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Valvular heart disease is a common comorbidity in patients with impaired renal function, especially in those with end-stage renal disease undergoing dialysis. Sclerosis and calcification of the heart valves and the valve ring are particularly relevant in the etiology of the diseases. These typically occur at the aortic and mitral valves and can lead to both insufficiency and stenosis of the affected valve. In the current guidelines of the European Society for Cardiology published in 2017, surgical treatment remains the standard of care for most forms of severe valvular heart disease; however, the presence of chronic kidney disease impairs clinical outcomes and is associated with higher mortality rates when compared to patients with preserved renal function. Catheter-based treatment options have emerged as an effective and safe alternative for patients >75 years and/or with increased surgical risk. Consequently, in patients with appropriate anatomy and elevated risk, interventional treatment options should also be discussed in the heart team.

Introduction: Flow diverters are increasingly being used to treat intracranial aneurysms. This study evaluates occurring complications of flow-diverting devices in the treatment of experimental aneurysms, involving the use of micro-CT and small animal MRI at 9.4 T, in correlation to angiographic and histological findings., Methods: We previously published two preclinical studies, in which we assessed two different flow diverters in the treatment of elastase-induced aneurysms. Devices have been implanted across the aneurysm neck as well as in the abdominal aorta. From these studies, a total of 65 devices (prototype FD (n = 30) and Derivo embolization device (n = 35)) additionally underwent micro-CT and MRI after angiographic follow-up and before being histologically examined., Results: The different architectures of both devices were precisely comparable due to high-resolution micro-CT imaging. Micro-CT revealed wire fractures in nine cases (30 %) only with the prototype FD. In three cases (10 %), severe wire fractures correlated with an in-stent stenosis due to intimal hyperplasia. Other complications, like distal stent occlusions and post-stent stenosis, were seen in both groups and verified with both imaging techniques. Osseous metaplasia were correlated to calcifications seen with micro-CT. MRI enabled visualization of the position of the implanted devices relative to the aneurysm and revealed incomplete aneurysm neck coverage with the prototype FD in two cases (6.7 %)., Conclusion: Micro-CT and 9.4-T MRI are valid to discover and understand occurring complications of flow diverters in the preclinical phase and can serve as evaluation tools to minimize complication rates of endovascular devices in the future.

Background: Healthcare personnel may be faced with different degrees of violence and aggression, particularly concerning preclinical care. However, systematic data with respect to the frequency and type of violence in emergency medicine in Germany has not been researched., Methods and Objectives: At an anesthesiology congress, an anonymous survey was distributed about the different kinds and extent of violent acts that the participants had experienced during their work in emergency medicine. Moreover, the participants' subjective feelings toward professional and personal safety when handling emergency cases were explored., Results: Every fourth participant in the survey (25.2 %) had experienced occupational physical violence within the last 12 months. Verbal harassment or insults within the last twelve months were reported by 58.2 % of the participants. While 80 % of the participants feel "entirely" or "mostly" safe with regard to the professional aspect of their occupation, personal safety was considered "entirely" in only 9.3 % and "mostly" in 46.4 % of the cases. Nearly every third participant (31.8 %) feels only "partially" safe and every eighth participant feels "rather not" or "not at all" safe during emergency medicine missions. Men appreciate their expertise as well as their personal safety more so than women (p < 0.001)., Conclusion: Aggression and violence towards healthcare personnel in emergency medicine occur on a regular basis in the German healthcare system. Little research has been conducted in this area, so the issue has not yet been perceived as a relevant problem. Appropriate training for healthcare personnel in emergency medicine should be targeted at developing the skills needed when encountered with aggression and occupational violence.

Background: Trauma care personnel are at risk of occupational exposure to blood-borne pathogens. Little is known regarding compliance with standard precautions or occupational exposure to blood and body fluids among multiple trauma care personnel in Germany., Aim: Compliance rates of multiple trauma care personnel in applying standard precautions, knowledge about transmission risks of blood-borne pathogens, perceived risks of acquiring hepatitis B, hepatitis C and human immunodeficiency virus (HIV) and the personal attitude towards testing of the index patient for blood-borne pathogens after a needlestick injury were evaluated., Material and Methods: In the context of an advanced multiple trauma training an anonymous questionnaire was administered to the participants., Results: Almost half of the interviewees had sustained a needlestick injury within the last 12 months. Approximately three quarters of the participants were concerned about the risk of HIV and hepatitis. Trauma care personnel had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of hepatitis C infection and underused standard precautionary measures. Although there was excellent compliance for using gloves, there was poor compliance in using double gloves (26.4 %), eye protectors (19.7 %) and face masks (15.8 %). The overwhelming majority of multiple trauma care personnel believed it is appropriate to test an index patient for blood-borne pathogens following a needlestick injury., Conclusion: The process of treatment in prehospital settings is less predictable than in other settings in which invasive procedures are performed. Periodic training and awareness programs for trauma care personnel are required to increase the knowledge of occupational infections and the compliance with standard precautions. The legal and ethical aspects of testing an index patient for blood-borne pathogens after a needlestick injury of a healthcare worker have to be clarified in Germany.

