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Out-of-hospital therapeutic hypothermia in cardiac arrest victims
Wilhelm Behringer, Jasmin Arrich, Michael Holzer, Fritz Sterz
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-52
Abstract: Sudden cardiac arrest remains a major unresolved public health problem. In Europe and the USA, approximately 425.000 people suffer of sudden cardiac death with very poor survival, usually less than 10% [1,2]. After cardiac arrest and brain ischemia, reperfusion initiates multiple independent chemical cascades and fatal pathways, resulting in neuronal death due to necrosis and apoptosis [3]. Because of the multi-factorial pathogenesis of post-arrest neuronal death, a multifaceted treatment strategy is required to achieve survival without brain damage. Hypothermia, a re-discovered promising treatment strategy, exerts its beneficial effects on brain ischemia by various mechanisms, and perfectly fulfils the requirements of a multifaceted treatment strategy [4].In therapeutic hypothermia, different degrees of cooling can be differentiated, though definition of these temperature levels may differ slightly between authors: mild (34 to 32°C), moderate (31 to 28°C), deep (27 to 11°C), profound (10 to 6°C), and ultra-profound (5 to 0°C) hypothermia. Protective hypothermia, induced before cardiac arrest, has to be differentiated from preservative hypothermia, induced during cardiac arrest treatment, and from resuscitative hypothermia, induced after successful resuscitation. Protective hypothermia is used in cardiac surgery and neurosurgery, but is clinically unrealistic in sudden cardiac death. This review will focus on a) preservative mild hypothermia during cardiac arrest treatment and b) resuscitative mild hypothermia after successful resuscitation in respect to its clinical application in the out-of-hospital setting.Preservative hypothermia can further be differentiated into the induction of hypothermia during ischemia (before initiation of resuscitation - or before reperfusion) and the induction of hypothermia during resuscitation.Research in myocytes showed that injury to cells not only occurs during ischemia itself, but mainly with reperfusion by initiating several casc
Surface cooling for induction of mild hypothermia in conscious healthy volunteers - a feasibility trial
Christoph Testori, Fritz Sterz, Wilhelm Behringer, Alexander Spiel, Christa Firbas, Bernd Jilma
Critical Care , 2011, DOI: 10.1186/cc10506
Abstract: The trial was set at a clinical research ward in a tertiary care center, and included 16 healthy male volunteers 18 to 70 years old. Surface cooling was established by a novel non-invasive cooling pad with an esophageal target temperature of 32 to 34°C and maintenance for six hours. Shivering-control was achieved with meperidine and buspirone and additional administration of magnesium in eight subjects.The primary endpoint to reach a target temperature of 32 to 34°C was only reached in 6 of the 16 participating subjects. Temperatures below 35°C were reached after a median cooling time of 53 minutes (38 to 102 minutes). Cooling rate was 1.1°C/h (0.7 to 1.8°C). Additional administration of magnesium had no influence on cooling rate. At no time during the cooling procedure did the participants report uncomfortable conditions for which termination of cooling had to be considered. No severe skin damage was reported.Cooling to body temperature below 35°C by the use of non-invasive surface cooling is feasible and safe in conscious healthy volunteers. Further studies are needed to investigate an altered cooling protocol to achieve temperatures below 35°C.ISRCTN: ISRCTN50530495Therapeutic hypothermia improves neurological outcome and reduces the risk of death in patients after cardiac arrest [1,2]. In recent years, growing evidence in animal and human studies have documented or suggested the beneficial outcome effects of mild hypothermia also for stroke [3-11], for acute myocardial infarction [12-16], and for cardiogenic shock [17]. Rather than interacting on a particular pathway of post-ischemic reperfusion damage hypothermia influences multiple reactions leading to cell death [18-20].So far, the majority of therapeutic hypothermia research has involved cardiac arrest patients, in whom the induction and maintenance of mild hypothermia is facilitated by post-anoxic coma, anesthesia and paralysis to avoid shivering. The typical patient presenting to an emergency department wi
Relationship between time to target temperature and outcome in patients treated with therapeutic hypothermia after cardiac arrest
