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Pediatric emergencies constitute a small proportion of prehospital cases yet pose unique diagnostic and therapeutic challenges for emergency physicians due to age-specific physiological differences, limited exposure, and infrequent opportunities for skill acquisition. Competency-based medical education frameworks and entrustable professional activities (EPAs) may offer suitable concepts to structure pediatric emergency training. This mixed-methods study combined a retrospective analysis of 9,409 prehospital emergency physician protocols (2012-2021) with a survey assessing self-perceived competence and training needs among emergency physicians. Pediatric emergency characteristics, clinical management, and utilized interventions were analyzed. Survey data captured demographic characteristics, perceived competency across defined scenarios, sources of knowledge acquisition, and perceived gaps in pediatric emergency preparedness. Among all prehospital missions, 606 pediatric emergencies (6.45%) were identified, predominantly involving adolescents with any condition, and any age with trauma and neurological conditions. Invasive interventions such as intubation, cardiopulmonary resuscitation, or intraosseous access were rarely needed. Survey responses (n = 437) revealed heterogeneous self-perceived competencies: seizures, anaphylaxis, and hypoglycemia were associated with high confidence, whereas neonatal care, pediatric polytrauma, and cardiopulmonary resuscitation demonstrated markedly lower confidence levels. Knowledge was primarily acquired during the initial emergency physician qualification training period, as well as through subsequent clinical exposure in routine practice, with limited engagement in ongoing pediatric-specific training. More than 70% of participants advocated for structured, mandatory, and simulation-based pediatric training. Pediatric emergencies in the prehospital setting are uncommon yet challenging, revealing gaps between training expectations, clinical exposure, and perceived competencies. Strengthened pediatric emergency training-particularly simulation-based practice and EPA-based curricular elements-may enhance preparedness, standardize entrustment decisions, and improve patient safety. Future work should operationalize nested pediatric EPAs and evaluate competency outcomes prospectively. IRB-2023-06.
This paper critically reviews current initiatives, regulatory measures, and safety standards addressing plastic pollution, highlighting developments in Europe. While numerous policies and standards are in place, their impact is often constrained by fragmented implementation across disciplines, nations, and sectors. The urgent need for focused scientific research is especially evident in the case of nanoplastics, whose distinctive physicochemical properties and interactions with other contaminants present complex challenges for risk assessment and environmental monitoring. We explore pathways toward sustainable solutions, focusing on reducing plastic footprints and embedding Safe and Sustainable by Design (SSbD) principles into innovation and production. Data-driven Operational Research (OR) tools are presented as a means to optimize decision-making, ensuring interventions remain efficient, evidence-based, and responsive to evolving scientific insights. Equally important is the adoption of rigorous quality assurance (QA) and quality control (QC) protocols in hazard and fate studies, which are vital for producing reliable, reproducible data that can inform both science and policy. This policy analysis situates pollutants within a complex, interconnected system and introduces the exposome approach as a framework for evaluating cumulative environmental exposures over time. Embedding exposome science within the One Health paradigm offers a forward-looking strategy that bridges research, governance, and technology. Such integration fosters interdisciplinary collaboration and enables more effective pollution management. Ultimately, progress in addressing global plastic pollution depends less on new legislation and more on overcoming fragmented efforts through coordinated, cross-sector action guided by One Health perspectives.
Blood gas analyses form part of routine testing in emergency medicine and intensive care in hospitals in the western world; however, this method has not yet become established in prehospital management, despite the fact that patients are comparable in terms of severity of the illnesses. This study aimed to assess whether the use of prehospital blood gas analysis has medical and/or organizational consequences for patient care. In two regions in Germany, seven emergency physician-staffed response units were equipped with portable blood gas analysis devices. After each use, providers were required to complete a 6-item questionnaire evaluating potential medical and organizational consequences for the patient. A total of 184 patients underwent prehospital blood gas analysis. In 85% of cases, providers reported consequences for patient management, including medical and/or organizational effects. In the majority of cases, prehospital blood gas analysis influenced the care of critically ill patients. Further research is needed to determine whether its use translates into improved clinical outcomes, such as reduced mortality. ZIELSETZUNG: In Krankenhäusern der westlichen Welt gehören Blutgasanalysen zur Routineuntersuchung in der Notfall- und Intensivmedizin. In der prähospitalen Versorgung ist diese Methode jedoch nicht etabliert, obwohl Patient:innen hinsichtlich des Schweregrads ihrer Erkrankung vergleichbar sind. Ziel dieser Studie war die Fragestellung nach medizinischen und organisatorischen Konsequenzen für die Patientenversorgung durch den Einsatz einer präklinischen Blutgasanalyse. In 2 Regionen Deutschlands wurden 7 notarztbesetzte Rettungsmittel mit tragbaren Blutgasanalysegeräten ausgestattet. Nach jeder Anwendung waren die Notärzt:innen verpflichtet, einen Fragebogen auszufüllen, um mögliche medizinische und organisatorische Konsequenzen für die Patientenversorgung zu analysieren. Insgesamt wurde bei 184 Patient:innen eine präklinische Blutgasanalyse durchgeführt. In 85 % der Fälle berichteten die Anwender:innen über medizinische und/oder organisatorische Konsequenzen für die Patientenversorgung. In der Mehrzahl der Fälle beeinflusste die präklinische Blutgasanalyse die Versorgung kritisch kranker Patient:innen. Weitere Forschung ist erforderlich, um nachzuweisen, ob der Einsatz einer präklinischen Blutgasanalyse zu verbesserten klinischen Ergebnissen, wie Reduktion der Mortalität, führt.
