Een nobele en pieuse carriere: Predikanten aan het negentiende-eeuwse Oranjehof

Lieburg, F.A. van [Promotor]Schutte, G.J. [Copromotor

Hardware/Software Co-design Applied to Reed-Solomon Decoding for the DMB Standard

This paper addresses the implementation of Reed- Solomon decoding for battery-powered wireless devices. The scope of this paper is constrained by the Digital Media Broadcasting (DMB). The most critical element of the Reed-Solomon algorithm is implemented on two different reconfigurable hardware architectures: an FPGA and a coarse-grained architecture: the Montium, The remaining parts are executed on an ARM processor. The results of this research show that a co-design of the ARM together with an FPGA or a Montium leads to a substantial decrease in energy consumption. The energy consumption of syndrome calculation of the Reed- Solomon decoding algorithm is estimated for an FPGA and a Montium by means of simulations. The Montium proves to be more efficient

a qualitative study comparing urban and rural sites

Objectives: The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low- acuity conditions for visiting an ED. Methods: We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites. Results: A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same. Conclusions: We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation. Trial registration number: DRK S0000605

Multicentre cross-sectional observational registry to monitor the safety of early discharge after rule-out of acute myocardial infarction by copeptin and troponin: the Pro-Core registry

Objectives: There is sparse information on the safety of early primary discharge from the emergency department (ED) after rule-out of myocardial infarction in suspected acute coronary syndrome (ACS). This prospective registry aimed to confirm randomised study results in patients at low-to-intermediate risk, with a broader spectrum of symptoms, across different institutional standards and with a range of local troponin assays including high-sensitivity cTn (hs-cTn), cardiac troponin (cTn) and point-of-care troponin (POC Tn). Design Prospective, multicentre European registry. Setting 18 emergency departments in nine European countries (Germany, Austria, Switzerland, France, Spain, UK, Turkey, Lithuania and Hungary) Participants: The final study cohort consisted of 2294 patients (57.2% males, median age 57 years) with suspected ACS. Interventions: Using the new dual markers strategy, 1477 patients were eligible for direct discharge, which was realised in 974 (42.5%) of patients. Main outcome measures: The primary endpoint was allcause mortality at 30 days. Results: Compared with conventional workup after dual marker measurement, the median length of ED stay was 60 min shorter (228 min, 95% CI: 219 to 239 min vs 288 min, 95% CI: 279 to 300 min) in the primary dual marker strategy (DMS) discharge group. All-cause mortality was 0.1% (95% CI: 0% to 0.6%) in the primary DMS discharge group versus 1.1% (95% CI: 0.6% to 1.8%) in the conventional workup group after dual marker measurement. Conventional workup instead of discharge despite negative DMS biomarkers was observed in 503 patients (21.9%) and associated with higher prevalence of ACS (17.1% vs 0.9%, p<0.001), cardiac diagnoses (55.2% vs 23.5%, p<0.001) and risk factors (p<0.01), but with a similar all-cause mortality of 0.2% (95% CI: 0% to 1.1%) versus primary DMS discharge (p=0.64). Conclusions Copeptin on top of cardiac troponin supports safe discharge in patients with chest pain or other symptoms suggestive of ACS under routine conditions with the use of a broad spectrum of local standard POC, conventional and high-sensitivity troponin assays. Trial registration number NCT02490969

Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study

Aims This randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design). Methods and results A total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30-7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32-7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38-7.97%) in the standard group, and 3.01% (95% CI 1.51-5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362). Conclusion After clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagate

Outcome und Charakteristika internistischer Notfallpatienten mit dem Schwerpunkt der Identifikation und Bewertung von Prädiktoren für die intrahospitale Mortalität

