[Sepsis detection in emergency medicine : Results of an interprofessional survey on sepsis detection in prehospital emergency medicine and emergency departments]. / Sepsis erkennen im Rettungsdienst : Ergebnisse einer interprofessionellen Befragung zur präklinischen und frühen innerklinischen Sepsiserkennung.

BACKGROUND: Sepsis is associated with a high mortality, which can be reduced by starting screening, diagnostics and treatment as early as possible. Due to multiple educational programs and increased awareness, a decreased sepsis mortality on intensive care units has been achieved. Many patients with sepsis are admitted by the prehospital emergency service to hospital emergency departments. Thus, prehospital emergency services and emergency departments provide an opportunity to start screening, diagnosis and treatment earlier. OBJECTIVES: To detect sepsis it is paramount that emergency personnel are aware of the disease and have a profound knowledge regarding symptoms, screening and diagnostics. The objective of this survey was to examine the state of knowledge regarding sepsis among staff working in emergency medicine. MATERIAL AND METHODS: To assess the awareness and knowledge, a paper-based, anonymous survey was conducted among prehospital and emergency department personnel from May to August 2017 in northeastern Germany. Testing of significance was carried out using the χ2-testand Fisher's exact test. RESULTS: Out of 411 persons polled 212 answered (response rate 51.6%) and 24 questionnaires were incomplete and thus excluded. A total of 188 questionnaires were included covering 55 emergency physicians, 23 nurses, 82 paramedics and 19 emergency dispatchers. On a 4-point Likert scale 100% of emergency doctors, 96% of nurses, 84% of paramedics and 84% of emergency dispatchers considered early initiation of sepsis treatment to be important. Additionally, 92% of emergency physicians and 65% of nurses had attended educational programs on sepsis within the last year, which is significantly higher than among paramedics (19%, p < 0.01) and emergency dispatchers (21%, p = 0.025). In addition, 38% of paramedics and 47% of emergency dispatchers had never attended lectures on sepsis. The quick sequential (sepsis-related) organ failure assessment (qSOFA) was known by 80% of emergency doctors, thus, significantly more often than by nurses (26%), paramedics (29%) and emergency dispatchers (29%, p < 0.01). The emergency personnel were asked to tick all symptoms they associated with sepsis from a display of 14 symptoms. Among all occupation groups the majority selected "increased body temperature", "drop in blood pressure" and "altered breathing". In relation to "increased body temperature" the symptom "altered mental status" was selected significantly more frequently by emergency doctors than by nurses and paramedics (p = 0.02 and p < 0.01, respectively). The combination of at least all 3 qSOFA parameters was selected significantly more often by emergency doctors (62%) than by nurses (13%) and paramedics (10%, p = 0.017 and p < 0.01, respectively). CONCLUSION: Although emergency personnel rated an early initiation of sepsis treatment as important, sepsis knowledge was limited. While the majority of emergency doctors and many nurses had attended educational programs on sepsis within the last year, an alarmingly high percentage of paramedics and emergency dispatchers had never received sepsis education. Emergency personnel are mostly unfamiliar with the qSOFA score and did not associate an altered mental status with sepsis. In light of the high sepsis morbidity and mortality, further achievements might be made by initiating sepsis screening and diagnostics in the prehospital setting. Analogous to advancements in intensive care units, increased educational programs for emergency personnel might lead to an earlier detection and improved prognosis of sepsis.

Self-organized nanocrack networks: a pathway to enlarge catalytic surface area in sputtered ceramic thin films, showcased for photocatalytic TiO2.

Sputter deposited photocatalytic thin films offer high adherence and mechanical stability, but typically are outperformed in their photocatalytic properties by colloidal TiO2 nanostructures, which in turn typically suffer from problematic removal. Here we report on thermally controlled nanocrack formation as a feasible and batch applicable approach to enhance the photocatalytic performance of well adhering, reactively sputtered TiO2 thin films. Networks of nanoscopic cracks were induced into tailored columnar TiO2 thin films by thermal annealing. These deep trenches are separating small bundles of TiO2 columns, adding their flanks to the overall catalytically active surface area. The variation of thin film thickness reveals a critical layer thickness for initial nanocrack network formation, which was found to be about 400 nm in case of TiO2. The columnar morphology of the as deposited TiO2 layer with weak bonds between respective columns and with strong bonds to the substrate is of crucial importance for the formation of nanocrack networks. A beneficial effect of nanocracking on the photocatalytic performance was experimentally observed. It was correlated by a simple geometric model for explaining the positive impact of the crack induced enlargement of active surface area on photocatalytic efficiency. The presented method of nanocrack network formation is principally not limited to TiO2 and is therefore seen as a promising candidate for utilizing increased surface area by controlled crack formation in ceramic thin films in general.

