Until now, systematic surveillance for infectious diseases in refugees is still missing. For that reason, this study aims at illustrating the prevalence of tuberculosis (TB) and notifiable skin diseases in a representative cohort of refugees in Lippe, a district of the federal state of North Rhine-Westphalia, Germany. We collected data on notifiable communicable diseases (TB, scabies, and head lice) from refugees (n = 8946) based on a medical screening after their arrival from October 2014 until May 2016. Data were analysed using descriptive and bivariate methods. Overall, we found 63 of 8764 screened refugees to have an abnormal TB screening result (0.72%). Of 8946 screened refugees, only 51 individuals were found to have scabies (0.57%) and a further 49 were tested positive for head lice (0.55%). The absolute number of TB cases indicate only a moderate public health burden. However, communicable skin diseases can become a problem in crowded holding camps, where they can cause local outbreaks.

INTRODUCTION:The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain. PATIENTS AND METHODS:Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4-7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity. RESULTS:Mean VAS pain score for the adolescent subgroup at baseline was ~ 61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was -24.5, -28.1, -31.6, and -31.7 mm for methoxyflurane and -14.6, -18.8, -19.2, and -23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (-9.9 mm; 95% CI: -17.4, -2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1-10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as "Excellent", "Very Good" or "Good" compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache. CONCLUSION:This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain. TRIAL REGISTRATION:Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006-December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain.Funding: Mundipharma International Ltd.

Acute pain remains highly prevalent in the Emergency Department (ED) setting. This double-blind, randomized, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED in the adult population of the STOP! trial.

Seit ihrem Ursprung vor mehr als 60 Jahren hat die britische Notfallmedizin bis zu ihrer Anerkennung als eigenständiges Fachgebiet zunächst einen steinigen Weg begangen. In den letzten 30 Jahren entwickelte sich die klinische Notfallmedizin dann dynamisch zu ihrer jetzigen Struktur. Ziel dieser Arbeit ist die Darstellung der Entwicklung und aktuellen Situation sowie der zukünftigen Herausforderungen und Perspektiven dieses sich innerhalb Europas zunehmend entwickelnden Fachgebiets.

Die klinische Notfallmedizin ist in 17 europäischen Mitgliedsstaaten als primäre Gebietsbezeichnung mit eigener Facharztweiterbildung anerkannt. Ferner gibt es in 5 weiteren Mitgliedsstaaten eine Zusatzbezeichnung in klinischer Notfallmedizin. Hieraus ergab sich die Notwendigkeit für eine eigene europäische Facharztprüfung, um die Ausbildung, Weiterbildung und Zertifizierung zukünftiger Notfallmediziner europaweit zu standardisieren. Das europäische Curriculum für Notfallmedizin wurde bereits 2009 von der Task Force der Europäischen Gesellschaft für Notfallmedizin (EuSEM) erstellt und liegt mittlerweile in deutscher Übersetzung vor.

DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK Emergency Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK Emergency Department, Birmingham Children’s Hospital, Birmingham, West Midlands, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK Emergency Department, Barnsley District General Hospital, Barnsley, UK Accident and Emergency Department, Colchester Hospital University Foundation NHS Trust, Colchester, UK

ObjectiveTo evaluate the short-term efficacy and safety of methoxyflurane for the treatment of acute pain in patients presenting to an emergency department (ED) with minor trauma.MethodsSTOP! was a randomised, double-blind, multicentre, placebo-controlled study conducted at six sites in the UK. A total of 300 patients, 90 of whom were adolescent patients (age 12–17 years), were randomised 150:150 to receive either methoxyflurane via a Penthrox inhaler or placebo. The primary end point of the study was the change in pain intensity as measured using the visual analogue scale (VAS) from baseline to 5, 10, 15 and 20 min after the start of study drug inhalation. Patients were supplied with one inhaler containing 3 mL methoxyflurane or 5 mL placebo after enrolment and initial assessments. Age group (adolescent/adult) and baseline VAS score were controlled for in the statistical analyses.ResultsA total of 149 patients received methoxyflurane, and 149 patients received placebo. Demographic and baseline characteristics were comparable between the groups. Methoxyflurane reduced pain severity significantly more than placebo (p<0.0001) at all time points tested, with the greatest estimated treatment effect of −18.5 mm (adjusted change from baseline) seen at 15 min after the start of treatment. Methoxyflurane was well tolerated, with the majority of adverse reactions being mild, transient and in line with anticipated pharmacological action.ConclusionThe results of this study suggest that methoxyflurane administered via the Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic.Trial registration number:NCT01420159.