Moritz Haugk, Christoph Testori, Fritz Sterz, Maximilian Uranitsch, Michael Holzer, Wilhelm Behringer, Harald Herkner, the Time to Target Temperature Study Group
Critical Care , 2011, DOI: 10.1186/cc10116
Abstract: Temperature data between April 1995 and June 2008 were collected from 588 patients and analyzed in a retrospective cohort study by observers blinded to outcome. The time needed to achieve an esophageal temperature of less than 34°C was recorded. Survival and neurological outcomes were determined within six months after cardiac arrest.The median time from restoration of spontaneous circulation to reaching a temperature of less than 34°C was 209 minutes (interquartile range [IQR]: 130-302) in patients with favorable neurological outcomes compared to 158 min (IQR: 101-230) (P < 0.01) in patients with unfavorable neurological outcomes. The adjusted odds ratio for a favorable neurological outcome with a longer time to target temperature was 1.86 (95% CI 1.03 to 3.38, P = 0.04).In comatose cardiac arrest patients treated with therapeutic hypothermia after return of spontaneous circulation, a faster decline in body temperature to the 34°C target appears to predict an unfavorable neurologic outcome.For patients who have been successfully resuscitated after cardiac arrest, therapeutic mild hypothermia increases the rate of a favorable outcome in comparison with standard life support. Randomized controlled trials, however, have not shown evidence of whether the time to target temperature correlates with neurological outcome [1-4]. Registries about the practical use of therapeutic hypothermia have also not found a significant association between the timing of therapeutic hypothermia and final outcome [5-7]. We expected a strong relationship between the time to target temperature (<34°C) and neurological outcome. Furthermore, we hypothesized that earlier achievement of target temperature would not necessarily improve outcome.The study was designed as a single-center retrospective cohort study on temperature data extracted from patients' charts by observers blinded to outcome. The protocol and consent procedures were approved by the ethics committee of the Medical University of
School children sufficiently apply life supporting first aid: a prospective investigation
Roman Fleischhackl, Alexander Nuernberger, Fritz Sterz, Christina Schoenberg, Tania Urso, Tanja Habart, Martina Mittlboeck, Nisha Chandra-Strobos
Critical Care , 2009, DOI: 10.1186/cc7984
Abstract: In pupils, who received six hours of CPR training from their teachers during a standard school semester at four months post training the following outcome parameters were assessed: CPR effectiveness, AED deployment, accuracy in checking vital signs, correctness of recovery position, and whether the ambulance service was effectively notified. Possible correlations of age, gender, body mass index (BMI), and outcome parameters were calculated.Of 147 students (mean age 13 ± 2 years), 86% performed CPR correctly. Median depth of chest compressions was 35 mm (inter quartile range (IQR) 31 to 41), and the median number of compressions per minute was 129 bpm (IQR 108 to 143). Sixty nine percent of the students tilted the mannequin head sufficiently for mouth to mouth resuscitation, and the median air volume delivered was 540 ml (IQR 0 to 750). Scores on other life supporting techniques were at least 80% or higher. Depth of chest compressions showed a correlation with BMI (r = 0.35; P < 0.0001), body weight (r = 0.38; P < 0.0001), and body height (r = 0.31; P = 0.0002) but not with age. All other outcomes were found to be unrelated to gender, age, or BMI.Students as young as 9 years are able to successfully and effectively learn basic life support skills including AED deployment, correct recovery position and emergency calling. As in adults, physical strength may limit depth of chest compressions and ventilation volumes but skill retention is good.Prompt Basic Life Support (BLS) improves survival in patients after cardiac arrest [1]. As a consequence many agencies have targeted efforts at training lay people in cardiopulmonary resuscitation (CPR) skills. Over the past eight years, this curriculum has been simplified to improve retention and increase its appeal to the lay rescuer. Three-hour BLS training programs have evolved to 30 minute programs [2-4]. Driven largely by the understanding that the knowledge of CPR represents a core skill, some investigators have reported on
CPR in medical schools: learning by teaching BLS to sudden cardiac death survivors – a promising strategy for medical students?
