Interdisciplinary and interprofessional communication in intensive and emergency care

Background Due to acuteness, time constraints, and psychological pressure as well as changing team compositions, professional communication constitutes a key challenge in the treatment of critically ill patients. Objectives The aim of this narrative review is to present the current literature on clinical relevance and current developments of interdisciplinary and interprofessional communication in intensive care and emergency medicine. Results Effective communication is of great importance in intensive care and emergency medicine, both for ensuring high-quality patient care and work satisfaction as well as mental health of the medical practitioners. Most conflicts occur between the medical and nursing staff, with communicative conflicts predominantly being related to discussions about the patient's prognosis and end-of-life decision-making. Structural measures such as regular team meetings and trainings seem suitable to specifically improve communication. However, the topic is commonly inadequately represented in everyday clinical practice as well as in research. Conclusions Even though the importance of interprofessional and interdisciplinary communication for high-quality patient care and workload reduction is increasingly being recognized, its routine application in everyday clinical practice is still scarce, particularly in intensive care and emergency medicine. Due to the specific structure and patient population of these fields of patient care, they can benefit more than other specialties from targeted measures to improve communication

Current status of ACL reconstruction in Germany

Introduction Reconstruction of the anterior cruciate ligament (ACL) is characterized by a variety of possibilities concerning its implementation. Different choices for grafts, fixation methods and tunnel positioning, as well as diverse technical tools are available and have clinical significance. Besides specific pre- and post-operative procedures, different indications for surgery and further surgeon-/clinic-related factors add variability to the treatment. In response to the lack of descriptive statistics about the implementation of these factors and the increasing numbers of ACL reconstructions this study has been conducted to display the current state of the treatment for ACL tears throughout Germany. Materials and methods 709 clinics with surgical and orthopedic departments were provided an online-questionnaire that surveyed their statistical records (e.g. annually implemented operations, number of surgeons, duration of operations), implemented techniques (e.g. choice of grafts, construction of drilling tunnel, tibial/femoral fixation) and personal assessment (e.g. frequency/cause of graft failure, frequency/handling of infection). The response rate was 22 % (n = 155). Based on the statistical records a specialized group within the respondents was identified, enabling a cross-comparison between high-and low-volume surgeons. Results On average, the German orthopedic surgeons in the clinics surveyed annually performs 35 ACL reconstructions, with each operation lasting an average of 67 min. After subdividing the data with references to annually performed surgeries into high-and low-volume-surgeons, differences and common features between the subgroups become apparent. Differences between high-and low-volume-surgeons, respectively, show shorter duration of both ACL reconstructions (55 vs. 71 min) and revision ACL reconstructions (75 vs. 90 min), higher membership rates in professional associations (83 vs. 38 % have at least one membership), more frequent implementation of stability examinations (47 vs. 21 %) and different frequencies of femoral drilling techniques (using the anterolateral portal in 71 vs. 54 %). With reference to evaluating operation dates, choosing grafts and assessing reasons for graft failure both groups share commonalities, as well as regarding the predominant use of monofixation for femoral fixation (88 % of the participants-mainly with endobutton in 38 % and transfixation pin in 27 %) and for tibial fixation (81 % of the participants-mainly with bioabsorbable screw in 60 %). Conclusions The treatment of ACL tears in the group of German clinics studied is characterized by a variety of surgical possibilities. This condition might reflect the entirety of clinics reconstructing ACL in Germany. For the first time, a descriptive statistical survey was implemented to display this variety and to provide insight into the current status quo. Within the entirety of surgeons implementing ACL reconstruction a specialized subgroup with a particular expertise seems to exist

Reactivation of EBV and CMV in Severe COVID-19-Epiphenomena or Trigger of Hyperinflammation in Need of Treatment? A Large Case Series of Critically ill Patients

