Acute Situations Research Articles

Update atrial fibrillation in older adults

Atrial fibrillation is the most frequent cardiac arrhythmia in old age. As aresult of the positive data on ablation, the focus has shifted to rhythm control. Older adults can also benefit from catheter ablation. Oral anticoagulation remains an essential part of the pharmacological treatment of atrial fibrillation. Recent study results show that geriatric patients require an individual treatment approach, which should be based on the recommendations of the current guidelines and the use of supplementary aids. The assessment of functionality should be taken into account in the treatment and the treatment goal planning as well as symptoms associated with atrial fibrillation. In acute situations cardioversion and long-term drug or interventional (catheter ablation) rhythm-stabilizing treatment are available for rhythm control.

Correlation of factor XIII subunit A with factor XIII activity in a population of parturient women.

The role of factor XIII in acute bleeding situations is gaining more and more importance. It has previously been shown that prepartum factor XIII activity has a significant impact on postpartum blood loss. Whether factor XIII antigen behaves in a similar manner is unknown. As postpartum hemorrhage is one of the leading causes of maternal morbidity and mortality worldwide and factor XIII antigen determination might be available more readily in some centers as compared to factor XIII activity, this is an important question to answer, especially in the emergency situation of a postpartum hemorrhage. To assess the correlation of prepartum factor XIII antigen with prepartum factor XIII activity and to evaluate the correlation between prepartum factor XIII antigen on measured postpartum blood loss. This is a secondary analysis of a prospective cohort study which analyzed the impact of prepartum blood coagulation factor XIII activity on postpartum blood loss in 1300 women at the University Hospital Zurich, Switzerland between October 2015 and November 2016 ("PPH-1300 study"). Blood loss was quantified using a previously validated technique. The association of factor XIII activity and factor XIII antigen was assessed by means of a Spearman rank correlation and differences were displayed using Bland-Altman plot and Passing-Bablok regression. The effect of the prepartum factor XIII antigen on blood loss was estimated by continuous outcome logistic regression. Prepartum factor XIII activity significantly correlated with prepartum factor XIII antigen (Spearman rank correlation coefficient for prepartum values 0.89, p < 0.001 and postpartum values 0.902, p < 0.001). Elevated values of prepartum factor XIII antigen showed a trend toward lower measured postpartum blood loss. The correlation of factor XIII activity with factor XIII antigen (subunit A) in a large real-world sample as well as an association of prepartum factor XIII antigen and postpartum blood loss is observed. Factor XIII antigen determination, a highly automatable test, could be useful in emergency situations such as a PPH (as well as other bleeding situations) if the determination of factor XIII activity is not possible. To evaluate whether FXIII replenishment reduces blood loss is the focus of ongoing studies.

PARALISIA PERIÓDICA HIPOCALÊMICA TIREOTÓXICA: RELATO DE CASO E REVISÃO BIBLIOGRÁFICA INTEGRATIVA

Thyrotoxic Hypokalemic Periodic Paralysis (THPP) is characterized by episodes of muscle weakness associated with hyperthyroidism and hypokalemia. The following study aims to report a case of Thyrotoxic Hypokalemic Periodic Paralysis, in addition to reviewing this uncommon topic in daily medical practice. The patient was a 38-year-old male patient, previously healthy, who was admitted to the emergency room due to pain syndrome in the lower limbs, concomitant with gradual, ascending and progressive loss of strength in the upper limbs, associated with generalized paresis. Hypokalemic flaccid paralysis was confirmed after gasometric and laboratory evidence of severe hypokalemia concomitant with the condition. Investigation was continued with a thyroid profile, which showed suppressed TSH and elevated free T4. The Burch and Wartofsky index was evaluated, compatible with imminent thyrotoxic crisis, and correction of hypokalemia and specific management with propylthiouracil (PTU), corticosteroid therapy and beta-blocker were instituted, with excellent clinical and laboratory response. Subsequently, the presence of antibodies above the reference values ​​was evidenced, confirming the presence of thyroid autoimmunity. Therefore, the insidious onset and rapid deterioration resulting from PPHT are emphasized, with the need for its early recognition as a differential diagnosis in the face of flaccid paralysis, considering the request for thyroid function tests in acute situations for adequate diagnosis and treatment.

