Publications by authors named "Florian Hoffmann"

50 Publications

[Pediatric emergencies].

Notf Rett Med 2021 4;24(1):1-3. Epub 2021 Feb 4.

Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland.

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http://dx.doi.org/10.1007/s10049-020-00831-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7860162PMC
February 2021

Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE).

Allergo J Int 2021 Jan 28:1-25. Epub 2021 Jan 28.

Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany.

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http://dx.doi.org/10.1007/s40629-020-00158-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841027PMC
January 2021

[Simulation-based pediatric emergency team training in times of the SARS-CoV-2 pandemic].

Monatsschr Kinderheilkd 2020 Nov 17:1-2. Epub 2020 Nov 17.

PAEDSIM e. V., Tübingen, Deutschland.

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http://dx.doi.org/10.1007/s00112-020-01055-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670288PMC
November 2020

More Than 500 Kids Could Be Saved Each Year! Ten Consensus Actions to Improve Quality of Pediatric Resuscitation in DACH-Countries (Austria, Germany, and Switzerland).

Front Pediatr 2020 7;8:549710. Epub 2020 Oct 7.

Dr. von Hauner University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.

• Quality and outcome of pediatric resuscitation often does not achieve recommended goals. • Quality improvement initiatives with the aim of better survival rates and decreased morbidity of resuscitated children are urgently needed. • These initiatives should include an action framework for a comprehensive, fundamental, and interprofessional reorientation of clinical and organizational structures concerning resuscitation and post-resuscitation care of children. • The authors of this DACH position statement suggest the implementation of 10 evidence-based actions (for out-of-hospital and in-house cardiac arrests) that should improve survival rates and decrease morbidity of resuscitated children with better neurological outcome and quality of life.
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http://dx.doi.org/10.3389/fped.2020.549710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575775PMC
October 2020

Comorbidity and long-term clinical outcome of laryngotracheal clefts types III and IV: Systematic analysis of new cases.

Pediatr Pulmonol 2021 Jan 5;56(1):138-144. Epub 2020 Nov 5.

Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.

Background: Long segment laryngotracheoesophageal clefts (LTECs) are very rare large-airway malformations. Over the last 40 years mortality rates declined substantially due to improved intensive care and surgical procedures. Nevertheless, long-term morbidity, comorbidity, and clinical outcomes have rarely been assessed systematically.

Methods: In this retrospective case series, the clinical presentation, comorbidities, treatment, and clinical outcomes of all children with long-segment LTEC that were seen at our department in the last 15 years were collected and analyzed systematically.

Results: Nine children were diagnosed with long segment LTEC (four children with LTEC type III and five patients with LTEC type IV). All children had additional tracheobronchial, gastrointestinal, or cardiac malformations. Tracheostomy for long-time ventilation and jejunostomy for adequate nutrition was necessary in all cases. During follow-up one child died from multiorgan failure due to sepsis at the age of 43 days. The clinical course of the other eight children (median follow-up time 5.2 years) was stable. Relapses of the cleft, recurrent aspirations, and respiratory tract infections led to repeated hospital admissions.

Conclusions: Long-segment LTECs are consistently associated with additional malformations, which substantially influence long-term morbidity. For optimal management, a multidisciplinary approach is essential.
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http://dx.doi.org/10.1002/ppul.25133DOI Listing
January 2021

Team performance during postsurgical patient handovers in paediatric care.

Eur J Pediatr 2020 Apr 19;179(4):587-596. Epub 2019 Dec 19.

Dr. von Hauner University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.

Postsurgical handover of paediatric patients from operating rooms to intensive care units is a critical moment. This process is susceptible to errors and inefficiencies particularly if poor teamwork in this multidisciplinary and ad hoc collaboration occurs. Through combining provider- and observer-rated team performance, we aimed to determine agreement levels on team performance and associations with mental demands, disruptions, and stress. An observational and multisource study of provider and concomitant expert-observer ratings was established. In an Academic Paediatric Hospital, we conducted standardized observations of postsurgical handovers to PICU. We applied established observational and self-reported teamwork tools. Nested fixed and mixed models were established to estimate agreement within teams, between providers' and observer's ratings, as well as for estimations between team performance and mental demands, disruptions, and stress outcomes. Thirty-one postsurgical patient handovers were included with overall 109 ratings of involved providers. Provider-perceived team performance was rated high. Within the receiving sub-team, situation awareness was perceived lower compared to the handoff sub-team [F(df = 1) = 4.41, p = .04]. Inter-provider agreement on handover team performance was low for the overall team yet higher within handover sub-teams. We observed that high level of distractions during the handover was associated with inferior team performance rated by observers (B = - 0.72, 95% CI = - 1.44, - 0.01).Conclusion: We observed substantial disagreements on how involved professionals as well as observers rated teamwork during patient transfers. Investigations into paediatric teamwork and particular team-based handovers should carefully consider if concurrent provider and observer assessments are a valid and reliable way to evaluate teamwork in paediatric care. Common handover language should be established and mandatory before jointly evaluating this process. Our findings advocate also that handovers should be performed under low levels of distractions.What is Known:• Efficient teamwork during transfers of critically ill children is fundamental to quality and safety of handover practice.• Postoperative handovers are often performed by ad hoc teams of caregivers with multiple backgrounds and are prone to suboptimal team performance, communication, and information transfer.What is New:• Our provider and expert evaluations of team performance during OR-PICU handovers showed poor agreement for team performance. Our findings challenge previous results drawing upon single source assessments and inform future studies to carefully consider what approach of team performance assessments is required.• We further demonstrate that high levels of disruptions are associated with poor team performance during patient handovers and that efforts to ensure undisrupted handover practices in clinical care are necessary.
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http://dx.doi.org/10.1007/s00431-019-03547-wDOI Listing
April 2020