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The potential human health and environmental risks of micro- and nanoplastics (MNPs) have received increasing scientific attention in recent years. However, methodological challenges, particularly in hazard identification and exposure assessment, continue to hinder reliable risk characterization of MNPs. Taking into account the often complex composition of MNPs as a mixture of polymer, additives, and possible chemical and biological contaminants, comprehensive and robust assessments based on reproducible and harmonized protocols are needed before evidence-based regulatory decisions can be made. Furthermore, given the increasing amounts of plastics in various applications, it is already necessary to develop risk-mitigating strategies aimed at minimizing potential adverse effects on ecosystems and human health. To address 1) the need for better networking of research and standardization across the entire analytical workflow and 2) the requirements for risk-minimizing design and labeling of plastics, an expert workshop was held in the course of a Horizon 2020 research and innovation project, PlasticsFatE. The results of the event contain concrete recommendations, such as 1) a graduated approach to methodological unification with harmonization in particle and hazard analysis and standardization in monitoring, 2) a risk-minimizing design of plastics, and 3) the obligation to label toxic substances.
The therapeutic efficacy of the cardiac glycoside digitoxin in patients with heart failure and reduced ejection fraction is not established. In this international, double-blind, placebo-controlled trial, we randomly assigned patients with chronic heart failure who had a left ventricular ejection fraction of 40% or less and a New York Heart Association (NYHA) functional class of III or IV or a left ventricular ejection fraction of 30% or less and an NYHA functional class of II in a 1:1 ratio to receive digitoxin (at a starting dose of 0.07 mg once daily) or matching placebo in addition to guideline-directed medical therapy. The primary outcome was a composite of death from any cause or hospital admission for worsening heart failure, whichever occurred first. Among 1240 patients who underwent randomization, 1212 fulfilled the criteria for inclusion in the modified intention-to-treat population: 613 patients in the digitoxin group and 599 in the placebo group. Over a median follow-up of 36 months, a primary-outcome event occurred in 242 patients (39.5%) in the digitoxin group and 264 (44.1%) in the placebo group (hazard ratio for death or first hospital admission for worsening heart failure, 0.82; 95% confidence interval [CI], 0.69 to 0.98; P = 0.03). Death from any cause occurred in 167 patients (27.2%) in the digitoxin group and 177 (29.5%) in the placebo group (hazard ratio, 0.86; 95% CI, 0.69 to 1.07). A first hospital admission for worsening heart failure occurred in 172 patients (28.1%) in the digitoxin group and 182 (30.4%) in the placebo group (hazard ratio, 0.85; 95% CI, 0.69 to 1.05). At least one serious adverse event occurred in 29 patients (4.7%) in the digitoxin group and 17 (2.8%) in the placebo group. Treatment with digitoxin led to a lower combined risk of death from any cause or hospital admission for worsening heart failure than placebo among patients with heart failure and reduced ejection fraction who received guideline-directed medical therapy. (Funded by the German Federal Ministry of Research, Technology, and Space and others; DIGIT-HF EudraCT number, 2013-005326-38.).
