Die diagnostische Aussagekraft der Schmerzlokalisation bei Brustschmerzpatienten in der Primärversorgung

Hintergrund Brustschmerz ist ein häufiges Symptom in der Primärversorgung. Die diagnostische Evaluation von Brustschmerzpatienten stellt für Hausärzte allerdings eine Herausforderung dar. Denn dem Leitsymptom Brustschmerz liegt ein breites Spektrum unterschiedlichster Erkrankungen zugrunde, worunter die schwerwiegenden kardiovaskulären Ätiologien nur selten sind. Für die differentialdiagnostische Beurteilung wurde der Schmerzlokalisation bisher ein diskriminativer Nutzen zugesprochen. Das Ziel dieses Projektes war es, digitale Bilder der Schmerzlokalisationen für eine große Kohorte von Brustschmerzpatienten aus der Primärversorgung zu aggregieren, um dadurch vor allem die folgende Forschungsfrage zu beantworten: Ist die Schmerzlokalisation bei Brustschmerzpatienten in der Primärversorgung hilfreich, um zwischen der koronaren Herzkrankheit (KHK) und anderen Erkrankungen zu diskriminieren? Methode Es handelt sich bei diesem Projekt um die Sekundäranalyse einer diagnostischen Querschnittsstudie aus der Primärversorgung, in der 1212 Brustschmerzpatienten aus 74 Hausarztpraxen des Bundeslandes Hessen konsekutiv rekrutiert wurden. Hausärzte zeichneten u.a. die Schmerzlokalisation und -ausstrahlung in eine Thoraxgraphik auf einem standardisierten Erhebungsbogen ein. Ein unabhängiges Referenzkomitee entschied nach Ablauf der Nachbeobachtungsperiode über die zugrunde liegende Diagnose bei Erstkonsultation. Für die vorliegende Subanalyse wurden die Schmerzgraphiken von insgesamt 1211 Pateinten ausgewertet. Anhand einer speziell entwickelten Computer-Software wurden die Graphiken mit dem Maus-Cursor manuell digitalisiert. Durch Aggregation der digitalen Einzelbilder konnte im Verlauf die Schmerzdistribution für verschiedene Erkrankungen graphisch dargestellt werden. Unterschiede hinsichtlich der Schmerzverteilung von unterschiedlichen Gruppen wurden durch zwei verschiedene Berechnungsverfahren analysiert, dem Hausdorff-Abstand und dem C-Index. Ergebnisse Die Schmerzen waren für fast alle Brustschmerzätiologien überwiegend in der linksanterioren Thoraxhälfte lokalisiert und konzentrierten sich auf die präkordiale Region. Im Vergleich zwischen den Patienten mit KHK und Patienten mit anderen häufigen Ursachen für Brustschmerz, wie beispielsweise dem Brustwandsyndrom (BWS), der gastroösophagealen Refluxerkrankung (GERD) und psychogenen Beschwerden, konnte kein signifikanter Unterschied in der Schmerzlokalisation ermittelt werden. Bei Patienten mit BWS, die dachten, dass ihre Schmerzen vom Herzen kämen, stellte die Schmerzlokalisation ein signifikantes Unterscheidungskriterium zu den Patienten mit BWS dar, die keine kardiale Genese vermuteten. Schlussfolgerung Die Schmerzlokalisation ist weder hilfreich, um zwischen der KHK und anderen Brustschmerzätiologien in der Primärversorgung zu unterscheiden, noch ist sie diagnostisch nützlich, um einzelne Erkrankungen zu identifizieren. In der Differentialdiagnostik des Leitsymptoms Brustschmerz ist sie daher alleine keine große Hilfe für Hausärzte und sollte nur in der Zusammenschau mit anderen klinischen Eigenschaften bewertet werden. Es ist zu vermuten, dass sich durch die Assoziation von linksthorakalem Brustschmerz mit kardialen Erkrankungen in der Bevölkerung, besonders die linksseitige Brustschmerzlokalisation zu einem Trigger für zunehmende Arztbesuche entwickelt hat. In der Konsequenz hat sich ihre Aussagekraft für die Primärversorgung reduziert. Das alleinige Symptom „Brustschmerzlokalisation“ hat daher für Hausärzte in der Evaluation von Brustschmerzpatienten nur einen limitierten diagnostischen Nutzen

Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? - A cross sectional study

BACKGROUND: Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. METHODS: We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. RESULTS: Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. CONCLUSIONS: Pain localization is not helpful in discriminating CHD from other common chest pain etiologies