IgE immunoadsorption: technical background, functionality, and first clinical experience

Summary Background The prevalence of allergic diseases has risen in the 21st century, drawing attention to specific therapeutic and preventive strategies. Due to the key role of immunoglobulin E (IgE) in the development of allergic reactions, IgE represents a key target treatment. In this scenario, IgE immunoadsorption (IgE-IA) has been investigated as a procedure that selectively removes circulating IgE antibodies from the bloodstream of patients with atopy. Methods This narrative review aims to critically summarize the current insights regarding IgE-IA in the context of the management of allergic diseases, ranging from the rationale to the technical aspects, as well as the benefits and unmet needs. Results IgE-IA might be a treatment strategy in well-selected patients with allergic diseases. IgE depletion through sessions of IgE-IA results in immediate clinical improvement and might be useful in acute situations when a rapid clinical response is required or when classic approaches are contraindicated or ineffective. Due to the reduced effectiveness over time, IgE-IA could be a valid first approach before starting another IgE depletion therapy, such as omalizumab, when its commencement would otherwise be contraindicated by too-high serum IgE levels. Conclusion Overall, IgE-IA is safe and well tolerated; however, this procedure is currently difficult to implement in routine clinical practice because of costs, time demands, need for hospitalization, and the invasiveness of the procedure, with the associated risks related to the necessity of venous catheterization.

Medical and Paramedical Students' Positive Experiences With Interprofessional Simulation: A Questionnaire Study.

Simulation is a common and beneficial learning method in healthcare education. Interprofessional simulation combines both interprofessional collaboration and simulation, and it has been found to improve teamwork, interprofessional collaboration, and patient safety. This study aimed to evaluate medical and paramedical students' attitudes toward interprofessional simulation and their competence to act in acute situations. High-fidelity interprofessional acute simulations focused on internal medicine emergencies and both child and adult resuscitation are part of medical and paramedical curricula at Tampere University and Tampere University of Applied Sciences. A total of 120 final-year medical students and 34 third-year paramedical students participated in these simulations in spring 2021 and were asked to answer pre- and post-questionnaires. The response rates were 91% (n=140) for the pre-questionnaire and 86% (n=132) for the post-questionnaire. A mixed method was used for analysis. The students' attitudes toward interprofessional simulations were positive, and interprofessional simulation was considered an effective and safe learning method. Students experienced interprofessional simulations as an excellent learning method. Before the interprofessional simulations, 66% of the students rated their skills to act in acute situations as good or very good, and after the interprofessional simulations, 95% of the students rated their skills to act in acute situations as good or very good. Effective debriefing and positive feedback were considered important for learning. Interprofessional simulations promoted understanding of other professions and interprofessional communication. When the students self-evaluated their skills to act in acute situations, improvement was detected. Medical and paramedical students appreciated interprofessional collaboration. The students considered interprofessional simulation as an effective learning method and promoting the understanding of other professions. Results confirm that interprofessional simulation is also a good way to teach non-technical skills such as communication and teamwork.

Monitoring the efficiency of reversal on anti-Xa direct oral anticoagulants using point-of-care viscoelastic testing

Bleeding events in patients receiving direct oral anticoagulation (DOAC) can be life-threatening even at therapeutic DOAC plasma concentrations, as anticoagulation impairs hemostasis and should therefore be identified immediately after hospital admission. The anticoagulatory effects of DOAC are typically not measurable in standard coagulation tests, such as PT or aPTT. Specific calibrated anti-FXa-tests allow specific drug monitoring, but they are too time-consuming for critical bleeding events and are commonly not available for 24 h/7 days in routine care. However, recent advances in point-of-care (POC) viscoelastic testing (VET) have shown a promising approach for rapid and quantitative detection of DOAC plasma concentrations using the Russell viper venom factor V activator (RVV for FXa-inhibitors) test or the ecarin clotting time (thrombin inhibitors). In acute bleeding situations, direct FXa inhibitors can be reversed by specific antidote andexanet alfa or hemostasis can be improved by prothrombin complex factor concentrates (PCCs). After reversal, confirmation of reversal efficacy is often requested, but no routine assays are currently available. Thus, the emergency management of bleeding DOAC patients is usually “blinded” with regard to reversal efficacy. POC VET laboratory assays might therefore also be helpful for measuring DOAC effects after reversal. We present a case series demonstrating the usefulness of RVV-clotting time post-DOAC reversal with andexanet alfa.