Since its early beginnings in the 1950s, emergency medicine (EM) in the UK has come of age and has long been a recognized clinical specialty in its own right. The late 1990s and the early part of the millennium saw an expansion of the previously mainly surgical- and trauma-orientated workload of emergency departments (EDs) into a more and more acute medical and critical care case-mix with increasing levels of acuity and complexity. A recent national trainee survey conducted by the General Medical Council in 2010 revealed a trend towards above-average overall trainee satisfaction scores for core EM trainees. UK EDs operate with relatively fewer consultant whole-time equivalents than comparable EDs in North America and Australasia. As of April 2011 a revised Health Resource Group 4.0 tariff came into effect, and it is expected that most UK EDs will see an increase in income generation by up to 40% as a result of this. With the development of EM as a specialty, the primary care sector has progressively withdrawn from urgent and emergency care provision, although this trend has seen a slight reversal since the restructuring of general practice commissioning. Early data seem to suggest, however, that EDs are clinically safer, more effective and more cost-efficient when compared to primary care-run urgent care centres.

Point-of-care echocardiography using portable machines is an exciting development in emergency medicine. Recent improvements in ultrasound quality mean that emergency physicians are finding echocardiography useful in a variety of clinical settings. Evidence suggests that emergency physicians are able to master the skills of basic echocardiography sufficiently to improve patient care in the resuscitation scenario. Patients with clinical conditions such as breathlessness, undifferentiated shock, chest pain and cardiac arrest may benefit. There is a steep learning curve involved in acquiring these skills and the specialty needs to take care in the way that its practitioners are accredited and perform echocardiography.

times: effect is still debatable The article by Dissmann and Le Clerc is a welcome addition to the prehospital literature. However, it is important to remind readers that the observation that doctors do not prolong prehospital on-scene times within their system is simply that: an observation. All observational studies are influenced by bias, confounding and the play of chance, and in this study there were a number of confounding variables that could have significantly influenced scene times. These include severity of injury, degree of entrapment, resources at scene, interventions before arrival of the helicopter, and the training and experience of the helicopter crew. Without robust case mix adjustment, the true effect of the presence of a doctor on the ‘‘on-scene time’’ cannot be properly established. The validity of the conclusion is therefore in doubt. There is also the possibility of bias regarding the types of calls that the doctor and the paramedic teams attended. From the data presented, it is not possible to say that the casualties they attended were comparable. Furthermore, most of the doctor-attended casualties seem to have required little or no intervention in addition to that provided by paramedics, so are unlikely to have remained on scene for long. With no information regarding how the outcome measure (on-scene time) was derived or validated, it is possible that significant bias was again introduced, especially if these times were accepted only from written report forms. In summary, the study explores a clinically relevant area of prehospital care especially since reduced on-scene times influence the outcome for patients. However, whether doctor-delivered advanced life support in the prehospital phase influences on-scene time is still debatable. Of course, the ultimate measure of the effectiveness of any prehospital critical care and retrieval system must be the outcome for patients. We need to know whether prognosis is affected by the presence of a prehospital critical care team (doctor or non-doctor based) and, in that context, the influence of prehospital time. Dissmann and Le Clerc have opened the debate: let us now develop collaborative research proposals to answer these questions.