A 45-year-old female with hypokalemic rhabdomyolysis due to VIP-producing composite pheochromocytoma.

The watery diarrhea, hypokalemia and achlorhydria (WHDA) syndrome due to vasoactive intestinal polypeptide (VIP)-producing extra-pancreatic tumors is rare. We report on a 45-year-old woman who suffered from persistent secretory diarrhea for six years and who was admitted to hospital with complaints of muscular weakness and myalgia. Biochemical testing revealed pronounced rhabdomyolysis due to severe hypokalemia. Gastrointestinal evaluation of long-standing diarrhea including endoscopy of the upper and lower gastrointestinal tract and the small intestine did not show any pathologies. An abdominal computed tomography scan revealed a mass of 4 × 5 cm in the left adrenal gland demonstrating a strong uptake in the 123I-labelled metaiodobenzylguanidine scintigraphy. Plasma levels of chromogranin A, calcitonin, parathormone, basal renin and most prominently VIP were increased in line with a increased 24 hour urinary secretion of noradrenaline, dopamine, normetanephrine and vanillymandelic acid. A WDHA (watery diarrhea, hypokalaemia, achlorhydria) syndrome with hypokalemic rhabdomyolysis due to a VIP-producing adrenal tumor was diagnosed that was removed surgically. The histological evaluation demonstrated a composite pheochromocytoma. Diarrhea stopped immediately after surgery together with a normalization of laboratory parameters. In conclusion, this case report focuses on the rare clinical presentation of secretory diarrhea and electrolyte disturbances in combination with hypokalemic rhabdomyolysis which was caused by a VIP-producing composite pheochromocytoma.

Properties and applications of the (2-nitrofluoren-9-yl)methoxycarbonyl group.

This paper presents a new protecting group, the (2-nitrofluoren-9-yl)methoxycarbonyl group. Investigations on the properties of this new modification of the Fmoc-system, such as the solvent-dependent photochemical cleavage, and enhanced lability towards bases, are described, as well as UV-kinetic measurements of the cleavage reaction. In addition, the incorporation of the (2-nitrofluoren-9-yl)methoxycarbonyl group into two peptides, and a sequence-dependent photochemical cleavage reaction are reported.

Stereo-random synthesis of highly functionalized proline analogues by azomethine cycloaddition.

Highly substituted proline analogues were synthesized on Wang-resin bearing bisprotected histidine as starting material. The proline analogues (1,5-diazabicyclo[3.3.0]octane-2-carboxylic acid) were generated by 1,3-dipolar cycloaddition of azomethine ylides with maleimides, thus creating a library of maximum stereochemical diversity. Every compound set with the same empirical formula can theoretically consist of four diastereomers and can be tested in biological assays as mixture. Additionally different methods for the acylation of the proline nitrogen were evaluated.

Monitoring of solid phase peptide synthesis by FT-IR spectroscopy.

Aggregation phenomena of growing peptides on the resin have seldom been investigated. We report here how conformations are determined by FT-IR spectroscopy. Therefore the sequence 80-99 of HIV 1-protease was synthesized. After every coupling a resin sample was taken out of the reaction column and a FT-IR spectrum recorded. The results were compared with the UV monitoring obtained from another synthesis of the same peptide.

A gene cluster closely related to type II secretion pathway operons of gram-negative bacteria is located on the large plasmid of enterohemorrhagic Escherichia coli O157 strains.

