Operationsduldungspflicht

Ohne Zusammenfassung a. E.     

Pseudoaneurysm: a complication of faulty technique in femoral arterial puncture

Pseudoaneurysm is a well-documented but rare complication of retrograde femoral arterial puncture. We present six patients in whom pseudoaneurysm complicated this procedure. The pseudoaneurysm arose from the superficial femoral artery in five patients and from the profunda femoris artery in one. An arteriovenous fistula also arose from the superficial femoral artery in one patient. In no patient did the pseudoaneurysm arise from the common femoral artery. Two mechanisms are postulated as to why pseudoaneurysms rarely complicate puncture of the common femoral artery.     

Wann lohnt es, eine medizinische überversorgung abzubauen?

ZusammenfassungHintergrund und Ziel:  Ein Abbau von medizinischer Überversorgung ist nur dann wirtschaftlich, wenn die Implementierungskosten zum Abbau der Überversorgung kleiner als die eingesparten medizinischen Leistungen sind. Eine Prognose über die zu erwartenden Nettofolgekosten hilft Entscheidungsträgern, unter der Vielzahl von Überversorgungsproblemen und Komponenten für Implementierungsprogramme eine Auswahl zu treffen. Ziel dieses Beitrags ist es, exemplarisch die Nettofolgekosten zu prognostizieren, die in Deutschland aus dem Abbau von Überversorgung mit teuren Antihypertonika und fraglichem Zusatznutzen durch Feedback an Hausärzte bzw. Besuch von Pharmakotherapieberatern resultieren.Methodik:  In einem mathematischen Modell, das die Beziehung zwischen Nettofolgekosten eines Implementierungsprogramms zum Abbau von Überversorgung und Grad der Überversorgung abbildet, wurden Literaturdaten verrechnet.Ergebnisse:  Wird zugrunde gelegt, dass gegenwärtig 30% der medikamentös behandelten Hypertoniker ohne Nutzeneinbuße auf Thiaziddiuretika und -kombinationen wechseln könnten, ist der Abbau von Überversorgung durch Feedback an Hausärzte oder Besuch von Pharmakotherapieberatern wirtschaftlich.Schlussfolgerung:  Bei einem hohen Überversorgungsgrad kann der Abbau von Überversorgung wirtschaftlich sein. Die explizite Berücksichtigung des Grades an Überversorgung bei der Wirtschaftlichkeitsbetrachtung von Maßnahmen zum Abbau von Überversorgung kann zu einem effizienteren Ressourceneinsatz im Gesundheitswesen beitragen.     

Sleep problems among persons with a lifetime history of posttraumatic stress disorder alone and in combination with a lifetime history of other psychiatric disorders: a replication and extension

Objective

Sleep problems are a clinical and/or diagnostic feature for a broad array of mood, substance use, and anxiety disorders, including posttraumatic stress disorder (PTSD). Previous research by Leskin et al (Leskin GA, Woodward SH, Young HE, Sheikh J. Effects of comorbid diagnoses on sleep disturbance in PTSD. J Psychiat Res 2002;36:449-452) using the baseline National Comorbidity Survey (NCS) data found that persons with PTSD and panic disorder had a greater proportion of sleep problems than persons with other comorbid disorders. The current study extends Leskin et al's findings using the replication of the NCS. It compared persons with a lifetime history of PTSD (either alone or in combination) with 6 comparison disorders (adult separation anxiety, alcohol dependence, generalized anxiety, dysthymia, major depression, and panic) on severity of sleep disorder symptoms.

Method

The NCS Replication was a national probability survey of 9282 individuals that examined the prevalence and correlates of mental disorders. Subjects were chosen through a multistage probability sample of US households and interviewed using a computer-aided version of the Composite International Diagnostic Interview.

Results

The PTSD (alone) group did not differ from the comparison disorders on difficulties of falling/staying asleep but did report more weeks per year when they had sleep difficulties than persons with adult separation anxiety, alcohol dependence, and major depression.

