Workforce strategies during the first wave of the COVID-19 pandemic: a retrospective online survey at intensive care units in Germany

BACKGROUND

As the COVID-19 pandemic swept across the globe at the beginning of 2020, healthcare systems were forced to rapidly adapt and expand to meet the sudden surge in demand for intensive care services. This study is the first systematic analysis of the strategies employed by German hospitals to recruit personnel and expand bed capacities during the first wave of the pandemic, and to evaluate the effectiveness of those recruitment measures.

METHODS

152 German hospitals with intensive care capacities were selected and invited to participate in an online-based retrospective survey. Factors like the geographic distribution, individual COVID burden and level of care were considered for inclusion in the sample. The data were analyzed descriptively.

RESULTS

A total of 41 hospitals participated in the survey. The additional demand for intensive care beds was met primarily by activating intensive care beds that were previously considered as non-operational in existing intensive care units (81% of respondents) and by upgrading recovery rooms (73%). The physician staffing requirements were met at approximately 75%, while the nursing staffing requirements were only met by about 45%. Staffing needs were met through reallocations/transfers (85%), staff recruitment from parental leave or retirement (49%), increased hours worked by internal staff (49%), new staff hiring (44%) and increased use of temporary staff (32%). Staff reallocations/transfers to critical care within a hospital were rated as the most effective measure. In this context, specialized personnel mostly from anesthesiology departments were appointed to intensive care medicine.

CONCLUSIONS

Despite multiple recruitment efforts, the pandemic has exacerbated the nursing staff shortage. The reallocation of existing staff within hospitals was a key element in covering the staffing needs. However, additional measures and efforts are required in order to ensure that critically ill patients can be cared for without compromise. The results of this study may have important implications for healthcare providers and policymakers, offering an evidence-based foundation for responding to future public health emergencies with agility, efficiency, and success.

Abstract P1-07-17: Discordant breast cancer: Genomic verse clinicopathologic

Background: Studies using the 21-gene recurrence score (RS) have shown early-stage, low-risk pathologic and genomic breast cancers do not benefit from systemic chemotherapy (CTx) whereas early stage, high-risk breast cancers have improved outcomes when treated with CTx. Data is lacking for patients with discordant risk factors and which feature, genomic or clinical, plays more of a role in determining outcomes.

Methods: A retrospective analysis was conducted to identify early-stage breast cancer patients with discordant features, defined as low-risk genomic/high-risk pathologic factors (LG/HP) or high-risk genomic/low-risk pathologic factors (HG/LP), from August 2011–December 2016. LG/HP breast cancer was defined as a RS <18 with ≥2 high-risk pathologic factors: tumor size (T) ≥2cm, lymph node (N) positivity, or grade 2-3 disease. HG/LP breast cancer was defined as a RS ≥31 with all three low-risk pathologic factors: T <2cm, N negativity, and grade 1-2 disease.

Results: There were 469 patients with low-risk RS identified of whom 118 (25%) met discordant high-risk pathologic criteria and 62 patients with high-risk RS of whom 14 (23%) met discordant low-risk pathologic criteria. Thirty patients in the LG/HP group received CTx despite a low RS. Of the 118 LG/HP patients, there were 22 (19%) breast cancer recurrences; 21 with locoregional and one with metastatic disease. Of the locoregional recurrences, 10 were contralateral breast whereas 11 were in-breast recurrence despite breast conservation therapy. Of the 14 HG/LP discordant patients, of whom 12 received CTx, 3 (21%) had breast cancer recurrence; one with metastatic disease to the lung and the other two with contralateral breast cancer. Majority of all recurrences occurred >5 years after initial diagnosis. Staging and management depicted below.

