[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).

Digital pen technology for conducting cognitive assessments: a cross-over study with older adults.

Many digitalized cognitive assessments exist to increase reliability, standardization, and objectivity. Particularly in older adults, the performance of digitized cognitive assessments can lead to poorer test results if they are unfamiliar with the computer, mouse, keyboard, or touch screen. In a cross-over design study, 40 older adults (age M = 74.4 ± 4.1 years) conducted the Trail Making Test A and B with a digital pen (digital pen tests, DPT) and a regular pencil (pencil tests, PT) to identify differences in performance. Furthermore, the tests conducted with a digital pen were analyzed manually (manual results, MR) and electronically (electronic results, ER) by an automized system algorithm to determine the possibilities of digital pen evaluation. ICC(2,k) showed a good level of agreement for TMT A (ICC(2,k) = 0.668) and TMT B (ICC(2,k) = 0.734) between PT and DPT. When comparing MR and ER, ICC(2,k) showed an excellent level of agreement in TMT A (ICC(2,k) = 0.999) and TMT B (ICC(2,k) = 0.994). The frequency of pen lifting correlates significantly with the execution time in TMT A (r = 0.372, p = 0.030) and TMT B (r = 0.567, p < 0.001). A digital pen can be used to perform the Trail Making Test, as it has been shown that there is no difference in the results due to the type of pen used. With a digital pen, the advantages of digitized testing can be used without having to accept the disadvantages.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]. / Empirische Versorgungsforschung in der Notfall- und Akutmedizin : Erste Ergebnisse eines begleitenden Monitorings zur Patientenrekrutierung und Stichprobenqualität.

BACKGROUND: Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce. STUDY AIM: A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection. MATERIALS AND METHODS: Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses. RESULTS: Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases. DISCUSSION: The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.

[Geriatric intensive care patients : Perspectives and limits of geriatric intensive care medicine]. / Geriatrische Intensivpatienten : Perspektiven und Grenzen der geriatrischen Intensivmedizin.

Critically ill geriatric patients are vitally endangered due to the aging processes of organs, the frequently existing multimorbidity with subsequent polypharmacy and the typical geriatric syndrome of functional impairments. Aging processes in organs lower the clinical threshold for organ dysfunction and organ failure. Physiological organ aging processes with practical consequences for intensive care medicine are atypical manifestion of sepsis in immunosenescence, altered pharmacokinetics, reduced tolerance to hypovolemia due to proportionally reduced water compartment of the body in old age, the frequently only apparently normal function of the kidneys and the continuous reduction in pulmonary function in old age. The main reasons for changes in therapeutic targets are the will of the patient and risk-benefit considerations. The guidelines of the ethics section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provide assistance and suggestions for a structured decision-making process.

Serum IgG levels and mortality in patients with severe sepsis and septic shock : The SBITS data.

BACKGROUND: The role of intravenous immune globulin (Ig) therapy in patients with severe sepsis and septic shock is discussed controversially. Low initial IgG levels could help to identify those patients who might benefit from an adjunctive Ig treatment. OBJECTIVES: To investigate the effect of initial serum IgG levels on 28-day mortality in patients with severe sepsis and septic shock. MATERIALS AND METHODS: In this retrospective analysis of the SBITS trial data, 543 patients were allocated to four groups (quartiles) depending on their initial serum IgG levels (1: IgG ≤ 6.1 g/l; 2: IgG 6.2-8.4 g/l; 3: IgG 8.5-11.9 g/l; 4: IgG > 11.9 g/l). The third quartile was taken as the reference quartile. For the applied logistic regression model clinically relevant confounders were defined and integrated into further risk-adjusted calculations. RESULTS: Patients with the lowest IgG levels had a mortality rate similar to those patients with initial IgG levels in the second and third quartile, representing the physiological IgG range in healthy people. Surprisingly, patients with the highest IgG levels even showed a significantly higher mortality in a risk-adjusted calculation compared to the reference quartile (OR 1.69, CI 1.01-2.81, p = 0.05). Subgroup analyses revealed that initial IgG levels were of no prognostic value in patients presenting with vasopressor-dependent septic shock on admission as well as in patients with either gram-positive or gram-negative sepsis. CONCLUSIONS: Initially low IgG levels do not discriminate between survival and nonsurvival in patients with severe sepsis and septic shock. Therefore, low IgG cannot help to identify those patients who might benefit from an adjunctive IgG sepsis therapy. Whether a high initial IgG serum level is an independent mortality risk factor needs to be investigated prospectively.

[Adherence to Phase III Cardiac Rehabilitation Programs: A Prospective, Randomized Comparison between a Conventionally Conducted Program and a Tai Chi-Based Program]. / Adhärenz in Herzgruppen: Ein prospektiver, randomisierter Vergleich einer konventionell durchgeführten Herzgruppe zu einer Tai-Chi-Herzgruppe.