Bedside ultrasound plays an important role in diagnostics and monitoring, especially in emergency medicine. Modern technology makes ultrasound available in a mobile and portable form, so it can be used even in prehospital emergency care with several interventional and diagnostic applications. This also raises the question of what kind of education and training is necessary for EMS (emergency medical services) physicians to be able to use Point-of-Care Ultrasound (POCUS) in the prehospital setting. This observational study investigates the use of prehospital POCUS in a rural EMS area. It focuses the question of what level of competence is needed for EMS physicians to use POCUS adequately in the prehospital emergency setting for correct application and interpretation of the findings. This was a quality assurance measure designed as a prospective cohort study. We investigated POCUS examinations performed by EMS physicians in the EMS Service Area of Nuremberg City, Germany between June 2021 and July 2022. Patients transported to three specific hospitals in Nuremberg city after care were followed up and the prehospital findings were compared with the in-hospital radiological results. The number of correct findings was correlated with the level of competence in POCUS examinations of the performing EMS physicians. Various classifications of competence were used to assess the influence of training and education on the safe application of prehospital POCUS. Two hundred fifty-eight prehospital POCUS examinations were documented, with 108 followed up, including 268 sonographic findings. There was a wide range of indications for POCUS use. In 79.5% of cases the prehospital findings correspond with those in-hospital. By correlating the correct findings with the participants level of competence, there was no significant difference between POCUS-experienced and -inexperienced EMS physicians, even when divided into different categories. POCUS can be used in prehospital emergency care for a wide range of indications safely, with a high number of correct diagnoses and findings. Our results suggest that emergency POCUS is easy to learn and EMS physicians do not need intensive training to perform POCUS adequately in the prehospital setting. Mobile ultrasound appears to be useful in the prehospital setting It can be used by EMS physicians even without extensive prior experience and expertise POCUS is able to find important findings for prehospital patient's care with a high level of certainty.
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This report presents the baseline characteristics of patients enrolled in the DIGIT-HF trial and compares them with participants from recent trials with improved outcomes in patients with heart failure (HF) and a reduced ejection fraction (HFrEF). DIGIT-HF, a randomized, double-blind, placebo-controlled, multicentre trial enrolling patients with symptomatic HFrEF (New York Heart Association [NYHA] functional class II and left ventricular ejection fraction [LVEF] ≤30%, or NYHA class III-IV and LVEF ≤40%), compares the efficacy and safety of digitoxin versus placebo in addition to standard treatment. Most baseline characteristics of the intention-to-treat population (1212 patients, mean age 66 ± 11 years, 20% women, mean LVEF 29 ± 7%) were similar to those in recent HFrEF trials. The distribution of NYHA class II, III, and IV was 30%, 66% and 4%, respectively, and indicates that the patients were sicker than in comparator HFrEF trials. Less patients had atrial fibrillation (27%) than those in recent HFrEF trials, but prescription rates of background therapy with beta-blockers (96%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (95%), mineralocorticoid receptor antagonists (76%), and diuretics (87%) were high and similar. Overall, 40% of patients were on angiotensin receptor-neprilysin inhibitors, 19% on sodium-glucose cotransporter 2 inhibitors, and 9% on ivabradine. Rates of implantable cardioverter-defibrillator (ICD, 64%) and cardiac resynchronization therapy (CRT, 25%) devices were much higher than in recent HFrEF trials. Patients included in DIGIT-HF display a more severe HF symptom burden and higher rates of ICD/CRT implants compared to participants in recent HFrEF trials, while pharmacotherapy was largely similar. EudraCT (2013-005326-38).
A diverse bacterial community colonizes the respiratory system, including commensals such as Staphylococcus epidermidis (S. epidermidis) and Streptococcus salivarius (S. salivarius), as well as facultative pathogens like Staphylococcus aureus (S. aureus). This study aimed to establish a colonized cell culture model to investigate the impact of these bacteria on influenza A virus (IAV) infection. Respiratory epithelial cells were exposed to S. epidermidis, S. salivarius, or S. aureus, using either live or heat-inactivated bacteria, followed by IAV infection. Cell integrity was assessed microscopically, cytotoxicity was measured via LDH assay, and inflammatory responses were analyzed through cytokine expression. Additionally, macrophage function was examined in response to bacterial colonization and IAV infection. While commensals maintained epithelial integrity for 48 h, S. aureus induced severe cell damage and death. The most pronounced epithelial destruction was caused by coinfection with S. aureus and IAV. Notably, commensals did not confer protection against IAV but instead enhanced epithelial inflammation. These effects were dependent on live bacteria, as inactivated bacteria had no impact. However, prior exposure to S. epidermidis and S. salivarius improved macrophage-mediated immune responses against IAV. These findings suggest that while individual commensals do not directly protect epithelial cells, they may contribute to immune training and enhance lung defense mechanisms.