Current evidence on the use of sugammadex for neuromuscular blockade antagonism during electroconvulsive therapy - a narrative review.

Depression is a common mental health problem that is associated with significant disability and mortality. Electroconvulsive therapy (ECT) has been demonstrated to be effective at resolving expression of suicidal intent in patients with depression. In less acute situations, patients are usually referred for ECT after several medication trials. Neuromuscular blocking agents (NMBAs) are used to block tonic-clonic motor activity and associated physical harm during the delivery of ECT. Succinylcholine (Sch), with its rapid onset of muscle relaxation, short self-terminating duration of action, and rapid subsequent return of spontaneous ventilation, is the NMBA of choice for ECT. However, the use of Sch is problematic or contraindicated is some situations. Although non-depolarizing NMBAs can be used, the variable time to onset of adequate muscle relaxation and prolonged duration of action have limited their widespread acceptance as alternatives to Sch. Recently, however, with the widespread availability of sugammadex, a chemically modified γ- cyclodextrin that rapidly and predictably reverses the effect of non-depolarizing NMBAs, the muscle relaxation achieved by rocuronium can predictably and effectively be reversed. In situations where Sch is contraindicated or otherwise problematic, rocuronium, followed by pharmacological antagonism with sugammadex, can provide a safe and effective muscle relaxation approach comparable to that of Sch in terms of duration of action. This review provides a summary of the current state of evidence for the use of sugammadex during ECT, which should lend support to further acceptance and future studies of sugammadex in the context of ECT.

Simulation as a method in a supervision course, experiences of midwives and specialist nurses: A qualitative study

AimTo explore supervisors’ experience of simulation in a student supervision course BackgroundThe relationship between student and supervisor is crucial for the students’ learning and quality of education. The supervisors have an important role in facilitating a good start and the best learning opportunities for students in clinical placement. Supervision can be demanding and there is a need to strengthen supervisors in their role. An interprofessional supervision course was designed, using simulation as a method. Simulation is frequently used for acute situations to improve patient safety but is less common in student supervision. In our supervision course, simulation was introduced in the digital component and practiced in the physical component. The 4–6 members of the interprofessional simulation groups were assigned roles as either participants or active observers. They were guided by a facilitator, who constructed student-supervisor scenarios, allocated roles and facilitated reflection. DesignA qualitative, explorative design involving focus groups and written reflections. MethodsTwo focus groups (n=9) were conducted following a pilot course in addition to written reflections (n= 80) after four courses. After revising the course and the interview guide, two additional focus groups (n =10) were held and a further 43 written reflections received. The empirical data were analyzed using thematic analysis by Braun and Clarke. ResultsThe three themes.1. Interprofessional simulation provides a wider perspective on the student- supervisor relationship.The participants experienced being active in different roles, followed by subsequent joint reflection. They expressed increased relational understanding as well as the importance of verbal and nonverbal communication in supervision through learning from other interprofessional supervisors.2. Simulation provides realism by entering into the situation. Simulation fostered activation of the senses that improved the supervisor’s ability to be attentive to the student’s needs.3.Challenging to simulate the role of supervisor. Most participants were willing to force themselves out of their comfort zone to learn. However, quite a few felt uncomfortable participating in simulation on communication and preferred observing others. ConclusionThe participants experienced simulation as valuable for strengthening their awareness of their ability to influence students’ learning and relational understanding. The results showed the value of reflective observation in addition to participating in simulation. Simulation might contribute to improved supervision, although different experiences that inhibit learning outcomes must be acknowledged.