Background Reactivation of viruses such as Epstein-Barr virus (EBV) and cytomegalovirus (CMV) are common in critically ill patients and have been described in patients with severe COVID-19. However, it is unclear whether these reactivations are associated with increased mortality and whether targeted treatments are beneficial. Methods In a retrospective single-center cohort study, patients with severe COVID-19 treated on our intensive care unit (ICU) were screened for EBV and CMV reactivation as detected by polymerase chain reaction. If present, patient characteristics, temporal connections to severe acute respiratory syndrome coronavirus 2 diagnosis and corticosteroid use, the use of targeted treatments as well as the course of disease and outcome were analyzed. As control group, non-COVID-19 patients with sepsis, treated within the same time period on our ICU, served as control group to compare incidences of viral reactivation. Results In 19 (16%) of 117 patients with severe COVID-19 treated on our ICU EBV reactivations were identified, comparable 18 (14%) of 126 in the non-COVID-19 control group (P = .672). Similarly, in 11 (9%) of 117 patients CMV reactivations were identified, comparable to the 16 (13%) of 126 in the non-COVID-19 sepsis patients (P = .296). The majority of EBV (58%) and CMV reactivations (55%) were detected in patients under systemic corticosteroid treatment. 7 (37%) of 19 patients with EBV reactivation survived the ICU stay, 2 (29%) of 7 patients with rituximab treatment and 5 (42%) of 12 patients without treatment (P = .568). Five (50%) of 10 patients with CMV reactivation survived the ICU stay, 5 (83%) of 6 patients with ganciclovir treatment and 0 of 4 patients without treatment (P = .048). Follow-up analysis in these patients showed that the initiation of treatment lead to decrease in viral load. Conclusion Critically ill patients with COVID-19 are at a high risk for EBV and CMV reactivations. Whether these reactivations are a cause of hyperinflammation and require targeted treatment remains uncertain. However, in patients with clinical deterioration or signs of hyperinflammation targeted treatment might be beneficial and warrants further studying

Current status of the management of isolated syndesmotic injuries in Germany

Introduction Although non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany. Materials and methods An online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS. Results Each question of the questionnaire was on average answered by 431 +/- 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior-posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices. Conclusions While arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany

Scheduled removal of central venous catheters (CVC) to prevent CVC-related bloodstream infections in patients with hematological disease or autologous stem cell transplantation: a registry-based randomized simulation-study

Although not generally recommended, scheduled central venous catheter (CVC) removal is sometimes carried out in order to reduce the CVC-related bloodstream infection (CRBSI) incidence. We conducted a simulation for scheduled CVC removal within the multicenter CRBSI registry (SECRECY). Non-tunneled jugular and subclavian CVC in patients with hematological disease or with germ cell tumors (including patients receiving autologous stem cell transplantation [SCT]) were included. Cases were randomized in a 1:1:1:1 ratio to either a simulated, scheduled CVC removal after 7, 14, and 21 days, or to non-simulated, unscheduled CVC removal (control group). The primary endpoint was definitive CRBSI incidence for a scheduled CVC removal after 14 days (dCRBSI-D14(rmv)). Among other, secondary endpoints were definite CRBSI incidence for a scheduled removal after 7 days (dCRBSI-D7(rmv)) and 21 days (dCRBSI-D21(rmv)). Data on 2984 CVC were included. Patients' median age was 59 (range 16-95) years, 58.8% being male. The vast majority (98.4%) were patients with hematological malignancies. Jugular veins were the main insertion site (93.2%). dCRBSI-D14(rmv) was 3.10/1000 CVC days as compared to 4.15/1000 CVC days in the control group (p = 0.23). There was a significant difference between dCRBSI-D7(rmv) (0.86/1000 CVC days) and controls (p < 0.001), but not between dCRBSI-D21(rmv) (4.10/1000 CVC days) and controls (p = 0.96). Our data suggest that in patients with hematological diseases or autologous SCT recipients scheduled CVC removal after 14 days does not result in a lower CRBSI incidence compared to unscheduled removal

