Objectives To determine whether 10 mg, 25 mg, or 50 mg metoclopramide combined with 8 mg dexamethasone, given intraoperatively, is more effective in preventing postoperative nausea and vomiting than 8 mg dexamethasone alone, and to assess benefit in relation to adverse drug reactions. Design Four-armed, parallel group, double blind, randomised controlled clinical trial. Setting Four clinics of a university hospital and four district hospitals in Germany. Participants 3140 patients who received balanced or regional anaesthesia during surgery. Main outcome measures Postoperative nausea and vomiting within 24 hours of surgery (primary end point); occurrence of adverse reactions. Results Cumulative incidences (95% confidence intervals) of postoperative nausea and vomiting were 23.1% (20.2% to 26.0%), 20.6% (17.8% to 23.4%), 17.2% (14.6% to 19.8%), and 14.5% (12.0% to 17.0%) for 0 mg, 10 mg, 25 mg, and 50 mg metoclopramide. In the secondary analysis, 25 mg and 50 mg metoclopramide were equally effective at preventing early nausea (0-12 hours), but only 50 mg reduced late nausea and vomiting ( > 12 hours). The most frequent adverse drug reactions were hypotension and tachycardia, with cumulative incidences of 8.8% (6.8% to 10.8%), 11.2% (9.0% to 13.4%), 12.9% (10.5% to 15.3%), and 17.9% (15.2% to 20.6%) for 0 mg, 10 mg, 25 mg, and 50 mg metoclopramide. Conclusion The addition of 50 mg metoclopramide to 8 mg dexamethasone (given intraoperatively) is an effective, safe, and cheap way to prevent postoperative nausea and vomiting. A reduced dose of 25 mg metoclopramide intraoperatively, with additional postoperative prophylaxis in high risk patients, may be equally effective and cause fewer adverse drug reactions. Trial registration Current Controlled Trials ISRCTN31625370.

Tasks are essential in fostering students' learning processes, and thinking skills are considered to be of central importance to learning. In order to analyse how tasks promote the development of thinking skills in school geography, we need an instrument that looks beyond a simple distinction between lower and higher order thinking. It should be able to identify types of tasks based on distinctive elements on the way to acquiring powerful knowledge or knowledge of high epistemic quality. In this paper, we describe the development of an instrument based on the adaptation of existing categorisations and the use of Bernstein's recognition and realisation rules. The instrument distinguishes five levels of thinking: lower order thinking, use of thinking strategies, parts of higher order thinking, higher order thinking, and reflection. The instrument was employed to analyse tasks in geography textbooks used in the Netherlands and the German State North Rhine-Westphalia, with researchers and teacher educators in both states considering its efficacy both plausible and practicable. The results show that the instrument is sufficiently sensitive to identify differences in types of tasks and the extent to which access to powerful knowledge is fostered.

In this retrospective multicentric cohort study, we evaluate the potential benefits of a clinical decision support system (CDSS) for the automated detection of Acute kidney injury (AKI). A total of 80,389 cases, hospitalized from 2017 to 2019 at a tertiary care hospital (University of Leipzig Medical Center (ULMC)) and two primary care hospitals (Muldentalkliniken (MTL)) in Germany, were enrolled. AKI was defined and staged according to the Kidney disease: improving global outcomes (KDIGO) guidelines. Clinical and laboratory data was automatically collected from electronic patient records using the frameworks of the CDSS. In our cohort, we found an overall AKI incidence proportion of 12.1%. We identified 6,393/1,703/1,604 cases as AKI stage 1/2/3 (8.0%/2.1%/2.0%, respectively). Administrative coding with N17 (ICD-10-GM) was missing in 55.8% of all AKI cases with the potential for additional diagnosis related groups (DRG) reimbursement of 1,204,200 € in our study. AKI was associated with higher hospital mortality, increased length of hospitalisation and more frequent need of renal replacement therapy. A total of 19.1% of AKI cases (n = 1,848) showed progression to higher AKI stages (progressive AKI) during hospitalization. These cases presented with considerably longer hospitalization, higher rates of renal replacement therapy and increased mortality (p<0.001, respectively). Furthermore, progressive AKI was significantly associated with sepsis, shock, liver cirrhosis, myocardial infarction, and cardiac insufficiency. AKI, and especially its progression during hospitalization, is strongly associated with adverse outcomes. Our automated CDSS enables timely detection and bears potential to improve AKI outcomes, notably in cases of progressive AKI.

Tasks are crucial for gaining access to powerful knowledge in geography and for fostering higher-order thinking in lessons; therefore, they are key to subject-specific pedagogy. After analysing tasks in geography textbooks for upper secondary education, it was revealed that higher-order thinking barely occurs in textbooks in the Netherlands and is more frequent in North Rhine-Westphalia, Germany. Subsequently, both curriculum contexts were systematically compared to determine factors that influence the use of tasks. The results show that evaluative rules play a crucial role. The assessment in North Rhine-Westphalia focuses on higher-order thinking and how this becomes visible in students’ work. Dutch assessment concentrates on students handling an outlined body of knowledge in defined settings. This raises questions of epistemic access, as students are less prepared for the skills expected at university level. Finally, we observed the importance of alignment between official institutions, the discipline of subject-specific pedagogy and support for teachers when it comes to fostering higher-order thinking in geography education.