Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure technique

BACKGROUND: Sternal instability and mediastinitis are rare but serious complications following cardiac surgery with median sternotomy. METHODS: This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The conventional sternal closure technique, the parameters considered to be risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. In addition, a literature research with the key words "sternal closure technique" and "sternal dehiscence" was performed. RESULTS: Conventional closure of primary sternotomy is done using many different methods, most often with surgical steel sutures (87 %) passed trans/peristernally (64 %). An osteoporotic or fractured sternum (70 x), and obesity (31 x) were the most frequently cited risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method of Robicsek (48 x). CONCLUSION: There is no uniform osteosynthetic method for primary sternal closure and there is substantial variation in the perception of risk factors for sternal instability and possible surgical consequences among the surgical heart centers in Germany.     

Continuous irrigation with suction started at early days after pancreatic surgery prevents severe complications

The management of pancreatic leakage is important after pancreatic resection because such leakagge can be associated with additional complications. In this paper, we present a new therapy "irrigation with suction" after pancreatic surgery. The addition of suction permits the start of irrigation early after surgery and prevents severe post-operative complications. Between January 1995 and June 2003, 29 consecutive patients underwent surgical treatment of the pancreas for a variety of indications. Among them, 18 patients were treated with continuous irrigation with suction prophylactically. In these 29 patients, we did not encounter any additional complications such as intraabdominal hemorrhage or abscess formation. A representative case report demonstrates the application of this treatment. The irrigation with suction therapy was started on the first post-operative day after the pylorus-preserving pancreatoduodenectomy with left lobectomy of the liver. CT with irrigation of contrast reagent showed that the reagent did not spread to the uninvolved abdominal area, and the patient did not develop hemorrhage or abscess. It seems that continuous irrigation with suction therapy was effective in preventing additional serious complications after pancreatic resection.     

Healthcare resource utilization for anemia management: current practice with erythropoiesis-stimulating agents and the impact of converting to once-monthly C.E.R.A

Background andMethods: A prospective, observational study in 12 German and UK dialysis centers which quantified personnel time for anemia treatment using erythropoiesis-stimulating agents (ESAs). Tasks directly observable were measured through the time-and-motion method; time for non-observable tasks was estimated by healthcare staff. Using activity-based costing methods, time was converted into monetary units. Modeling was used to estimate potential time and cost savings using once-monthly C.E.R.A., a continuous erythropoietin receptor activator. Results: For current ESAs in Germany and the UK, respectively: mean observed time was 1.67 and 2.67 min/patient/administration, corresponding to 31 and 42 days/year/center/100 patients; mean total time/center/100 patients/year was estimated at 79 and 95 days, equivalent to EUR 17,031 and GBP 18,739. Assuming 100% once-monthly C.E.R.A. uptake, the observed time/patient/year may decrease by 79 and 84% in Germany and the UK, respectively, compared with traditional ESAs. Conclusion: Conversion to once-monthly C.E.R.A. may offer the potential to reduce time spent on ESA administration in hemodialysis centers.     

Current structures of cardiac centers

The "Working Group for Congenital Heart Surgery and Pediatric Heart Surgery" of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) has analysed and recommended structures for congenital heart surgery departments in Germany. The document was worked out according to a similar paper approved earlier by the European Association for Cardio-thoracic Surgery (EACTS). The "Working Group" unifies the majority of cardiac surgeons involved in congenital heart surgery in Germany. Current structures of cardiac centers vary. Therefore the aim of this document is to elucidate additional structural needs for both highly specialized institutions and those for standard care. Specialized centers should allow for treatment of newborns and adult patients with congenital heart disease, include implementation of assist devices and transplantation, possess research facilities and ensure highest standards of education and training. Standard care units do not necessarily need to cater for the above mentioned spectrum. However, the evaluation of quality of care should be given priority in all centers involved in care of patients with congenital heart disease. Data acquisition and transfer must be guaranteed to both the GSTCVS and EACTS in order to ensure national and international comparison of surgical results. This may also give further guidance for improved patient care.     