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Stigmatizing attitudes held by health care professionals against individuals with substance use disorder (SUD) result in worse clinical outcomes. Story-listening has been shown to help mitigate bias for medical trainees. We created a narrative-based small-group facilitated discussion between medical students and an individual in recovery from SUD through a direct partnership with a community peer-recovery organization. All session materials were formulated in direct partnership with the community organization. After completing prework, second-year medical students engaged in a 1.5-hour facilitated discussion with a community member in recovery and one attending physician preceptor. Student perceptions of the session and SUD were evaluated using open-ended and Likert-scale questions through an online survey. Community members engaged in their own postsession debrief. One hundred twenty-four second-year medical students, 16 attending physician preceptors, and 10 community members in recovery participated in the session. Students agreed or strongly agreed that they appreciated the session format (92%), that they learned something new about SUD (83%), and that the session was applicable to their future career (92%). Students appreciated the small-group format and hearing someone's lived experience/perspective. Community members expressed how the session helped humanize health care providers and had interest in participating in future sessions. Working in direct partnership with a local community organization to create an intimate narrative-based educational experience for medical students is feasible, appreciated by medical student participants, and mutually beneficial to community members and can facilitate positive changes in student knowledge and, potentially, bias regarding SUD.
Proximal hamstring tendon avulsion injuries are severe and potentially career-threatening for elite athletes. Until now, no data have been published on the non-operative treatment of this injury in elite athletes. Therefore, the objective of this case series was to describe return to performance in elite athletes after non-operative treatment of full-thickness proximal hamstring tendon avulsion injuries as well as provide detailed description of the rehabilitation process and provide a mechanobiological hypothesis on processes leading to successful outcomes. In this retrospective case series, we included three elite athletes with four MRI-confirmed acute proximal hamstring tendon avulsions of the conjoint tendon and/or the semimembranosus tendon who opted for non-operative treatment following shared decision-making, consisting of an individualised rehabilitation programme. The primary outcome was time to return to performance (in weeks). Secondary outcomes were time to and rate of return to competition, rate of return to performance and re-injury rate. Four proximal hamstring tendon avulsions in three elite athletes were included. All elite athletes returned to performance within 8-33 weeks, which for three out of four cases was at Olympic (gold medal) level. This (pilot) case series indicates that non-operative treatment for full-thickness proximal hamstring avulsion injury can result in return to performance in elite athletes. Non-operative treatment may therefore be a viable treatment option in selected (elite) athletes.
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Colic in infants is defined as excessive crying in an otherwise healthy and thriving baby. Colic is a common but poorly understood and often frustrating problem for caregivers. To study whether osteopathic treatments of infants with infantile colic / excessive crying (IC/EC) have an impact on the subjectively perceived psychological stress of caregivers compared to usual care. The study was designed as a prospective, multicenter, randomized controlled trial. Infants aged 1 week to 3 months and who met Rome IV criteria for IC/EC were included. By means of external randomization, infants were allocated to an intervention group or a control group. Infants in the intervention group received three osteopathic treatments at intervals of one weeks. The treatments were custom-tailored and based on osteopathic principles. Controls received their osteopathic treatment after a 3 week untreated period. The primary outcome parameter was the assessment of parental psychological stress (three questions), measured using a numeric rating scale (NRS; 0-10). Furthermore, the average daily crying time (measured using the Likert scale), the crying intensity (measured using the NRS) and the parents' self-confidence (measured using the Karitane Parenting Confidence Scale) were assessed. A total of 103 infants (average age 39.4 ±19.2 days) were included, 52 in the intervention group and 51 in the control group. An inter-group comparison of changes revealed clinically relevant improvements in favor of the intervention group for the main outcome - parameter psychological stress - for all 3 questions (e.g., for question 2 respectively 3, NRS: between group difference of means 3.5; 95% CI: 2.6 to 4.4; p < 0.001). For the secondary outcome parameters of crying intensity and crying time/day, the changes were of similar magnitude. Three osteopathic treatments given over a period of two weeks led to statistically significant and clinically relevant positive changes of parental psychological stress. German Clinical Trials Register: DRKS00025867, registration date 10.08.21.