Patterns of antimicrobial consumption in neonatal and pediatric intensive care units in Germany and Brazil.

Eur J Clin Microbiol Infect Dis 2020 Feb 31;39(2):249-255. Epub 2019 Oct 31.

Infectiology Service, Dr. von Hauner Children's Hospital, LMU Munich, 80337, Munich, Germany.

Antibiotic consumption (AC) is a key component of antimicrobial stewardship programs to recognize local patterns of antibiotic use. Our aim was to measure AC in neonatal units, including neonatal (NICU)/paediatric (PICU) intensive care units in different countries. We conducted a multicenter, retrospective, cohort study in three NICUs, one neonatal ward, and three PICUs with a total of 84 beds. Global and individual AC in days of therapy (DOT) and DOT per 1000 patient-days were assessed. During the study period, 2567 patients were admitted, corresponding to 4961 patient-days in neonatal units and 9243 patient-days in PICUs. Multidrug-resistant Gram-negative bacteria and methicillin-resistant Staphylococcus aureus were more frequent in Brazil than in Germany. Average AC was 386.5 and 1335.5 DOT/1000PD in German and Brazilian neonatal units, respectively. Aminopenicillins plus 3rd generation cephalosporins were the most commonly prescribed antibiotics in German neonatal units, while aminopenicillins plus aminoglycosides were the class most commonly used in Brazilian NICU. Average AC was 888.1 and 1440.7 DOT/1000PD in German and Brazilian PICUs, respectively. Antipseudomonal penicillins were most commonly used in the German PICU, and glycopeptides were the most frequently prescribed in Brazilian PICUs. Carbapenems represented 2.3-14% of total DOTs in German neonatal units and 4% in the Brazilian NICU and 13.0% in the German PICU and 6-12.2% in Brazilian PICUs. We concluded that different patterns of most commonly prescribed antibiotics were observed in neonatal units and PICUs in these two countries, probably related to different local patterns of antibiotic resistance, with a higher antibiotic consumption in Brazilian study units.
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http://dx.doi.org/10.1007/s10096-019-03714-9DOI Listing
February 2020

Detection of Erosions in Sacroiliac Joints of Patients with Axial Spondyloarthritis Using the Magnetic Resonance Imaging Volumetric Interpolated Breath-hold Examination.

J Rheumatol 2019 11 15;46(11):1445-1449. Epub 2019 Feb 15.

From the Rheumazentrum Ruhrgebiet, Herne, Ruhr-University Bochum, Herne, Germany; and the Department of Rheumatology, Chinese PLA General Hospital, Beijing, China.

Objective: The volumetric interpolated breath-hold examination (VIBE) magnetic resonance imaging (MRI) technique can visualize erosive cartilage defects in peripheral joints. We evaluated the ability of VIBE to detect erosions in sacroiliac joints (SIJ) of patients with axial spondyloarthritis (axSpA) compared to the established T1-weighted MRI sequence and computed tomography (CT).

Methods: MRI (T1-weighted and VIBE) and CT scans of SIJ of 109 patients with axSpA were evaluated by 2 blinded readers based on SIJ quadrants (SQ). Erosions were defined according to Assessment of Spondyloarthritis international Society (ASAS) definitions. Scores were recorded if readers were in agreement.

Results: Erosions were less frequently detected by CT (153 SQ) than by T1-weighted MRI (182 SQ; p = 0.008) and VIBE-MRI (199 SQ; p < 0.001 vs CT and p = 0.031 vs T1-weighted MRI). Taking CT as the gold standard, the sensitivity of VIBE-MRI (71.2%) was higher than that for T1-weighted MRI (63.4%), with similar specificity (87.3% vs 88%, respectively). In linear regression analysis, younger age was significantly associated with occurrence of erosions independently in VIBE-MRI (β = 0.384, p < 0.001) and T1-weighted MRI (β = 0.369, p < 0.001) compared to CT.

Conclusion: The VIBE-MRI sequence was more sensitive than T1-weighted MRI in identifying erosive damage in the SIJ, especially in younger patients. This might be due to the ability of VIBE-MRI to identify structural changes in the cartilage that have not yet extended to the underlying bone, where CT seems to be superior.
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http://dx.doi.org/10.3899/jrheum.181304DOI Listing
November 2019

A multinational survey on the infrastructural quality of paediatric intensive care units.

