Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study

Background: Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions. Methods: A “hub-and-spoke” network structure was implemented connecting three academic neurological centres (“hubs”) and rural hospitals (“spokes”) caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission. Discussion: Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed. Study registration: German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS0001306

Improved Anaerobic Fermentation of Wheat Straw by Alkaline Pre-Treatment and Addition of Alkali-Tolerant Microorganisms

The potential of two alkali-tolerant, lignocellulolytic environmental enrichment cultures to improve the anaerobic fermentation of Ca(OH)2-pre-treated wheat straw was studied. The biomethane potential of pre-treated straw was 36% higher than that of untreated straw. The bioaugmentation of pre-treated straw with the enrichment cultures did not enhance the methane yield, but accelerated the methane production during the first week. In acidogenic leach-bed fermenters, a 61% higher volatile fatty acid (VFA) production and a 112% higher gas production, mainly CO2, were observed when pre-treated instead of untreated straw was used. With one of the two enrichment cultures as the inoculum, instead of the standard inoculum, the VFA production increased by an additional 36% and the gas production by an additional 110%, again mainly CO2. Analysis of the microbial communities in the leach-bed processes revealed similar bacterial compositions in the fermenters with pre-treated straw, which developed independently of the used inoculum. It was suggested that the positive metabolic effects with the enrichment cultures observed in both systems were due to initial activities of the alkali-tolerant microorganisms tackling the alkaline conditions better than the standard inocula, whereas the latter dominated in the long term