Nursing intervention in acute or critically ill patients with thirst: an integrated review

Aim: Analyze the existing nursing interventions and their effectiveness in managing thirst and promoting the person’s comfort. Background: Thirst is a symptom often experienced by people hospitalized in an acute and/or critical situation, but it is still frequently under-evaluated and under-treated in clinical practice, one of the main reasons being the difficulty in assessing thirst when it comes to people with an altered state of consciousness. Methods: To analyze the existing nursing interventions in managing thirst and promoting the person’s comfort, an integrative review was elaborated through electronic databases MEDLINE, CINAHL, PubMed, and other sources from March 2023 to August 2023. The review protocol is registered (PROSPERO CRD42023413584) and this review integrates a Project in a Higher School of Nursing. Results: After assessing eligibility, 16 final documents were obtained for data extraction and analysis. The results obtained show that several effective strategies were identified to thirst relief, such as drinking cold liquids, ingestion of carbohydrate drinks when fasting is really necessary, the use of ice, performing oral hygiene, applying lip moisturizer, using mentholated substances, controlling the ambient temperature, use of salivary stimulants and artificial saliva. Conclusions: This is a sensitive area of nursing care. Thus, a more significant investment in the scope of nursing research and the development of innovative technology that can improve nursing interventions for the management and thirst relief, would be beneficial to improve the quality of the nursing care provided for hospitalized patients in critical care.

Narrativizing the Nexus between Climate Crisis and Immigration in Amitav Ghosh's Gun Island: An Ecocritical Exploration

Eco-criticism is a branch of literary scholarship that finds tangible connections between the environment and literature. The environmental problem is one of the most prominent issues of current generation. Climate crisis stands as a sole factor in the environment in view of ecological imbalance. This is an ever increasingly presence in our daily lives. prominent causes of climate change are an increase of green house gasses, deforestation to develop human settlements, excessive use of fossil fuels and so on. Decline in agricultural productivity is another impact of climate change. Thus, this is widely recognized as a contributing and exacerbating factor in immigration. The climate crisis, migration and refugees' acute situation have allegedly lost security and stability of humans and non-humans. The paper attempts to look how Amitav Ghosh has put his best endeavors to discover the inordinate use of nature by human beings. The materialistic and anthropocentric attitudes of human beings undergo extreme climate crisis and the displacement of livings. Now, the major environmental issues become the ethical concerns in the eco pages of literary writers to highlight the problems of ecosystem. The novel "Gun Island" deals with the issue of climate crisis and immigration. Planetary environmentalism identifies the planetary crisis caused by climate change. It seeks environmental justice both for humans and nonhumans across the planet. The whole planet goes beyond geographical boundary because of threatening of climate change. Ghosh in this novel wants to procure awareness among the readers regarding the impending calamities of the global environment and thus a warning to mend exploitative attitudes towards our Mother Nature.

Adaptive Top-K Algorithm for Medical Conversational Diagnostic Model.

With advancements in computing technology and the rapid progress of data science, machine learning has been widely applied in various fields, showing great potential, especially in digital healthcare. In recent years, conversational diagnostic systems have been used to predict diseases through symptom checking. Early systems predicted the likelihood of a single disease by minimizing the number of questions asked. However, doctors typically perform differential diagnoses in real medical practice, considering multiple possible diseases to address diagnostic uncertainty. This requires systems to ask more critical questions to improve diagnostic accuracy. Nevertheless, such systems in acute medical situations need to process information quickly and accurately, but the complexity of differential diagnosis increases the system's computational cost. To improve the efficiency and accuracy of telemedicine diagnostic systems, this study developed an optimized algorithm for the Top-K algorithm. This algorithm dynamically adjusts the number of the most likely diseases and symptoms by real-time monitoring of case progress, optimizing the diagnostic process, enhancing accuracy (99.81%), and increasing the exclusion rate of severe pathologies. Additionally, the Top-K algorithm optimizes the diagnostic model through a policy network loss function, effectively reducing the number of symptoms and diseases processed and improving the system's response speed by 1.3-1.9 times compared to the state-of-the-art differential diagnosis systems.

Real-time integrated water availability – Salt intrusion modelling and management during droughts