Overview: On the transport and transformation of pollutants in the outflow of major population centres – observational data from the EMeRGe European intensive operational period in summer 2017

Megacities and other major population centres (MPCs) worldwide are major sources of air pollution, both locally as well as downwind. The overall assessment and prediction of the impact of MPC pollution on tropospheric chemistry are challenging. The present work provides an overview of the highlights of a major new contribution to the understanding of this issue based on the data and analysis of the EMeRGe (Effect of Megacities on the transport and transformation of pollutants on the Regional to Global scales) international project. EMeRGe focuses on atmospheric chemistry, dynamics, and transport of local and regional pollution originating in MPCs. Airborne measurements, taking advantage of the long range capabilities of the High Altitude and LOng Range Research Aircraft (HALO, https://www.halo-spp.de, last access: 22 March 2022), are a central part of the project. The synergistic use and consistent interpretation of observational data sets of different spatial and temporal resolution (e.g. from ground-based networks, airborne campaigns, and satellite measurements) supported by modelling within EMeRGe provide unique insight to test the current understanding of MPC pollution outflows. In order to obtain an adequate set of measurements at different spatial scales, two field experiments were positioned in time and space to contrast situations when the photochemical transformation of plumes emerging from MPCs is large. These experiments were conducted in summer 2017 over Europe and in the inter-monsoon period over Asia in spring 2018. The intensive observational periods (IOPs) involved HALO airborne measurements of ozone and its precursors, volatile organic compounds, aerosol particles, and related species as well as coordinated ground-based ancillary observations at different sites. Perfluorocarbon (PFC) tracer releases and model forecasts supported the flight planning, the identification of pollution plumes, and the analysis of chemical transformations during transport. This paper describes the experimental deployment and scientific questions of the IOP in Europe. The MPC targets – London (United Kingdom; UK), the Benelux/Ruhr area (Belgium, the Netherlands, Luxembourg and Germany), Paris (France), Rome and the Po Valley (Italy), and Madrid and Barcelona (Spain) – were investigated during seven HALO research flights with an aircraft base in Germany for a total of 53 flight hours. An in-flight comparison of HALO with the collaborating UK-airborne platform Facility for Airborne Atmospheric Measurements (FAAM) took place to assure accuracy and comparability of the instrumentation on board. Overall, EMeRGe unites measurements of near- and far-field emissions and hence deals with complex air masses of local and distant sources. Regional transport of several European MPC outflows was successfully identified and measured. Chemical processing of the MPC emissions was inferred from airborne observations of primary and secondary pollutants and the ratios between species having different chemical lifetimes. Photochemical processing of aerosol and secondary formation or organic acids was evident during the transport of MPC plumes. Urban plumes mix efficiently with natural sources as mineral dust and with biomass burning emissions from vegetation and forest fires. This confirms the importance of wildland fire emissions in Europe and indicates an important but discontinuous contribution to the European emission budget that might be of relevance in the design of efficient mitigation strategies. The present work provides an overview of the most salient results in the European context, with these being addressed in more detail within additional dedicated EMeRGe studies. The deployment and results obtained in Asia will be the subject of separate publications

Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? - A cross sectional study

BACKGROUND: Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. METHODS: We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. RESULTS: Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. CONCLUSIONS: Pain localization is not helpful in discriminating CHD from other common chest pain etiologies

TRY plant trait database – enhanced coverage and open access

Plant traits - the morphological, anatomical, physiological, biochemical and phenological characteristics of plants - determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait‐based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits - almost complete coverage for ‘plant growth form’. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait–environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives

Die diagnostische Aussagekraft der Schmerzlokalisation bei Brustschmerzpatienten in der Primärversorgung