Minimally invasive treatment of thoracic empyema.

BACKGROUND: The present study was undertaken to assess the efficacy of serial thoracocentesis and saline irrigation for the treatment of pleural empyema, for post-pneumonia versus other causes. METHODS: Included were 42 consecutive patients with complicated pleural effusion (n=14) or frank pus (n=28) at diagnostic thoracocentesis, of mean age 57.5 +/- 23.7 years. Pneumonia was the probable cause in 29 patients, other causes (principally thoracic surgery) in 13. In addition to antibiotics in all patients, ultrasonography-guided serial suction thoracocentesis with saline irrigation was used as therapy of first choice in most patients: 28/29 post-pneumonia and 9/13 non-pneumonic empyema. Exceptions were mainly on the grounds of preceding thoracic surgery. RESULTS: Success rate was 86% in the post-pneumonia group, with no crossovers to more invasive therapy. Mortality was 14%, none empyema-related. Treatment was less successful in the non-pneumonia group at 69%, with a 56% crossover rate from thoracocentesis due to therapy failure. Mortality was 23 %. CONCLUSIONS: Results indicate that timely, minimally invasive therapy is a feasible modality for the management of post-pneumonia thoracic empyema. Serial thoracocentesis was less suitable for the treatment of non-pneumonic empyema, however, particularly if it was a surgical complication. More invasive strategies seem preferable in such cases.     

Strukturelle und organisatorische Voraussetzungen zur Durchführung des Transkatheter-Aortenklappenersatzes (TAVI)

This paper summarises personal, organisational and structural requirements which seem necessary for performing TAVI procedures in a high quality manner. The recommendations are widely in line with the joint statement of the German Societies for Cardiology (DGK) and Heart Surgery (DGTHG) published earlier in this journal. Based on the analysis and interpretation of current registry data and the partner studies the following treatment modalities also seem acceptable: Well functioning cooperations between cardiologists, heart surgeons, anaesthesiologists and imaging specialists also apart from the so-called institutionalised or in-house heart surgery should be accepted as long as the given prerequisites are fulfilled. Patients who do not have a realistic option for heart surgery beyond a treatment for myocardial perforation or who strictly refuse heart surgery (possibly by a written statement) could also be treated in an optimally equipped catheterisation laboratory by an experienced team of cardiologists following the aforementioned definitions and criteria.     

Exercise testing and training in German CF centers

Physical exercise is increasingly recognized as a valuable diagnostic and therapeutic modality for patients with cystic fibrosis (CF). We sought to characterize the use of exercise testing and training as well as the attitude toward both issues through a national survey. A questionnaire was sent to 107 specialized CF centers (caring for a total of 5,231 patients) and 7 inpatient rehabilitation institutions. Answers were available from 62 specialized centers caring for 3,580 patients and from 4 rehabilitation centers with 520 treatment episodes per year. Sixty percent of specialized centers performed some sort of exercise testing at an average frequency of 1 in 2.3 years for patients aged 8 and above. However, protocols and indication criteria were often unstandardized or not specified at all. Equipment availability was no major problem, and the majority of tests were conducted by a physician alone. Nineteen centers had adopted exercise testing as part of their diagnostic routine. Two thirds of caregivers advised their patients to engage in physical activity, but failed to discuss specific modalities and potential hazards. Nevertheless, physical exercise was viewed as "extremely important" or "very important" by 87%. In a rehabilitation setting, an exercise test was conducted 1.1 times per patient stay, and a training program offered in 100% of cases. In conclusion, standardized exercise testing and training programs appear to be underused in German CF centers, despite a high degree of interest in the topic. Supplementary material for this article can be found on the Pediatric Pulmonology website (http//www.interscience.wiley.com/jpages/8755-6863/suppmat).     

