations might therefore help to facilitate physicians' daily work.

Point-of-Care Speech-Recognition Based mHealth Solution to Facilitate Physicians' Daily Work.

We developed and implemented a smartphone-based mobile application that uses speech recognition for the point-of-care ordering of radiological examinations. 21 out of 30 physicians completed a usability questionnaire including the Short version of the User Experience Questionnaire (UEQ-S) and the Unified Theory of Acceptance and Use of Technology (UTAUT). The mobile application showed high user acceptance and superior user experience when compared to the conventional workflow. Due to the high usability of our mHealth solution, it might help to facilitate the physician's daily work.

New Approach against Chondrosoma Cells-Cold Plasma Treatment Inhibits Cell Motility and Metabolism, and Leads to Apoptosis.

(1) Background: Chondrosarcoma (CS) is a malignant primary bone tumor with a cartilaginous origin. Its slow cell division and severely restricted vascularization are responsible for its poor responsiveness to chemotherapy and radiotherapy. The decisive factor for the prognosis of CS patients is the only adequate therapy-surgical resection. Cold atmospheric pressure plasma (CAP) is emerging as a new option in anti-cancer therapy. Its effect on chondrosarcomas has been poorly investigated. (2) Methods: Two CS cell lines-SW 1353 and CAL 78-were used. Various assays, such as cell growth kinetics, glucose uptake, and metabolic activity assay, along with two different apoptosis assays were performed after CAP treatment. A radius cell migration assay was used to examine cell motility. (3) Results: Both cell lines showed different growth behavior, which was taken into account when using the assays. After CAP treatment, a reduction in metabolic activity was observed in both cell lines. The immediate effect of CAP showed a reduction in cell numbers and in influence on this cell line's growth rate. The measurement of the glucose concentration in the cell culture medium showed an increase after CAP treatment. Live-dead cell imaging shows an increase in the proportion of dead cells over the incubation time for both cell lines. There was a significant increase in apoptotic signals after 48 h and 72 h for both cell lines in both assays. The migration assay showed that CAP treatment inhibited the motility of chondrosarcoma cells. The effects in all experiments were related to the duration of CAP exposure. (4) Conclusions: The CAP treatment of CS cells inhibits their growth, motility, and metabolism by initiating apoptotic processes.

Healthcare Utilization and Costs in Sepsis Survivors in Germany-Secondary Analysis of a Prospective Cohort Study.

Background: Survivors of sepsis often face long-term sequelae after intensive care treatment. Compared to the period of hospitalization, little is known about the ambulatory healthcare utilization in sepsis patients. The study evaluated healthcare utilization and associated costs of sepsis care including allied health professions after initial hospitalization. Methods: Secondary analysis was performed on data in 210 sepsis patients prospectively enrolled from nine intensive care study centers across Germany. Data was collected via structured surveys among their Primary care (Family-) physicians (PCPs) within the first month after discharge from ICU (baseline) and again at 6, 12 and 24 months after discharge, each relating to the period following the last survey. Costs were assessed by standardized cost unit rates from a health care system's perspective. Changes in healthcare utilization and costs over time were calculated using the Wilcoxon rank-sum test. Results: Of the 210 patients enrolled, 146 (69.5%) patients completed the 24 months follow-up. In total, 109 patients were hospitalized within the first 6 months post-intensive care. Mean total direct costs per patient at 0-6 months were €17,531 (median: €6047), at 7-12 months €9029 (median: €3312), and at 13-24 months €18,703 (median: €12,828). The largest contributor to the total direct costs within the first 6 months was re-hospitalizations (€13,787 (median: €2965). After this first half year, we observed a significant decline in inpatient care costs for re-hospitalizations (p ≤ 0.001). PCPs were visited by more than 95% of patients over 24 months. Conclusions: Sepsis survivors have high health care utilization. Hospital readmissions are frequent and costly. Highest costs and hospitalizations were observed in more than half of patients within the first six months post-intensive care. Among all outpatient care providers, PCPs were consulted most frequently. Clinical impact: Sepsis survivors have a high healthcare utilization and related costs which persist after discharge from hospital. Within outpatient care, possible needs of sepsis survivors as physiotherapy or psychotherapy seem not to be met appropriately. Development of sepsis aftercare programs for early detection and treatment of complications should be prioritized.