Background: The benefits of helicopter emergency medical services (HEMSs) attending the severely injured have been documented in the past. The benefits of doctors attending HEMS casualties have been demonstrated in particular in inner-urban and metropolitan areas. However, for UK regions with potentially less major trauma, concerns have been raised by ambulance services that a willingness of doctors to "stay and play" may lead to unnecessary delays on-scene without any additional benefit to the patient.Aims: To identify factors that do prolong on-scene time, establish whether doctors "stay and play" on-scene compared with paramedics and document how often advanced medical skills may have to be used by HEMS doctors working outside the London HEMS environment.Methods: Patient report form data were studied with regard to the number of and mean on-scene times of missions flown to (A) road-traffic collisions (RTCs), (B) other trauma calls (OTCs) and (C) medical emergencies. Trauma missions (categories A and B) were further subcategorised with regard to associated patient entrapment. Any advanced medical interventions (AMIs) performed by HEMS doctors were recorded and categorised. Finally, we looked at the difference in on-scene times for physician-paramedic partnerships (PPPs) and conventional paramedic crews (CPCs) for the above categories and subcategories.Results: A total of 203 patient report forms were identified and examined. In all, 44.3% of missions were flown to RTCs with a further 44.3% for OTCs and 11.4% to medical emergencies. AMIs were performed by HEMS doctors in 34.1% of PPP missions, with a prehospital rapid sequence induction rate of 3.8%. Overall mean on-scene time was 25 min, with no difference for PPP and CPC missions. The mean on-scene time was prolonged by 6 min for RTCs (p=0.006) and by 23 min for patient entrapment (p<0.001). No significant differences were found for the comparison between PPPs and CPCs in any of the subgroups A-C. However, there seemed to be trend towards reduced on-scene times of PPPs for medical emergencies and patient entrapments.Discussion: This study did not show any significant prolongation of mean on-scene times for PPP missions either overall or for any of the subgroups A-C. The fact that AMIs were performed in a large number of missions attended by HEMS doctors seems to further justify their current role in providing improved care at the roadside without leading to any delays in transfer to definitive care.

The Ottawa ankle rules are a clinical instrument calibrated towards a high sensitivity in order not to miss any fractures of the ankle or mid-foot. This is at the cost of a mean specificity of around only 32%. The aim of this study was to determine the suitability of tuning fork testing in combination with existing Ottawa guidance for increasing the specificity in detecting fractures of the lateral malleolus. A prospective pilot study was carried out, in which a single trained investigator examined all patients with already "Ottawa positive" findings for possible lateral malleolus injury by applying a tuning fork (C degrees 128 Hz). The tuning fork test findings were compared with formal reports of plain ankle radiographs using simple cross-table analysis. The observed prevalence of ankle fractures was 5 of 49 (10%). Sensitivity and specificity were calculated as 100% and 61%, respectively, for tuning fork testing on the tip of the lateral malleolus (TLM), and as 100% and 95%, respectively, for testing on the distal fibula shaft (DFS). The associated positive and negative likelihood ratios were 2.59 and 0 (TLM), and 22 and 0 (DFS), respectively. The data were significant, with p = 0.014 (TLM) and p < 0.001 (DFS). This study suggests that additional tuning fork testing of "Ottawa positive" patients may lead to a marked reduction in ankle radiographs, with consequently reduced radiation exposure and journey time. This may be particularly relevant in situations where radiological facilities are not readily available (expedition medicine) or where access to these has to be prioritised (major incidents, natural catastrophes).