Hintergrund Brustschmerz ist ein häufiges Symptom in der Primärversorgung. Die diagnostische Evaluation von Brustschmerzpatienten stellt für Hausärzte allerdings eine Herausforderung dar. Denn dem Leitsymptom Brustschmerz liegt ein breites Spektrum unterschiedlichster Erkrankungen zugrunde, worunter die schwerwiegenden kardiovaskulären Ätiologien nur selten sind. Für die differentialdiagnostische Beurteilung wurde der Schmerzlokalisation bisher ein diskriminativer Nutzen zugesprochen. Das Ziel dieses Projektes war es, digitale Bilder der Schmerzlokalisationen für eine große Kohorte von Brustschmerzpatienten aus der Primärversorgung zu aggregieren, um dadurch vor allem die folgende Forschungsfrage zu beantworten: Ist die Schmerzlokalisation bei Brustschmerzpatienten in der Primärversorgung hilfreich, um zwischen der koronaren Herzkrankheit (KHK) und anderen Erkrankungen zu diskriminieren? Methode Es handelt sich bei diesem Projekt um die Sekundäranalyse einer diagnostischen Querschnittsstudie aus der Primärversorgung, in der 1212 Brustschmerzpatienten aus 74 Hausarztpraxen des Bundeslandes Hessen konsekutiv rekrutiert wurden. Hausärzte zeichneten u.a. die Schmerzlokalisation und -ausstrahlung in eine Thoraxgraphik auf einem standardisierten Erhebungsbogen ein. Ein unabhängiges Referenzkomitee entschied nach Ablauf der Nachbeobachtungsperiode über die zugrunde liegende Diagnose bei Erstkonsultation. Für die vorliegende Subanalyse wurden die Schmerzgraphiken von insgesamt 1211 Pateinten ausgewertet. Anhand einer speziell entwickelten Computer-Software wurden die Graphiken mit dem Maus-Cursor manuell digitalisiert. Durch Aggregation der digitalen Einzelbilder konnte im Verlauf die Schmerzdistribution für verschiedene Erkrankungen graphisch dargestellt werden. Unterschiede hinsichtlich der Schmerzverteilung von unterschiedlichen Gruppen wurden durch zwei verschiedene Berechnungsverfahren analysiert, dem Hausdorff-Abstand und dem C-Index. Ergebnisse Die Schmerzen waren für fast alle Brustschmerzätiologien überwiegend in der linksanterioren Thoraxhälfte lokalisiert und konzentrierten sich auf die präkordiale Region. Im Vergleich zwischen den Patienten mit KHK und Patienten mit anderen häufigen Ursachen für Brustschmerz, wie beispielsweise dem Brustwandsyndrom (BWS), der gastroösophagealen Refluxerkrankung (GERD) und psychogenen Beschwerden, konnte kein signifikanter Unterschied in der Schmerzlokalisation ermittelt werden. Bei Patienten mit BWS, die dachten, dass ihre Schmerzen vom Herzen kämen, stellte die Schmerzlokalisation ein signifikantes Unterscheidungskriterium zu den Patienten mit BWS dar, die keine kardiale Genese vermuteten. Schlussfolgerung Die Schmerzlokalisation ist weder hilfreich, um zwischen der KHK und anderen Brustschmerzätiologien in der Primärversorgung zu unterscheiden, noch ist sie diagnostisch nützlich, um einzelne Erkrankungen zu identifizieren. In der Differentialdiagnostik des Leitsymptoms Brustschmerz ist sie daher alleine keine große Hilfe für Hausärzte und sollte nur in der Zusammenschau mit anderen klinischen Eigenschaften bewertet werden. Es ist zu vermuten, dass sich durch die Assoziation von linksthorakalem Brustschmerz mit kardialen Erkrankungen in der Bevölkerung, besonders die linksseitige Brustschmerzlokalisation zu einem Trigger für zunehmende Arztbesuche entwickelt hat. In der Konsequenz hat sich ihre Aussagekraft für die Primärversorgung reduziert. Das alleinige Symptom „Brustschmerzlokalisation“ hat daher für Hausärzte in der Evaluation von Brustschmerzpatienten nur einen limitierten diagnostischen Nutzen

Overview: On the transport and transformation of pollutants in the outflow of major population centres – observational data from the EMeRGe European intensive operational period in summer 2017