Background: In the year 2000 a working group of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) defined a core data set on quality assurance for the first time. In the following years the participating intensive care units sent data to the registry on a voluntary basis and received an annual report on benchmarking data. Alterations in the quality in the field of intensive care medicine have so far only been published to a very low extent., Aim: This study analyzed the core date set of the DIVI between 2000 and 2010 in respect to changes in disease severity using the simplified acute physiology score (SAPS II), the sequential organ failure assessment (SOFA), the need for therapeutic interventions with the therapeutic intervention scoring system (TISS 28) and intensive care unit (ICU) mortality., Material and Methods: Inclusion criteria were participation in the registry for at least 4 years, SAPS II, SOFA, TISS28 scores available and data on ICU discharge. A standardized mortality rate (SMR) was calculated for each year., Results: The mean SAPS II score including 94,398 patients increased by 0.23 points/year with a standard error (SE) of 0.02 to 26.9 ± 12 points (p < 0.001). Similarly, the SOFA score on admission to the ICU increased by 0.14 points/year (SE 0.04) to 3.4 ± 2.7 points (p < 0.001), the proportion of patients with a two organ failure doubled to 7.1 % and the number of patients dependent on ventilation increased by 13.6 % to 59.8 %. The mean time on ventilation increased by 0.17 ventilator days/year (SE 0.01, p < 0.001) to 3.1 ± 7.5 days/patient. The mean number of therapeutic interventions increased by 8.7 % to 26.3 ± 8.3 TISS 28 points/day. The mean length of stay on the ICU (4.3 ± 8 days) and the age of the patients (63.2 ± 17.0 years) remained unchanged. The readmission rate showed no significant changes between the years 2004 and 2010. The readmission rate to the ICU within 48 h after primary discharge was 3.1 % with a 95 % confidence interval (CI) of 3.0-3.3 in contrast to 1.5 % (95 % CI 1.4-1.6) for readmission to the ICU after 48 h. The length of stay in hospital before admission to the ICU decreased for patients with scheduled surgery (6.3 ± 9.7 days vs. 4.2 ± 6.9 days), increased slightly for patients with medically indicated admission to the ICU (2.4 ± 8.2 days 3.1 ± 8.6 days) and remained unchanged for patients with unscheduled admission to the ICU after surgery (4.1 ± 8.6 days). The SMR decreased between 2000 and 2004 from 0.97 to 0.72 and increased again thereafter to 0.99 (ICU mortality 8.5 %)., Conclusion: The severity of disease on admission to the ICU, the proportion of patients on ventilation and the workload of therapeutic interventions increased between 2000 and 2010 in German ICUs but the length of stay of patients in the ICU remained unchanged. The SMR decreased until 2005 and increased thereafter to return to the initial values. The overall ICU mortality was low compared to international data.

Introduction: In this study, we analyzed angiographic and histologic aneurysm occlusion of a newly designed flow diverting device. Visibility and flexibility, as well as occlusions of side branches and neointimal proliferation were also evaluated., Methods: Aneurysms were induced in 18 New Zealand white rabbits and treated with a braided, “closed-loop-designed” device of nitinol. Additional devices were implanted in the abdominal aorta to cover the origin of branch arteries.Angiographic follow-ups were performed immediately after placement of the device, after 3 months (n=9) and 6 months(n =9). The status of aneurysm occlusion (using a five-point scale) and the patency of branch arteries were assessed., Results: Aneurysm occlusion rates were noted as grade 0 in 2 (11 %), grade I in 1 (6 %), grade II in 1 (6 %), grade III in 9(50 %), and grade IV in 5 (28 %) of 18 aneurysms, respectively, indicating a complete or near-complete occlusion of 78 % under double antiplatelet therapy. Aneurysm occlusion was significantly higher at 6 months follow-up (P =0.025). Radiopaque markers provided excellent visibility. Limited device flexibility led to incomplete aneurysm neck coverage and grade 0 occlusion rates in two cases. Distal device occlusions were found in three cases, most likely due to an extremely undersized vessel diameter in the subclavian artery.No case of branch artery occlusion was seen. Intimal proliferation and diameter stenosis were moderate., Conclusion: The tested flow diverter achieved near-complete and complete aneurysm occlusion under double antiplatelet therapy of elastase-induced aneurysms in 78 %, while preserving branch arteries.

