152 research outputs found
Does Telemedical Support of First Responders Improve Guideline Adherence in an Offshore Emergency Scenario? A Simulator-Based Prospective Study
OBJECTIVE:
To investigate, in a simulator-based prospective study, whether telemedical support improves quality of emergency first response (performance) by medical non-professionals to being non-inferior to medical professionals.
SETTING:
In a simulated offshore wind power plant, duos (teams) of offshore engineers and teams of paramedics conducted the primary survey of a simulated patient.
PARTICIPANTS:
38 offshore engineers and 34 paramedics were recruited by the general email invitation.
INTERVENTION:
Teams (randomised by lot) were supported by transmission technology and a remote emergency physician in Berlin.
OUTCOME MEASURES:
From video recordings, performance (17 item checklist) and required time (up to 15 min) were quantified by expert rating for analysis. Differences were analysed using two-sided exact Mann-Whitney U tests for independent measures, non-inferiority was analysed using Schuirmann one-sided test. The significance level of 5 % was Holm-Bonferroni adjusted in each family of pairwise comparisons.
RESULTS:
Nine teams of engineers with, nine without, nine teams of paramedics with and eight without support completed the task. Two experts quantified endpoints, insights into rater dependence were gained. Supported engineers outperformed unsupported engineers (p<0.01), insufficient evidence was found for paramedics (p=0.11). Without support, paramedics outperformed engineers (p<0.01). Supported engineers' performance was non-inferior (at one item margin) to that by unsupported paramedics (p=0.03). Supported groups were slower than unsupported groups (p<0.01).
CONCLUSIONS:
First response to medical emergencies in offshore wind farms with substantially delayed professional care may be improved by telemedical support. Future work should test our result during additional scenarios and explore interdisciplinary and ecosystem aspects of this support.
TRIAL REGISTRATION NUMBER:
DRKS0001437
A Pilot Study
Background Alcohol withdrawal syndrome is a potentially life-threatening
condition, which can occur when patients with alcohol use disorders undergo
general anesthesia. Excitatory amino acids, such as glutamate, act as
neurotransmitters and are known to play a key role in alcohol withdrawal
syndrome. To understand this process better, we investigated the influence of
isoflurane, sevoflurane, and desflurane anesthesia on the profile of
excitatory and inhibitory amino acids in the nucleus accumbens (NAcc) of
alcohol-withdrawn rats (AWR). Methods Eighty Wistar rats were randomized into
two groups of 40, pair-fed with alcoholic or non-alcoholic nutrition.
Nutrition was withdrawn and microdialysis was performed to measure the
activity of amino acids in the NAcc. The onset time of the withdrawal syndrome
was first determined in an experiment with 20 rats. Sixty rats then received
isoflurane, sevoflurane, or desflurane anesthesia for three hours during the
withdrawal period, followed by one hour of elimination. Amino acid
concentrations were measured using chromatography and results were compared to
baseline levels measured prior to induction of anesthesia. Results Glutamate
release increased in the alcohol group at five hours after the last alcohol
intake (p = 0.002). After 140 min, desflurane anesthesia led to a lower
release of glutamate (p < 0.001) and aspartate (p = 0.0007) in AWR compared to
controls. GABA release under and after desflurane anesthesia was also
significantly lower in AWR than controls (p = 0.023). Over the course of
isoflurane anesthesia, arginine release decreased in AWR compared to controls
(p < 0.001), and aspartate release increased after induction relative to
controls (p20min = 0.015 and p40min = 0.006). However, amino acid levels did
not differ between the groups as a result of sevoflurane anesthesia.
