Sind spezielle Scores für Schwerverbrannte nötig?

Zusammenfassung Ein Vergleich der Mortalit?ts- und Sepsis-Vorhersage zwischen speziellen Verbrennungs-Scores und allgemeinen Intensiv-Scores stand im Mittelpunkt dieser retrospektiven Untersuchung. Hierbei wurden bei 51 Schwerverbrannten der ,,Abbreviated Burn Severity Index`` (ABSI) und der ,,Baltimore Sepsis Scale`` (BSS) als spezielle Verbrennungs-Scores auf der einen Seite sowie die allgemeinen Intensiv-Scores ,,Mortality Prediction Model`` (MPM II), ,,Simplified Acute Physiology Score`` (SAPS II), APACHE II (ApII), ,,Hannover Intensiv Score`` (HIS) und der Sepsis-Score nach Elebute und Stoner (ES) auf der anderen Seite erhoben. Am Tag 1 und 3 wurde für alle Scores aus der Sensitivit?t und Spezifit?t eine ,,Receiver Operating Characteristic – ROC`` erstellt und die Fl?che unter dem Graphen als Gütekriterium der Scores berechnet (ROC-Wert: max. 1,0; min. 0,5). Weiterhin wurden die Score-Werte von Patienten mit und ohne septischen Verlauf an den Tagen 1, 2, 3, 5, 7, 10, 14, 21 und 28 auf einen statistischen Unterschied (Mann-Whitney-U-Test) geprüft. Ergebnisse: Bezüglich der Mortalit?tsvorhersage zeigten ABSI, BSS sowie die allgemeinen Scores HIS, ApII und ES ROC-Werte von über 0,8 und eine absolute Korrektheit von über 75%. Der MPM II und der SAPS II schnitten deutlich schlechter ab. Für die Sepsisvorhersage zeigten alle Systeme ROC-Werte zwischen 0,6 und 0,7. Obwohl die ROC-Werte am Tag 3 gegenüber dem ersten Behandlungstag teilweise anstiegen, so blieben insgesamt doch die ROC-Werte, die absolute Richtigkeit und der positiv pr?diktive Wert hinter den Ergebnissen der Mortalit?tsvorhersage zurück. Die Unterscheidungskraft der Scores zwischen Patienten mit und ohne septischen Verlauf war am deutlichsten und frühesten mit Hilfe von BSS und HIS m?glich. Bereits am 2. Behandlungstag zeigte sich ein signi-fikanter Unterschied im Mann-Whitney-U-Test. Schlu?folgerung: Spe-zielle Verbrennungs-Scores bieten hinsichtlich einer Mortalit?tsvorhersage keine entscheidenden Vorteile gegenüber allgemeinen Intensiv-Scores. Die Vorhersage einer Sepsis scheint hingegen mit keinem der untersuchten Systeme m?glich. Ein Sepsis-Monitoring ist sowohl mit dem speziellen Verbrennungs-Score BSS als auch mit den allgemeinen Systemen m?glich. Die vorliegende Arbeit liefert einen Hinweis auf eine m?gliche Vereinfachung der immer verwirrenderen Vielfalt von Score-Systemen. Eine Reduktion würde jedoch wesentlich zur allgemeinen Akzeptanz beitragen. Eingegangen: 12. September 1996 Akzeptiert: 4. Oktober 1996     

To test or not: A registry-based observational study of an online decision support for prostate-specific antigen tests

BackgroundWatchful waiting is an essential part in the handling of patients with prostate cancer (PC). More effective disease management may be achieved by this strategy. Correct use of prostate-specific antigen (PSA) test is crucial and the general practitioner (GP) may therefore benefit from access to a clinical decision support system (CDSS) that focuses on this challenge. There are many barriers to the use of CDSSs. The aim of the present paper is to study if such barriers may be overcome by granting GPs easier access to a web-based CDSS via a hyperlink in the GPs’ electronic medical record system (EMR).MethodsIn the present population-based observational registry study with an intervention and control group, we created a web-based CDSS that was made accessible to GPs via hyperlink inserted into the EMR medical chart contents. The intervention was introduced 1 January 2011. Our outcome measure was the number of age-standardised PSA test rates per 1000 men per practice during three equally sized periods of 6 months within the study period from 1 January 2010 to 30 June 2011.ResultsWe found that none of the differences between intervention and control groups were statistically significant.ConclusionsProviding GPs with access to a CDSS to aid their decision to use the PSA, had no measurable effect on the GPs’ PSA testing behaviour.     

Implementation of a Cross-specialty Training Program in Basic Laparoscopy

Background and Objectives:

Several surgical specialties use laparoscopy and share many of the same techniques and challenges, such as entry approaches, equipment, and complications. However, most basic training programs focus on a single specialty. The objective of this study was to describe the implementation of a regional cross-specialty training program for basic laparoscopy, to increase the flexibility of educational courses, and to provide a more efficient use of simulation equipment.

Methods:

Using a regional training program in basic laparoscopy for gynecology as a model, we developed a cross-specialty training program for residents in surgery, gynecology, urology, and thoracic surgery. We reviewed data on training for the first year of the program and evaluated the program by using a scoring system for quality criteria for laparoscopic curricula and skills.

Results:

We held 6 full-day theoretical courses involving 67 residents between September 1, 2013, and August 31, 2014. In the weeks following each course, residents practiced in a self-directed, distributed, and proficiency-based manner at a simulation center and in local hospital departments. A total of 57 residents completed the self-practice and a subsequent practical animal laboratory–based course. The structure of the training program was evaluated according to identified quality criteria for a skills laboratory, and the program scored 38 of a maximum 62 points.

