„Der epidurale Blood Patch: ein Auftrag für den versierten Anästhesisten?“

Die Anaesthesiologie -     

Stationäre Versorgung der peripheren arteriellen Verschlusskrankheit (PAVK) durch die Gefäßchirurgie

Background

The incidence of peripheral arterial occlusive disease (PAOD) is increasing continuously in Germany. Besides vascular surgery other medical disciplines participate in the management whereby in addition to vascular surgery only angiology as a specialty exclusively includes the treatment of vascular diseases. A current survey among vascular surgeons in leading positions was initiated to estimate the importance of vascular surgery for the treatment of PAOD in Germany. In addition the therapeutic spectrum within the discipline of vascular surgery was evaluated.

Material and methods

Between February and May 2013 a structured survey was sent to all head vascular surgeons of the 262 German vascular departments and sections registered by the Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin (DGG, German Vascular Society). Besides questions on structural characteristics of the institution, there were also questions on diagnostic techniques, the conservative and invasive therapeutic spectrum as well as mortality and amputation rates as quality indicators. All participants were instructed to give the answers in accordance with the officially recognized internal hospital control data.

Results

A total of 120 questionnaires were returned (45.8?%) collating data from 45 basic and regular care hospitals (37.5?%), 42 primary care hospitals (35?%), 25 maximum care hospitals (20.8?%) and 7 university hospitals (5.8?%) and included 8 outpatient institutions with inhospital treatment possibilities (6.7?%). Of the institutions 29 were not certified as German vascular centers (24.17?%) but all other institutions were either certified according to the DGG (17.5?%) or in combination with the Deutsche Gesellschaft für Angiologie (DGA, German Society of Angiology) and the Deutsche Röntgengesellschaft (DRG, German Radiology Society) (24.2?%) and 5 institutions were exclusively certified according to the DGA (4.2?%). The whole spectrum of operative, hybrid and conservative treatment of PAOD was available at all vascular surgical institutions as well as duplex sonography (95.8?%) and angiography (91.4?%) as diagnostic tools within the department or in cooperation with other departments. All vascular surgery departments performed conservative therapy for PAOD in addition to surgical therapeutic interventions but the majority were invasive procedures. Of the invasive procedures 51.8?% were performed as percutaneous interventions and in the infragenual region 55.7?% of procedures were performed as percutaneous endovascular interventions. Among all PAOD patients operative pelvic procedures were associated with the highest mortality rate (3.8?%) and the lowest (0.8?%) with percutaneous transluminal angioplasty (PTA). The major amputation rate was 7.7?% following open or hybrid surgery and 3.2?% following PTA. The status of certification had no effect on these quality indicators.

Conclusion

Departments of vascular surgery in Germany comprehensively cover the wide spectrum of interventions including conservative, endovascular and open surgical treatment of PAOD. Vascular surgery plays a major role in the management of PAOD patients in Germany.     

Cost‐of‐illness of chronic leg ulcers in Germany

Chronic wounds are important because of their frequency, their chronicity and high costs of treatment. However, there are few primary data on the cost‐of‐illness in Germany. The aim was to determine the cost‐of‐illness of venous leg ulcers (VLU) in Germany. Prospective cost‐of‐illness study was performed in 23 specialised wound centres throughout Germany. Direct, medical, non medical and indirect costs to the patient, statutory health insurers and society were documented. Thereover, health‐related quality of life (QoL) was recorded as intangible costs using the Freiburg quality of life assessment for wounds (FLQA‐w, Augustin). A total of 218 patients (62.1% female) were recruited consecutively. Mean age was 69.8 ± 12.0 years. The mean total cost of the ulcer per year and patient was € 9569, [ € 8658.10 (92%) direct and € 911.20 (8%) indirect costs]. Of the direct costs, € 7630.70 was accounted for by the statutory health insurance and € 1027.40 by the patient. Major cost factors were inpatient costs, outpatient care and non drug treatments. QoL was strikingly reduced in most patients. In Germany, VLU are associated with high direct and indirect costs. As a consequence, there is a need for early and qualified disease management. Deeper‐going cost‐of‐illness‐studies and cost‐benefit analyses are necessary if management of chronic wounds is to be improved.     