Oliver Robak, Johannes Kulnig, Fritz Sterz, Thomas Uray, Moritz Haugk, Andreas Kliegel, Michael Holzer, Harald Herkner, Anton N Laggner, Hans Domanovits
BMC Medical Education , 2006, DOI: 10.1186/1472-6920-6-27
Abstract: Medical students who enrolled in our curriculum had to pass a 2 semester problem based learning session about the principles of cardiac arrest, CPR, BLS and defibrillation (CPR-D). Then the students taught cardiac arrest survivors who were randomly chosen out of a cardiac arrest database of our emergency department. Both, the student and the Sudden Cardiac Death (SCD) survivor were asked about their skills and knowledge via questionnaires immediately after the course. The questionnaires were then used to evaluate if this new teaching strategy is useful for learning CPR via a problem-based-learning course. The survey was grouped into three categories, namely "Use of AED", "CPR-D" and "Training". In addition, there was space for free answers where the participants could state their opinion in their own words, which provided some useful hints for upcoming programs.This new learning-by-teaching strategy was highly accepted by all participants, the students and the SCD survivors. Most SCD survivors would use their skills in case one of their relatives goes into cardiac arrest (96%). Furthermore, 86% of the trainees were able to deal with failures and/or disturbances by themselves. On the trainer's side, 96% of the students felt to be well prepared for the course and were considered to be competent by 96% of their trainees.We could prove that learning by teaching CPR is possible and is highly accepted by the students. By offering a compelling appreciation of what CPR can achieve in using survivors from SCD as trainees made them go deeper into the subject of resuscitation, what also might result in a longer lasting benefit than regular lecture courses in CPR.Sudden cardiac arrest is a major public health problem. The use of automatic external defibrillators (AED) not only by security personal, but also by concerned laymen and their relatives has become an important part of emergency medical systems [1]. Still, the outcome of an out-of-hospital cardiac arrest is bad, mostly
Mechanische Kreislaufunterstützung bei Patienten im kardiogenen Schock
Siostrzonek P,Heinz G,Sterz F
Journal für Kardiologie , 1999,
Abstract: Die Letalit t von Patienten mit linksventrikul rem Pumpversagen ist hoch. Die M glichkeiten der pharmakologischen Kreislaufstabilisierung sind im kardiogenen Schock begrenzt. Mechanische Kreislaufunterstützungsverfahren gew hrleisten demgegenüber eine effektivere Verbesserung der Organperfusion und k nnen die Entwicklung eines schockbedingten Multiorganversagens verhindern. Bei akuter Koronarisch mie und Schock erm glichen perkutane Verfahren wie die intraaortale Ballonpumpe eine rasche h modynamische Stabilisierung. Der Einsatz der perkutanen Herzlungenmaschine bleibt speziellen Situationen wie dem akuten h modynamischen Kollaps im Herzkatheterlabor vorbehalten. Chirurgische parakorporale Verfahren werden nach erfolglosem Abgehen von der Herzlungenmaschine nach einer Herzoperation überbrückend bis zur Erholung der Myokardfunktion eingesetzt. Ausgew hlte Patienten mit therapierefrakt rer chronischer Herzinsuffizienz werden vorzugsweise mit einem implantierbaren Unterstützungsverfahren bis zur Herztransplantation geführt.