Assessment of family physicians' knowledge about fibromyalgia in Egypt

Aim of the workTo assess knowledge of Egyptian family physicians about the diagnostic criteria and treatment modalities of fibromyalgia.Subjects and methodsA questionnaire and an informed consent were sent by email to family physicians working in primary health care centers in Egypt. The questionnaire assessed 3 areas: sociodemographic and professional data; knowledge about diagnosis; and knowledge about treatment modalities. Scoring system was used to categorize levels of knowledge into very low, low, moderate, high and very high.ResultsA total of 108 family physicians responded, with a response rate of 60%.The respondents were 27 consultants, 54 specialists and 27 residents, with a median age of 33 years and a median experience of 12 years. Very low, low and moderate levels of familiarity with fibromyalgia were perceived by 28.7%, 30.6% and 28% respectively. Close to half of participants (46.2%) gained their knowledge about fibromyalgia through self-study. According to the scoring system, 39.8% had low level of knowledge about clinical presentation and 37% had the same level of knowledge about treatment modalities. About three quarters (76%) of participants agreed that patients with fibromyalgia should be referred to rheumatologists. The most common selected clinical presentations were widespread pain (94.4%) and excessive fatigue (91.7%), while the most selected treatment modalities were non-steroidal anti-inflammatory drugs (89.8%) and selective serotonin reuptake inhibitors (47.2%).ConclusionKnowledge about clinical presentation and treatment modalities of fibromyalgia among Egyptian family physicians is low. Continuing medical education about fibromyalgia is needed to improve quality of health care.     

Predictors, therapeutic options and long-term outcome of abrupt reclosure

To ascertain the clinical and procedural factors that relate to the occurrence and management of abrupt reclosure, data on 1,160 consecutive patients who underwent coronary angioplasty between December 1981 and December 1986 were analyzed. Abrupt reclosure occurred in 54 patients (4.7%), developing during the dilatation procedure in 43 patients (80%) and delayed by 11 +/- 2 hours after the procedure in 11 patients (20%). Patients were divided into 3 groups based on subsequent management: (1) 22 patients (40%) in whom the involved vessel was reopened by additional dilatation, (2) 14 patients (26%) in whom the involved vessel was not reopened but the patient was treated medically, and (3) 18 patients (33%) in whom abrupt reclosure was managed by emergency bypass surgery, yielding an overall emergency surgery rate of 1.6%. Patients whose abrupt reclosure was reopened were more likely to have luminal thrombus (54 vs 28%) and less likely to have extensive local dissection after dilatation (14 vs 61%; p less than 0.025) than patients undergoing emergency surgery. Patients treated medically despite continued vessel occlusion were more likely to have collateral blood flow to the occluded zone (54 vs 11%, p less than 0.01) than patients undergoing surgery. While 10 of 18 patients (56%) undergoing emergency surgery sustained a myocardial infarction, all patient subgroups appeared to do well during long-term follow-up.     

电子支气管镜治疗手术后急性肺不张临床研究

目的观察电子支气管镜(EBS)治疗手术后急性肺不张的临床疗效。方法治疗组28例,通过运用局部支气管冲洗、吸取和清除气道内分泌物、痰痂、血块,钳取坏死组织,清除呼吸道阻塞物。对照组30例,行气管切开经导管吸除阻塞物。结果治疗组总有效率为96.4%(27/28),对照组为93.3%(28/30),两组比较(P>0.05)。治疗组治疗后心率、呼吸频率下降,住院天数缩短,优于对照组(P<0.01)。治疗组治疗后血气指标较治疗前好转(P<0.01)。结论 EBS治疗术后急性肺不张具有操作简单、创伤小、疗效确切、安全性高等优点,可以避免气管切开,是一种有效且安全的治疗方法。     

Aktuelle Versorgungsstruktur der Therapie des akuten Herzinfarkts in Deutschland

Background

The goal of this analysis was to obtain an overview of the structure and procedures followed by clinics in Germany that care for patients with acute myocardial infarction (AMI).

Methods

Those hospitals that treat patients with AMI were identified via hospital directories, the Internet, and telephone inquiries. A standardized questionnaire on hospital structure and AMI treatment was sent to these clinics and the results were evaluated centrally.