Management (Mgt) of Discordant Risk Cancers LG/HP initial diagnosis (n=118)LG/HP recurrence (n=22)HG/LP initial diagnosis (n=14)HG/LP recurrence (n=3)Stage    004001A1411142IB14100IIA56500IIB25000IIIA2000IV0101Surgical Mgt    Partial mastectomy737102Simple mastectomy431440LN Mgt    Sentinel LN biopsy8510132Axillary LN dissection25310Unknown/Not Applicable6800Radiation Mgt    Yes816103*No/Unknown351500Hormonal Therapy    Yes9417143No/Unknown24500Systemic CTx    Neoadjuvant6100Adjuvant242122No/Refused881921*metastatic pt with SBRT to lung

Conclusions: Using traditional low-risk RS of 18, we observed more than expected recurrences in our LG/HP discordant patients. Thus suggesting, in patients with discordant results, clinicians must consider both pathologic and genomic factors to optimize patient-specific treatment. Further studies are needed to improve the outcomes of this unique patient population.

Citation Format: Blankenship LM, Ezekwudo D, Jaiyesimi I, Stender M, Alassi O, Kresge C, Gaikazian S. Discordant breast cancer: Genomic verse clinicopathologic [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-17.

Platelet activity and in vivo arterial thrombus formation in rats with mild hyperhomocysteinaemia

Elevated plasma levels of total homocysteine (hcy) have been associated with an increased occurrence of arterial thrombosis. In the present study, we investigated the influence of hyperhomocysteinaemia on platelet aggregation and arterial thrombus formation in vivo. Fifty-one rats were included in the study, of which 29 received hcy in the drinking water for 4 weeks. Blood samples were withdrawn for measurement of platelet count and mean platelet volume. Platelet aggregation response in platelet-rich plasma following adenosine diphosphate or collagen stimulation were examined. In vivo thrombus formation was investigated by transillumination and videotape recording of the rat femoral artery after a thrombogenic injury was established. Off-line videotape analysis using computer-assisted planimetry permitted quantification of the thrombus area, and area versus time curves were obtained. In the intervention group receiving hcy, total hcy in plasma increased two-fold to 14.3 micromol/l, as compared with 7.3 micromol/l in the control group (P < 0.001). The platelet count and mean platelet volume did not differ between the two groups. In vivo thrombus formation expressed as the area under the curve or maximum thrombus area was not found to be altered in the presence of an increased homocysteine level, neither was adenosine diphosphate-induced platelet aggregation. However, collagen-induced platelet aggregation significantly decreased in the hcy group (P = 0.02). Pro-thrombotic effects of isolated mild hyperhomocysteinaemia are not supported by the present study in rats.

Synthesis and Characterization of HC{C(Me)N(C6H3-2,6-i-Pr2)}2MX2 (M = Al, X = Cl, I; M = Ga, In, X = Me, Cl, I): Sterically Encumbered β-Diketiminate Group 13 Metal Derivatives

A series of group 13 metal complexes featuring the beta-diketiminate ligand [[(C(6)H(3)-2,6-i-Pr(2))NC(Me)](2)CH](-) (i.e., [Dipp(2)nacnac](-), Dipp = C(6)H(3)-2,6-i-Pr(2)) have been prepared and spectroscopically and structurally characterized. The chloride derivatives Dipp(2)nacnacMCl(2) (M = Al (3), Ga (5), In (8)) were isolated in good yield by the reaction of 1 equiv of Dipp(2)nacnacLi.Et(2)O (2) and the respective metal halides. The iodide derivatives Dipp(2)nacnacMI(2) (M = Al (4), Ga (6), In (9)), which are useful for reduction to afford M(I) species, were made by a variety of routes. Thus, 4 was obtained by treatment of the previously reported Dipp(2)nacnacAlMe(2) with I(2), whereas the gallium analogue 6 was obtained as a product of the reaction of "GaI" with Dipp(2)nacnacLi.Et(2)O, and 9 was obtained by direct reaction of InI(3) and the lithium salt. The methyl derivatives Dipp(2)nacnacMMe(2) (M = Ga (7), In (10)), which are analogous to the previously reported Dipp(2)nacnacAlMe(2), were synthesized by the reaction of GaMe(3) with Dipp(2)nacnacH (1) or by reaction of the indium chloride derivative 8 with 2 equiv of MeMgBr in diethyl ether. The compounds 3-10 exist as colorless, air- and moisture-sensitive crystalline solids. Their X-ray crystal structures feature nearly planar C(3)N(2) arrays in the Dipp(2)nacnac ligand backbone with short C-C and C-N distances that are consistent with a delocalized structure. However, there are large dihedral angles between the C(3)N(2) plane and the N(2)M metal coordination plane which have been attributed mainly to steric effects. The relatively short M-N distances are consistent with the coordination numbers of the metals and the normal/dative character of the nitrogen ligands. The compounds were also characterized by (1)H and (13)C NMR spectroscopy. (1)H NMR data for 7 revealed equivalent methyl groups whereas the spectrum of 10 displayed two In-Me signals which indicated that ring wagging was slow on the (1)H NMR time scale.