Only I Know Now, of Course, How to Deal With it, or Better to Deal With it: A Mixed Methods Phase II Study of a Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness.

CONTEXT: Episodic breathlessness is characterized by increased breathlessness intensity, and it is burdensome for patients. A vicious cycle of breathlessness-anxiety/panic-breathlessness leads to emergencies that can rarely be alleviated by drugs. Non-pharmacological interventions seem to be beneficial: Can a brief cognitive and behavioral intervention help patients to better manage episodic breathlessness? OBJECTIVES: To evaluate the feasibility, safety, acceptability, and potential effects of a brief cognitive and behavioral intervention for the management of episodic breathlessness. METHODS: Between February 2019 and February 2020, 49 patients with life-limiting diseases suffering from episodic breathlessness were enrolled in the single-arm phase II study. The baseline assessment was followed by the one- to two-hour intervention. In weeks two, four, and six after the intervention, the outcomes (main outcome of potential effects: mastery of breathlessness) were assessed, and in week six, a qualitative interview, and the final assessment took place. A mixed-methods approach was used to evaluate mainly the feasibility, including interviewing informal carers. RESULTS: 46/49 patients (24 female; 36 with COPD; mean age: 66.0 years) participated in the baseline assessment, 38 attended the intervention, 32 completed the final assessment, and 22 were interviewed. Study procedures and the intervention were feasible and mainly well accepted and patients did not experience burdens caused by it (28/32). In the interviews, patients described a positive change in their competencies in managing episodic breathlessness and feelings of anxiety during the episode. Mastery of breathlessness improved after the intervention. CONCLUSION: The brief cognitive and behavioral intervention and the study procedures are feasible, safe, and well accepted. We can describe a change for better management of episodic breathlessness in patients after the intervention, still, this needs to be evaluated in a Phase III trial for inclusion in the management of episodic breathlessness.

Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care.

As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.

Trajectories of depression in sepsis survivors: an observational cohort study.

BACKGROUND: Advances in critical care medicine have led to a growing number of critical illness survivors. A considerable part of them suffers from long-term sequelae, also known as post-intensive care syndrome. Among these, depressive symptoms are frequently observed. Depressive symptom trajectories and associated factors of critical illness survivors have rarely been investigated. Study objective was to explore and compare different trajectories of depressive symptoms in sepsis survivors over 1 year after discharge from ICU. METHODS: Data of a randomized controlled trial on long-term post-sepsis care were analyzed post hoc. Depressive symptoms were collected at 1, 6 and 12 months post-ICU discharge using the Major Depression Inventory (MDI), among others. Statistical analyses comprised descriptive analysis, univariate and multivariate, linear and logistic regression models and Growth Mixture Modeling. RESULTS: A total of 224 patients were included into this analysis. We identified three latent classes of depressive symptom trajectories: Over the course of 1 year, 152 patients recovered from mild symptoms, 27 patients showed severe persistent symptoms, and 45 patients recovered from severe symptoms. MDI sum scores significantly differed between the three classes of depressive symptom trajectories at 1 and 6 months after ICU discharge (p < 0.024 and p < 0.001, respectively). Compared with other classes, patients with the mild recovered trajectory showed lower levels of chronic pain (median sum score of 43.3 vs. 60.0/53.3 on the Graded Chronic Pain Scale, p < 0.010) and posttraumatic stress (4.6% with a sum score of ≥ 35 on the Posttraumatic Stress Scale 10 vs. 48.1%/33.3%, p < 0.003); and higher levels of health-related quality of life (HRQOL) using the Short Form-36 scale within 1 month after ICU discharge (p < 0.035). CONCLUSIONS: In the first year after discharge from ICU, sepsis survivors showed three different trajectories of depressive symptoms. Course and severity of depressive symptoms were associated with chronic pain, posttraumatic stress and reduced HRQOL at discharge from ICU. Regular screening of sepsis survivors on symptoms of depression, chronic pain and posttraumatic stress within 1 year after ICU may be considered. Trial registration ISRCTN, ISRCTN 61744782. Registered April 19, 2011-Retrospectively registered, http://www.isrctn.com/ISRCTN61744782 .