Ann Intensive Care 2018 Nov 6;8(1):105. Epub 2018 Nov 6.

Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria.

Background: The aim of the present study was to assess whether paediatric intensive care units (PICUs) in three central European countries comply with guidelines concerning infrastructure provided by the European Society of Intensive Care Medicine (ESICM). Between July 2016 and May 2017, a survey was conducted based on the ESICM guidelines. The questionnaire was structured into four categories: structural quality, diagnostic/therapeutic equipment, personnel and organization. All PICUs treating paediatric patients in the D-A-CH region [Germany (D), Austria (A) and Switzerland (CH)] were researched through the national societies. A total of 126 PICUs were contacted (D: 106; A: 12; and CH: 8).

Results: Eighty-five of 126 PICUs responded (D: 67%; A: 61%; and CH: 100%). A median of 500 patients was treated annually (D: 500; A: 350; and CH: 600) with a median of 12 beds (D: 12; A: 8; and CH: 12). Recommendations regarding infrastructure were met as follows: structural quality 62% in D, 71% in A and 75% in CH; diagnostic/therapeutic equipment: 87% in D, 91% in A and 89% in CH; personnel: 65% in D, 87% in A and 85% in CH; and organization: 75% in D, 73% in A and 88% in CH.

Conclusions: This survey reveals deficits concerning structural quality in all countries. Furthermore, shortcomings regarding personnel were found in Germany and for organization in Germany and Austria. These issues need to be addressed urgently to further improve treatment quality and patient safety in the future.
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http://dx.doi.org/10.1186/s13613-018-0451-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219992PMC
November 2018

Childhood Stroke: Awareness, Interest, and Knowledge Among the Pediatric Community.

Front Pediatr 2018 25;6:182. Epub 2018 Jun 25.

Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.

Acute childhood stroke is an emergency requiring a high level of awareness among first-line healthcare providers. This survey serves as an indicator of the awareness of, the interest in, and knowledge of childhood stroke of German pediatricians. Thousand six hundred and ninety-seven physicians of pediatric in- and outpatient facilities in Bavaria, Germany, were invited via email to an online-survey about childhood stroke. The overall participation rate was 14%. Forty-six percent of participants considered a diagnosis of childhood stroke at least once during the past year, and 47% provide care for patients who have suffered childhood stroke. The acronym FAST (Face-Arm-Speech-Time-Test) was correctly cited in 27% of the questionnaires. Most commonly quoted symptoms of childhood stroke were hemiparesis (90%), speech disorder (58%), seizure (44%), headache (40%), and impaired consciousness (33%). Migraine (63%), seizure (39%), and infections of the brain (31%) were most frequently named as stroke mimics. Main diagnostic measures indicated were magnetic resonance imaging (MRI) (96%) and computer tomography (CT) (55%). Main therapeutic strategies were thrombolysis (80%), anticoagulation (41%), neuroprotective measures, and thrombectomies (15% each). Thirty-nine percent of participants had taken part in training sessions, 61% studied literature, 37% discussed with colleagues, and 25% performed internet research on childhood stroke. Ninety-three percent of participants approve skill enhancement, favoring training sessions (80%), publications (43%), and web based offers (35%). Consent for offering a flyer on the topic to caregivers in facilities was given in 49%. Childhood stroke constitutes a topic of clinical importance to pediatricians. Participants demonstrate a considerable level of comprehension concerning the subject, but room for improvement remains. A multi-modal approach encompassing an elaborate training program, regular educational publications in professional journals, and web based offers could reach a broad range of health care providers. Paired with a public adult and childhood stroke awareness campaign, these efforts could contribute to optimize the care for children suffering from stroke.
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http://dx.doi.org/10.3389/fped.2018.00182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026646PMC
June 2018

Duration to Establish an Emergency Vascular Access and How to Accelerate It: A Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms.

Pediatr Crit Care Med 2018 05;19(5):468-476

Pediatric Working Group, Austrian Resuscitation Council, Graz, Austria.

Objectives: To compare the duration to establish an umbilical venous catheter and an intraosseous access in real hospital delivery rooms and as a secondary aim to assess delaying factors during establishment and to provide recommendations to accelerate vascular access in neonatal resuscitation.

Design: Retrospective analysis of audio-video recorded neonatal simulation training.

Settings: Simulation training events in exact replications of actual delivery/resuscitation rooms of 16 hospitals with different levels of care (Austria and Germany). Equipment was prepared the same way as for real clinical events.

Subjects: Medical teams of four to five persons with birth-related background (midwives, nurses, neonatologists, and anesthesiologists) in a realistic team composition.

Interventions: Audio-video recorded mannequin-based simulated resuscitation of an asphyxiated newborn including the establishment of either umbilical venous catheter or intraosseous access.