Frequency of liver disease in type 2 diabetic patients treated with oral antidiabetic agents

OBJECTIVE

We evaluated liver disease in conventionally treated type 2 diabetic patients to provide a reference against which reports of liver disease related to novel oral antidiabetic treatments could be compared.

RESEARCH DESIGN AND METHODS

In this follow-up study, patients with type 2 diabetes who were treated with oral antidiabetic agents were identified from the U.K.-based General Practice Research Database and were followed to determine whether they developed liver disease. The specific types and etiologies of liver disorders were determined. Incidence rates were calculated based on the accumulated exposure time to oral antidiabetic agents.

RESULTS

Among 44,406 type 2 diabetic patients, 605 had a computer diagnosis of liver disease with an incidence rate of 53.2/10,000 person-years (95% CI 49.2-57.6). Of the 605 subjects, 186 had nonsymptomatic, mild, and transient liver disorders; 249 had a predisposing condition; and 113 had another cause for the disease. A total of 57 cases were possibly drug induced with an incidence rate of 5.0/10,000 person-years (3.9-6.5). Of the cases, 11 were attributed to other drugs, 8 were attributed to fatty liver disease of diabetes, and the remaining cases were attributed to uncertain causes. Oral antidiabetic agents were continued in 51 of these 57 cases, and we could not rule out oral antidiabetic agents as a cause of liver disease in 2 cases with an incidence rate of 0.2/10,000 person-years (< 0.1-0.6).

CONCLUSIONS

In this population, the background incidence of liver disease was high. Most cases involved other systemic diseases that may cause liver disease.

Prevalence of respiratory and atopic disorders among children in the East and West of Germany five years after unification

Living conditions in eastern Germany have changed rapidly since unification in 1990 and little is known about how these changes affect the prevalence of atopic diseases. This study describes methods and prevalences of a large epidemiological project investigating determinants of childhood asthma and allergies in eastern (Dresden and Leipzig) and western (Munich) Germany in 1995/1996. Community based random samples of 9-11 yr old children in Dresden (n=3,017) and Munich (n=2,612), and of 5-7 yr old children in Dresden (n=3,300), Leipzig (n=3,167) and Munich (n=2,165) were studied by parental questionnaires, bronchial challenges with hypertonic saline, skin examination, skin-prick tests, and measurements of specific and total serum immunoglobulin (Ig)E using Phase II modules of the International Study of Asthma and Allergies in Childhood (ISAAC). In 9-11 yr old children, the prevalence of physician diagnosed asthma (7.9% versus 10.3%; p<0.01) and bronchial hyperresponsiveness (15.7% versus 19.9%; p<0.05) was lower in Dresden than in Munich. No difference between Munich and Dresden was observed in the prevalence of diagnosed hay fever, skin test reactivity to > or = 1 allergen, and increased levels (>0.35 kU x L(-1)) of specific IgE against inhalant and food allergens. Symptoms and visible signs of atopic eczema tended to be more prevalent in Dresden. Similar East-West differences between the three study areas were seen in the younger age group. These findings are in line with recently observed increases in the prevalence of hay fever and atopic sensitization, but not of asthma and bronchial hyperresponsiveness, among 9-11 yr old children in Leipzig.