INTRODUCTION: In patients with cardiac diseases, lifestyle changes such as an increase in physical activity are recommended to prevent further cardiac events. In Germany this is possible by attending outpatient heart groups. A problem inherent in these programs is the lack of adherence since more than two thirds of patients stop attending cardiac rehabilitation programs after six months. An alternative to the conventional implementation of heart groups is Tai Chi, which was found to improve adherence to cardiac rehabilitation programs in international studies. METHODS: Patients were randomly assigned to a conventional heart group or a heart group with Tai Chi exercises. At the beginning of the study, a medical history was taken and physical and instrumental tests were carried out, including an assessment of anxiety/depression (HADS questionnaire) and physical well-being (SD-12). Follow-up tests were performed every three months. RESULTS: Patients were 62.6 ±â€Š8.5 years old, the mean BMI was 28.6 ±â€Š62 kg/m(2), and the proportion of women was 29.8 %. The groups were different in terms of age (conventional heart group: 65.0 ±â€Š7.5; Tai Chi group: 59.9 ±â€Š8.9 years). Therefore, age-adjusted analyses were performed in addition to the planned analyses. Regarding the primary endpoint of the study, there was no difference between the groups. After twelve months, 50 % of subjects were active in the Tai Chi group and 48 % in the conventional heart group (odds ratio 0.92, p = 0.891). After adjustment for age by logistic regression, the odds ratio was 0.47 (p = 0.285). Furthermore, both the participation period in weeks (Tai Chi group: 43.3 ±â€Š26.0; conventional group: 45.5 ±â€Š24.2, p = 0.766) and the participation rate (Tai Chi group: 66.8 ±â€Š19.2 % Tai Chi, conventional group: 76.3 ±â€Š16.5 %, p = 0.074) did not differ between the two groups. A further analysis showed a non-significant trend for improvement of anxiety, depression and physical well-being in the Tai Chi group compared with the conventional group. CONCLUSION: The insight gained in international studies regarding a better adherence to Tai Chi-guided prevention programs was not transferable to heart group participants from Germany. However, there was a trend regarding a better mental condition in the Tai Chi group.

Relation of impaired interorgan communication and parasympathetic activity in chronic heart failure and multiple-organ dysfunction syndrome.

BACKGROUND: We investigated the relationship of impaired autonomic function and severity of illness in chronic heart failure (CHF) and multiple-organ dysfunction syndrome (MODS) as an end stage of CHF. Furthermore, we assessed the link of parasympathetic modulation of the heart rate and inflammatory activation in CHF and MODS. METHODS: Sixty-five patients admitted for worsening of CHF were retrospectively enrolled in this study. In addition, 65 age- and sex-matched patients with pronounced MODS were assigned for comparison of autonomic function and C-reactive protein in patients with CHF or MODS, respectively. Heart rate variability (HRV) parameters of the time and frequency domain as markers of autonomic function were analyzed from 24-hour Holter electrocardiograms. RESULTS: The more pronounced the severity of illness as expressed by the Acute Physiology and Chronic Health Evaluation score, the more the HRV was impaired. This effect was particularly seen for overall variability (SD of RR intervals) and HRV parameters characterizing the parasympathetic modulations of the heart rate (high, very low frequency power). C-reactive protein levels as markers of inflammation were inversely related to high and very low frequencies. CONCLUSION: Our results allow for speculation that autonomic dysfunction in CHF indicates a beginning of uncoupled interorgan communication potentially leading to MODS as characterized by disruption of communication between the organs.

[Situation of acute inpatient geriatric patients. A retrospective analysis of health care processes of geriatric and non-geriatric patients with acute myocardial infarction]. / Akutstationäre Versorgungssituation geriatrischer Patienten. Retrospektive Analyse der Versorgungsverläufe geriatrischer und nichtgeriatrischer Patienten mit akutem Myokardinfarkt.

BACKGROUND: Although cardiovascular diseases belong to the most frequent causes of inpatient treatment of older people the specific characteristics of geriatric patients in the acute care unit still receive marginal attention. The aim of this study was the descriptive representation of clinical health care processes of geriatric and non-geriatric patients with acute myocardial infarction. PATIENTS AND METHODS: Using a retrospective document analysis 83 medical patient records were examined with regard to nursing, therapeutic as well as medical measures and social counseling. The classification in geriatric and non-geriatric patients was based on a predefined list of criteria. RESULTS: In the study a total of 48 geriatric and 35 non-geriatric patients could be identified. There was a comprehensive need for support of nursing and therapeutic care, a high frequency of complications and a long length of stay as well as specifics concerning the place of discharge in geriatric patients. CONCLUSIONS: Complex problems and special care needs of geriatric patients with acute myocardial infarction were shown. This vulnerable group of patients should be given more attention in acute care. Further investigations with a prospective character are necessary in order to detect the specific needs of geriatric patients in acute care.