Measurements And Main Results: The duration of access establishment (time from decision to first flush/aspiration), preparation (decision to start of procedure), and the procedure itself (start to first flush/aspiration) was significantly longer for umbilical venous catheter than for intraosseous access (overall duration 199 vs 86 s). Delaying factors for umbilical venous catheter establishment were mainly due to the complex approach itself, the multitude of equipment required, and uncertainties about necessary hygiene standards. Challenges in intraosseous access establishment were handling of the unfamiliar material and absence of an intraosseous access kit in the resuscitation room. There was no significant difference between the required duration for access establishment between large centers and small hospitals, but a trend was observed that duration for umbilical venous catheter was longer in small hospitals than in centers. Duration for intraosseous access was similar in both hospital types.

Conclusions: Vascular access establishment in neonatal resuscitation could be accelerated by infrastructural improvements and specific training of medical teams. In simulated in situ neonatal resuscitation, intraosseous access is faster to establish than umbilical venous catheter. Future studies are required to assess efficacy and safety of both approaches in real resuscitation settings.
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http://dx.doi.org/10.1097/PCC.0000000000001508DOI Listing
May 2018

Purpura fulminans - It's Not Always Sepsis.

Klin Padiatr 2018 07 30;230(4):225-226. Epub 2018 Jan 30.

Dr. v. Hauner Children's Hospital, LMU Munich, (3) Pediatric Intensive Care Unit, Munich, Germany.

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http://dx.doi.org/10.1055/s-0044-100620DOI Listing
July 2018

Purpura fulminans - It's Not Always Sepsis.

Klin Padiatr 2018 07 30;230(4):225-226. Epub 2018 Jan 30.

Dr. v. Hauner Children's Hospital, LMU Munich, (3) Pediatric Intensive Care Unit, Munich, Germany.

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http://dx.doi.org/10.1055/s-0044-100620DOI Listing
July 2018

Evaluation of a Pilot Project to Introduce Simulation-Based Team Training to Pediatric Surgery Trauma Room Care.

Int J Pediatr 2017 14;2017:9732316. Epub 2017 Feb 14.

Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.

. Several studies in pediatric trauma care have demonstrated substantial deficits in both prehospital and emergency department management. . In February 2015 the PAEDSIM collaborative conducted a one and a half day interdisciplinary, simulation based team-training course in a simulated pediatric emergency department. 14 physicians from the medical fields of pediatric surgery, pediatric intensive care and emergency medicine, and anesthesia participated, as well as four pediatric nurses. After a theoretical introduction and familiarization with the simulator, course attendees alternately participated in six simulation scenarios and debriefings. Each scenario incorporated elements of pediatric trauma management as well as Crew Resource Management (CRM) educational objectives. Participants completed anonymous pre- and postcourse questionnaires and rated the course itself as well as their own medical qualification and knowledge of CRM. . Participants found the course very realistic and selected scenarios highly relevant to their daily work. They reported a feeling of improved medical and nontechnical skills as well as no uncomfortable feeling during scenarios or debriefings. . To our knowledge this pilot-project represents the first successful implementation of a simulation-based team-training course focused on pediatric trauma care in German-speaking countries with good acceptance.
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http://dx.doi.org/10.1155/2017/9732316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5329660PMC
February 2017

Epileptic Seizure, Postictal Hemiparesis, and Hyperleukocytosis.

Glob Pediatr Health 2016 13;3:2333794X16681934. Epub 2016 Dec 13.

Dr. von Hauner Children's Hospital, LMU Munich, Germany.

Acute ischemic stroke (AIS) is a rare event in infancy. Besides vasculopathy, thrombophilia, or cardiac disorders, cancer and chemotherapy are known predisposing factors for AIS. Leukemia can be associated with different abnormal coagulation parameters, but severe bleeding or thrombosis occurs rarely. We report the case of a 2-year-old boy who was presented to our emergency ward after a prolonged seizure with right sided postictal hemiparesis. Cranial computed tomography scan revealed a large infarction and edema due to thrombosis of the left carotid artery, the middle cerebral artery, and the anterior cerebral artery. Laboratory workup showed 196 g/L leukocytes with 75% myeloid blast cells. Immediate exchange transfusion, hydration, and chemotherapy with cytarabine were started. During the hospital course intracranial pressure increased and the patient developed a unilateral dilated pupil unresponsive to light. Cranial computed tomography scan revealed a new infarction in the right middle cerebral artery territory. Refractory increased intracranial pressure and brain stem herniation developed, and the child died 3 days after admission to hospital. Seizures with postictal hemiparesis due to cerebral infarction can be a rare manifestation of acute myeloid leukemia. Leukocytosis and cancer-induced coagulopathy are main reasons for thrombosis and/or hemorrhage. High leukocyte counts need immediate interventions with hydration, careful chemotherapy, and perhaps exchange transfusion or leukapharesis. In the presence of thrombosis, anticoagulation must be discussed despite the risk of bleeding due to hyperfibrinolysis and low platelet counts. Mortality may be reduced by awareness of this rare presentation of leukemia and prompt institution of leucoreductive treatment.
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http://dx.doi.org/10.1177/2333794X16681934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308527PMC
December 2016

[The remains of the day: A working day in a university children's hospital].