The association between self-reported symptoms of asthma and allergic rhinitis and self-reported traffic density on street of residence in adolescents

We examined the association between self-reported symptoms of asthma and allergic rhinitis and self-reported exposure to motor vehicle traffic in adolescents in Münster, Germany. A total of 3,703 German students age 12-15 years completed a written and video questionnaire in 1994-1995. We found positive associations between both wheezing and symptoms of allergic rhinitis during the past 12 months and self-reported frequency of truck traffic. The sex- and age-adjusted prevalence odds ratios and 95% confidence intervals (CI) for truck traffic, contrasting the categories "frequent" and "constant" against "never," were, for wheezing obtained by written questionnaire: 1.53 (95% CI = 1.15-2.05) and 2.15 (95% CI = 1.44-3.21); for wheezing obtained by video questionnaire: 1.61 (95% CI = 1.26-2.07) and 2.47 (95% CI = 1.74-3.52); and for symptoms of allergic rhinitis: 1.71 (95% CI = 1.36-2.15) and 1.96 (95% CI = 1.40-2.76), respectively. We found a similar positive association with self-reports on traffic noise. Putative confounding variables, including indicators of socio-economic status, smoking, etc, did not alter these associations substantially. The results correspond closely with findings of a survey carried out in 1991 in Bochum, Germany. Our results support the hypothesis that exposure to motor vehicle traffic is related to symptoms of asthma and allergic rhinitis in children, but we cannot rule out misclassification due to self-reports of traffic exposure.

[Correlation between dietary behavior and educational attainment: results of the 1984/85 nutrition survey of the Augsburg MONICA project]

The relationship between educational attainment and dietary behaviour was examined in a South German population of men aged 45 to 64 years. Analyses are based on data from the MONICA Augsburg Dietary Survey 1984/85 (7-day dietary records, n = 899). The evaluation of the daily food consumption shows that men with higher educational attainment prefer healthier food items than men with lower educational attainment. The healthier food pattern in men with higher educational attainment is reflected in a lower cholesterol intake and in a higher fibre intake. The mean daily intake of vitamins, minerals and trace elements is better in men with higher educational attainment with the exception of the vitamin niacin. The total daily caloric intake, fat intake and the combination of saturated, monounsaturated and polyunsaturated fatty acids is independent of educational attainment. The percentage of carbohydrates, protein and fat of the total caloric intake is nearly the same in all educational attainment groups. The results concerning food pattern and nutrient intake by educational attainment offer important information with regard to the development of strategies for the improvement of nutrition habits.

Association between a deletion polymorphism of the angiotensin-converting-enzyme gene and left ventricular hypertrophy

BACKGROUND

Epidemiologic studies have shown that left ventricular hypertrophy is often found in the absence of an elevated cardiac workload. To investigate whether such hypertrophy is determined in part by genetic factors, we studied the association between this condition, as assessed by electrocardiographic criteria, and a deletion (D)-insertion (I) polymorphism of the angiotensin-converting-enzyme (ACE) gene.

METHODS

A population-based random sample of 711 women and 717 men 45 to 59 years of age was studied cross-sectionally in Augsburg, Germany. Electrocardiographic indexes, including the Sokolow-Lyon index, Minnesota Code 3.1, and the Rautaharju equations, were used to detect left ventricular hypertrophy. The status of the ACE gene with respect to the deletion-insertion allele was determined by the polymerase chain reaction in all subjects with left ventricular hypertrophy and an identical number of control subjects without the condition who were matched for age, sex, and blood-pressure status.

RESULTS

We identified 141 women and 149 men with evidence of left ventricular hypertrophy. Among these subjects, an excess were homozygous for the D allele of the ACE gene (odds ratio, 1.76; 95 percent confidence interval, 1.22 to 2.53; P = 0.003). The association of the DD genotype with left ventricular hypertrophy was stronger in men (odds ratio, 2.63; 95 percent confidence interval, 1.50 to 4.64; P < 0.001) than in women and was most prominent when blood-pressure measurements were normal (odds ratio, 4.05; 95 percent confidence interval, 1.76 to 9.28; P = 0.001). This association was evident for each of the scores recorded in the electrocardiographic testing for left ventricular hypertrophy.

CONCLUSIONS

The findings suggest that left ventricular hypertrophy is partially determined by genetic disposition. They identify the DD genotype of ACE as a potential genetic marker associated with an elevated risk of left ventricular hypertrophy in middle-aged men.

