ABSTRACT
In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.
Subject(s)
Curriculum , Emergency Medicine , Emergency Service, Hospital , Internal Medicine , Internal Medicine/education , Humans , Germany , Emergency Medicine/education , Clinical Competence , Education, Medical, GraduateABSTRACT
A holistic understanding of plant strategies to acquire soil resources is pivotal in achieving sustainable food security. However, we lack knowledge about variety-specific root and rhizosphere traits for resource acquisition, their plasticity and adaptation to drought. We conducted a greenhouse experiment to phenotype root and rhizosphere traits (mean root diameter [Root D], specific root length [SRL], root tissue density, root nitrogen content, specific rhizosheath mass [SRM], arbuscular mycorrhizal fungi [AMF] colonization) of 16 landraces and 22 modern cultivars of temperate maize (Zea mays L.). Our results demonstrate that landraces and modern cultivars diverge in their root and rhizosphere traits. Although landraces follow a 'do-it-yourself' strategy with high SRLs, modern cultivars exhibit an 'outsourcing' strategy with increased mean Root Ds and a tendency towards increased root colonization by AMF. We further identified that SRM indicates an 'outsourcing' strategy. Additionally, landraces were more drought-responsive compared to modern cultivars based on multitrait response indices. We suggest that breeding leads to distinct resource acquisition strategies between temperate maize varieties. Future breeding efforts should increasingly target root and rhizosphere economics, with SRM serving as a valuable proxy for identifying varieties employing an outsourcing resource acquisition strategy.
Subject(s)
Adaptation, Physiological , Droughts , Mycorrhizae , Plant Roots , Rhizosphere , Soil , Zea mays , Zea mays/physiology , Zea mays/microbiology , Plant Roots/microbiology , Plant Roots/physiology , Soil/chemistry , Mycorrhizae/physiology , Phenotype , Nitrogen/metabolismABSTRACT
Biophysicochemical rhizosheath properties play a vital role in plant drought adaptation. However, their integration into the framework of plant drought response is hampered by incomplete mechanistic understanding of their drought responsiveness and unknown linkage to intraspecific plant-soil drought reactions. Thirty-eight Zea mays varieties were grown under well-watered and drought conditions to assess the drought responsiveness of rhizosheath properties, such as soil aggregation, rhizosheath mass, net-rhizodeposition, and soil organic carbon distribution. Additionally, explanatory traits, including functional plant trait adaptations and changes in soil enzyme activities, were measured. Drought restricted soil structure formation in the rhizosheath and shifted plant-carbon from litter-derived organic matter in macroaggregates to microbially processed compounds in microaggregates. Variety-specific functional trait modifications determined variations in rhizosheath drought responsiveness. Drought responses of the plant-soil system ranged among varieties from maintaining plant-microbial interactions in the rhizosheath through accumulation of rhizodeposits, to preserving rhizosheath soil structure while increasing soil exploration through enhanced root elongation. Drought-induced alterations at the root-soil interface may hold crucial implications for ecosystem resilience in a changing climate. Our findings highlight that rhizosheath soil properties are an intrinsic component of plant drought response, emphasizing the need for a holistic concept of plant-soil systems in future research on plant drought adaptation.
Subject(s)
Ecosystem , Soil , Soil/chemistry , Droughts , Carbon/analysis , Plants , Plant Roots/physiologyABSTRACT
In Germany per year approximately 60,000 and in Austria 5,000 adult patients suffer from out-of-hospital cardiac arrest. Only 10-15% of these patients survive without neurological damage. For decades hypothermic temperature control has been a central component of post-resuscitation treatment, but is controversial due to recently published studies.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medicine , Out-of-Hospital Cardiac Arrest , Humans , Out-of-Hospital Cardiac Arrest/therapy , Austria , Temperature , Critical CareABSTRACT
Patients with potential or proven cardiovascular diseases represent a relevant proportion of the total spectrum in the emergency department. Their monitoring for cardiovascular surveillance until the diagnostics and acute treatment are initiated, often poses an interdisciplinary and interprofessional challenge, because resources are limited, nevertheless a high level of patient safety has to be ensured and the correct procedure has a major prognostic significance. This consensus paper provides an overview of the practical implementation, the modalities of monitoring and the application in a selection of cardiovascular diagnoses. The article provides specific comments on the clinical presentations of acute coronary syndrome, acute heart failure, cardiogenic shock, hypertensive emergency events, syncope, acute pulmonary embolism and cardiac arrhythmia. The level of evidence is generally low as no randomized trials are available on this topic. The recommendations are intended to supplement or establish local standards and to assist all physicians, nursing personnel and the patients to be treated in making decisions about monitoring in the emergency department.