Z Evid Fortbild Qual Gesundhwes 2016 Nov 30;117:20-26. Epub 2016 Sep 30.

Institut für Soziale Pädiatrie und Jugendmedizin, Ludwig-Maximilians-Universität München, Deutschland.

Background: Limited time available for direct patient contact and a lot of time required for administrative duties have been reported by physicians working in adult medicine.

Objective: To characterize the typical daily work routine in a major pediatric university hospital.

Materials And Methods: A self-administered questionnaire was completed by physicians in the University Children's Hospital, Munich. The questionnaire captured the time spent on direct patient contact and on administrative tasks as well as the physicians' clinical experience and the location where the respective work was actually carried out (inpatient ward, outpatient emergency department, specialized outpatient clinic or department for developmental medicine).

Results: Most physicians (91.7 %) reported daily working hours beyond the regular schedule of 8.5hours. The proportion of time dedicated to direct patient contact was 31.2 % (95 % confidence interval: 25.2-37.1). Considering the number of patients in the work units, the average amount of time available for each individual patient varied between 14 minutes in the pediatric ward and 52 minutes in the department for developmental medicine. The reported times spent on patient contact did not significantly differ between physicians with > 5 years and those with ≤ 5 years of clinical experience.

Conclusion: Although physicians in a university pediatric hospital work long daily hours, only restricted time is available for direct patient contact defined as physical examination of the child and face-to-face communication with patients and families.
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http://dx.doi.org/10.1016/j.zefq.2016.09.002DOI Listing
November 2016

Ultrasound Assisted Endovascular Thrombolysis in Adolescents: 2 Case Reports.

Pediatrics 2016 07 9;138(1). Epub 2016 Jun 9.

Institute for Clinical Radiology, Ludwig-Maximilians-Universität Munich, Munich, Germany.

Descending iliofemoral thrombosis in children is a rare event. Anticoagulation therapy with low-molecular-weight-heparin is standard of care. However, patency cannot be achieved in all cases, increasing the risk for rethrombosis and postthrombotic syndrome. To reduce the risk of venous valve failure in adults, local catheter-directed thrombolysis is used to reopen vessels. Two adolescent girls (17 and 15 years old) presented with acute descending iliofemoral thrombosis of the left common iliac, external, and common femoral veins. Anticoagulation with enoxaparin was started until insertion of an EkoSonic Mach 4e catheter for ultrasound-assisted local thrombolysis with recombinant tissue plasminogen activator and administration of unfractionated heparin. Success was monitored by increases in D-dimer levels and ultrasound findings. After 24 hours respectively 48 hours, complete recanalization was obtained. No complication occurred except minimal local bleeding. Screening for hereditary thrombophilia revealed a heterozygous antithrombin mutation in 1 girl (ie, the 15-year-old). May-Thurner syndrome was identified in both girls, necessitating stenting of the left common iliac veins and continuation of anticoagulation therapy with enoxaparin and acetylsalicylic acid. No rethrombosis or complications occurred during the follow-up period. Ultrasound-assisted catheter-directed local thrombolysis with the EkoSonic Mach 4e system was effective in achieving immediate recanalization of the occluded veins and should be considered in children experiencing descending iliofemoral thrombosis. The fast recanalization might reduce the incidence of postthrombotic syndrome. May-Thurner syndrome is regularly found in these patients, and if present, requires stenting of the common iliac vein to avoid early reocclusion. However, long-term patency of iliac vein stenting in children remains to be examined.
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http://dx.doi.org/10.1542/peds.2016-0022DOI Listing
July 2016

Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting.

Prehosp Emerg Care 2016 Jul-Aug;20(4):493-8. Epub 2016 Mar 8.

Objective: The pediatric Glasgow coma scale (pGCS) is a consciousness score that, although widely applied, requires skill to apply. The AVPU scale uses four simple categories (Alert; Verbal response; response to Pain; Unresponsive), but has not been studied in a large pediatric population. We compared the performance of the AVPU and pGCS scales in a large pediatric cohort in an acute, prehospital setting.

Methods: In a six-month-long prospective cohort study, AVPU and pGCS scores were determined by emergency physicians in children less than 10 years of age at their first prehospital encounter.

Results: We included 302 children (median age 2.3 years) with a broad spectrum of diagnoses. Data were complete for 287 children. AVPU and pGCS scores showed good a correlation in the extreme categories A and U (positive predictive values of 98% and 100%, respectively). Corresponding pGCS scores for each AVPU category were as follows: 11-15 for A; 5-15 for V; 4-12 for P; and 3-5 for U. The positive predictive value to detect patients with pGCS ≥ 8 for AVPU category V was 100%.

Conclusions: We demonstrated good correlation of simple and fast consciousness AVPU scoring to the standard pGCS in a large cohort of pediatric patients in a prehospital setting. The AVPU category "V" identifies patients with a pGCS of or exceeding 8 and, therefore, identifies children at low risk requiring more invasive procedures or intensive care treatment.