Climate change and population increase are major challenges when guaranteeing a sustainable water supply in densely populated river basins worldwide, where different water users such as industry, drinking water production and agriculture typically come into conflict. During dry periods, real time monitoring and short term forecasting of the water availability are crucial to prepare and take appropriate action. Integrated water quantity and water quality models of complex surface water systems are indispensable to achieve this. However, existing model techniques often focus on a single aspect of the water system, are computationally too demanding and are hard to integrate with other sub models. This paper proposes a framework for developing efficient, integrated water quantity/quality models in support of real-time management and forecasting of complex surface water systems. Its three main components are: a low-flow prediction for the supplying river(s) during dry periods, a conceptual water quantity-quality model with semi-automated retrieval of necessary boundary conditions and input data, and classification models to predict the water quality state of the considered system during forecasts or scenario analyses. The novelty of the methodology lies in the use of parsimonious, computationally efficient sub-models that still allow to consider numerous operational rules, competing water users and water supply and quality constraints. The framework was tested in the context of water availability and salt intrusion management during droughts in the Campine Canals in the Scheldt-Meuse-Rhine delta, considering boundary conditions of shipping traffic, pumping at locks, hydropower stations, level regulation, and water abstractions for drinking water supply, industry, agriculture and nature reserves. Despite the complexity of the considered system, the model is able to describe the state of the water system in terms of water levels, discharges and salt intrusion impacts on water production with an acceptable accuracy. The research shows that the Campine Canal network is susceptible to water scarcity due to the increased risk of low flows in summer as a consequence of climate change. Local decision makers should adopt both effective adaptation strategies as well as real-time forecasts in acute drought situations to increase the region’s defence and resiliency against water shortages.

Effects of health education applying role play on decision making in acute myocardial infarction situation among older adults in community

Acute myocardial infarction is a silent killer for people worldwide, especially older adults who often experience atypical symptoms, causing late decision-making and a high mortality rate. The unrecognition of atypical symptoms, unconcerned about their risk, and not knowing how to deal with this critical situation are the barriers to a quick decision to visit the emergency department and delaying treatment, resulting in serious adverse outcomes. Therefore, specific and effective health education among older adults is needed. This double-blinded randomized controlled trial explored the effectiveness of health education by applying a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence among community-dwelling older adults. The participants were 96 community-dwelling older adults in central northeastern Thailand. We collected data between November 2021 and April 2022. The multi-stage sampling was applied to include participants. The intervention was the role-play promoting decision-making ability program and home visit. Outcomes were measured a week before attending and after finishing the intervention. T-tests, Mann–Whitney U test, Chi-square, and Wilcoxon Signed Rank test compared the outcomes between and within groups. Moreover, adjusted analysis was also demonstrated. Results revealed that participants who attended the program improved their knowledge, belief, and decision-making; only perceived susceptibility did not show improvement. Moreover, after demonstrating an adjusted analysis, the program participants had better knowledge about symptoms, perceived benefits, barriers, self-regulation, possible calling 1669, and first action. In conclusion, a role-play promoting decision-making ability program can promote knowledge, belief, and decision-making when expecting acute myocardial infarction occurrence among community-dwelling older adults. This study proved that role-play is one strategy to promote the program's effectiveness by inducing attention before giving older adults health information. Nurses and other healthcare professionals can implement this program as part of standard practice.Clinical Trial Registration Number: TCTR20210928004 on 28/09/2021.

Enhancing the Capabilities of Continuous Glucose Monitoring With a Predictive App.

Despite abundant evidence demonstrating the benefits of continuous glucose monitoring (CGM) in diabetes management, a significant proportion of people using this technology still struggle to achieve glycemic targets. To address this challenge, we propose the Accu-Chek® SmartGuide Predict app, an innovative CGM digital companion that incorporates a suite of advanced glucose predictive functionalities aiming to inform users earlier about acute glycemic situations. The app's functionalities, powered by three machine learning models, include a two-hour glucose forecast, a 30-minute low glucose detection, and a nighttime low glucose prediction for bedtime interventions. Evaluation of the models' performance included three data sets, comprising subjects with T1D on MDI (n = 21), subjects with type 2 diabetes (T2D) on MDI (n = 59), and subjects with T1D on insulin pump therapy (n = 226). On an aggregated data set, the two-hour glucose prediction model, at a forecasting horizon of 30, 45, 60, and 120 minutes, achieved a percentage of data points in zones A and B of Consensus Error Grid of: 99.8%, 99.3%, 98.7%, and 96.3%, respectively. The 30-minute low glucose prediction model achieved an accuracy, sensitivity, specificity, mean lead time, and area under the receiver operating characteristic curve (ROC AUC) of: 98.9%, 95.2%, 98.9%, 16.2 minutes, and 0.958, respectively. The nighttime low glucose prediction model achieved an accuracy, sensitivity, specificity, and ROC AUC of: 86.5%, 55.3%, 91.6%, and 0.859, respectively. The consistency of the performance of the three predictive models when evaluated on different cohorts of subjects with T1D and T2D on different insulin therapies, including real-world data, offers reassurance for real-world efficacy.