Conclusion

Unlike Leskin et al, the additive effects of a second disorder on sleep difficulties are not unique to panic disorder. However, when sleep difficulties were indexed by the number of weeks per year, differences between diagnostic groups emerged. If the goal of a diagnostic system is to carve nature at its joints, a sleep disturbance symptom reflecting frequency of difficulties in this way is clearly superior to less precise alternatives.     

Shunting of the microcirculation after mesenteric ischemia and reperfusion is a function of ischemia time and increases mortality

OBJECTIVE: Shunting of the microcirculation contributes to the pathology of sepsis and septic shock. The authors address the hypothesis that shunting of the microcirculation occurs after superior mesenteric artery occlusion (SMAO) and reperfusion, and explore functional consequences. METHODS: Spontaneously breathing animals (rats) (n = 30) underwent SMAO for 0 (controls), 30 (SMAO_30) or 60 min (SMAO_60) followed by reperfusion (4 h) with normal saline. Leukocyte-endothelial interactions in mesenteric venules were quantified in an exteriorized ileal loop using intravital microscopy. Abdominal blood flow was recorded continuously, and arterial blood gases were analyzed at intervals. The above groups were matched by comparable groups with continuous superior mesenteric artery blood flow measurements and without exteriorizing an ileal loop (controls*, SMAO_30*, SMAO_60*). RESULTS: Adherent leukocytes increased shortly after reperfusion in ischemia groups, and plateaued in these groups. Centerline velocity in the recorded venules was significantly reduced after reperfusion down to low-flow/no-flow in SMAO_60 as compared to SMAO_30 and controls, whereas perfusion of the SMA and ileal vessels persisted. The microcirculatory changes in SMAO_60 were accompanied by progressive metabolic acidosis, substantially larger volumes of intravenous fluids needed to support arterial blood pressure and significantly reduced survival (30%). SMA blood flow increased in relation to abdominal blood flow after reperfusion in SMAO_60*, and remained constant in SMAO_30* and controls*. Survival was 80% in SMAO_60*. CONCLUSION: Shunting of the microcirculation can be observed after SMAO for 60 min and reperfusion, and contributes significantly to the pathology of mesenteric ischemia and poor outcome.     

Burns and scalds

Every year, 20000 children and adults in Germany sustain serious bums resulting from the influence of strong heat on their skin. To cool down the burnt skin immediately relieves the pain and prevents further damage to deeper parts of the skin. According to the extent of the damage, different clinical degrees of burns are defined, which determine the appropriate therapeutic treatment.     

Validation of a prediction rule to maximize curative (R0) resection of early-stage pancreatic adenocarcinoma

Background:

The surgeon''s contribution to patients with localized pancreatic adenocarcinoma (PAC) is a margin negative (R0) resection. We hypothesized that a prediction rule based on pre-operative imaging would maximize the R0 resection rate while reducing non-therapeutic intervention.

Methods:

The prediction rule was developed using computed tomography (CT) and endoscopic ultrasound (EUS) data from 65 patients with biopsy-proven PAC who underwent attempted resection. The rule classified patients as low or high risk for non-R0 outcome and was validated in 78 subsequent patients.

Results:

Model variables were: any evidence of vascular involvement on CT; EUS stage and EUS size dichotomized at 2.6 cm. In the validation cohort, 77% underwent resection and 58% achieved R0 status. If only patients in the low-risk group underwent surgery, the prediction rule would have increased the resection rate to 92% and the R0 rate to 73%. The R0 rate was 40% higher in low-risk compared with high-risk patients (P < 0.001). High risk was associated with a 67% rate of non-curative surgery (unresectable disease and metastases).

Conclusion:

The prediction rule identified patients most likely to benefit from resection for PAC using pre-operative CT and EUS findings. Model predictions would have increased the R0 rate and reduced non-therapeutic interventions.