Discussion:

Implementation of a regional cross-specialty training program in basic laparoscopy is feasible. There are several logistic benefits of using a cross-specialty approach; however, it is important that local departments include specialty-specific components, together with clinical departmental follow-up.     

Exercise training in older patients with systolic heart failure: Adherence,exercise capacity,inflammation and glycemic control

Objectives. Training improves exercise capacity in patients with heart failure (CHF) but most evidence is on selected younger patients with systolic CHF. Design. All patients diagnosed with CHF over 3 years were screened for inclusion and exclusion criteria. Fifty two patients with systolic CHF (LVEF<45, NYHA II-III) received supervised exercise training twice weekly for 8 weeks. Results. Mean age was 68.2 (+/?SD 11.3) years. Despite marked improvements in physical fitness (workload, 6 minute walk test, incremental shuttle walk test and sit to stand test), there were no changes in serological markers of glycemic control (glucose, insulin, glycerol, free fatty acids, HbA1c), inflammation and endothelial function (hsCRP, orosomucoid, interleukin 6, TNF-alpha, urine-orosomucoid and -albumin/creatinin), lipid metabolism, NT-proBNP or other regulatory hormones (cortisol, epinephrine and IGF-1). There were no changes in quality of life. Conclusions. The effect of exercise training in these older CHF-patients was not as impressive as reported in younger and more selected patients. More studies on the efficiency of exercise training that reflect the age- and co-morbidity of the majority of CHF-patients are needed.     

Clinical value of 18F-FDG-PET/CT in suspected serious disease with special emphasis on occult cancer

Annals of Nuclear Medicine - Suspected serious disease (SSD) is a disease designation often given to patients with one or more non-specific symptoms of severe disease that could be due to cancer;...     

Efficacy and safety of terlipressin in cirrhotic patients with variceal bleeding or hepatorenal syndrome

Terlipressin is an analog of the natural hormone arginine-vasopressin. It is used in the treatment of patients with cirrhosis and bleeding esophageal varices (BEV) and in patients with hepatorenal syndrome (HRS): two of the most dramatic and feared complications of cirrhosis. Terlipressin exerts its main pharmacological effect through stimulation of vasopressin-1 receptors. These receptors are located in vascular smooth muscle and mediate vasoconstriction. In patients with cirrhosis and portal hypertension, treatment with terlipressin increases mean arterial pressure and decreases portal flow and pressure within minutes of administration. Furthermore, in patients with ascites terlipressin improves glomerular filtration and excretion of sodium. Terlipressin decreases failure of initial hemostasis by 34%, decreases mortality by 34%, and is considered a first-line treatment for BEV, when available. Terlipressin in combination with albumin reverses type 1 HRS in 33%–60% of cases and is the only treatment with proven efficacy in randomized trials. The safety profile is favorable when considering the clinical efficacy and the high mortality of these clinical entities. Adverse events are mostly cardiovascular and related to vasoconstriction. Mortality and withdrawal of terlipressin due to adverse events occurs in less than 1% of cases. Mild adverse events related to terlipressin treatment occur in 10%–20% of patients. The benefit, however, of terlipressin on long-term survival in HRS remains to be determined. At present, treatment with terlipressin and albumin is considered the most efficient therapy and should therefore be recommended for the treatment of type 1 HRS-1.     

CYP2C19*17 increases clopidogrel‐mediated platelet inhibition but does not alter the pharmacokinetics of the active metabolite of clopidogrel

The aim of the present study was to determine the impact of CYP2C19*17 on the pharmacokinetics and pharmacodynamics of the active metabolite of clopidogrel and the pharmacokinetics of proguanil. Thus, we conducted an open‐label two‐phase cross‐over study in 31 healthy male volunteers (11 CYP2C19*1/*1, 11 CYP2C19*1/*17 and nine CYP2C19*17/*17). In Phase A, the pharmacokinetics of the derivatized active metabolite of clopidogrel (CAMD) and platelet function were determined after administration of a single oral dose of 600 mg clopidogrel (Plavix; Sanofi‐Avensis, Horsholm, Denmark). In Phase B, the pharmacokinetics of proguanil and its metabolites cycloguanil and 4‐chlorphenylbiguanide (4‐CPB) were determined in 29 of 31 subjects after a single oral dose of 200 mg proguanil given as the combination drug Malarone (GlaxoSmithKline Pharma, Brondby, Denmark). Significant correlations were found between the area under the time–concentration curve (AUC_0–∞) of CAMD and both the absolute ADP‐induced P2Y₁₂ receptor‐activated platelet aggregation (r = ?0.60, P = 0.0007) and the percentage inhibition of aggregation (r = 0.59, P = 0.0009). In addition, the CYP2C19*17/*17 and CYP2C19*1/*17 genotype groups had significantly higher percentage inhibition of platelet aggregation compared with the CYP2C19*1/*1 subjects (geometric mean percentage inhibition of 84%, 73% and 63%, respectively; P = 0.014). Neither the absolute ADP‐induced P2Y₁₂ receptor‐activated platelet aggregation, exposure to CAMD nor the pharmacokinetic parameters of proguanil, cycloguanil and 4‐CPB exhibited any significant differences among the genotype groups. In conclusion, carriers of CYP2C19*17 exhibit higher percentage inhibition of platelet aggregation, but do not have significantly lower absolute P2Y₁₂ receptor‐activated platelet aggregation or higher exposure to the active metabolite after a single oral administration of 600 mg clopidogrel.