Analysis of 14.162 kb of DNA derived from plasmid pO157 of enterohemorrhagic Escherichia coli (EHEC) O157:H7 strain EDL933, extending in the 5' direction of the recently described EHEC-hly operon, revealed 13 open reading frames (ORF) which showed great similarities to genes of members of the type II pathway secretion systems of Gram-negative bacteria. We named the ORFs etpC to etpO for EHEC type II secretion pathway. In addition, an IS911-like insertion element was found to separate the etp genes from the EHEC-hlyC gene. Hybridization experiments with a specific etp probe and various categories of enteric E. coli pathotypes revealed that the etp gene cluster occurred in all 30 EHEC strains of serogroup O157 (100%) tested and is distributed sporadically among other EHEC serogroups (60%). In addition, the etp genes were rarely detected in STEC isolated from bovine feces (10%). Moreover, it was found not to occur in enteropathogenic E. coli, enteroaggregative E. coli, enterotoxigenic E. coli and enteroinvasive E. coli. The results obtained with the etp probe were confirmed by a PCR approach to specifically detect an internal fragment of the etpD gene.

[Bilateral coronary fistula: a case report and review]. / Beidseitige Koronarfistel: Eine Fallpräsentation und Ubersicht.

A case is presented of an atypical arteriovenous coronary artery fistula which occurred in a young man who was admitted to hospital with constant stress-dependent dyspnea and a feeling of thoracic constriction. A continuous systolic-diastolic murmur above the 5th intercostal space to the left of the sternum was present. By means of transoesophageal echocardiography and heart catheterization a rather atypical bilateral coronary fistula was found. A bilateral coronary fistula had been formed from RCA and RCX which drained via a common intramural cavity into the right ventricle. The fistula was operatively closed. Bilateral coronary artery fistula are rare, being found with a frequency of 0.002-0.013% in heart catheterization. In 36 reported instances of bilateral fistulae it has been noted that drainage into the pulmonary artery is more common than is the case with single coronary artery fistulae. The therapeutic considerations correspond with those for single fistulae.

Polymerase chain reaction for the identification of Porphyromonas gingivalis collagenase genes.

Porphyromonas gingivalis has been shown to exhibit genetic diversity possibly resulting in variation of virulence. In the present study a potential virulence factor was targeted for the detection of P. gingivalis. A 548 bp fragment of the collagenase gene (prtC) from Porphyromonas gingivalis ATCC 33277 was amplified by polymerase chain reaction (PCR) using oligonucleotides derived from the middle portion of prtC. From 16 of 21 clinical P. gingivalis strains, a PCR product of similar size to the prtC could be obtained. These 16 P. gingivalis strains were confirmed as positive for prtC using DNA hybridization with a digoxigenin-labeled prtC PCR product as a probe. In 12 of the 16 prtC positive strains, the restriction analysis of the PCR products revealed fragment patterns identical to the known sequence. In the other 4 prtC positive strains, 4 distinct patterns were found. Of these strains, nucleotide sequence analysis of a 400 bp PCR product stretch revealed 79.1%, 83.0%, 84.8 and 89.5% homology with the known nucleotide sequence for this specific region. Sequence analysis of the PCR products from the ATCC 33277 strain demonstrated 93.7% homology. The limit of detection for the PCR was about 100 organisms. None of the other 48 tested strains of 16 bacterial species derived from oral and extraoral infections yielded a PCR product. The PCR was also used for the detection of prtC sequences in dental plaque. Our data indicate that not all P. gingivalis strains have prtC. Nucleotide heterogeneity exists among P. gingivalis with prtC.(ABSTRACT TRUNCATED AT 250 WORDS)

Chicken vigilin gene organization and expression pattern. The domain structure of the protein is reflected by the exon structure.

Chicken vigilin was identified as a member of an evolutionary-conserved protein family with a unique repetitive domain structure. 14 tandemly repeated domains are found in chicken vigilin, all of which consist of a conserved sequence motif (subdomain A) and a potential alpha-helical region (subdomain B) [1]. We have established the physical structure of the chicken vigilin gene by restriction-fragment analysis and DNA sequencing of overlapping clones isolated from a phage lambda genomic DNA library. The chicken vigilin gene is a single-copy gene with a total of 27 exons which are distributed over a region of some 22 kbp. Exon 1 codes for a portion of the 5' untranslated region, exon 2 contains the translation start point and forms, along with exons 3 and 4, the N-terminal non-domain region. Exons 5-25 encode the vigilin domains 1-14 and the remaining exons 26 and 27 contain the non-domain C-terminal as well as the untranslated regions. The domain structure of the protein is reflected in the positioning of introns which demarcate individual domains. While domains 1-3 and 8-10 are each encoded by a single exon (5-7, 16-18); all other domains are contained in a set of two exons which are separated by introns interspersed at variable positions of the DNA segment coding for the conserved sequence motif. In conclusion, the data presented suggest that the chicken vigilin gene evolved by amplification of a primordial exon unit coding for the fundamental bipartite vigilin domain.