The telomerase RNA component (Terc) constitutes a non-coding RNA critical for telomerase function, commonly associated with aging and pivotal in immunomodulation during inflammation. Our study unveils heightened susceptibility to pneumonia caused by Staphylococcus aureus (S. aureus) in Terc knockout (Tercko/ko) mice compared to both young and old infected counterparts. The exacerbated infection in Tercko/ko mice correlates with heightened inflammation, manifested by elevated interleukin-1β (IL-1β) levels and activation of the NLR family pyrin domain containing 3 (NLRP3) inflammasome within the lung. Employing mRNA sequencing methods alongside in vitro analysis of alveolar macrophages (AMs) and T cells, our study elucidates a compelling correlation between Tercko/ko, inflammation, and impaired T cell functionality. Terc deletion results in compromised T cell function, characterized by dysregulation of the T cell receptor and absence of CD247, potentially compromising the host's capacity to mount an effective immune response against S. aureus. This investigation provides insights into the intricate mechanisms governing increased vulnerability to severe pneumonia in the context of Terc deficiency, which might also contribute to aging-related pathologies, while also highlighting the influence of Terc on T cell function.
Ageing is a major risk factor that contributes to increased mortality and morbidity rates during influenza A virus (IAV) infections. Macrophages are crucial players in the defense against viral infections and display impaired function during ageing. However, the impact of ageing on macrophage function in response to an IAV infection remains unclear and offers potential insight for underlying mechanisms. In this study, we investigated the immune response of young and aged human monocyte-derived macrophages to two different H1N1 IAV strains. Interestingly, macrophages of aged individuals showed a lower interferon response to IAV infection, resulting in increased viral load. Transcriptomic data revealed a reduced expression of stimulator of interferon genes (STING) in aged macrophages albeit the cGAS-STING pathway was upregulated. Our data clearly indicate the importance of STING signaling for interferon production by applying a THP-1 STING knockout model. Evaluation of mitochondrial function during IAV infection revealed the release of mitochondrial DNA to be the activator of cGAS-STING pathway. The subsequent induction of apoptosis was attenuated in aged macrophages due to decreased STING signaling. Our study provides new insights into molecular mechanisms underlying age-related immune impairment. To our best knowledge, we are the first to discover an age-dependent difference in gene expression of STING on a transcriptional level in human monocyte-derived macrophages possibly leading to a diminished interferon production.
Prefilled syringes (PFS) and various types of pens are available for subcutaneous injection of methotrexate (MTX) in patients with rheumatoid arthritis or moderate to severe psoriasis. A new MTX pen with modernized button-free autoinjection technology was developed as a successor to a button-activated pen (metoject®/metex® PEN). To assess the needs of users and the relevance of features of the new MTX autoinjector an international online survey was performed. A structured questionnaire was distributed to physicians, nurses and patients in Germany, France, and the United Kingdom. Participants received illustrations and information about features of the new MTX autoinjector. In total, 189 rheumatologists, 111 dermatologists, 90 nurses, and 180 patients answered the questions. Specific reasons for a preference for the use of MTX pens over PFS could predominantly be assigned to the categories "dosing/administration" and "ease of use". The first impression of the new MTX autoinjector was positive in 82% of physicians, 87% of nurses, and 76% of patients, respectively. The four most important features of the new MTX autoinjector were 2-step autoinjector mechanism (receiving a mean 14.1 to 18.1 chips of a total of 100 chips), small injection volume (9.7 to 11.7 chips), 10 different doses for dose flexibility (8.0 to 13.2 chips), and short injection time below 5 seconds (8.5 to 11.1 chips). Arguments for the use of MTX pens as opposed to PFS predominantly refer to dosing/administration and ease of use. The new button-free MTX autoinjector combines a number of advantageous features identified by the international survey. Subcutaneous injection of methotrexate (MTX) is an option to treat patients with specific inflammatory diseases. A new MTX autoinjector with button-free activation of the injection and no need to build a skin fold was developed to address some of the reasons for non-adherence. The importance of specific needs of users as well as the relevance of features of the new MTX autoinjector are unknown. Therefore, a structured questionnaire was distributed to physicians, nurses and patients in Germany, France, and the United Kingdom. Illustrations and information about features of the new MTX autoinjector were distributed to the participants. The results of the study show that arguments for the use of MTX pens as opposed to prefilled syringes predominantly affect the categories dosing/administration and ease of use followed by safety/side effects. In addition, the study identified four main advantageous features of the new MTX autoinjector, ie simplicity due to the 2-step button-free autoinjector mechanism, the small injection volume, 10 different doses for dose flexibility, and the short injection time below 5 seconds.