Neumotórax espontáneo bilateral metastásico. Inusual manifestación de metástasis pulmonar / Spontaneous metastatic bilateral pneumothorax. Unusual manifestation of lung metastasis

Resumen Objetivo: Comunicar el caso de una paciente de 77 años tratada de un angiosarcoma de cuero cabelludo, que evoluciona con neumotórax bilateral, cuyo estudio histopatológico informa enfermedad metastásica. Materiales y Método: Revisión de ficha clínica electrónica, registro informático de imagenología e informes de biopsias. Seguimiento ambulatorio en policlínico de cirugía. Resultados: Se realiza manejo por videotoracoscopía bilateral, con bulectomía más pleurodesis. Discusión: El neumotórax secundario por enfermedad metastásica es poco frecuente, aproximadamente 1% a 2% de los casos. De los tumores que más frecuentemente metastizan al pulmón se encuentran los sarcomas. Conclusión: El neumotórax metastásico es poco frecuente y requiere un alto índice de sospecha. Su manejo va a depender del pronóstico y de las condiciones generales del paciente.

Aim: To report the case of a 77-year-old patient treated for angiosarcoma of the scalp, who evolves with bilateral pneumothorax, whose histopathological study reports metastatic disease. Materials and Method: Review of electronic clinical record, computerized imaging record and biopsy reports. Outpatient follow-up at the polyclinic of surgery. Results: Management was performed by bilateral videothoracoscopy, with bulectomy plus pleurodesis. Discussion: Secondary pneumothorax due to metastatic disease is rare, approximately 1 to 2% of cases. Sarcomas are among the tumors that most frequently metastasize to the lung. Conclusion: Metastatic pneumothorax is infrequent and requires a high index of suspicion. Its management will depend on the prognosis and the general conditions of the patient.

[Do COVID-19 restrictions lead to a decrease in severely injured patients at a level 1 trauma center in Germany?] / Führt eine COVID-19-bedingte Ausgangsbeschränkung zu einer Reduktion schwer verletzter Patienten an einem überregionalen Traumazentrum?

BACKGROUND: Intensive care and ventilator capacities are essential for treatment of COVID-19 patients. Severely injured patients are often in continuous need of intensive care and ventilator treatment. The question arises, whether restrictions related to COVID-19 have led to a decrease in severely injured patients and thus to an increase in intensive care unit (ICU) capacity. MATERIAL AND METHODS: A retrospective analysis of all seriously injured patients with an injury severity score (ISS) ≥16 was performed between 17 March and 30 April 2020 at a level 1 trauma center in Germany. The mechanism of injury and the ISS were recorded. Further data were collected as to whether it was a work-related accident, a documented suicide attempt and if surgery was necessary in the first 24 h after arrival in hospital. Data from 2018 and 2019 served as a control group. RESULTS: There was no substantial difference in the total number of seriously injured patients (2018 n = 30, 2019 n = 23, 2020 n = 27). Furthermore, there was no relevant difference in the number of patients needing intensive care or ventilator treatment when leaving the shock room. The number of patients needing an operative intervention within the first 24 h after arriving at hospital was slightly higher in 2020. The mean ISS was at a constant level during all 3 years. In 2020 there was no polytraumatized motorbike rider, who did not have a work-related accident (2018 n = 5, 2019 n = 4, 2020 n = 0). A noticeable increase in work-related accidents was observed (2018: 10%, 2019: 26.1%, 2020 44.4%). DISCUSSION: Restrictions related to COVID-19 did not lead to a reduction in seriously injured patients needing ICU care. Due to the monocentric data analysis there is room for misinterpretation. In general, intensive care and operating capacities should be managed with adequate consideration for seriously injured patients even in times of crisis, such as the COVID-19 pandemic. Confirmation through the German Trauma Register is pending.