Prevalence, awareness, treatment and control of hypertension in a population over the age of 65 years: results from the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY)

OBJECTIVE

To assess the prevalence of hypertension and isolated systolic hypertension and the level of awareness, treatment and control of hypertension, in a population aged over 65 years.

DESIGN

Cross-sectional survey of the total population aged > or = 65 years of two Bavarian villages with a representative age distribution.

PATIENTS

From a total of 1190 inhabitants aged > or = 65 years, 982 (394 male, 588 female) participated (response rate 82.5%).

METHODS

All of the participants were visited at home by physician observers. After a standardized questionnaire, blood pressure was measured three times on one occasion with the subject in the sitting position, using a standard mercury sphygmomanometer. 'Actual' hypertension was defined as systolic blood pressure (SBP) > or = 160 or diastolic blood pressure (DBP) > or = 95 mmHg, or both, or current use of antihypertensive drugs given for the indication hypertension in patients with blood pressure < 160/95 mmHg. Isolated systolic hypertension was defined as SBP > or = 160 and DBP < 90 mmHg. All 'actual' hypertensives were further classified as 'unaware' of hypertension, 'aware' (but not treated), 'treated' (current use of antihypertensive drugs for the indication hypertension and blood pressure > or = 160/95 mmHg) or 'controlled' (treated and blood pressure < 160/95 mmHg).

RESULTS

Mean +/- SD blood pressure was 154.5 +/- 24.4/84.9 +/- 11.6 mmHg (when 52 institutionalized participants were excluded, 155.6 +/- 24.4/85.3 +/- 11.6 mmHg). The SBP was significantly higher in females than in males and increased up to the age group 80-84 years both in males and in females. The DBP decreased with age. The prevalence of 'actual' hypertension was 53% and increased up to the age group 75-79 years in males and 80-84 years in females. The prevalence of isolated systolic hypertension was 17% (with patients currently using antihypertensive drugs excluded). Of the patients with 'actual' hypertension, 34% were 'unaware' of the diagnosis, 12% 'aware', 32% 'treated' and 22% 'controlled'.

CONCLUSIONS

In central Europe hypertension, with a prevalence of > 50%, remains the most common cardiovascular risk factor in the elderly. Although most elderly hypertensives are currently treated with antihypertensive agents, less than one-quarter are controlled, and more than one-third are still unaware of the diagnosis. These levels of awareness and control call for better strategies in the diagnosis and treatment of hypertension in the elderly.

Lack of an association between serum vitamin E and myocardial infarction in a population with high vitamin E levels

The antioxidant effects of vitamin E may protect low density lipoproteins from peroxidation and thus inhibit the development of arteriosclerosis. Inverse associations between vitamin E levels and coronary heart disease have been reported from cross-sectional and ecologic studies. In the population-based MONICA Augsburg cohort (2023 men, 1999 women, age 25-64 years at baseline in 1984, 93% of whom were reexamined in 1987/88) we investigated the relationship between serum vitamin E concentrations and the risk of subsequent myocardial infarction (MI). Between 1984 and 1991, 46 cases of fatal and non-fatal myocardial infarction from this cohort were recruited for a nested case-control study. Four controls were sampled from the cohort for each case of MI with matching for age, sex, and total cholesterol. There were no marked differences between cases and their matched controls in the means of vitamin E concentrations (33.9 mumol/l vs. 32.8 mumol/l, P = 0.37) or in the mean vitamin E/total cholesterol ratios (4.89 mumol/mmol vs. 4.82 mumol/mmol, P = 0.75). The covariate adjusted relative risk (RR) for fatal plus non-fatal MI in the lowest tertile of vitamin E relative to the upper two tertiles was 0.72 (90% confidence interval: 0.33-1.57). Likewise, for the lowest tertile of the ratio (vitamin E/total cholesterol) the RR was 0.81 (0.42-1.56). The association was not modified by history of previous coronary heart disease, fatality of MI, temporal distance of MI onset from vitamin E determinations, or season.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical activity at work and cardiovascular disease risk: results from the MONICA Augsburg study