Influence of Expert Video Feedback, Peer Video Feedback, Standard Video Feedback and Oral Feedback on Undergraduate Medical Students’ Performance of Basic Surgical Skills  [PDF]
Marieke Lehmann, Jasmina Sterz, Maria-Christina Stefanescu, Julian Zabel, Kenan Dennis Sakmen, Miriam Ruesseler
Creative Education (CE) , 2018, DOI: 10.4236/ce.2018.98091
Abstract: Purpose: In daily clinical practice, sterile working conditions, as well as patient safety and self-protection, are essential. Thus, these skills should be taught appropriately during undergraduate training. Receiving constructive feedback can significantly improve future performance. Furthermore, reviewing one’s performance using video tools is a useful approach. This study investigates the impact of different modes of video feedback on the acquisition of practical surgical skills, including wound management and a bedside test. Methods: Third-year medical students completed a structured training of practical skills as part of their mandatory surgery rotation. All students received the same practical skills training for performing wound management and a bedside test. However, for feedback regarding their performance, students were assigned to one of four study groups: expert video feedback (receiving feedback by an expert after reviewing the recorded performance), peer video feedback (receiving feedback by a fellow student after reviewing the recorded performance), standard video (giving feedback to a standardized video of the skill), or oral feedback (receiving feedback by an expert without a video record). Afterwards, students completed two 5-minute OSCE stations in which they were assessed with respect to their acquired competencies. Effects on long-term retention were measured at two further measurement points. Results: A total of 199 students were included in the study (48 for expert video feedback, 49 for peer video feedback, 52 for standard video feedback, and 50 for oral feedback). All teaching methods were feasible in the given timeframe of 210 minutes for each module. There were nearly no statistically significant differences among the groups with regard to the technical and non-technical ratings for the three measurement points. Conclusion: In the present study, video-assisted feedback in various forms offered no significant benefit over oral feedback
Climate Change Favors Grapevine Production in Temperate Zones  [PDF]
Bruno Koch, Fritz Oehl
Agricultural Sciences (AS) , 2018, DOI: 10.4236/as.2018.93019
Abstract: Wine production has a long-standing history in Palatinate (Southwestern Germany), dating back to Roman times. Especially “Riesling”, but also several “Pinot” varieties gained major significance. Red wine varieties gained prominence over the last 20 years only, which may be a consequence of climate change. Our objective was to review temperature and rainfall data over the last 40 years, measured “on-winery” in Hainfeld and correlate these data with grapevine growth parameters: the development of bud break, flowering, veraison and harvest dates, yields and grape sugar concentrations of “Pinot Gris”, “Pinot Noir”, “Riesling”, “Silvaner” and “Müller-Thurgau”. Since the 1970s, bud break, flowering and veraison are 11 - 15, 18 - 22 and 16 - 22 days earlier; harvest dates are 25 - 40 days earlier. Sugar concentrations increased significantly, but yields decreased. Annual rainfall has not significantly risen, while the mean annual minimum and maximum air-temperatures rose by ~0.9°C, and by ~3.4°C, respectively, resulting in an average increase of the mean annual temperature of ~2.1°C. Remarkably, both mean monthly minimum and maximum temperatures rose especially in springtime, which should have been the driver for earlier bud break and flowering. A change in the climatic conditions, therefore, appears to be one of the key reasons for more favorable grapevine production in Palatinate, especially for “Pinot Noir”, which showed the highest increase in sugar concentrations. The Huglin-index, a measure for the suitability of growing specific grapevine varieties in given environments, increased from 1685 to 2063. According to this index, the climate change may be favorable already for growing grape varieties so far rarely grown in temperate zones, such as “Cabernet Sauvignon”, “Syrah” and “Tempranillo” that are more suited to warmer, Mediterranean climates.
Re-Finding PL.AC.E. for Walking: Assessment of Key-Elements Using Questionnaire  [PDF]
Fritz Akhmad Nuzir, Bart Dewancker
Current Urban Studies (CUS) , 2015, DOI: 10.4236/cus.2015.34023
Abstract: Many studies had already been conducted to acknowledge the contribution of walking in sustainable urban development. After conducting a literature study, authors identified the 3 (three) keyelements and introduced them as PL.AC.E. (abbreviation of Profile, Activity, and Environment), of the pedestrian. The Pedestrian Profile was defined as a combination of the following key-attributes: age; financial income; physical condition; gender; mobility choice; employment and education; social cultural capital; pedestrian type; and public transportation usage. The Pedestrian Activity was defined from the key-attributes as follow: walking-related purposes; social interaction; walking intensity; walking habits; and transport modes interaction. Then the Pedestrian Environment was defined within key-attributes of: spatial planning; walk-ability; neighborhood livability; traffic safety; pedestrian facilities (hard elements); pedestrian facilities (soft elements); and environmental quality. In this study, authors would assess those key-elements by distributing a questionnaire to a group of freshmen of the Department of Architecture in the University of Kitakyushu, Japan as a trial experiment. Total 58 responses were recorded and then analyzed using correlations type statistical analysis. It was then concluded that there are indications that those key-elements could be addressed in the planning process of a walk-able urban environment. However in order to validate the result, authors would continue to further distribute the questionnaire to various respondents within different case study areas.
Helicobacter pylori and gastric cancer
EL Fritz
Continuing Medical Education , 2009,
Abstract: Gastric cancer is a common form of cancer which generally has a poor prognosis.
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