Conclusions Each of three volatile anesthetics we studied showed different
effects on excitatory and inhibitory amino acid concentrations. Under
desflurane anesthesia, both glutamate and aspartate showed a tendency to be
lower in AWR than controls over the whole timecourse. The inhibitory amino
acid arginine increased in AWR compared to controls, whereas GABA levels
decreased. However, there were no significant differences in amino acid
concentrations under or after sevoflurane anesthesia. Under isoflurane,
aspartate release increased in AWR following induction, and from 40 min to 140
min arginine release in controls was elevated. The precise mechanisms through
which each of the volatile anesthetics affected amino acid concentrations are
still unclear and further experimental research is required to draw reliable
conclusions
Circulating metastasis associated in colon cancer 1 transcripts in gastric cancer patient plasma as diagnostic and prognostic biomarker
METHODS: We provide for the first time a blood-based assay for transcript
quantification of the metastasis inducer MACC1 in a prospective study of
gastric cancer patient plasma. MACC1 is a strong prognostic biomarker for
tumor progression and metastasis in a variety of solid cancers. We conducted a
study to define the diagnostic and prognostic power of MACC1 transcripts using
76 plasma samples from gastric cancer patients, either newly diagnosed with
gastric cancer, newly diagnosed with metachronous metastasis of gastric
cancer, as well as follow-up patients. Findings were controlled by using
plasma samples from 54 tumor-free volunteers. Plasma was separated, RNA was
isolated, and levels of MACC1 as well as S100A4 transcripts were determined by
quantitative RT-PCR. RESULTS: Based on the levels of circulating MACC1
transcripts in plasma we significantly discriminated tumor-free volunteers and
gastric cancer patients (P < 0.001). Levels of circulating MACC1 transcripts
were increased in gastric cancer patients of each disease stage, compared to
tumor-free volunteers: patients with tumors without metastasis (P = 0.005),
with synchronous metastasis (P = 0.002), with metachronous metastasis (P =
0.005), and patients during follow-up (P = 0.021). Sensitivity was 0.68
(95%CI: 0.45-0.85) and specificity was 0.89 (95%CI: 0.77-0.95), respectively.
Importantly, gastric cancer patients with high circulating MACC1 transcript
levels in plasma demonstrated significantly shorter survival when compared
with patients demonstrating low MACC1 levels (P = 0.0015). Furthermore,
gastric cancer patients with high circulating transcript levels of MACC1 as
well as of S100A4 in plasma demonstrated significantly shorter survival when
compared with patients demonstrating low levels of both biomarkers or with
only one biomarker elevated (P = 0.001). CONCLUSION: Levels of circulating
MACC1 transcripts in plasma of gastric cancer patients are of diagnostic value
and are prognostic for patient survival in a prospective study
Outcome after surgery for prosthetic valve endocarditis and the impact of preoperative treatment
ObjectivesThis study examined the outcomes of surgery for active prosthetic valve endocarditis in a recent decade, with special interest in preoperative treatment and predictors for early and late events.MethodsFrom 2000 to 2010, a cohort of 149 consecutive patients (mean age, 64 ± 13.9 years; 72% were male) underwent redo-surgery for prosthetic valve endocarditis and were reviewed regarding early (≤60 days) and late (>60 days) events (death, reinfection, reoperation). Kaplan–Meier survival curves and Cox regression analysis were used to investigate the impact of preoperative intervals and predictors for events, respectively.ResultsPreoperative status was critical (European System for Cardiac Operative Risk Evaluation >20%) in 121 patients (81.2%). Staphylococci were the most common infecting microorganisms (27.5%). The median interval between onset of symptoms and diagnosis and between diagnosis and operation was 2 days (interquartile range, 1-5) and 8 days (interquartile range, 2-23), respectively. Operative mortality (≤30 days) was 12.8%. Mean follow-up was 4 ± 2.9 years. In 53 patients, 47 early (24 deaths, 14 recurrences, 9 reoperations) and 22 late events (11 deaths, 9 recurrences, 2 reoperations) occurred. Overall and event-free survivals at 10 years were 75% ± 3.8% and 64% ± 4.0%, respectively. Freedom from recurrent infection and reoperation at 10 years were 81% ± 3.6% and 91% ± 2.6%, respectively. In multivariate Cox regression, mechanical circulatory support, prolongation between onset of symptoms and diagnosis more than 30 days, and preoperative presence of renal failure predicted early events, and double valve replacement predicted late events.ConclusionsCardiac and renal function, need for double valve replacement, and preoperative treatment predicted outcomes. A prolonged interval in which patients were left untreated while symptomatic, but not prolongation of preoperative antibiotic treatment, increased risk
Vitamin D and Disease Severity in Multiple Sclerosis-Baseline Data From the Randomized Controlled Trial (EVIDIMS)
Objective: To investigate the associations between hypovitaminosis D and disease activity in a cohort of relapsing remitting multiple sclerosis (RRMS) and clinically isolated syndrome (CIS) patients.