Fluorine-18 labelled fluoromisonidazole ([18F]FMISO) has been shown to accumulate in hypoxic tissue in inverse proportion to tissue oxygenation. In order to evaluate the potential of [18F]FMISO as a possible positron emission tomography (PET) tracer for imaging of liver tissue hypoxia, we measured the [18F]FMISO uptake in 13 domestic pigs using dynamic PET scanning. Hypoxia was induced by segmental arterial hepatic occlusion. During the experimental procedure the fractional concentration of inspired oxygen (FiO2) was set to 0.67 in group A (n=6) and to 0.21 in group B (n=7) animals. Before and after arterial occlusion, the partial pressure of O2 in tissue (TPO2) and the arterial blood flow were determined in normal flow and flow-impaired liver segments. Standardised uptake values [SUV=kBq tissue (in g) / body weight (in kg) × injected dose (in kBq)] for [18F]FMISO were calculated from PET images obtained 3 hours after injection of about 10 MBq/kg body weight [18F]FMISO. Immediately before PET scanning, the mean arterial blood flow was significantly decreased in arterially occluded segments [group A: 0.41 (0.32–0.52); group B: 0.24 (0.16–0.33) ml min–1 g–1] compared with normal flow segments [group A: 1.05 (0.76–1.46); group B: 1.14 (0.83–1.57) ml min–1 g–1; geometric mean (95% confidence limits); P<0.001 for both groups]. After PET scanning, the TPO2 of occluded segments (group A: 5.1 (4.1–6.4); group B: 3.5 (2.6–4.9) mmHg] was significantly decreased compared with normal flow segments [group A: 26.4 (21.2–33.0); group B: 18.2 (13.3–25.1) mmHg; P<0.001 for both groups]. During the 3-h PET scan, the mean [18F]FMISO SUV determined in occluded segments increased significantly to 3.84 (3.12–4.72) in group A and 5.7 (4.71–6.9) in group B, while the SUV remained unchanged in corresponding normal liver tissue [group A: 1.4 (1.14–1.71); group B: 1.31 (1.09–1.57); P<0.001 for both groups]. Regardless of ventilation conditions, a significant inverse exponential relationship was found between the TPO2 and the [18F]FMISO SUV (r2=0.88, P<0.001). Our results suggest that because tracer delivery to hypoxic tissues was maintained by the portal circulation, the [18F]FMISO accumulation in the liver was found to be directly related to the severity of tissue hypoxia. Thus, [18F]FMISO PET allows in vivo quantification of pig liver hypoxia using simple SUV analysis as long as tracer delivery is not critically reduced.

Die Lokalisation und Quantifizierung einer Leberhypoxie ist bislang mit klinischen Methoden nicht möglich, könnte jedoch für die Beurteilung chronischer Lebererkrankungen, für das „Follow-up“ nicht resezierender Therapieverfahren bei primären und sekundären Lebertumoren sowie für die diagnostische Evaluation von Lebertransplantatfunktionstörungen von Bedeutung sein. Herkömmliche Verfahren wie die Leberfunktionsszintigraphie, die Doppler-Flowmetrie und die selektive Leberarterienangiographie erlauben lediglich semiquantitative Aussagen zu regionalen Perfusionsverhältnissen. Mit [18F]Fluormisonidazol (18FMISO) steht ein geeigneter PET-Tracer zur Visualisierung einer Gewebe- [1, 2] und Tumorhypoxie [3, 4] zur Verfügung. Misonidazol unterliegt als Nitroimidazolverbindung einer intrazellulären Radikalbildung. Unter aeroben Bedingungen ist diese Radikalbildung durch Reoxidierung zu einem diffusiblen Molekül reversibel, da Sauerstoff als Elektronenakzeptor zur Verfügung steht. Unter hypoxischen Bedingungen kommt es hingegen zu einer intrazellulären Anreicherung von Misonidazol, da es zu einer kovalenten Bindung an intrazelluläre Makromoleküle kommt. Aufgrund der physiologischen Metabolisierung von Misonidazol in der Leber wurde die Anwendung von 18FMISO als Hypoxie-tracer bei Lebererkrankungen eher zurückhaltend beurteilt. Jedoch verändert sich der hepatische Metabolismus von 18FMISO sobald hypoxische Verhältnisse herrschen [5].