Diffusion-weighted imaging of patients with subacute cerebral ischemia: comparison with conventional and contrast-enhanced MR imaging

BACKGROUND AND PURPOSE: The importance of diffusion-weighted imaging (DWI) for delineating acute ischemic lesions has been investigated extensively; however, few studies have investigated the role of DWI in the subacute stage of stroke. Because these lesions tend to appear bright throughout the first days of ischemia, owing to restricted diffusion, we speculated that DWI could also improve the detection of subacute infarcts as compared with conventional and contrast-enhanced MR imaging. METHODS: Interleaved echo-planar DWI with phase navigation was performed on a 1.5-T MR unit in a consecutive series of 53 patients (mean age, 66 +/- 14 years) with suspected recent cerebral ischemia. The interval between onset of clinical symptoms and MR imaging ranged from 1 to 14 days (mean, 6 +/- 4 days). Contrast material was given to 28 patients in a dose of 0.1 mmol/kg. RESULTS: DWI clearly delineated recent ischemic damage in 39 patients (74%) as compared with 33 (62%) in whom lesions were identified or suspected on conventional T2-weighted images. DWI provided information not accessible with T2-weighted imaging in 17 patients when evidence of lesion multiplicity or detection of clinically unrelated recent lesions was included for comparison. Subacute ischemic lesions were also seen more frequently on DWI sequences than on contrast-enhanced images (20 versus 13 patients). DWI was more likely to make a diagnostic contribution in the first week of stroke and in patients with small lesions or preexisting ischemic cerebral damage than was conventional MR imaging. CONCLUSION: Recent ischemic damage is better shown on DWI sequences than on conventional and contrast-enhanced MR images throughout the first days after stroke and may provide further information about the origin of clinical symptoms. Adding DWI to imaging protocols for patients with subacute cerebral ischemia is recommended.     

Salvage therapy for acute myeloid leukemia with fludarabine,cytarabine, and idarubicin with or without gemtuzumab ozogamicin and with concurrent or sequential G‐CSF

The current salvage therapies for relapsed/refractory acute myeloid leukemia (AML) are unsatisfactory. Over the past 7 years, we have used two salvage regimens: fludarabine, cytarabine, and idarubicin with (FLAG‐IM) or without gemtuzumab ozogamicin (GO) (9 mg/m² on Day 8) (FLAG‐I) in relapsed/refractory AML. Three‐quarters of patients also received concurrent G‐CSF. Seventy‐one patients were treated, 23 with FLAG‐I and 48 with FLAG‐IM. The median duration of follow‐up was 30.6 months. The treatment groups were well balanced with median ages of 48 years (range 18–70) and 47 years (range 20–68), unfavorable cytogenetics in 57% and 35%, prior allogeneic stem cell transplant in 43% and 42%, and CR1 duration <1 year in 60% and 67%, respectively, for FLAG‐I and FLAG‐IM. The complete remission (CR) rate in the FLAG‐I group was 39% with an additional 13% achieving a CRp [overall response rate (ORR) 52%]; the CR rate in the FLAG‐IM group was 29% with an additional 27% achieving a CRp (ORR 56%). The median duration of response (DOR; 16.8 vs. 8.3 months), event‐free survival (EFS; 7.4 vs. 4.1 months), and overall survival (OS; 8.8 vs. 5.0 months) trended to favor FLAG‐I over FLAG‐IM. The patients who received G‐CSF concurrent with chemotherapy had superior overall response rate (ORR; 62% vs. 29%, P = 0.026), median EFS (6.2 vs. 3.4 months, P = 0.010), and OS (8.8 vs. 3.9 months, P = 0.004) when compared with those who sequentially received G‐CSF and chemotherapy, regardless of chemotherapy regimen. The addition of GO, at this dose and schedule, to FLAG‐I failed to improve the outcomes in patients with relapsed/refractory AML. The patients who received G‐CSF concurrently with chemotherapy had improved outcomes. Am. J. Hematol., 2009. © 2009 Wiley‐Liss, Inc.     

The value of the MDR1 reversal agent PSC-833 in addition to daunorubicin and cytarabine in the treatment of elderly patients with previously untreated acute myeloid leukemia (AML), in relation to MDR1 status at diagnosis

To determine whether MDR1 reversal by the addition of the P-glycoprotein (P-gp) inhibitor PSC-833 to standard induction chemotherapy would improve event-free survival (EFS), 419 untreated patients with acute myeloid leukemia (AML) aged 60 years and older were randomized to receive 2 induction cycles of daunorubicin and cytarabine with or without PSC-833. Patients in complete remission were then given 1 consolidation cycle without PSC-833. Neither complete response (CR) rate (54% versus 48%; P = .22), 5-year EFS (7% versus 8%; P = .53), disease-free survival (DFS; 13% versus 17%; P = .06) nor overall survival (OS; 10% in both arms; P = .52) were significantly improved in the PSC-833 arm. An integrated P-gp score (IPS) was determined based on P-gp function and P-gp expression in AML cells obtained prior to treatment. A higher IPS was associated with a significantly lower CR rate and worse EFS and OS. There was no significant interaction between IPS and treatment arm with respect to CR rate and survival, indicating also a lack of benefit of PSC-833 in P-gp-positive patients. The role of strategies aimed at inhibitory P-gp and other drug-resistance mechanisms continues to be defined in the treatment of patients with AML.