Können wir unseren Fachbüchern vertrauen? - Leitlinienkonformität deutscher Lehrbücher bei der präklinischen Behandlung des Schlaganfalls

HINTERGRUND: Bei der Therapie des Schlaganfalls spielt die präklinische Versorgung eine wichtige Rolle. Ziel unseres Projekts war es, die Vollständigkeit und Zuverlässigkeit von medizinischen Lehrbüchern mit Therapieanleitungen zur präklinischen Schlaganfallversorgung zu untersuchen. Lehrbücher sind für Ärzte wie Studenten nach wie vor, trotz der aufkommenden Alternativen in Form digitaler Medien, sehr wichtige Informationsquellen für Examina und medizinische Entscheidungen. METHODEN: Wir führten eine systematische Lehrbuch-Literatursuche gemäß den PRISMA-Kriterien durch. Die Inhalte zur präklinischen Therapie des Schlaganfalls wurden durch zwei unabhängige Untersucher evaluiert. Qualitätsstandard der Evaluation waren die aktuellen Schlaganfall-Leitlinien. Die endgültige Bewertung erfolgte in einem Konsensus Prozess. ERGEBNISSE: Von 68 Lehrbüchern zur Notfallmedizin zwischen 2011 und 2014 konnten 16 mit Inhalten zur präklinischen Therapie des Schlaganfalls bewertet werden. Die meisten untersuchten Lehrbücher zeigten gravierende Auslassungen und Abweichungen im Vergleich zu den Handlungsempfehlungen anerkannter aktueller Leitlinien. In fast allen Büchern fehlten die Quellennachweise. ZUSAMMENFASSUNG: Die meisten Notfallmedizinlehrbücher zur präklinischen Therapie des Schlaganfalls vermitteln momentan nicht die notwendigen Inhalte für eine erfolgreiche Therapie. Wegen fehlender Quellenangaben fehlt den Lesern auch die Möglichkeit Wissensinhalte nachzuvollziehen und zu vertiefen. Es ist dringend notwendig Lehrbuchinhalte auf einen Qualitätsstandard zu bringen, wie er von der evidenz-basierten Medizin gefordert wird

Arzneimitteltherapiesicherheit gefördert durch die interprofessionelle Zusammenarbeit von Arzt und Apotheker auf Intensivstationen in Deutschland

Hintergrund Kritisch kranke Patienten sind besonders anfällig für unerwünschte Arzneimittelereignisse. Internationale Studien zeigen, dass pharmazeutische Betreuung die Patienten- und Arzneimitteltherapiesicherheit positiv beeinflusst. National wird die Integration von Apothekern in das multidisziplinäre Team und eine Teilnahme an Visiten gefordert. Ziel dieser Arbeit ist es, Art und Umfang der pharmazeutischen Betreuung in der Intensivmedizin in Deutschland zu erheben. Methode In einer Literatur- und Datenbankrecherche wurden 13 relevante pharmazeutische Tätigkeiten identifiziert. Darauf aufbauend wurde von einem Expertengremium ein Onlinesurvey mit 27 Fragen zur Implementierung der pharmazeutischen Betreuung auf Intensivstationen erstellt. Die Umfrage wurde an Leiter deutscher Intensivstationen versandt. Ergebnisse Eine regelmäßige pharmazeutische Betreuung ist bei 35,3 % (59/167) der Intensivstationen etabliert. Arzneimittelinformation (89,7 % [52/58]), pharmazeutische Interventionen mit Therapieumstellung (z. B. in der Visite; 67,2 % [39/58]), regelmäßige Evaluation der Verordnung (Medikationsanalyse; 65,5 % [38/58]) sowie die Überwachung der Medikation (hinsichtlich von Nebenwirkungen, Effektivität und Kosten; 63,8 % [37/58]) zählen zu den meistgenannten Tätigkeiten. Die Teilnehmer mit pharmazeutischer Betreuung (58/168) stufen 7 von 13 Tätigkeiten als „essenziell/unverzichtbar“ ein, wohingegen es nur zwei bei den Teilnehmern ohne pharmazeutische Betreuung (104/168) sind. Schlussfolgerung Nur wenige Intensivstationen in Deutschland haben den Stationsapotheker bereits in das multidisziplinäre Team integriert. Ist ein pharmazeutischer Service etabliert, wird mehreren pharmazeutischen Tätigkeitsfeldern eine höhere Gewichtung/Bedeutung zugeschrieben

The effects of midazolam on intraocular pressure in children during examination under sedation