Complete cDNA sequence of chicken vigilin, a novel protein with amplified and evolutionary conserved domains.

The complete cDNA (4375 bp), coding for a new protein called vigilin, was isolated from chicken chondrocytes. The cDNA shows an open reading frame of 1270 amino acids which are organized in 14 tandemly repeated homologous domains. Each domain consists of two subdomains, one with a conserved sequence motif of 35 amino acids (subdomain A) and another one with a presumptive alpha-helical structure of 21-33 amino acids (subdomain B). 149 amino acids at the N-terminus and 71 amino acids at the C-terminus of vigilin do not show the characteristic domain structure. No sequence characteristic of a signal peptide has been found, which argues for an intracellular localisation of vigilin. Vigilin is highly expressed in freshly isolated chicken chondrocytes but little in chondrocytes after prolonged time in culture. Vigilin mRNA exists in two size species, 4.4 kb and 6.5 kb in length due to the usage of different polyadenylation sites. Comparison of the vigilin sequence with data bases showed a remarkable similarity to protein HX from Saccharomyces cerevisiae [Delahodde, A., Becam, A. M., Perea, J. & Jacq, C. (1986) Nucleic Acids Res. 14, 9213-9214]. The yeast protein consists of eight homologous domains with 11 conserved amino acid residues within a set of 35 amino acids. The N-terminal and C-terminal regions of vigilin and protein HX do not reveal any sequence similarity. These results, together with the demonstration of the characteristic vigilin sequence motif in a human cDNA clone, suggest that the repeats represent evolutionary conserved autonomous domains within a family of proteins found in yeast, chicken and man.

Standardized noninvasive assessment of myocardial free fatty acid kinetics by means of 15-(p-iodo-phenyl) pentadecanoic acid (123I-pPPA) scintigraphy: II. Clinical results.

Our results establish that myocardial regions supplied by a significantly stenosed coronary vessel can be distinguished with high statistical significance from healthy regions on account of changes in the myocardium/background ratio, i.e. a reduction of regional uptake of 15-(p-iodo-phenyl) pentadecanoic acid (pPPA). The statistical significance applies to patients with coronary artery disease (CAD), to all examined CAD areas without areas of infarction as well as to infarcted regions. Our results also confirm the suitability of labelled fatty acids, such as pPPA, for the visualization of damaged myocardial regions. The results further indicate that pPPA practically is of comparable value to 201Tl with regard to their respective qualities as 'static' imaging agents for the heart muscle. This study, with the help of a simultaneous analysis of regional myocardial perfusion rates (rMBF) and of a parameter for the metabolism of fatty acids, practised here for the first time, could demonstrate interindividual differences between patients and groups of patients with a correlation between perfusion and the utilization of pPPA in patients with CAD. The reciprocal of the rMBF, the mean transit time (MTT), was significantly prolonged after stress in patients with CAD (P less than 0.05), suggesting impaired 'microcirculation' in the patient group. The determination of elimination half-lives (T1/2) contributes little if any information towards delineation of cardiac disease entities. The wide overlap of T1/2 values between various clinical syndromes and entities with extreme standard deviations remained an annoying problem in our studies. Nevertheless, certain trends in T1/2 behaviour could be recorded, but they did not yield any statistical significances, because of the high degree of individual variability. A considerable variability of T1/2 values among healthy controls was recorded as well as intra-individually in different regions of the heart muscle. The wide range of 'normal' values rendered statistical evaluation almost, if not entirely, impossible. It appears that the high degree of variability results amongst others, from technical shortcomings in the external recording instruments, i.e. gamma cameras, as well as from the presence of interfering alternate substrates such as glucose and lactate. Nevertheless, the wide range of measured results in healthy control subjects suggests the presence of a considerable regional intra-individual heterogeneity of cardiac substrate metabolism. One must therefore accept, at least in our opinion, that T1/2 values are not sufficiently reliable as an indicator of myocardial metabolism and are of little value with respect to clinical diagnostic considerations and to prognosis as well. Possible explanations for this finding are offered and discussed in this paper.