Einleitung Das Patientenaufkommen in deutschen Krankenhäusern und Notaufnahmen steigt kontinuierlich an. Demgegenüber steht die stetige Verknappung der Ressourcen im Gesundheitssystem. Dies betrifft nicht nur die Reduktion von Krankenhäusern und Krankenhausbetten, sondern auch Einsparungen im Personalbereich. Zeitgleich steigt der Anteil unbesetzter Arztstellen. Im Bereich der Notfallmedizin muss eine adäquate und effiziente Notfallversorgung trotz knapper Ressourcen und erhöhtem Patientenaufkommen gewährleistet werden. Um diesen Anforderungen zu entsprechen, wird durch den Einsatz von Triageverfahren, Behandlungsalgorithmen, Risikoscores und detaillierten Standard Operating Procedures (SOPs) ein möglichst effizienter und standardisierter Notaufnahmeprozess angestrebt. Durch diese Maßnahmen sollen lange Wartezeiten oder eine ungerechtfertigte Entlassung von Patienten verhindert werden. Die initiale Untersuchung liefert essentielle Daten zur Risikostratifizierung der Patienten. Ziel der vorliegenden Arbeit ist es, unter diesen bei Aufnahme erhobenen Vital- und Laborparametern geeignete Prädiktoren für die intrahospitale Mortalität von unselektierten internistischen Notfallpatienten zu identifizieren. Methodik Es handelt sich um eine prospektive Beobachtungsstudie. Der Studienzeitraum erstreckte sich vom 15. Februar 2009 bis zum 15. Februar 2010. Es wurden Daten von zwei Notaufnahmen der Charité verwendet. Insgesamt wurden 34.333 Patienten in diese Studien einbezogen. Bei den verwendeten Daten handelt es sich um Sekundärdaten aller konservativer Patienten, welche im Rahmen von Qualitätssicherungsmaßnahmen aus dem Krankenhausinformationssystem (KIS) abgefragt wurden. Patienten, welche lebend entlassen wurden und im Krankenhaus verstorbene Patienten wurden hinsichtlich ihrer Charakteristika, Diagnosen und bezüglich des Krankenhausverlaufes verglichen. Labor- und Vitalparameter, welche bei Aufnahme erhoben wurden, wurden als Prädiktoren für einen fatalen intrahospitalen Verlauf bivariat, in multivariaten Regressionsmodellen, sowie anhand von ROC-Kurven (receiver operating characteristics), analysiert. Ergebnisse Sowohl in bivariaten Analysen, als auch unter Verwendung multivariater Regressionsmodelle und CART-Analyse, konnten insbesondere die Biomarker C-reaktives Protein (CRP) und die Erythrozytenverteilungsbreite (RDW) als Prädiktoren für das Versterben der Patienten während des initialen Krankenhausaufenthaltes identifiziert werden. C-reaktives Protein zeigte in der bivariaten Analyse ein relatives Risiko für den intrahospitalen Exitus von 7,6 (95%-Konfidenzintervall: 6,4-8,9) bei einem Cut-Off von 7,19 mg/dl und erzielte eine Fläche unter der ROC-Kurve von 0,795 (95%-Konfidenzintervall: 0,776-0,813). RDW zeigte in der bivariaten Analyse ein relatives Risiko von 6,9 (95%-Konfidenzintervall: 5,9-8,1) bei einem Cut-Off von 16,2% und erzielte eine Fläche unter der ROC-Kurve von 0,805 (95%-Konfidenzintervall: 0,788-0,823). In einem multivariaten Regressionsmodell gemeinsam mit anderen Prädiktoren konnten diese Ergebnisse bestätigt werden, die ermittelten Odds Ratios unter Verwendung der oben genannten Cut-Offs waren für CRP 3,7 (95%-Konfidenzintervall: 3,01-3,52) und für RDW 2,91 (95%-Konfidenzintervall: 2,37-3,58). Die Kombinierte ROC-Kurve aus allen Parametern des endgültigen Modelles zeigte eine Fläche unter der Kurve von 0,863 (95%-Konfidenzintervall: 0,848-0,877). Schlussfolgerung Die beschriebenen Ergebnisse zeigen, dass CRP und RDW Potential für die Risikostratifizierung unselektierter, internistischer Notfallpatienten aufweisen. Eine Kombination dieser Marker gemeinsam mit dem Alter der Patienten scheint generell dazu geeignet, Patienten mit einem erhöhten Mortalitätsrisiko zeitnah nach der Aufnahme zu identifizieren. Eine Risikostratifizierung anhand dieser Parameter könnte insbesondere in Situationen des Overcrowdings in der Notaufnahme hilfreich sein. Inwiefern die Zuweisung von Patienten mit erhöhtem Risiko zu einem priorisierten Behandlungsprozess geeignet ist das Outcome der Patienten zu verbessern muss in Interventionsstudien untersucht werden.Introduction In German hospitals and Emergency Departments a time trend of ever increasing patient numbers has been observed over recent years while, at the same time, resources, including number of hospitals, hospital beds and also qualified personnel have been decreasing. In order to assure an adequate and efficient treatment despite these facts, the importance of effective triage-systems, early risk-stratification and a good quality management with detailed standard operating procedures (SOPs) is increasing. The first physical and laboratory examinations of the patients, usually performed early after admission to the ED, provide essential information for an early risk- assessment. In this analysis, the value of the routine vital and laboratory parameters obtained at admission was assessed for their potential role in risk stratification. The investigated endpoint was the in-hospital mortality. Methods In this observational study, secondary data of all patients who attended the internal Emergency Departments of the Charité Campus Virchow Klinikum and Benjamin Franklin between 15th February 2009 and 15th February 2012 were retrieved from the hospital information system in an IT-supported, automated way (n=34.333). Laboratory and vital parameters were investigated as potential predictors for a fatal in-hospital outcome in bivariate and multivariate analyses. Additionally, the area under the ROC-Curve (receiver operating characteristic) was calculated for every single predictor and also for the final regression model. Results C-reactive protein (CRP) and Red cell distribution width (RDW) were the best predictors of mortality in bivariate analysis with an area under the ROC-curve of 0.805 (95%-Confidence interval: 0.788-0.823) and 0.795 (95%-Confidence interval: 0.776-0.813) respectively. In univariate analysis, CRP showed a relative risk of 7.6 (95%-Confidence interval: 6.4-8.9) at a cut-off value of 7.19 mg/dl. The relative risk for RDW was 6.9 (95%-Confidence interval: 5.9-8.1) at a cut-off-level of 16.2%. In multivariate analysis, the odds ratios at the respective cut-off points were 3.7 (95%-Confidence interval: 3.01-3.52) for CRP and 2.91 (95%-Confidence interval: 2.37-3.58) for RDW. All predictors in the final regression model in combination achieved an area under the curve of 0.863 (95%-Confidence interval: 0.848-0.877). Additionally, CART-Analysis was performed and revealed similar results. Conclusion The results of this analysis are indicating that CRP and RDW have potential as predictors for an unfavorable in-hospital course in unselected internal ED-patients. Both markers in combination with age might be useful for the early identification of patients with an increased risk for in-hospital mortality. Risk stratification by the identified markers might be particularly useful in the setting of overcrowding. The clinical impact of risk-stratification and prioritized treatment of high-risk patients on patient´s outcome needs to be evaluated in further interventional studies