Does it need an app? – Differences between app-guided breathing and natural relaxation in adolescents after acute stress

A key component of stress management and biofeedback training is the use of relaxation exercises, such as slow/deep breathing (6 breaths/minute) in heart coherence exercises (HCEs). Breathing exercises are also increasingly being integrated into smartphones as part of health apps, though their effectiveness in adolescents after acute stress has rarely been validated scientifically. The aim of the current study was to investigate the effectiveness of an app-guided HCE (n = 36) after an acute stress situation (Trier Social Stress Test) compared with natural relaxation (n = 37), among healthy adolescents (aged 11–17 years). Endocrine, autonomic, and psychological stress parameters (cortisol, alpha-amylase, heart rate, heart rate variability, mood) were examined in 73 adolescents (46 female, 27 male; Mage = 13.86, SDage = 1.87). Significant group differences were found in heart rate variability, with higher values in the low frequency band and low-to-high frequency ratio for the HCE condition, possibly indicating improved physiological functions through the stimulation of vagal tone and baroreflex. The use of a general breathing technique (natural and app-guided) also resulted in stronger relaxation reactions in cortisol when controlling for the previous stronger stress reactivity. On the other hand, app-guided slow breathing without a long training may be experienced as more uncomfortable during relaxation. The integration of breathing exercises in health apps for adolescents appears to be useful, offering a helpful and low-threshold coping/relaxation strategy during acute stress situations. Further studies should examine the benefits of app-guided breathing exercises in both psychiatric samples and the general population across a wide age range.

An Expert-Based Review on the Relevance and Management of Type 2 Endoleaks Following Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

Ruptured abdominal aortic aneurysms (rAAAs) are life-threatening and require emergent surgical therapy. Endovascular aortic repair for rupture (rEVAR) has become the leading strategy due to its minimal invasive approach with expected lower morbidity and mortality, especially in patients presenting with hemodynamic instability and relevant comorbidities. Following rEVAR, intraoperative angiography or early postinterventional computed tomography angiography have to exclude early type 1 or 3 endoleaks requiring immediate reintervention. Persistent type 2 endoleaks (T2ELs) after rEVAR, in contrast to elective cases, can cause possibly lethal situations due to continuing extravascular blood loss through the remaining aortic aneurysm rupture site. Therefore, early identification of relevant persistent T2ELs associated with continuous bleeding and hemodynamic instability and immediate management is mandatory in the acute postoperative setting following rEVAR. Different techniques and concepts for the occlusion of T2ELs after rEVAR are available, and most of them are also used for relevant T2ELs after elective EVAR. In addition to various interventional embolization procedures for persistent T2ELs, some patients require open surgical occlusion of T2EL-feeding arteries, abdominal compartment decompression or direct surgical patch occlusion of the aneurysm rupture site after rEVAR. So far, in the acute situation of rAAAs, indications for preemptive or intraoperative T2EL embolization during rEVAR have not been established. In the long term, persistent T2ELs after rEVAR can lead to continuous aneurysm expansion with the possible development of secondary proximal type I endoleaks and an increased risk of re-rupture requiring regular follow-up and early consideration for reintervention. To date, only very few studies have investigated T2ELs after rEVAR or compared outcomes with those from elective EVAR regarding the special aspects of persisting T2ELs. This narrative review is intended to present the current knowledge on the incidence, natural history, relevance and strategies for T2EL management after rEVAR.

Prescribing benzodiazepines in young adults with anxiety: a qualitative study of GP perspectives.