Introduction: In this study, we analyzed angiographic and histologic aneurysm occlusion of a newly designed flow-diverting device. Visibility and flexibility, as well as occlusions of side branches and neointimal proliferation were also evaluated., Methods: Aneurysms were induced in 18 New Zealand white rabbits and treated with a braided, "closed-loop-designed" device of nitinol. Additional devices were implanted in the abdominal aorta to cover the origin of branch arteries. Angiographic follow-ups were performed immediately after placement of the device, after 3 months (n = 9) and 6 months (n = 9). The status of aneurysm occlusion (using a five-point scale) and the patency of branch arteries were assessed., Results: Aneurysm occlusion rates were noted as grade 0 in 2 (11 %), grade I in 1 (6 %), grade II in 1 (6 %), grade III in 9 (50 %), and grade IV in 5 (28 %) of 18 aneurysms, respectively, indicating a complete or near-complete occlusion of 78 % under double antiplatelet therapy. Aneurysm occlusion was significantly higher at 6 months follow-up (P = 0.025). Radiopaque markers provided excellent visibility. Limited device flexibility led to incomplete aneurysm neck coverage and grade 0 occlusion rates in two cases. Distal device occlusions were found in three cases, most likely due to an extremely undersized vessel diameter in the subclavian artery. No case of branch artery occlusion was seen. Intimal proliferation and diameter stenosis were moderate., Conclusion: The tested flow diverter achieved near-complete and complete aneurysm occlusion under double antiplatelet therapy of elastase-induced aneurysms in 78 %, while preserving branch arteries.

Background: Numerous cases of swine-origin 2009 H1N1 influenza A virus (H1N1)-associated acute respiratory distress syndrome (ARDS) bridged by extracorporeal membrane oxygenation (ECMO) therapy have been reported; however, complication rates are high. We present our experience with H1N1-associated ARDS and successful bridging of lung function using superimposed high-frequency jet ventilation (SHFJV) in combination with continuous positive airway pressure/assisted spontaneous breathing (CPAP/ASB)., Methods: We admitted five patients with H1N1 infection and ARDS to our intensive care unit. Although all patients required pure oxygen and controlled ventilation, oxygenation was insufficient. We applied SHFJV/CPAP/ASB to improve oxygenation., Results: Initial PaO2/FiO2 ratio prior SHFJV was 58-79 mmHg. In all patients, successful oxygenation was achieved by SHFJV (PaO2/FiO2 ratio 105-306 mmHg within 24 h). Spontaneous breathing was set during first hours after admission. SHFJV could be stopped after 39, 40, 72, 100, or 240 h. Concomitant pulmonary herpes simplex virus (HSV) infection was observed in all patients. Two patients were successfully discharged. The other three patients relapsed and died within 7 weeks mainly due to combined HSV infection and in two cases reoccurring H1N1 infection., Conclusions: SHFJV represents an alternative to bridge lung function successfully and improve oxygenation in the critically ill.

Acute renal failure is a common complication in intensive care medicine. While the incidence of acute renal failure increases, mortality still remains at a high level. In Europe continuous renal replacement therapy (CRRT) has become the standard treatment for acute renal failure. Continuous renal replacement therapy has the advantage of achieving a more stable haemodynamic situation and an easier volume management compared to intermittent haemodialysis (IHD). Until now there has been no evidence to suggest that either classical IHD or CRRT is superior in reducing mortality. Using CRRT in patients with acute renal failure, an ultrafiltration rate adjusted to the patient's bodyweight at 35 ml/kg x h is recommended. A new approach in renal replacement therapy is the slow extended daily dialysis (SLEDD), which combines the advantages of CRRT and IHD. First results are promising, but further investigations are needed to show whether outcome can be improved. A final evidence-based recommendation on the dosing of CRRT or a definitive answer to the question whether daily IHD is better than CRRT, can probably only be possible after two running multicentre studies, the VA/NIH Acute Renal Failure Trial Network (ATN) study and the Augmented Versus Normal Renal Replacement Therapy in Severe Acute Renal Failure Study (ANZICS 2005) Australia and New Zealand Intensive Care Group.