Point‐of‐care testing for influenza in a university emergency department: A prospective study

Background: Seasonal influenza is a burden for emergency departments (ED). The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures. Objectives The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures. Methods: Using a cross-over design, the cobas (R) Liat (R) Influenza A/B POC PCR test (Liat) was compared with standard clinical practice during the 2019/2020 influenza season. All adult patients (aged >= 18 years) with fever (>= 38 degrees C) and respiratory symptoms were included. Primary end points were the prevalence of influenza infections in the ED and staff sick days. Secondary end points were frequency of antiviral and antibacterial therapy, time between admission and test result or treatment initiation, patient disposition, ED length of stay (LOS), and for inpatients mortality and LOS. Nurses were interviewed about handling and integration of POC testing. The occurrence of SARS-CoV-2 infections coincided with the second half of the study. Results A total of 828 patients were enrolled in the study. All 375 patients of the intervention group were tested with Liat, and 103 patients of them (27.6%) tested positive. During the intervention period, staff sick days were reduced by 34.4% (P = .023). Significantly, more patients in the intervention group received antiviral therapy with neuraminidase inhibitors (7.2% vs 3.8%, P = .028) and tested patients received antibiotics more frequently (40.0% vs 31.6%, P = .033). Patients with POC test were transferred to external hospitals significantly more often (5.6% vs 1.3%, P = .01). Conclusion: We conclude that POC testing for influenza is useful in the ED, especially if it is heavily frequented by patients with respiratory symptoms

Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments

IntroductionIt has not yet been possible to ascertain the exact proportion, characterization or impact of low-acuity emergency department (ED) attendances on the German Health Care System since valid and robust definitions to be applied in German ED routine data are missing.MethodsInternationally used methods and parameters to identify low-acuity ED attendances were identified, analyzed and then applied to routine ED data from two EDs of the tertiary care hospitals Charite-Universitatsmedizin Berlin, Campus Mitte (CCM) and Campus Virchow (CVK).ResultsBased on the three routinely available parameters `disposition ', `transport to the ED ' and `triage ' 33.2% (n = 30 676) out of 92 477 presentations to the two EDs of Charite-Universitatsmedizin Berlin (CVK, CCM) in 2016 could be classified as low-acuity presentations.ConclusionThis study provides a reliable and replicable means of retrospective identification and quantification of low-acuity attendances in German ED routine data. This enables both intra-national and international comparisons of figures across future studies and health care monitoring