Incident benzodiazepine prescriptions in primary care for anxiety decreased between 2003 and 2018. However, from 2008, incident prescribing of benzodiazepines for anxiety increased among those aged 18-34 years. There are increasing concerns around prescribing of benzodiazepines. Further, although guidelines state benzodiazepines should only be prescribed short term, in 2017, 44% of incident prescriptions were prescribed for longer than the recommended duration of 2-4 weeks. To understand when and why GPs prescribe benzodiazepines for anxiety in young adults. A qualitative study was undertaken using in-depth interviews with 17 GPs from 10 general practices in South West England. Interviews were conducted by telephone or videocall. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and data analysed using reflexive thematic analysis. GPs described caution in prescribing benzodiazepines for anxiety in young adults, but thought they had an important role in acute situations. GPs described caution in prescribing duration, but some thought longer-term prescriptions could be appropriate. In light of these views, some GPs questioned whether primary care needs to revisit how clinicians are using benzodiazepines. GPs perceived that some young adults requested benzodiazepines and suggested this might be because they wanted quick symptom relief. GPs noted that refusing to prescribe felt uncomfortable and that the number of young adults presenting to general practice, already dependent on benzodiazepines, had increased. Patient-driven factors for prescribing benzodiazepines suggest there are current unmet treatment needs among young adults with anxiety. Given increases in prescribing in this age group, it may be timely to revisit the role of benzodiazepines in the management of people with anxiety in primary care.

Emergencies in nephrology

Emergencies in nephrology are mainly acute life-threatening situations for patients. Furthermore, one needs to consider constellations that are so damaging to the kidneys that the need for permanent dialysis develops within ashort period of time. Acute kidney failure as an immediate consequence is categorized using the Acute Kidney Injury Network (AKIN) stages and is pathophysiologically subdivided into pre-, intra- and post-renal. This leads to changes in volume status, acid base and electrolytes, while the terms nephrotic and nephritic describe the amount of kidney damage and help to choose diagnostic steps wisely. Patients that are already undergoing dialysis treatment or have received akidney transplant are afurther specific group in the case of emergencies.

Proximal and distant expression of growth differentiation factor 15 (GDF15) correlate with neurological deficit following experimental ischemic stroke.

Growth differentiation factor 15 (GDF15) has emerged as a promising biomarker in cerebro-cardiovascular disease, particularly in acute and chronic inflammatory stress situations. However, understanding the origins, targets and functions of GDF15 in clinical situations, such as ischemic stroke, remains a complex challenge. This study aims to assess the sources of GDF15 production following an experimental ischemic stroke. Adult male Wistar rats underwent cerebral embolization through microspheres injection into the left or right internal carotid artery. Two hours post-surgery, GDF15 expression was analyzed in the brain, blood, lungs, liver and heart using quantitative RT-PCR and Western blotting. Stroke model induced large cerebral infarcts accompanied by severe neurological deficits. GDF15 gene expression exhibited a substantial increase in the ipsilateral cortex and cerebellum, with a lesser extent in the contralateral cortex. Regarding GDF15 protein expression, proGDF15 levels were elevated in the 3 aforementioned organs mentioned and the heart. However, the mature form of GDF15 was exclusively present and increased in the heart. Finally, the expression of GDF15 expression was correlated with the neurological deficit score. Our findings suggest that both the GDF15 gene and pro-protein are expressed in the ischemic brain after a stroke, while only its mature form is expressed remotely in in the heart. The impact of increased GDF15 in the heart following a stroke remains to be established. This is particularly relevant in understanding its relationships with poor neurological outcomes, determining whether it may contribute to stroke-induced cardiac dysfunction.

Evaluation of an On-Site Disaster Medical Management Course in Nepal.

The great 2015 Nepal earthquake of magnitude 7.6 killed about 9000 people. To better ensure a more coordinated disaster response, a Basic On-Site Disaster Medical Support (BOS-DMS) course was designed in 2017. This study evaluates the effectiveness of the BOS-DM course. The course was conducted twice and attended by 135 participants, of whom 113 (83.7%) answered pre-test and post-test based multiple-choice questions. Qualitative and quantitative feedback was provided by 94 participants (69.6%). Mean test scores for the participants increased from 4.24 ± 1.42 to 6.55 ± 2.16 (p-value < 0.0001; paired t-test). More than 92.0% of participants felt that the course prepared healthcare workers to manage acute medical situations at a disaster site. Subject knowledge scores increased from 34.8% to 90.2%. A three-day BOS_DMS course has the potential to improve on-site disaster management knowledge. Our study noted that precise scheduling, making attendance compulsory, translating course materials into the local language, inclusion of disaster exercises and training local master trainers can enhance course effectiveness.