Rationale Bildgebung bei Pneumonien

As one of the most common infectious diseases pneumonia is associated with a high morbidity and mortality. A rapid and rational diagnostic work-up is crucial to improve patient prognosis and outcome. The diagnosis of pneumonia requires the detection of pulmonary infiltrates; therefore, radiological methods are a key part of the diagnostic algorithm to demonstrate the presence of infiltrates and to confirm the diagnosis. The accepted standard method is chest X-ray at two levels, posteroanterior (PA) and lateral radiographs. Computed tomography is mainly used for immunocompromised patients, patients with pre-existing structural lung disease, therapy refractory pneumonia and in the differential diagnosis of suspected underlying diseases, such as pulmonary embolism or malignancy. Increasing evidence suggests that lung ultrasound is a promising, precise technology which is readily available and with no irradiation of patient.     

Autonomy and reason: treatment choice in breast cancer

The practice of offering choice to those women with breast cancer for whom either breast conserving surgery or mastectomy would be equally beneficial has come to be seen as an important aspect of medical care. As well as improving satisfaction with treatment, this is seen as satisfying the ethical principle of respect for autonomy. A number of studies, however, show that women are not always comfortable with such choice, preferring to leave treatment decisions to their surgeons. A question then arises as to the extent that these women can be seen as autonomous or as exercising autonomy. This paper argues, however, that the understanding of autonomy which is applied in current approaches to breast cancer care does not adequately support the exercise of autonomy, and that the clinical context of care means that women are not able to engage in the kind of reasoning that might promote the exercise of autonomy. Where respect for autonomy is limited to informed consent and choice, there is a danger that women's interests are overlooked in those aspects of their care where choice is not appropriate, with very real, long‐term consequences for some women. Promoting the exercise of autonomy, it is argued, needs to go beyond the conception of autonomy as rational individuals making their own decisions, and clinicians need to work with an understanding of autonomy as relational in order to better involve women in their care.     

Potential functional and survival benefit of double over single lung transplantation for selected patients with idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a frequent indication for lung transplantation (LTX) with pulmonary hypertension (PH) negatively affecting outcome. The optimal procedure type remains a debated topic. The aim of this study was to evaluate the impact of pretransplant PH in IPF patients. Single LTX (SLTX, n = 46) was the standard procedure type. Double LTX (DLTX, n = 30) was only performed in cases of relevant PH or additional suppurative lung disease. There was no significant difference for pretransplant clinical parameters. Preoperative mean pulmonary arterial pressure was significantly higher in DLTX recipients (22.7 ± 0.8 mmHg vs. 35.9 ± 1.8 mmHg, P < 0.001). After transplantation, 6‐min‐walk distance and BEST‐FEV₁ were significantly higher for DLTX patients (6‐MWD: 410 ± 25 m vs. 498 ± 23 m, P = 0.02; BEST‐FEV₁: 71.2 ± 3.0 (% pred) vs. 86.2 ± 4.2 (% pred), P = 0.004). Double LTX recipients demonstrated a significantly better 1‐year‐, overall‐ and Bronchiolitis obliterans Syndrome (BOS)‐free survival (P < 0.05). Cox regression analysis confirmed SLTX to be a significant predictor for death and BOS. Single LTX offers acceptable survival rates for IPF patients. Double LTX provides a significant benefit in selected recipients. Our data warrant further trials of SLTX versus DLTX stratifying for potential confounders including PH.     

Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects

Background: Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. Amelogenins are involved in the formation of enamel and periodontal attachment formation during tooth development. Objectives: To test whether EMD is effective, and to compare EMD versus GTR, and various BG procedures for the treatment of intrabony defects. Search strategy: We searched the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomized controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: February 2009. Selection criteria: RCTs on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year follow‐up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events. The following time‐points were to be evaluated: 1, 5 and 10 years. Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two authors. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). It was decided not to investigate heterogeneity, but a sensitivity analysis for the risk of bias of the trials was performed. Main results: Thirteen trials were included out of 35 potentially eligible trials. No included trial presented data after 5 years of follow‐up, therefore all data refer to the 1‐year time point. A meta‐analysis including nine trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.1 mm, 95% CI 0.61 to 1.55) and PPD reduction (0.9 mm, 95% CI 0.44 to 1.31) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had <2 mm PAL gain in the control group, with RR 0.53 (95% CI 0.34 to 0.82). Approximately nine patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 25%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating only trials at a low risk of bias in a sensitivity analysis (four trials), the effect size for PAL was 0.62 mm (95% CI 0.28 to 0.96), which was less than 1.1 mm for the overall result. Comparing EMD with GTR (five trials), GTR showed statistically significant more postoperative complications (three trials, RR 0.12, 95% CI 0.02 to 0.85) and more REC (0.4 mm 95% CI 0.15 to 0.66). The only trial comparing EMD with a bioactive ceramic filler found statistically significant more REC (‐1.60 mm, 95% CI ?2.74 to ?0.46) at the EMG treated sites. Authors’ conclusions: One year after its application, EMD significantly improved PAL levels (1.1 mm) and PPD reduction (0.9 mm) when compared to a placebo or control, however, the high degree of heterogeneity observed among trials suggests that results have to be interpreted with great caution. In addition, a sensitivity analysis indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications in the GTR group, there was no evidence of clinically important differences between GTR and EMD. Bone substitutes may be associated with less REC than EMD. Plain language summary: Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects. Emdogain might have some advantages over other methods of regenerating the tissue supporting teeth lost by gum disease, such as less postoperative complications, but has not been shown to save more compromised teeth or that patients noticed any aesthetic improvement 1 year after its application. Bacteria in plaque can cause gum disease (periodontitis) that breaks down tissue supporting teeth. Surgical cleaning tries to stop the disease to save loose teeth. Bone grafting, guided tissue regeneration and enamel matrix derivatives (such as Emdogain) aim to regenerate support tissues. Emdogain contains proteins (derived from developing pig teeth) believed to regenerate tooth attachment. The review found that adjunctive application of Emdogain regenerates about 1 mm more tissue than surgical cleaning alone, although it is unclear to which extent such improvement is noticeable since patients did not find any difference in the aesthetic results. Emdogain showed similar clinical results to guided tissue regeneration, but is simpler to use and determines less complications. Bone substitutes may induce less gum retraction than Emdogain. No serious adverse reactions to Emdogain were reported in trials.     

Developing indicators for measuring Research Capacity Development in primary care organizations: a consensus approach using a nominal group technique

Research Capacity Development (RCD) in the National Health Service supports the production of evidence for decision-making in policy and practice. This study aimed to establish a level of consensus on a range of indicators to measure research capacity in primary care organizations. Indicators were developed in a two-stage process using workshops and modified nominal group technique. In 2005, workshops were used to generate possible indicators from a wide range of research active and research-interested people. A theoretical framework of six principles of RCD was used to explore and identify indicators. Data were thematically coded, and a 129-item, 9-point Likert scale questionnaire was developed. A purposive sample of nine experts in developing research capacity in primary care agreed to take part in a nominal group in April 2006. The questionnaire was circulated prior to the meeting, and analysis of the responses formed the basis for structured discussion. Participants were then asked to rescore the questionnaire. Only seven participants were able to take part in the discussion and rescore stages. Data were analysed in two ways: level of relevance attributed to each indicator as a measure of organizational RCD, represented by median responses (medians of 7–9 defined strong support, 4–6 indicated moderate support and 1–3 indicated weak support), and level of consensus reached by the group. Consensus was reached if 85% of the group rated an indicator within the same band. Eighty-nine (68%) indicators were ranked as strongly relevant, and for seventy-three of these indicators, a consensus was reached. The study was successful in generating a set of agreed indicators considered relevant for measuring RCD in primary care organizations. These will form the basis of a pilot tool kit to assist primary care organizations to develop research capacity. Further work will explore the applicability of the indicators in practice.     

An exploration of nurses' attitudes to the nursing care of the suicidal patient in an acute psychiatric ward

Suicidal patients admitted to hospital following a suicidal attempt or expressing suicidal ideation present a real challenge to health professionals with regard to their therapeutic Co. Antrim care. This study was undertaken to explore the attitudes of psychiatric nurses caring for such patients. Results reveal that psychiatric nurses do hold positive views on caring for potentially suicidal patients, contradicting previous studies where more negative feelings were expressed by nurses, especially those with initial contact. Findings also show that some nurses experience an element of distress, and the length of experience within such a working environment does not affect the nurses' level of satisfaction gained on caring for the suicidal patient. This study also identifies an expression of need for further education and practice in interpersonal skills and therapeutic modalities to enhance and develop a more effective delivery of care for this group of patients.     

Evaluation of a low-threshold clinic for opiate-dependent drug users

This study reports on the development and outcome of a Low Threshold Clinic (LTC) for opiate-dependent drug users. The service originated as a nursing initiative within an inner city Drug Dependency Centre (DDC) and its rationale and treatment approach are explored in relation to the literature and local circumstances. Client baseline and outcome data were systematically gathered to assess service uptake and service efficacy in terms of client outcome. Data are presented for the first two years of operation during which a total of 59 clients entered the LTC. The sociodemographic characteristics and patterns of drug use among this group suggest the service was successful in targeting clients who previously failed to enter traditional treatment programmes despite initial referral to the DDC. Outcome data indicate a tendency for clients to inject less frequently, engage in less criminal activity and, by 12 months, to reduce their dose of prescribed methadone whilst attending the LTC. Tentative conclusions are drawn concerning the value of this service for 'hard-to-reach' drug users and those who may be at a precontemplation stage of change. Recommendations are made for a more comprehensive evaluative study that involves comparison with other treatment approaches.