[Smartphone-based photographic wound documentation improves the quality of medical accounting in orthopedic and plastic surgery]. / Qualitätssteigerung der Abrechnungsprüfung durch Smartphone-basierte Fotodokumentation in der Unfall­, Hand- und plastischen Chirurgie.

BACKGROUND: Photographic documentation of wounds, decubitus ulcers, tumors, open fractures and infections is an important part of digital patient files. It is unclear whether the photographic documentation has an effect on medical accounting with health insurance companies. OBJECTIVE: It was hypothesized that Smartphone-based systematic photographic documentation can improve the confirmation of proceeds-relevant diagnoses and procedures as well as the duration. MATERIAL AND METHODS: Staff in the emergency room, operating theater, outpatient clinic and on the wards were equipped with digital devices (Smartphone, tablet) including a photo-app. Medical accounting with the health insurance companies and identification of all case conferences in which the photographic documentation had effected a change in proceeds were analyzed for 2019 in a retrospective manner. RESULTS: Overall, 372 cases were discussed of which 27 cases were affected by the digital photographic documentation. Photographic documentation was used for clarification of the operative procedure (n = 5), primary diagnosis (n = 10), secondary diagnosis (n = 3), and length of hospitalization (n = 9). An average of 2119 € was negotiated and added per case affected by photographic documentation. Hereby, a level 1 trauma center gained an estimated 65,328 € in revenue. DISCUSSION: The use of Smartphone based photographic documentation can improve the overall quality of patient files and thus avoid loss of revenue. The implementation of digital devices with corresponding software is an important component of the digital structural change in hospitals.

Cement-augmented screw fixation for calcaneal fracture treatment: a biomechanical study comparing two injectable bone substitutes.

BACKGROUND: The role of cement-augmented screw fixation for calcaneal fracture treatment remains unclear. Therefore, this study was performed to biomechanically analyze screw osteosynthesis by reinforcement with either a calcium phosphate (CP)-based or polymethylmethacrylate (PMMA)-based injectable bone cement. METHODS: A calcaneal fracture (Sanders type IIA) including a central cancellous bone defect was generated in 27 synthetic bones, and the specimens were assigned to 3 groups. The first group was fixed with four screws (3.5 mm and 6.5 mm), the second group with screws and CP-based cement (Graftys® QuickSet; Graftys, Aix-en-Provence, France), and the third group with screws and PMMA-based cement (Traumacem™ V+; DePuy Synthes, Warsaw, IN, USA). Biomechanical testing was conducted to analyze peak-to-peak displacement, total displacement, and stiffness in following a standardized protocol. RESULTS: The peak-to-peak displacement under a 200-N load was not significantly different among the groups; however, peak-to-peak displacement under a 600- and 1000-N load as well as total displacement exhibited better stability in PMMA-augmented screw osteosynthesis compared to screw fixation without augmentation. The stiffness of the construct was increased by both CP- and PMMA-based cements. CONCLUSION: Addition of an injectable bone cement to screw osteosynthesis is able to increase fixation strength in a biomechanical calcaneal fracture model with synthetic bones. In such cases, PMMA-based cements are more effective than CP-based cements because of their inherently higher compressive strength. However, whether this high strength is required in the clinical setting for early weight-bearing remains controversial, and the non-degradable properties of PMMA might cause difficulties during subsequent interventions in younger patients.

[German recommendations on lung and thoracic ultrasonography in patients with COVID-19]. / Empfehlungen zur Lungen- und Thoraxsonographie bei Patienten mit COVID-19-Erkrankung.

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV­2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).

Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors.

BACKGROUND: Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools. METHODS: Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters. RESULTS: One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001). CONCLUSIONS: Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.