High variability of tibial slope measurement methods in daily clinical practice: Comparisons between measurements on lateral radiograph, magnetic resonance imaging, and computed tomography

Background: Tibial slope measurements are important in guiding clinical decisions in the field of orthopedic surgery. However, there are multiple techniques across different medical imaging modalities and little is known about its impact on result and validity of the measurement. Therefore, the purpose of this study was to compare tibial slope measurements from lateral radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) scans in order to better assess the clinical significance of measured tibial slope values. Methods: Twenty patients with complete medical imaging (lateral radiographs. MRI, CT scans) undergoing anterior cruciate ligament revision surgery were included. The tibial slope of the medial and lateral plateau were measured and compared using the methods of Dejour et al. and Utzschneider et al. on lateral radiographs, by Hudek et al. and Hashemi et al. on MRI and CT scans, and by Zhang et al. on three-dimensional reconstructions of CT scans. Results: Mean differences up to 5.4 +/- 2.8 degrees (P < 0.05) and 4.9 +/- 2.6 degrees (P < 0.05) between different measurement methods were found for the medial and lateral tibial slope, respectively. Depending on how the tibial shaft axis was defined, significant differences between the respective measurement methods and a relevant degree of variability were identified. Pearson correlation coefficients between the measurement methods varied distinctly from moderate to strong correlations. Conclusions: Tibial slope measurements have a high degree of variability and inaccuracy between imaging modalities and different measurement methods. Care must be taken when deciding on indications based on individual modality measurements. (C) 2020 Elsevier B.V. All rights reserved

Does VO(2)peak Provide a Prognostic Value in Esophagectomy and Gastrectomy for Post-operative Outcomes?

Background/Aim: Esophagectomy and gastrectomy are procedures with considerable physical burden and intense post-operative care of which the patient's physical condition seems to be a relevant predictor. The gold standard of the cardiorespiratory fitness is the peak oxygen consumption (VO(2)peak). This pilot study examined the prognostic value of VO(2)peak on post-surgery outcomes in esophageal and gastric cancer patients. Patients and Methods: In this prospective cross-sectional study, patients scheduled for esophagectomy or gastrectomy were examined 24 h before the surgery regarding their VO(2)peak. The post-operative complications according to Clavien-Dindo grade IIIb/IV/V, Intensive-Care-Unit days, and overall hospital stay were documented following surgery. In a subset, body weight changes from surgery until hospital discharge and first aftercare visit were recorded. Results: The functional capacity was significantly reduced in 34/35 of the included patients compared to matched norm-values (p= 17 ml/min/kg suggested small, non-significant differences in post-surgery outcomes and significant differences in the body weight change from surgery to hospital discharge, favoring the higher-VO(2)peak subgroup. Conclusion: The impaired functional capacity following esophagectomy or gastrectomy may strengthen the rational for exercise programs during neoadjuvant and pre-surgery phases. The prognostic value of VO(2)peak on post-operative outcomes remains uncertain due to noticeable descriptive differences, but no significant correlations, potentially limited by the small-sized population. Nonetheless, a correlation between VO(2)peak and body weight change post-surgery was observed and indicates a potential prognostic value of VO(2)peak

Team-specific impacts of the corona pandemic on intensive care medicine personnel of a maximum care hospital

The ongoing strain on personnel in the healthcare system during the COVID-19 pandemic is considerable and poses major emotional and psychological challenges for the personnel. In a team evaluation (physicians and nurses), team-specific stress, possible relief strategies, positive and negative experiences, and wishes for improvement of the situation in an intensive care unit were collected. While both occupational groups perceived equally high emotional stress intensities, nursing additionally perceived high stress intensities in the organizational and physical areas. Thus, the occupational group of nurses proves to be the most stressed by the COVID-19 pandemic. The findings presented here can be used to derive instructions for future actions