Results

There are currently 1,076 hospitals in Germany that treat patients with AMI. A cardiac catheterization laboratory is available in 393 centers (36.5%), 332 (30.8%) provide 24-h intervention services, and 79 (7.3%) have a department of cardiac surgery. Primary PCI is the main form of reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) in 98% of the centers with a cath lab and in 90% of those without a cath lab. Fibrinolysis is performed in 40% of the centers with a cath lab and in 61% without. The proportion of patients receiving fibrinolytic therapy is 5 and 20%, respectively. Invasive diagnostic procedures are routinely undertaken in >95% of patients after STEMI without primary PCI and for NSTEMI and only in <5% with recurrent angina or positive evidence of myocardial ischemia.

Conclusion

Primary PCI is the preferred treatment for patients with STEMI in hospitals with as well as those without a cardiac catheterization laboratory. This is due to the increasing organization of hospitals with and without 24-h provision of PCI into heart attack networks.     

Patients’ awareness, utilization, and satisfaction with treatment modalities for the management of their osteoarthritis

The objective of this study was to evaluate the knowledge, awareness, utilization, and satisfaction of patients with different treatment modalities for osteoarthritis (OA). Patients with a diagnosis of OA of the knee or hip who had attended a rheumatology referral clinic over the preceding 2 years were eligible. A six-page self-administered questionnaire was mailed to them. Responses were anonymous. One hundred and six completed questionnaires were returned. The average age of the respondents was 64 years and included 71 females. Ninety-four percent of respondents had at least 8 years of formal education, and 75% had had OA for at least 5 years. Seventy-five percent successfully defined OA. The majority had heard of most treatment modalities. Seventy-one percent had tried cyclooxygenase-2 inhibitors (COXIBs), 79% analgesics, and 56% physiotherapy. Twenty-six percent had had surgery for their OA. Of those that had tried the various treatment options, the most satisfaction occurred with surgery, pool therapy, walking aids, and narcotic analgesics. Fifty-five percent found traditional nonsteroidal anti-inflammatory drugs (NSAIDs) helpful and 65% benefited from the COXIBs. Treatment reported as providing the most improvement in function was surgery, followed by steroid injections, COXIB therapy, and traditional NSAIDs. Treatment modalities providing the most symptomatic improvement were surgery, followed by COXIBs and steroid injections. When treatment options were compared, their rank ordering differed when considering overall satisfaction, functional improvement, and symptomatic relief. The participants in this study were well informed as to the nature of their disease and its treatment. A wide number of therapies had been tried, most of which were well tolerated. According to patient perception, those undergoing surgical treatment had the best improvement in symptoms and function. For those using anti-inflammatories (NSAIDs or COXIBs) improvement occurred in >50%, though this was less than for physiotherapy and analgesics. Based on this cohort of patients, treatments that were rated highly (such as surgery) were not necessarily those that were the most widely experienced. Conversely, those therapies that were the most widely accessed (such as analgesics) were not necessarily those that provided the maximum perceived benefit. We conclude that in the continued absence of specific disease-modifying therapies for OA, multiple therapeutic options need to be explored to address individual patients functional and symptomatic needs.     

Treatment of angioimmunoblastic lymphadenopathy (AILD)-type T-cell lymphoma using prednisone with or without the COPBLAM/IMVP-16 regimen. A multicenter study. Kiel Lymphoma Study Group.