Methods: In 51 RRMS and 2 CIS patients on stable interferon-β-1b (IFN-β-1b) treatment recruited to the EVIDIMS study (Efficacy of Vitamin D Supplementation in Multiple Sclerosis (NCT01440062) baseline serum vitamin D levels were evaluated. Patients were dichotomized based on the definition of vitamin D deficiency which is reflected by a < 30 vs. ≥ 30 ng/ml level of 25-hydroxyvitamin D (25(OH)D). Possible associations between vitamin D deficiency and both clinical and MRI features of the disease were analyzed.
Results: Median (25, 75% quartiles, Q) 25(OH)D level was 18 ng/ml (12, 24). Forty eight out of 53 (91%) patients had 25(OH)D levels < 30 ng/ml (p < 0.001). Patients with 25(OH)D ≥ 30 ng/ml had lower median (25, 75% Q) T2-weighted lesion counts [25 (24, 33)] compared to patients with 25(OH)D < 30 ng/ml [60 (36, 84), p = 0.03; adjusted for age, gender and disease duration: p < 0.001]. Expanded disability status scale (EDSS) score was negatively associated with serum 25(OH)D levels in a multiple linear regression, including age, sex, and disease duration (adjusted: p < 0.001).
Interpretation: Most patients recruited in the EVIDIMS study were vitamin D deficient. Higher 25(OH)D levels were associated with reduced T2 weighted lesion count and lower EDSS scores
In vivo application of Granulocyte-Macrophage Colony-stimulating Factor enhances postoperative qualitative monocytic function
BACKGROUND: Granulocyte macrophage colony-stimulating factor (GM-CSF) can be
used as a potent stimulator for immune suppressed patients as defined by a
decrease of human leukocyte antigen-D related expression on monocytes (mHLA-
DR) after surgery. However, the exact role of GM-CSF on monocytic and T cell
function is unclear. METHODS: In this retrospective randomized controlled
trial (RCT) subgroup analysis, monocytic respectively T cell function and T
cell subspecies of 20 immune suppressed (i.e. mHLA-DR levels below 10,000
monoclonal antibodies (mAb) per cell at the first day after surgery) patients
after esophageal or pancreatic resection were analyzed. Each 10 patients
received either GM-CSF (250 μg/m²/d) or placebo for a maximum of three
consecutive days if mHLA-DR levels remained below 10,000 mAb per cell. mHLA-DR
and further parameters of immune function were measured preoperatively (od)
until day 5 after surgery (pod5). Statistical analyses were performed using
nonparametric statistical procedures. RESULTS: In multivariate analysis, mHLA-
DR significantly differed between the groups (p < 0.001). mHLA-DR was
increased on pod2 (p < 0.001) and pod3 (p = 0.002) after GM-CSF application.
Tumor necrosis factor-α (TNF-α) release of lipopolysaccharide (LPS) stimulated
monocytes multivariately significantly differed between the groups (p < 0.008)
and was increased in the GM-CSF group on pod2 (p < 0.001) and pod3 (p =
0.046). Th17/regulatory T (Treg) cell ratio was higher after GM-CSF treatment
on pod2 (p = 0.041). No differences were seen in lymphocytes and T helper cell
(Th)1/Th2 specific cytokine production after T cell stimulation with
Concanavalin (Con) A between the groups. CONCLUSIONS: Postoperative
application of GM-CSF significantly enhanced qualitative monocytic function by
increased mHLA-DR and TNF-α release after LPS stimulation and apparently
enhanced Th17/Treg ratio
a previously undescribed entity
Background: There are few studies describing periodic limb movement syndrome
(PLMS) in rapid eye movement (REM) sleep in patients with narcolepsy, restless
legs syndrome, REM sleep behavior disorder, and spinal cord injury, and to a
lesser extent, in insomnia patients and healthy controls, but no published
cases in multiple sclerosis (MS). The aim of this study was to investigate
PLMS in REM sleep in MS and to analyze whether it is associated with age, sex,
disability, and laboratory findings. Methods: From a study of MS patients
originally published in 2011, we retrospectively analyzed periodic limb
movements (PLMs) during REM sleep by classifying patients into two subgroups:
PLM during REM sleep greater than or equal to ten per hour of REM sleep (n=7)
vs less than ten per hour of REM sleep (n=59). A univariate analysis between
PLM and disability, age, sex, laboratory findings, and polysomnographic data
was performed. Results: MS patients with more than ten PLMs per hour of REM
sleep showed a significantly higher disability measured by the Kurtzke