Physicochemical characterization of tetraether lipids from Thermoplasma acidophilum. V. Evidence for the existence of a metastable state in lipids with acyclic hydrocarbon chains.

The main glycophospholipid of Thermoplasma acidophilum, grown at 39 degrees C, is composed of a di-isopranol-2,3-glycerotetraether. It has been characterized in hydrated systems by calorimetry. Unlike its equivalent grown at 59 degrees C, it shows complex phase properties, which include at least three different phases, (1) a liquid-analogue state (C), which is stable above 20 degrees C, (2) a metastable solid-analogue state (A) formed by supercooling of the liquid-analogue state (C) and (3) a stable solid-analogue state (B), which is slowly formed and may include a close chain packing of lipids and a network of hydrogen bonds between the headgroups. A high fraction of acyclic isopranol chains seems to be a prerequisite for the formation of state (B). A phase diagram, displaying the observed states and the transitions between them is proposed.

Hemodynamics during PEEP ventilation in patients with severe left ventricular failure studied by transesophageal echocardiography.

The effects of mechanical ventilation with PEEP were investigated in five patients with normal cardiopulmonary function (group A) and in 11 patients with severe left ventricular failure (group B). Cross-sectional area of the right and left atrium (RA/LA), left ventricle (LV), and right ventricle (RV) was determined at EDA/ESA using transesophageal echocardiography. Hemodynamic parameters and transesophageal pressure were measured simultaneously at PEEP levels 0, 4, 8, 12, and 16 cm H2O. End-diastolic area of the right atrium decreased significantly in both groups. The RA pressure increased, while transmural pressure remained unaltered. The CI decreased in both groups. The decrease in cardiac output by PEEP ventilation was related to the decrease in RV filling volume by external compression. In patients with congestive heart failure, PEEP ventilation with 8 to 10 cm H2O did not worsen LV function.

Echocardiographic findings in patients with proved pulmonary embolism.

Echocardiographic studies were performed in 105 patients with acute and recurrent pulmonary emboli. Pulmonary embolism was confirmed by pulmonary angiography (n = 48), autopsy (n = 6), and lung perfusion scintigraphy (n = 51). Seventy of 93 patients (75%) displayed a dilated right ventricle, 38 of 91 patients (42%) had reduced left ventricular cavity dimension, 41 of 82 patients (50%) had a decreased EF slope of the mitral valve, and 78 of 101 patients (77%) showed dilatation of the right pulmonary artery. The motion of the interventricular septum was abnormal in 41 of 93 patients (44%). Right-sided thrombi were seen in 13 patients within the right pulmonary artery (n = 11) and in the right ventricle (n = 3); in one patient they were found in the superior vena cava, in the innominate vein, and the right atrium. Two patients suffered from right-sided endocarditis. Thus echocardiographic changes were frequently found in patients with proved pulmonary emboli. The echocardiographic findings of right-sided cardiac and pulmonary artery abnormalities indicate hemodynamically active pulmonary emboli.

Stimulus-induced vulnerability in the early and late postinfarction phase.

In 45 survivors of myocardial infarction, cardiac catheterization was performed one and six months after the acute event. After completion of the angiographic investigation, ventricular vulnerability was assessed, using programmed right ventricular stimulation (rates 120 and 140 min-1, single and double premature impulses). In 27/45 patients the results of programmed electrical stimulation were comparable at one and six months. The overall incidence of repetitive ventricular response did not change. There was no correlation between the change of repetitive ventricular response and the change of effective right ventricular refractory period and the change of angiographic parameters (Gensini score, left ventricular ejection fraction and volume indices). It is concluded that between the first and the sixth month after infarction there is no relevant alteration in the propensity to repetitive ventricular response.

Attempt to modify Rauscher-virus leukemogenesis by modulation of lymphoreticular and hematopoietic tissue.

Rauscher erythroleukemia virus of the mouse was originally isolated from an animal bearing a lymphocytic neoplasm. In order to control extraneous influences on leukemia development, we modulated thymus-dependent and bursa-dependent lymphatic tissues and the granulopoietic and erythropoietic components of hemoreticular tissues during the latent period of leukemia development. In all experiments the same type of erythroleukemia was found with some variation in the course of the disease.