Subject(s)
Acute Coronary Syndrome , Heart Failure , Humans , Consensus , Emergency Service, Hospital , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/therapy , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/therapyABSTRACT
Approximately 84 out of 100,000 inhabitants in Europe suffer from an out of hospital cardiac arrest (OHCA) each year. The mortality after cardiac arrest (CA) is high and is particularly determined by the predominant cardiogenic shock condition and hypoxic ischemic encephalopathy. For almost two decades hypothermic temperature control was the only neuroprotective intervention recommended in guidelines for postresuscitation care; however, recently published studies failed to demonstrate any improvement in the neurological outcome with hypothermia in comparison to strict normothermia in postresuscitation treatment. According to the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) guidelines published in 2022, unconscious adults after CA should be treated with temperature management and avoidance of fever; however, many questions remain open regarding the optimal target temperature, the cooling methods and the optimal duration. Despite these currently unanswered questions, a structured and high-quality postresuscitation care that includes a targeted temperature management should continue to be provided for all patients in the postresuscitation phase, independent of the selected target temperature. Furthermore, fever avoidance remains an important component of postresuscitation care.
Subject(s)
Cardiopulmonary Resuscitation , Hypothermia, Induced , Hypothermia , Out-of-Hospital Cardiac Arrest , Adult , Humans , Cardiopulmonary Resuscitation/methods , Hypothermia, Induced/adverse effects , Out-of-Hospital Cardiac Arrest/therapy , Cold Temperature , Hypothermia/etiology , Fever/therapyABSTRACT
Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.
Subject(s)
Emergency Medical Services , Emergency Medicine , Humans , Consensus , Ultrasonography , Emergency Medicine/education , GermanyABSTRACT
Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.
Subject(s)
Emergency Medical Services , Emergency Medicine , Humans , Consensus , Ultrasonography , Emergency Medicine/education , GermanyABSTRACT
BACKGROUND: Temperature control is recommended after out of hospital cardiac arrest (OHCA) by international guidelines. This survey aimed to investigate current clinical practice and areas of uncertainty. METHODS: Online survey targeting members of three medical emergency and critical care societies in Germany (April 21-June 6, 2022) assessing post-cardiac arrest temperature control management. RESULTS: Of 341 completed questionnaires 28% (n = 97) used temperature control with normothermic target and 72% (n = 244) temperature control with hypothermic target. The definition of fever regarding patients with cardiac arrest ranged from ≥ 37.7 to 39.0 °C. Temperature control was mainly started in the ICU (80%, n = 273) and most commonly core cooling (74%, n = 254) and surface cooling (39%, n = 134) with feedback were used. Temperature control was maintained for 24 h in 18% (n = 61), 48 h in 28% (n = 94), 72 h in 42% (n = 143) and longer than 72 h in 13% (n = 43). 7% (n = 24) were using different protocols for OHCA with initial shockable and non-shockable rhythm. Additional 14% (n = 48) were using different temperature control protocols after in-hospital cardiac arrest (IHCA) compared with OHCA. Overall, 37% (n = 127) changed practice after the publication of the ERC-2021 guidelines and 33% (n = 114) after the recent publication of the revised ERC-ESICM guideline on temperature control. CONCLUSIONS: One-third of the respondents changed clinical practice since recent guideline update. However, a majority of physicians further trusts in temperature control with a hypothermic target. Of interest, 14% used different temperature control strategies after IHCA compared with OHCA and 7% for shockable and non-shockable initial rhythm. A more individualized approach in post resuscitation care may be warranted.