Key Words: Glasgow coma scale (GCS); Alert-verbal-pain-unresponsive-score; AVPU-score; consciousness assessment; children, pediatric emergency.
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http://dx.doi.org/10.3109/10903127.2016.1139216DOI Listing
October 2017

[Erratum to: Interdisciplinary consensus statement on airway management with supraglottic airway devices in pediatric emergency medicine--Laryngeal mask is state of the art].

Anaesthesist 2016 Feb;65(2):121

Institut für Notfallmedizin und Medizinmanagement (INM), Kinderklinik und Kinderpoliklinik, Klinikum der Universität München, Lindwurmstr. 4, 80337, München, Deutschland.

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http://dx.doi.org/10.1007/s00101-015-0132-5DOI Listing
February 2016

[Burn injury in children--recent trends in treatment].

Authors:
Florian Hoffmann

MMW Fortschr Med 2015 Oct;157(17):58-60

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http://dx.doi.org/10.1007/s15006-015-3594-0DOI Listing
October 2015

Structured performance assessment in three pediatric emergency scenarios: a validation study.

J Pediatr 2015 Jun 15;166(6):1498-504.e1. Epub 2015 Apr 15.

Dr. von Hauner University Children's Hospital, Munich, Germany.

Objective: To develop and validate 3 performance evaluation checklists (PECs) for systematic performance assessment in 3 clinical scenarios: cardiopulmonary arrest, dyspnea with oxygen desaturation after intubation, and respiratory syncytial virus (RSV).

Study Design: The 3 PECs were developed using an integrative approach and used to rate 50 training sessions in a simulator environment by different raters. Construct validity was tested by correlating the checklist scores with external constructs (ie, global rating, team experience level, and time to action). Further interrater reliability was tested for all 3 PECs.

Results: The PECs for the desaturation and cardiopulmonary arrest scenarios were valid and reliable, whereas the PEC for RSV had limited validity and reliability.

Conclusion: For 2 pediatric emergencies, the PEC is a valid and reliable tool for systematic performance assessment. The unsatisfactory results for the PEC for RSV may be related to limitations of the simulation setting and require further investigation. Structured assessment of clinical performance can augment feedback on technical performance aspects and is essential for training purposes as well as for research. Only reliable and valid performance measures will allow medical educators to accurately evaluate the behavioral effects of training interventions and further enhance the quality of patient care.
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http://dx.doi.org/10.1016/j.jpeds.2015.03.015DOI Listing
June 2015

Endobronchial lesions caused by nontuberculous mycobacteria in apparently healthy pediatric patients.

Pediatr Infect Dis J 2015 May;34(5):532-5

From the Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.

Pulmonary disease caused by nontuberculous mycobacteria in healthy children is rare, and its pathogenesis is unknown in most cases and standardized treatment is lacking. Here, we report various endobronchial manifestations in 5 patients including hitherto undescribed diffuse tracheobronchial granulomas in 2 patients. Bronchoscopic debulking was performed in all patients and tuberculostatic treatment in 4. All patients including 1 without tuberculostatic treatment showed remission.
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http://dx.doi.org/10.1097/INF.0000000000000606DOI Listing
May 2015

Workflow interruptions and mental workload in hospital pediatricians: an observational study.

BMC Health Serv Res 2014 Sep 24;14:433. Epub 2014 Sep 24.

Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University, Munich, Germany.

Background: Pediatricians' workload is increasingly thought to affect pediatricians' quality of work life and patient safety. Workflow interruptions are a frequent stressor in clinical work, impeding clinicians' attention and contributing to clinical malpractice. We aimed to investigate prospective associations of workflow interruptions with multiple dimensions of mental workload in pediatricians during clinical day shifts.

Methods: In an Academic Children's Hospital a prospective study of 28 full shift observations was conducted among pediatricians providing ward coverage. The prevalence of workflow interruptions was based on expert observation using a validated observation instrument. Concurrently, Pediatricians' workload ratings were assessed with three workload dimensions of the well-validated NASA-Task Load Index: mental demands, effort, and frustration.

Results: Observed pediatricians were, on average, disrupted 4.7 times per hour. Most frequent were interruptions by colleagues (30.2%), nursing staff (29.7%), and by telephone/beeper calls (16.3%). Interruption measures were correlated with two workload outcomes of interest: frequent workflow interruptions were related to less cognitive demands, but frequent interruptions were associated with increased frustration. With regard to single sources, interruptions by colleagues showed the strongest associations to workload.

Conclusions: The findings provide insights into specific pathways between different types of interruptions and pediatricians' mental workload. These findings suggest further research and yield a number of work and organization re-design suggestions for pediatric care.
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http://dx.doi.org/10.1186/1472-6963-14-433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263126PMC
September 2014

Five steps to develop checklists for evaluating clinical performance: an integrative approach.