expanded disability status scale (EDSS) (P=0.023). The presence of more than
ten PLMs per hour of REM sleep was associated with a greater likelihood of
disability (odds ratio 22.1; 95% confidence interval 3.5–139.7; P<0.0001),
whereas there were no differences in laboratory and other polysomnographic
findings. Conclusion: PLMs during REM sleep were not described in MS earlier,
and they are associated with disability measured by the EDSS
Smoking, Gender, and Overweight Are Important Influencing Factors on Monocytic HLA-DR before and after Major Cancer Surgery
Background. Monocytic human leukocyte antigen D related (mHLA-DR) is essential
for antigen-presentation. Downregulation of mHLA-DR emerged as a general
biomarker of impaired immunity seen in patients with sepsis and pneumonia and
after major surgery. Influencing factors of mHLA-DR such as age, overweight,
diabetes, smoking, and gender remain unclear. Methods. We analyzed 20 patients
after esophageal or pancreatic resection of a prospective, randomized,
placebo-controlled, double-blind trial (placebo group). mHLA-DR was determined
from day of surgery (od) until postoperative day (pod) 5. Statistical analyses
were performed using multivariate generalized estimating equation analyses
(GEE), nonparametric multivariate analysis of longitudinal data, and
univariate post hoc nonparametric Mann–Whitney tests. Results. In GEE, smoking
and gender were confirmed as significant influencing factors over time.
Univariate analyses of mHLA-DR between smokers and nonsmokers showed lower
preoperative levels () and a trend towards lower levels on pod5 () in smokers.
Lower mHLA-DR was seen in men on pod3 () and on pod5 (). Overweight patients
(BMI > 25 kg/m2) had lower levels of mHLA-DR on pod3 () and pod4 ().
Conclusion. Smoking is an important influencing factor on pre- and
postoperative immune function while postoperative immune function was
influenced by gender and overweight. Clinical trial registered with
ISRCTN27114642
A substudy of a randomized controlled trial
Data on early markers for acute kidney injury (AKI) after noncardiovascular
surgery are still limited. This study aimed to determine the diagnostic value
of plasma neutrophil-gelatinase-associated lipocalin (pNGAL) and
intraoperative diuresis for AKI in patients undergoing major abdominal surgery
treated within a goal-directed hemodynamic algorithm. This study is a post-hoc
analysis of a randomized controlled pilot trial comparing intravenous
solutions within a hemodynamic goal-directed algorithm based on the esophageal
Doppler in patients undergoing epithelial ovarian cancer surgery. The
diagnostic value of plasma NGAL obtained at ICU admission and intraoperative
diuresis was determined with respect to patients already meeting AKI criteria
6 hours after surgery (AKI6h) and to all patients meeting AKI criteria at
least once during the postoperative course (AKItotal). AKI was diagnosed by
the definition of the Kidney Disease Improving Global Outcome (KDIGO) group
creatinine criteria and was screened up to postoperative day 3. Receiver
operating characteristic curves including a gray zone approach were performed.
A total of 48 patients were analyzed. None of the patients had increased
creatinine levels before surgery and 14 patients (29.2%) developed AKI after
surgery. Plasma NGAL was predictive for AKI6h (AUCAKI6h 0.832 (95% confidence
interval [CI], 0.629–0.976), P = .001) and AKItotal (AUCAKItotal 0.710 (CI
0.511–0.878), P = .023). The gray zones of pNGAL calculated for AKI6h and
AKItotal were 210 to 245 and 207 to 274 ng mL−1, respectively. The lower
cutoffs of the gray zone at 207 and 210 ng mL−1 had a negative predictive
value (NPV) (i.e., no AKI during the postoperative course) of 96.8% (CI
90–100) and 87.1% (CI 78–97), respectively. Intraoperative diuresis was also
predictive for AKI6h (AUCAKI6h 0.742 (CI 0.581–0.871), P = .019) with a gray
zone of 0.5 to 2.0 mL kg−1 h−1. At the lower cutoff of the gray zone at 0.5 mL
kg−1 h−1, corresponding to the oliguric threshold, the NPV was 84.2% (78–92).
This study indicates that pNGAL can be used as an early marker to rule out AKI
occurring within 3 days after major abdominal surgery. Intraoperative diuresis
can be used to rule out AKI occurring up to 6 hours after surgery
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