Subject(s)
Cardiopulmonary Resuscitation , Hypothermia, Induced , Out-of-Hospital Cardiac Arrest , Humans , Adult , Cardiopulmonary Resuscitation/methods , Temperature , Out-of-Hospital Cardiac Arrest/therapy , Germany , Surveys and Questionnaires , Hypothermia, Induced/methodsABSTRACT
BACKGROUND AND AIMS: Stomatal regulation allows plants to promptly respond to water stress. However, our understanding of the impact of above and belowground hydraulic traits on stomatal regulation remains incomplete. The objective of this study was to investigate how key plant hydraulic traits impact transpiration of maize during soil drying. We hypothesize that the stomatal response to soil drying is related to a loss in soil hydraulic conductivity at the root-soil interface, which in turn depends on plant hydraulic traits. METHODS: We investigate the response of 48 contrasting maize (Zea mays) genotypes to soil drying, utilizing a novel phenotyping facility. In this context, we measure the relationship between leaf water potential, soil water potential, soil water content and transpiration, as well as root, rhizosphere and aboveground plant traits. KEY RESULTS: Genotypes differed in their responsiveness to soil drying. The critical soil water potential at which plants started decreasing transpiration was related to a combination of above and belowground traits: genotypes with a higher maximum transpiration and plant hydraulic conductance as well as a smaller root and rhizosphere system closed stomata at less negative soil water potentials. CONCLUSIONS: Our results demonstrate the importance of belowground hydraulics for stomatal regulation and hence drought responsiveness during soil drying. Furthermore, this finding supports the hypothesis that stomata start to close when soil hydraulic conductivity drops at the root-soil interface.
Subject(s)
Desiccation , Zea mays , Zea mays/genetics , Genotype , Phenotype , Plant Leaves/genetics , Plant Transpiration , Soil , Plant Stomata , Plant Roots/geneticsABSTRACT
Since 2020, digital health applications (DiGA) can be prescribed at the expense of the German statutory health insurance (SHI) system after undergoing an approval procedure by the Federal Institute for Drugs and Medical Devices (BfArM). DiGA can be approved provisionally for 1 year (with the option of extension) or permanently. The latter is dependent on scientific evidence of a positive effect on care, which can be a medical benefit or a patient-relevant structural and procedural improvement in care. However, it is apparent that the investigation of DiGA in scientific studies is challenging, as they are often complex interventions whose success also includes user and prescriber factors. In addition, health services research data underpinning the benefits of DiGA are lacking to date. In the current article, methodological considerations for DiGA research are presented, and a selection of internal medicine DiGAs is used to critically discuss current research practice.
Subject(s)
Health Services Research , National Health Programs , Humans , Digital TechnologyABSTRACT
BACKGROUND: This study was conducted to determine the effect of hypothermic temperature control after in-hospital cardiac arrest (IHCA) on mortality and functional outcome as compared with normothermia. METHODS: An investigator initiated, open-label, blinded-outcome-assessor, multicenter, randomized controlled trial comparing hypothermic temperature control (32-34°C) for 24 h with normothermia after IHCA in 11 hospitals in Germany. The primary endpoint was all-cause mortality after 180 days. Secondary end points included in-hospital mortality and favorable functional outcome using the Cerebral Performance Category scale after 180 days. A Cerebral Performance Category score of 1 or 2 was defined as a favorable functional outcome. RESULTS: A total of 1055 patients were screened for eligibility and 249 patients were randomized: 126 were assigned to hypothermic temperature control and 123 to normothermia. The mean age of the cohort was 72.6±10.4 years, 64% (152 of 236) were male, 73% (166 of 227) of cardiac arrests were witnessed, 25% (57 of 231) had an initial shockable rhythm, and time to return of spontaneous circulation was 16.4±10.5 minutes. Target temperature was reached within 4.2±2.8 hours after randomization in the hypothermic group and temperature was controlled for 48 hours at 37.0°±0.9°C in the normothermia group. Mortality by