OBJECTIVE: To describe the clinical course of patients with angioimmunoblastic lymphadenopathy (AILD)-type lymphoma with a sequential treatment with prednisone and COPBLAM/IMVP-16. DESIGN: A multicenter, prospective, nonrandomized trial. SETTING: University medical centers and community hospitals. PATIENTS: Sixty-seven patients were registered, 28 were excluded, and 39 patients were evaluable for response (median age, 59 years; range, 25 to 82 years) (stages I and II, 10%; stages III and IV, 90%; B symptoms, 74%). MEASUREMENTS: Response, survival, and relapse. INTERVENTION: Patients initially received prednisone and no further treatment if a complete remission was achieved. Relapsing or refractory patients were treated with COPBLAM/IMVP-16. Patients with life-threatening tumor progression or extension received COPBLAM/IMVP-16 initially. Treatments were chosen in accordance with tumor extension and response to prednisone. Treatment modalities were not compared. RESULTS: Twenty-eight patients received primary prednisone, 18 received secondary prednisone, and 11 received primary chemotherapy. The complete response rates (with 95% CIs) were 29% (CI, 12% to 46%), 56% (CI, 33% to 79%), and 64% (CI, 36% to 92%), respectively. The median observation time of surviving patients was 28 months (range, 7 to 53). The median overall survival time was 15 months. The probabilities (with 95% CIs) of overall survival, event-free survival, and relapse at 36 months were 40.5% (CI, 24% to 56%), 32.3% (CI, 17% to 47%), and 34.6% (CI, 14% to 56%), respectively. At the time of evaluation, 22 of 39 patients had died, 7 of noninfectious complications and 14 of infections. CONCLUSIONS: Prednisone with or without COPBLAM/IMVP-16 treatment in AILD-type lymphoma leads to complete remissions in about half of the patients and in long-term, disease-free survival for one third.     

Risk scores currently used in German heart surgery

BACKGROUND: Risk scores (RS) in heart surgery assess mortality and morbidity and mirror the degree of severity of disease of the patients when presented for surgery. We examined the use and dissemination of RS in Germany. MATERIAL AND METHODS: Our survey included 79 German heart surgery institutes in Fall 1999 and Winter 2000. RESULTS: Four institutes did not respond. Out of 75 (ad 100 %) responders 56 (75 %) institutes did not use RS, 17 (22 %) institutes used one RS method and 2 (3 %) institutes used two RS methods. The most frequently applied RS methods were the Cleveland Clinic Score and the Euro Score (n = 7, each) followed by institution-specific, internally developed RS methods (n = 5), Parsonnet's RS (n = 1) and the RS from the STS database (n = 1). Fourteen institutes used RS for internal quality control. Of these, 2 institutes publish their RS data for external quality control. The patient-related individual procedure risk was used in 6 institutes. CONCLUSIONS: A quarter of the German heart surgery institutes use one or more RS methods. The most commonly used were the Cleveland Clinic Score and the Euro Score, followed by internally developed RS methods. RS methods were most frequently used for internal quality control. The degree of the severity of disease of the patients who presented for surgery could only be compared between a small number of institutes using the same RS.     

Revision of guidelines for the management of patients with congenital heart failure in Germany

The German Society for Thoracic and Cardiovascular Surgery (GSTCVS) regards 250 operations on patients with congenital heart disease per institution as an optimal number (Thorac Cardiov Surg 2006; 54: 73 - 77). In addition, all German institutions ought to participate unequivocally on data transfer to the European Association for Cardiothoracic Surgery. However, these "optimal German structures" need to be translated into action now. It will have to be the GSTCVS to ask for a hearing at the Federal Joint Committee (G-BA) (www.g-ba.de). This medical self-governing body, formed from the national associations of doctors and dentists, the German Hospital Federation and the health insurance funds, gives concrete definition to the legal requirements and implements them. Recently, the Federal Joint Committee released concrete measures for the care of newborns (Press release 21. 9. 2005, section sign 91 Abs. 7 SGB V). The obvious thing to do now would be considering measures for care of patients with congenital heart disease. We conclude, that whereas treatment and results should be further improved by quality control and quality transparency, structures of institutions involved in the care of patients with congenital heart disease can only be implemented by the Federal Joint Committee.     