Background: To obtain reliable and accurate measurements of the intraocular pressure (IOP) in children often requires sedation or anaesthesia. Therefore, we investigated the effects of oral midazolam on IOP in children. Methods: In a prospective study, IOP was measured in 72 eyes of 36 cooperative children without glaucoma requiring general anaesthesia (mean age 3.5±1.3 years, body weight ≤20 kg) by using a Perkins hand-held tonometer. Measurements of IOP were performed before, and 15 and 30 min after sedation with orally administered midazolam (1 mg/kg) given as preoperative medication, and 5 and 15 min after induction of general anaesthesia. The individual IOP courses were analysed. Results: In all of the cooperative children, IOP measurement was possible after sedation with midazolam. Mean IOP was 11.2±0.3 mmHg before sedation, 10.9±0.2 mmHg at 15 min, and 10.7±0.3 mmHg 30 min after administration of midazolam. This small decrease was not statistically significant, whilst the IOP decline at 5 and 15 min after induction of general anaesthesia was statistically significant (p<0.0001). Conclusion: Sedation with midazolam can be assumed to be an applicable, well-tolerated, safe method for IOP measurements in children

Transcranial Ultrasound from Diagnosis to Early Stroke Treatment - Part 2: Prehospital Neurosonography in Patients with Acute Stroke - The Regensburg Stroke Mobile Project

Background and Purpose: The primary aim of this study was to investigate the diagnostic accuracy and time frames for neurological and transcranial color-coded sonography (TCCS) assessments in a prehospital ‘911’ emergency stroke situation by using portable duplex ultrasound devices to visualize the bilateral middle cerebral arteries (MCAs). Methods: This study was conducted between May 2010 and January 2011. Patients who had sustained strokes in the city of Regensburg and the surrounding area in Bavaria, Germany, were enrolled in the study. After a ‘911 stroke code’ call had been dispatched, stroke neurologists with expertise in ultrasonography rendezvoused with the paramedic team at the site of the emergency. After a brief neurological assessment had been completed, the patients underwent TCCS with optional administration of an ultrasound contrast agent in cases of insufficient temporal bone windows or if the agent had acute therapeutic relevance. The ultrasound studies were performed at the site of the emergency or in the ambulance during patient transport to the admitting hospital. Relevant timelines, such as the time from the stroke alarm to patient arrival at the hospital and the duration of the TCCS, were documented, and positive and negative predictive values for the diagnosis of major MCA occlusion were assessed. Results: A total of 113 patients were enrolled in the study. MCA occlusion was diagnosed in 10 patients. In 9 of these 10 patients, MCA occlusion could be visualized using contrast-enhanced or non-contrast-enhanced TCCS during patient transport and was later confirmed using computed tomography or magnetic resonance angiography. One MCA occlusion was missed by TCCS and 1 atypical hemorrhage was misdiagnosed. Overall, the sensitivity of a ‘field diagnosis’ of MCA occlusion was 90% [95% confidence interval (CI) 55.5–99.75%] and the specificity was 98% (95% CI 92.89–99.97%). The positive predictive value was 90% (95% CI 55.5–99.75%) and the negative predictive value was 98% (95% CI 92.89–99.97%). The mean time (standard deviation) from ambulance dispatch to arrival at the patient was 12.3 min (7.09); the mean time for the TCCS examination was 5.6 min (2.2); and the overall mean transport time to the hospital was 53 min (18). Conclusion: Prehospital diagnosis of MCA occlusion in stroke patients is feasible using portable duplex ultrasonography with or without administration of a microbubble contrast agent. Prehospital neurological as well as transcranial vascular assessments during patient transport can be performed by a trained neurologist with high sensitivity and specificity, perhaps opening an additional therapeutic window for sonothrombolysis or neuroprotective strategies

Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound

Background Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination. Methods Following a '911 stroke code' call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care. Results We enrolled '232 stroke code' patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as 'stroke mimics'. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis 'any stroke' showed a sensitivity of 94% and a specificity of 48%. 'Major MCA or ICA stroke' diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%. Conclusions The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment

Effects of single-point acupuncture (HT7) in the prevention of test anxiety: Results of a RCT

Background The number of students using neuro enhancement to improve their performance and to prevent test anxiety is increasing. The acupuncture point Heart 7 (HT7) has been described as being prominent in reducing states of anxiety. Methods We conducted a randomized placebo-controlled, two-armed pilot trial to investigate the efficacy of a single-point acupuncture treatment at bilateral HT7 compared to sham laser acupuncture on test anxiety. Test anxiety was induced applying the standardised protocol of the Trier Social Stress Test. Outcome measures included saliva samples analysed for cortisol and amylase, anxiety questionnaires and heart rate variability. Results Twenty-five male subjects (age 28 ± 5 years) were allocated to either verum acupuncture (n = 12) or sham laser acupuncture (n = 13). Cortisol peaked 20 min after the stress test (2-fold, 18.11 ± 2 nmol/l) and amylase 10 min after (2-fold, 259 ± 49 U/ml) with no difference between groups. There were no differences between groups regarding either anxiety questionnaires or physiological parameters. Compared to reference data (3-fold increase in cortisol), increase in stress hormones and heart rate seemed somewhat reduced. Conclusions Acupuncture may be a possible approach for the treatment of anxiety. Due to the lack of a no control treatment group, we cannot determine the magnitude of possible specific needle effects at HT7 to promote specific effects in the neuroendocrine system. Finally this study only examines the efficacy of a single time treatment