day 180 was 72.5% (87 of 120) in hypothermic temperature control arm, compared with 71.2% (84 of 118) in the normothermia group (relative risk, 1.03 [95% CI, 0.79-1.40]; P=0.822). In-hospital mortality was 62.5% (75 of 120) in the hypothermic temperature control as compared with 57.6% (68 of 118) in the normothermia group (relative risk, 1.11 [95% CI, 0.86-1.46, P=0.443). Favorable functional outcome (Cerebral Performance Category 1 or 2) by day 180 was 22.5% (27 of 120) in the hypothermic temperature control, compared with 23.7% (28 of 118) in the normothermia group (relative risk, 1.04 [95% CI, 0.78-1.44]; P=0.822). The study was prematurely terminated because of futility. CONCLUSIONS: Hypothermic temperature control as compared with normothermia did not improve survival nor functional outcome at day 180 in patients presenting with coma after IHCA. The HACA in-hospital trial (Hypothermia After Cardiac Arrest in-hospital) was underpowered and may have failed to detect clinically important differences between hypothermic temperature control and normothermia. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique Identifier: NCT00457431.
Subject(s)
Cardiopulmonary Resuscitation , Hypothermia, Induced , Out-of-Hospital Cardiac Arrest , Humans , Male , Middle Aged , Aged , Aged, 80 and over , Female , Hypothermia, Induced/adverse effects , Temperature , Coma , Hospitals , Treatment OutcomeABSTRACT
BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.
Subject(s)
COVID-19 , Heart Failure , Myocardial Infarction , COVID-19/epidemiology , Data Analysis , Emergency Service, Hospital , Humans , Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Pandemics , Retrospective Studies , SARS-CoV-2ABSTRACT
In patients with suspected pulmonary embolism (PE), the number of unnecessary computed tomography pulmonary angiography (CTPA) scans remains high, especially in patients with low pre-test probability (PTP). So far, no study showed any additional benefit of capillary blood gas analysis (BGA) in diagnostic algorithms for PE. In this retrospective analysis of patients with suspected PE and subsequent CTPA, clinical data, D-dimer levels and BGA parameters (including standardized PaO2) were analyzed. Logistic regression analyses were performed to identify independent predictors for PE and reduce unnecessary CTPA examinations in patients with low PTP according to Wells score. Of 1538 patients, PE was diagnosed in 433 patients (28.2%). The original Wells score (odds ratio: 1.381 [95% CI 1.300-1.467], p < 0.001) and standardized PaO2 (odds ratio: 0.987 [95% CI 0.978-0.996], p = 0.005) were independent predictors for PE. After cohort adjustment for low PTP a D-dimer cut-off < 1.5 mg/L (278 patients (18.1%) with 18 PE (6.5%)) was identified in which a standardized PaO2 > 65 mmHg reduced the number of unnecessary CTPA by 31.9% with a 100% sensitivity. This approach was further validated in additional 53 patients with low PTP. In this validation group CTPA examinations were reduced by 32.7%. No patient with PE was missed. With our novel algorithm combining BGA testing with low PTP according to Wells score, we were able to increase the D-Dimer threshold to 1.5 mg/L and reduce CTPA examinations by approximately 32%.
Subject(s)
Pulmonary Embolism , Humans , Blood Gas Analysis , Fibrin Fibrinogen Degradation Products/analysis , Oxygen , Predictive Value of Tests , Probability , Pulmonary Embolism/diagnosis , Retrospective StudiesSubject(s)
Echocardiography , Emergency Medicine , Algorithms , Humans , Point-of-Care Systems , UltrasonographyABSTRACT
Since 2020 physicians can prescribe digital health applications (DiGA), also colloquially known as apps on prescription, which are reimbursed by the statutory health insurance when they are approved by the Federal Institute for Drugs and Medical Devices (BfArM) and are included in the DiGA Ordinance. Currently, there is one approved DiGA (indication obesity) for internal medicine. There are many questions on the practical use of the DiGA, ranging from the prescription, the effectiveness, the complexities and reimbursement as well as the liability risks. The DiGA are innovative new means, which maybe support internal medicine physicians in the diagnostics and treatment in the future. The benefits in this field of indications are limited by unclarified issues, especially on the prescription practice and the currently low number of DiGA available in internal medicine.