The capacity of normal murine alveolar macrophages to function as antigen-presenting cells for the initiation of primary antibody-forming cell responses to sheep erythrocytes in vitro

The precise role of resident alveolar macrophages (AM) in the induction of immune responses to inhaled antigens is not known. In order to gain insight into the immune functions of AM in vivo, the present studies were performed to characterize several immune functional capacities of normal murine AM, to compare these with normal peritoneal macrophages (PM), and to determine the capacity of AM to serve as antigen-presenting cells for the induction of primary antibody-forming cell (AFC) responses to sheep erythrocytes (SRBC) in vitro. We compared the capacities of normal murine AM and of PM to: elaborate interleukin-1 (IL-1), express surface membrane Ia antigen, serve as accessory cells for mitogen-induced blastogenesis, and induce generation of primary AFC responses to SRBC in Mishell-Dutton cultures. We observed that: AM and PM elaborate equivalent IL-1 activity after stimulation with phorbal myristate acetate (PMA); AM "conditioned" with supernatants of concanavilin-A-stimulated spleen cells express surface Ia but do so proportionately less than similarly treated PM; normal AM can serve as accessory cells for mitogen-induced blastogenesis but do so significantly less effectively than do PM; AM substitute poorly for PM with respect to the induction of primary AFC responses to SRBC in standard Mishell-Dutton cultures; however, AM exert potent suppressive activity in these cultures, and this suppression can be reversed by the addition of indomethacin and catalase to cultures, suggesting that both prostaglandins and hydrogen peroxide play suppressive roles; after reversal of suppression in drug-modified Mishell-Dutton cultures, AM can induce primary AFC responses to SRBC but do so less effectively than do similarly treated PM.(ABSTRACT TRUNCATED AT 250 WORDS)     

Initial German Experience With Transapical Implantation of a Second-Generation Transcatheter Heart Valve for the Treatment of Aortic Regurgitation

ObjectivesThis analysis reports on the initial German multicenter experience with the JenaValve (JenaValve Technology GmbH, Munich, Germany) transcatheter heart valve for the treatment of pure aortic regurgitation.BackgroundExperience with transcatheter aortic valve implantation (TAVI) for severe aortic regurgitation is limited due to the risk of insufficient anchoring of the valve stent within the noncalcified aortic annulus.MethodsTransapical TAVI with a JenaValve for the treatment of severe aortic regurgitation was performed in 31 patients (age 73.8 ± 9.1 years) in 9 German centers. All patients were considered high risk for surgery (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 23.6 ± 14.5%) according to a local heart team consensus. Procedural results and clinical outcomes up to 6 months were analyzed.ResultsImplantation was successful in 30 of 31 cases (aortic annulus diameter 24.7 ± 1.5 mm); transcatheter heart valve dislodgement necessitated valve-in-valve implantation in 1 patient. Post-procedural aortic regurgitation was none/trace in 28 of 31 and mild in 3 of 31 patients. During follow-up, 2 patients underwent valvular reinterventions (surgical aortic valve replacement for endocarditis, valve-in-valve implantation for increasing paravalvular regurgitation). All-cause mortality was 12.9% and 19.3% at 30 days and 6 months, respectively. In the remaining patients, a significant improvement in New York Heart Association class was observed and persisted up to 6 months after TAVI.ConclusionsAortic regurgitation remains a challenging pathology for TAVI. After initial demonstration of feasibility, this multicenter study revealed the JenaValve transcatheter heart valve as a reasonable option in this subset of patients. However, a significant early noncardiac mortality related to the high-risk population emphasizes the need for careful patient selection.     

Coronary Artery Fistula Ligation in a Child with Use of the Starfish Heart Positioner

The Starfish™ Heart Positioner aids off-pump coronary artery surgery in adult patients by providing posterior cardiac exposure without incurring hemodynamic instability. Herein, we describe its use in a 17-month-old girl who had a right coronary artery fistula that drained to the right ventricle. Use of the device enabled exposure that afforded closure of the fistula without cardiopulmonary bypass. The patient was discharged from the hospital 2 days postoperatively. Six weeks later, she was well, and echocardiography showed no residual fistulous flow.Key words: Cardiac surgical procedures, child, preschool, coronary artery disease/surgery, coronary vessel anomalies/physiopathology/surgery, equipment design, fistula/diagnosis/surgery, hemodynamics, patient selection, suction/instrumentation, treatment outcome, vascular fistula/physiopathology/surgeryThe Starfish™ Heart Positioner (Medtronic, Inc.; Minneapolis, Minn) aids off-pump coronary artery surgery in adult patients.¹ Use of the device enables hands-free manipulation of the heart, thereby preventing coronary artery compression and permitting exposure of the posterior surface of the heart without incurring ischemia. Here, we describe the use of a Starfish Heart Positioner in a 17-month-old girl who had a right coronary artery-to-right ventricular fistula.     