Acad Med 2014 Jul;89(7):996-1005

Mr. Schmutz is research associate, Industrial Psychology and Human Factors, Department of Psychology, University of Fribourg, Fribourg, Switzerland. Dr. Eppich is assistant professor of pediatrics and medical education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Dr. Hoffmann is senior pediatrician, Dr. von Hauner University Children's Hospital, Munich, Germany. Dr. Heimberg is pediatrician, University Children's Hospital, Tübingen, Germany. Dr. Manser is associate professor for industrial psychology and human factors, Department of Psychology, University of Fribourg, Fribourg, Switzerland.

Purpose: The process of developing checklists to rate clinical performance is essential for ensuring their quality; thus, the authors applied an integrative approach for designing checklists that evaluate clinical performance.

Method: The approach consisted of five predefined steps (taken 2012-2013). Step 1: On the basis of the relevant literature and their clinical experience, the authors drafted a preliminary checklist. Step 2: The authors sent the draft checklist to five experts who reviewed it using an adapted Delphi technique. Step 3: The authors devised three scoring categories for items after pilot testing. Step 4: To ensure the changes made after pilot testing were valid, the checklist was submitted to an additional Delphi review round. Step 5: To weight items needed for accurate performance assessment, 10 pediatricians rated all checklist items in terms of their importance on a scale from 1 (not important) to 5 (essential).

Results: The authors have illustrated their approach using the example of a checklist for a simulation scenario of infant septic shock. The five-step approach resulted in a valid, reliable tool and proved to be an effective method to design evaluation checklists. It resulted in 33 items, most consisting of three scoring categories.

Conclusions: This approach integrates published evidence and the knowledge of domain experts. A robust development process is a necessary prerequisite of valid performance checklists. Establishing a widely recognized standard for developing evaluation checklists will likely support the design of appropriate measurement tools and move the field of performance assessment in health care forward.
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http://dx.doi.org/10.1097/ACM.0000000000000289DOI Listing
July 2014

Self-administered procedural analgesia using nitrous oxide/oxygen (50:50) in the pediatric surgery emergency room: effectiveness and limitations.

Eur J Pediatr Surg 2015 Jun 12;25(3):250-6. Epub 2014 May 12.

Department of Pediatric Surgery, Dr. von Haunersche Kinderspital, München, Germany.

Introduction: Minor surgical interventions in children are often at times challenging due to the lack of cooperation by the child. Procedural sedation and analgesia is often appropriate, but unpleasant or painful applications of medication add additional discomfort to the child. A mixture of nitrous oxide (N2O)/oxygen (O2) in a ratio of 50:50, functioning as an inhalational sedative analgesic, may be a viable alternative, in particular in an emergency care setting because such mixtures require no fasting period and are self-administered. Therefore, in this study we investigated the feasibility and the effectiveness of N2O/O2 (50:50) as a sedative analgesic when performing minor surgical procedures.

Patients And Methods: Procedural sedation and analgesia with an N2O/O2 (50:50) mixture applied during minor surgical procedures were prospectively evaluated over 2.5 years in a major pediatric hospital in Germany. Indications for sedation were either minor painful interventions, the injection of a local anesthetic, or a digital block in an emergency care setting. Diagnosis, type of surgery, inhalation time, complications, side effects, pain scores, and the child's behavioral reaction were assessed.

Results: A N2O/O2 (50:50) mixture was administered in 210 children, ages 2.7 to 16.5 years (mean 9.0 years). Three treatments were terminated because of lack of compliance, nausea, or dizziness. No other side effects were encountered. During the intervention, 80.5% of all patients were pain free, and 81.9% were relaxed and calm. A higher rate of insufficient pain control was observed when the indication was an injection of a digital block or a reposition of fractures and dislocations.

Conclusions: The use of self-administered N2O/O2 (50:50) mixture for minor painful procedures in children is safe and adequate pain control can be achieved in most cases. The benefits of this approach for the child and its parents are its good acceptance and adequate pain control. The benefit for the health care provider is the lack of a fasting period before administration, good anxiolysis at minimum sedation, and a cooperative patient. Limitations are unsatisfying analgesia in some cases. Though not found in our study, potentially serious adverse events are a possibility and standard safety guidelines for minimal sedation should always be applied.
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http://dx.doi.org/10.1055/s-0034-1371716DOI Listing
June 2015

Hospital paediatricians' workflow interruptions, performance, and care quality: a unit-based controlled intervention.

Eur J Pediatr 2014 May 10;173(5):637-45. Epub 2013 Dec 10.

Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Munich University, Munich, Germany,

Objective: Frequent workflow interruptions jeopardise clinicians' efficiency and quality of clinical care. We sought to determine the effect of a documentation-assistant intervention. Our hypothesis was that the expected decrease of workflow interruptions enhances paediatricians' performance and simultaneously improves patients' perceived quality of care.

Methods: This was a controlled intervention study with data collected before and after the intervention at a University Children's Hospital. For the intervention, a documentation assistant was assigned to an inpatient ward. The main outcome measures were workflow interruptions, paediatricians' performance, as well as patients' perceived quality of care. Workflow interruptions were assessed via standardised expert observations. Paediatricians' evaluated their performance in terms of productivity, quality, and efficiency. Additionally, standardised patients' reports on perceived quality of care were collected.