Abstract. EMeRGe (Effect of Megacities on the transport and transformation of pollutants on the Regional to Global scales) is an international project focusing on atmospheric chemistry, dynamics and transport of local and regional pollution originating in megacities and other major population centres (MPCs). Airborne measurements, taking advantage of the long range capabilities of the HALO research platform (High Altitude and Long range research aircraft, www.halo-spp.de), are a central part of the research project. In order to provide an adequate set of measurements at different spatial scales, two field experiments were positioned in time and space to contrast situations when the photochemical transformation of plumes emerging from MPCs is large. These experiments were conducted in summer 2017 over Europe and in the inter-monsoon period over Asia in spring 2018. The intensive observational periods (IOP) involved HALO airborne measurements of ozone and its precursors, volatile organic compounds, aerosol particles and related species as well as coordinated ground-based ancillary observations at different sites. Perfluorocarbon (PFC) tracer releases and model forecasts supported the flight planning and the identification of pollution plumes. This paper describes the experimental deployment of the IOP in Europe, which comprised 7 HALO research flights with aircraft base in Oberpfaffenhofen (Germany) for a total of 53 flight hours. The MPC targets London (Great Britain), Benelux/Ruhr area (Belgium, The Netherlands, Luxembourg and Germany), Paris (France), Rome and Po Valley (Italy), Madrid and Barcelona (Spain) were investigated. An in-flight comparison of HALO with the collaborating UK-airborne platform FAAM took place to assure accuracy and comparability of the instrumentation on-board. Generally, significant enhancement of trace gases and aerosol particles are attributed to emissions originating in MPCs at distances of hundreds of kilometres from the sources. The proximity of different MPCs over Europe favours the mixing of plumes of different origin and level of processing and hampers the unambiguous attribution of the MPC sources. Similarly, urban plumes mix efficiently with natural sources as desert dust and with biomass burning emissions from vegetation and forest fires. This confirms the importance of wildland fire emissions in Europe and indicates an important but discontinuous contribution to the European emission budget that might be of relevance in the design of efficient mitigation strategies. The synergistic use and consistent interpretation of observational data sets of different spatial and temporal resolution (e.g. from ground-based networks, airborne campaigns, and satellite measurements) supported by modelling within EMeRGe, provides a unique insight to test the current understanding of MPC pollution outflows. The present work provides an overview of the most salient results and scientific questions in the European context, these being addressed in more detail within additional dedicated EMeRGe studies. The deployment and results obtained in Asia will be the subject of separate publications

Overview: On the transport and transformation of pollutants in the outflow of major population centres – observational data from the EMeRGe European intensive operational period in summer 2017

Megacities and other major population centres (MPCs) worldwide are major sources of air pollution, both locally as well as downwind. The overall assessment and prediction of the impact of MPC pollution on tropospheric chemistry are challenging. The present work provides an overview of the highlights of a major new contribution to the understanding of this issue based on the data and analysis of the EMeRGe (Effect of Megacities on the transport and transformation of pollutants on the Regional to Global scales) international project. EMeRGe focuses on atmospheric chemistry, dynamics, and transport of local and regional pollution originating in MPCs. Airborne measurements, taking advantage of the long range capabilities of the High Altitude and LOng Range Research Aircraft (HALO, https://www.halo-spp.de, last access: 22 March 2022), are a central part of the project. The synergistic use and consistent interpretation of observational data sets of different spatial and temporal resolution (e.g. from ground-based networks, airborne campaigns, and satellite measurements) supported by modelling within EMeRGe provide unique insight to test the current understanding of MPC pollution outflows.In order to obtain an adequate set of measurements at different spatial scales, two field experiments were positioned in time and space to contrast situations when the photochemical transformation of plumes emerging from MPCs is large. These experiments were conducted in summer 2017 over Europe and in the inter-monsoon period over Asia in spring 2018. The intensive observational periods (IOPs) involved HALO airborne measurements of ozone and its precursors, volatile organic compounds, aerosol particles, and related species as well as coordinated ground-based ancillary observations at different sites. Perfluorocarbon (PFC) tracer releases and model forecasts supported the flight planning, the identification of pollution plumes, and the analysis of chemical transformations during transport.This paper describes the experimental deployment and scientific questions of the IOP in Europe. The MPC targets – London (United Kingdom; UK), the Benelux/Ruhr area (Belgium, the Netherlands, Luxembourg and Germany), Paris (France), Rome and the Po Valley (Italy), and Madrid and Barcelona (Spain) – were investigated during seven HALO research flights with an aircraft base in Germany for a total of 53 flight hours. An in-flight comparison of HALO with the collaborating UK-airborne platform Facility for Airborne Atmospheric Measurements (FAAM) took place to assure accuracy and comparability of the instrumentation on board.Overall, EMeRGe unites measurements of near- and far-field emissions and hence deals with complex air masses of local and distant sources. Regional transport of several European MPC outflows was successfully identified and measured. Chemical processing of the MPC emissions was inferred from airborne observations of primary and secondary pollutants and the ratios between species having different chemical lifetimes. Photochemical processing of aerosol and secondary formation or organic acids was evident during the transport of MPC plumes. Urban plumes mix efficiently with natural sources as mineral dust and with biomass burning emissions from vegetation and forest fires. This confirms the importance of wildland fire emissions in Europe and indicates an important but discontinuous contribution to the European emission budget that might be of relevance in the design of efficient mitigation strategies. The present work provides an overview of the most salient results in the European context, with these being addressed in more detail within additional dedicated EMeRGe studies. The deployment and results obtained in Asia will be the subject of separate publications