In the MONICA Augsburg study the relationship between physical activity at work, cardiovascular risk factors, incidence of fatal and non-fatal myocardial infarction (MI) and total mortality was investigated in employed men. The MONICA Augsburg baseline survey of 1984/85 was designed as a cross-sectional study with follow-up. Physical activity was determined in 45-64 year old men by interview (n = 1074, 83.6%) and by a 7-day activity diary (n = 797, 62.0%). Employed men were categorized into an active versus inactive group based on interview data on physical activity at work (PAW) which had been validated against the 7-day activity diary. When stratified by PAW, age-adjusted means of diastolic (DBP) and systolic blood pressure (SBP) and total-cholesterol (T-C) were lower and the age-adjusted mean of HDL-cholesterol (HDL-C) was higher in active than in inactive men. A linear regression model controlling for age, body mass index, alcohol consumption, smoking, and heart rate confirmed this relationship for physical activity at work; regression coefficients: DBP: beta = -2.38 (95% confidence interval [CI] : -3.85(-)-0.91); SBP: beta = -2.87 (95% CI : -5.22(-)-0.52); T-C: beta = -2.80 (95% CI : -9.31-3.71); HDL-C: beta = 3.48 (95% CI : 1.28-5.79). Survey participants were followed-up for a period of 5.8 years. The incidence density (per 1000 person-years) of fatal plus non-fatal MI was 6.8 for active men versus 5.9 for inactive men; the incidence density for total mortality was 11.2 versus 5.9, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of 2 methods for the assessment of physical activity]

There is no standardized method for the assessment of physical activity, so it is important to investigate the validity and the comparability of different measures. In the first survey (1984/85) of the MONICA Augsburg project of the World Health Organisation (WHO), physical activity was determined by two different methods, an interview and a seven-day activity diary, and these are compared in this analysis. In the first MONICA Augsburg survey 2023 men and 1999 women participated (overall response 80.0% men and 78.7% women). The seven-day activity diary was completed only by men of the age group 45 to 64 years (overall response 62.2%). On the assumption that the seven-day activity diary is an instrument of proven validity, the interview was validated against this reference method in men aged 45-64 years. Activity scores for occupational and leisure time physical activity were formed by means of the data from the seven-day diary. Participants were classified as active or inactive, by using energy expenditure during work as an estimate for occupational physical activity, and duration of sport as an estimate for leisure time physical activity. The interview offered four possibilities for answering the activity questions. By means of these answers the participants were again classified into active and inactive groups, for both leisure time and occupational physical activity. This grouping was compared to the one obtained by the reference diary method. Validity of the interview-based scores required an efficiency of at least 160% and an error rate not above 20%.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid appearance of hypomethylated DNA in livers of rats fed cancer-promoting, methyl-deficient diets

Prolonged intake of diets deficient in sources of methyl groups leads to development of hepatomas in rats and promotes chemical carcinogenesis in both rats and certain strains of mice. Since methylation of cytosine residues in regulatory regions can affect gene activity, several investigators have postulated that the effects of methyl-deficient diets on tumorigenesis result from the inability of cells to maintain normal patterns of DNA methylation. However, significant decreases in the 5-methylcytosine content of liver DNA have not been reported to occur until rats have consumed methyl-deficient diets for several months. To determine whether methyl-deficient diets have immediate effects on nucleic acid methylation, we assessed the degree to which hepatocyte DNA and tRNA were methylated in vivo, by measuring their ability to act as methyl acceptors in vitro. Hypomethylation of DNA and tRNA was detected within 1 week after rats were started on a diet deficient In methionine, choline, folic acid, and vitamin B12 and it persisted throughout the 4 weeks of study. A significant elevation in liver DNA synthesis occurred in parallel with increased hypomethylation of DNA. Chronic failure to fully methylate DNA that is newly synthesized in response to liver damage induced by methyl-deficient diets provides a feasible mechanism for changing patterns of DNA methylation. Our results indicate that such changes could occur rapidly enough to play a causal role in the cancer-promoting and, in some instances, cancer-inducing properties of the diet.