Subject(s)
National Health Programs , Physicians , Germany , Humans , Internal MedicineABSTRACT
BACKGROUND: Little is known about sex differences in elderly patients after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) and subsequent target temperature management (TTM). Therefore, this study was designed to evaluate sex-specific differences in survival and neurological outcome in elderly patients at 28-day and 180-day follow-up. METHODS: A total of 468 nontraumatic OHCA survivors with preclinical ROSC and an age of ≥â¯65 years were included in this study. Sex-specific differences in survival and a favorable neurological outcome according to the cerebral performance category (CPC) score were evaluated as clinical endpoints. RESULTS: Of all participants included, 70.7% were men and 29.3% women. Women were significantly older (pâ¯= 0.011) and were more likely to have a nonshockable rhythm (pâ¯= 0.001) than men. Evaluation of survival rate and favorable neurological outcome by sex category showed no significant differences at 28-day and 180-day follow-up. In multiple stepwise logistic regression analysis, age (odds ratio 0.932 [95% confidence interval 0.891-0.951], pâ¯= 0.002) and time of hypoxia (0.899 [0.850-0.951], pâ¯< 0.001) proved to be independent predictors of survival only in male patients, whereas an initial shockable rhythm (4.325 [1.309-14.291], pâ¯= 0.016) was associated with 180-day survival in female patients. The majority of patients (93.7%) remained in the same CPC category when comparing 28-day and 180-day follow-up. CONCLUSION: Our results show no significant sex-specific differences in survival or favorable neurological outcome in elderly patients after having survived OHCA, but sex-specific predictors for 180-day survival. Moreover, the neurological assessment 28 days after the index event also seems to provide a valid indication for the further prognosis in elderly patients.
Subject(s)
Cardiopulmonary Resuscitation , Out-of-Hospital Cardiac Arrest , Female , Humans , Male , Aged , Out-of-Hospital Cardiac Arrest/therapy , Cardiopulmonary Resuscitation/methods , Sex Characteristics , Survival Rate , Prognosis , Retrospective StudiesABSTRACT
OBJECTIVES: The influence of age on intensive care unit (ICU) decision-making is complex, and it is unclear if it is based on expected subjective or objective patient outcomes. To address recent concerns over age-based ICU decision-making, we explored patient-assessed quality of life (QoL) in ICU survivors before the COVID-19 pandemic. DESIGN: A systematic review and meta-analysis of cohort studies published between January 2000 and April 2020, of elderly patients admitted to ICUs. PRIMARY AND SECONDARY OUTCOME MEASURES: We extracted data on self-reported QoL (EQ-5D composite score), demographic and clinical variables. Using a random-effect meta-analysis, we then compared QoL scores at follow-up to scores either before admission, age-matched population controls or younger ICU survivors. We conducted sensitivity analyses to study heterogeneity and bias and a qualitative synthesis of subscores. RESULTS: We identified 2536 studies and included 22 for qualitative synthesis and 18 for meta-analysis (n=2326 elderly survivors). Elderly survivors' QoL was significantly worse than younger ICU survivors, with a small-to-medium effect size (d=0.35 (-0.53 and -0.16)). Elderly survivors' QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (-0.44 and -0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (-0.43 and 0.00)). Mortality rates and length of follow-up partly explained heterogeneity. Reductions in QoL seemed primarily due to physical health, rather than mental health items. CONCLUSIONS: The results suggest that the proportionality of age as a determinant of ICU resource allocation should be kept under close review and that subjective QoL outcomes should inform person-centred decision -aking in elderly ICU patients. PROSPERO REGISTRATION NUMBER: CRD42020181181.