Results: For paediatricians in the intervention ward, workflow interruptions decreased significantly from 5.2 to 3.1 disruption events per working hour (decrease in the control unit was from 3.8 to 3.1). Furthermore, paediatricians reported at follow-up significantly enhanced productivity, quality, and efficiency. Similarly, patients' ratings of care quality improved significantly over time. In multivariate analyses, we found substantial changes attributable to the intervention: for all three outcomes, we found a significant interaction effect of the intervention over study time.

Conclusions: The intervention streamlined paediatricians' workflow, improved day-to-day functioning of the ward, and enhanced organisational efficiency and delivery of paediatric care. Future studies should investigate potential influences between the reduction of workflow interruptions, paediatricians' perceived performance, and patient-related outcomes in quality and efficiency of paediatric care.
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http://dx.doi.org/10.1007/s00431-013-2232-zDOI Listing
May 2014

Synthesis of 2,2,5,5-tetrasubstituted 1,4-dioxa-2,5-disilacyclohexanes via organotin(IV)-catalyzed transesterification of (acetoxymethyl)alkoxysilanes.

Chemistry 2013 Apr 18;19(15):4818-25. Epub 2013 Feb 18.

Wacker-Lehrstuhl für Makromolekulare Chemie, Institut für Siliciumchemie, Technische Universität München, Lichtenbergstrasse 4, 85747 Garching, Germany.

(Acetoxymethyl)silanes 2, 7a-c, and 10a-c with at least one alkoxy group, of the general formula (AcOCH2 )Si(OR)3-n(CH3)n (R: Me, Et, iPr; n=0, 1, 2), were synthesized from the corresponding (chloromethyl)silanes 1, 6a-c, and 9a-c by treatment with potassium acetate under phase-transfer-catalysis conditions. These compounds were found to provide 2,2,5,5-organo-substituted 1,4-dioxa-2,5-disilacyclohexanes 3, 8a-c, and 11a-c if treated with organotin(IV) catalysts such as dioctyltin oxide. The reaction proceeds through transesterification of the acetoxy and alkoxy units followed by ring-closure to form a dimeric six-membered ring. The corresponding alkyl acetates are formed as the reaction by-products. With these mild conditions, the method overcomes the drawbacks of previously reported synthetic routes to furnish 2,2,5,5-tetramethyl-1,4-dioxa-2,5-disilacyclohexane (3) and even allows the synthesis of 1,4-dioxa-2,5-disilacyclohexanes bearing hydrolytically labile alkoxy substituents at the silicon atom in good yields and high purity. These new materials were fully characterized by NMR spectroscopy, elemental analysis, mass spectrometry, and X-ray analysis (trans-8a).
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http://dx.doi.org/10.1002/chem.201202124DOI Listing
April 2013

The repetitive oligopeptide sequences modulate cytopathic potency but are not crucial for cellular uptake of Clostridium difficile toxin A.

PLoS One 2011 Mar 18;6(3):e17623. Epub 2011 Mar 18.

Institut für Toxikologie, Medizinische Hochschule Hannover, Hannover, Germany.

The pathogenicity of Clostridium difficile is primarily linked to secretion of the intracellular acting toxins A (TcdA) and B (TcdB) which monoglucosylate and thereby inactivate Rho GTPases of host cells. Although the molecular mode of action of TcdA and TcdB is well understood, far less is known about toxin binding and uptake. It is acknowledged that the C-terminally combined repetitive oligopeptides (CROPs) of the toxins function as receptor binding domain. The current study evaluates the role of the CROP domain with respect to functionality of TcdA and TcdB. Therefore, we generated truncated TcdA devoid of the CROPs (TcdA(1-1874)) and found that this mutant was still cytopathic. However, TcdA(1-1874) possesses about 5 to 10-fold less potency towards 3T3 and HT29 cells compared to the full length toxin. Interestingly, CHO-C6 cells even showed almost identical susceptibility towards truncated and full length TcdA concerning Rac1 glucosylation or cell rounding, respectively. FACS and Western blot analyses elucidated these differences and revealed a correlation between CROP-binding to the cell surface and toxin potency. These findings refute the accepted opinion of solely CROP-mediated toxin internalization. Competition experiments demonstrated that presence neither of TcdA CROPs nor of full length TcdA reduced binding of truncated TcdA(1-1874) to HT29 cells. We assume that toxin uptake might additionally occur through alternative receptor structures and/or other associated endocytotic pathways. The second assumption was substantiated by TER measurements showing that basolaterally applied TcdA(1-1874) exhibits considerably higher cytotoxic potency than apically applied mutant or even full length TcdA, the latter being almost independent of the side of application. Thus, different routes for cellular uptake might enable the toxins to enter a broader repertoire of cell types leading to the observed multifarious pathogenesis of C. difficile.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0017623PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060812PMC
March 2011