Selective approach in the treatment of esophageal perforations

BACKGROUND: Treatment of esophageal perforation remains controversial and recommendations vary from initially non-operative to aggressive surgical management. Several factors are responsible for this life-threatening event, which has led to more individualized treatment ensuring adequate pleuromediastinal drainage with sufficient irrigation. We analyzed our data, evaluating morbidity and mortality in this selective approach. METHODS: During 1985 to 2001, 17 of the 38 patients with esophageal perforation treated in our hospital underwent primarily a thoracotomy, wide drainage and debridement of chest/ mediastinum and enteral hyperalimentation. Twenty-one patients (55%) initially were treated non-operatively (NPO, nasogastric tube, hyperalimentation, antibiotics and chest tube), but surgery was required in 9 patients (43%). RESULTS: Most perforations were iatrogenic (45%; 17/38) followed by spontaneous perforations (32%; 12/38). Cervical perforations were managed earlier (< 24 h) than thoracic tears, 8/10 (80%) and 17/28 (61%) respectively. Initial conservative treatment failed in all spontaneous ruptures and more in thoracic lesions (62%) than in cervical lesions (13%). Most patients with thoracic perforations and 'free' intrathoracic contamination underwent primary surgery. Surgery with adequate drainage (n = 23) was based on signs of sepsis, empyema and progression of pneumomediastinum/thorax. Mortality occurred in one patient (3%), initially treated conservatively. Median intensive care and duration of hospitalization were not different between the conservative (5 and 7 days, respectively) and the primary surgical approach (21 and 27 days, respectively), but were higher after secondary surgery (13 and 50 days, respectively). CONCLUSIONS: Spontaneous esophageal perforations require early surgical exploration with drainage and irrigation of mediastinum and pleural cavity, while most iatrogenic lesions can be managed conservatively. Cervical perforations can be treated adequately non-operatively, but thoracic perforations often require surgical intervention.     

Asthma management practices in adults – findings from the German Health Update (GEDA) 2010 and the German National Health Interview and Examination Survey (DEGS1) 2008–2011

Objectives: In Germany, population-wide data on adherence to national asthma management guidelines are lacking, and performance measures (PM) for quality assurance in asthma care are systematically monitored for patients with German national asthma disease management program (DMP) enrollment only. We used national health survey data to assess variation in asthma care PM with respect to patient characteristics and care context, including DMP enrollment. Methods: Among adults 18–79 years with self-reported physician-diagnosed asthma in the past 12 months identified from a recent German National Health Interview Survey (GEDA 2010: N?=?1096) and the German National Health interview and Examination Survey 2008–2011 (DEGS1: N?=?333), variation in asthma care PM was analyzed using logistic regression analysis. Results: Overall, 38.4% (95% confidence interval: 32.5–44.6%) of adults with asthma were on current inhaled corticosteroid therapy. Regarding non-drug asthma management, low coverage was observed for inhaler technique monitoring (35.2%; 31.2–39.3%) and for provision of an asthma management plan (27.3%; 24.2–30.7%), particularly among those with low education. Specific PM were more complete among persons with than without asthma DMP enrollment (adjusted odds ratios ranging up to 10.19; 5.23–19.86), even if asthma patients were regularly followed in a different care context. Conclusions: Guideline adherence appears to be suboptimal, particularly with respect to PM related to patient counseling. Barriers to the translation of recommendations into practice need to be identified and continuous monitoring of asthma care PM at the population level needs to be established.