Assessment of Myocardial Function During Blood Pressure Manipulations Using Feature Tracking Cardiovascular Magnetic Resonance.

Background: Coronary autoregulation is a feedback system, which maintains near-constant myocardial blood flow over a range of mean arterial pressure (MAP). Yet in emergency or peri-operative situations, hypotensive or hypertensive episodes may quickly arise. It is not yet established how rapid blood pressure changes outside of the autoregulation zone (ARZ) impact left (LV) and right ventricular (RV) function. Using cardiovascular magnetic resonance (CMR) imaging, measurements of myocardial tissue oxygenation and ventricular systolic and diastolic function can comprehensively assess the heart throughout a range of changing blood pressures. Design and methods: In 10 anesthetized swine, MAP was varied in steps of 10-15 mmHg from 29 to 196 mmHg using phenylephrine and urapidil inside a 3-Tesla MRI scanner. At each MAP level, oxygenation-sensitive (OS) cine images along with arterial and coronary sinus blood gas samples were obtained and blood flow was measured from a surgically implanted flow probe on the left anterior descending coronary artery. Using CMR feature tracking-software, LV and RV circumferential systolic and diastolic strain parameters were measured from the myocardial oxygenation cines. Results: LV and RV peak strain are compromised both below the lower limit (LV: Δ1.2 ± 0.4%, RV: Δ4.4 ± 1.2%, p < 0.001) and above the upper limit (LV: Δ2.1 ± 0.4, RV: Δ5.4 ± 1.4, p < 0.001) of the ARZ in comparison to a baseline of 70 mmHg. LV strain demonstrates a non-linear relationship with invasive and non-invasive measures of oxygenation. Specifically for the LV at hypotensive levels below the ARZ, systolic dysfunction is related to myocardial deoxygenation (ß = -0.216, p = 0.036) in OS-CMR and both systolic and diastolic dysfunction are linked to reduced coronary blood flow (peak strain: ß = -0.028, p = 0.047, early diastolic strain rate: ß = 0.026, p = 0.002). These relationships were not observed at hypertensive levels. Conclusion: In an animal model, biventricular function is compromised outside the coronary autoregulatory zone. Dysfunction at pressures below the lower limit is likely caused by insufficient blood flow and tissue deoxygenation. Conversely, hypertension-induced systolic and diastolic dysfunction points to high afterload as a cause. These findings from an experimental model are translatable to the clinical peri-operative environment in which myocardial deformation may have the potential to guide blood pressure management, in particular at varying individual autoregulation thresholds.

Family medicine in Tanzania: Seize the moment.

In the context of addressing the pressing health needs for the global population, the World Health Organization has repeatedly called for universal health coverage (UHC) to be prioritised by its member countries. This is to be achieved through a high-quality primary health care (PHC) approach that provides comprehensive and integrated generalist care as close to where people live as well as links the clinical care to health promotion and disease prevention. In this paper, we argue for the introduction of family medicines as a critical player in the healthcare system of Tanzania to strengthen the strategies towards UHC. The paper reviews how PHC is understood, the context of family medicine in sub-Saharan Africa and makes a case for how family medicine can assist in addressing the current burden of disease in Tanzania.

Therapeutic plasma exchange in acute liver failure.

BACKGROUND: Multi-organ dysfunction in acute liver failure (ALF) has been attributed to a systemic inflammatory response directly triggered by the injured liver. High-volume therapeutic plasma exchange (HV-TPE) has been demonstrated in a large randomized controlled trial to improve survival. Here, we investigated if a more cost-/ resource effective low-volume (LV) TPE strategy might have comparable beneficial effects. METHODS: This retrospective study evaluated the effect of LV-TPE on remote organ failure, hemodynamical and biochemical parameters as well as on survival in patients with ALF. Twenty patients treated with LV-TPE in addition to standard medical therapy (SMT) were identified and 1:1 matched to a historical ALF cohort treated with SMT only. Clinical and biochemical parameters were recorded at admission to the intensive care unit and the following 7 days after LV-TPE. RESULTS: Mean arterial pressure increased following first LV-TPE treatments (d0: 68 [61-75] mm Hg vs d7: 88 [79-98] mm Hg, P = .003) and norepinephrine dose was reduced (d0: 0.264 [0.051-0.906] µg/kg/min vs d3: 0 [0-0.024] µg/kg/min, P = .016). Multi-organ dysfunction was significantly diminished following LV-TPE (CLIF-SOFA d0: 17 [13-20] vs d7: 7 [3-11], P = .001). Thirty-day in-hospital survival was 65% in the LV-TPE cohort and 50% in the SMT cohort (Hazard-ratio for TPE: 0.637; 95% CI: 0.238-1.706, P = .369). CONCLUSIONS: Patients treated with LV-TPE showed improved surrogate parameters comparable with the effects reported with HV-TPE. These data need to be interpreted with caution due to their retrospective character. Future controlled studies are highly desirable.

Equally Interchangeable? How Sex and Gender Affect Transplantation.

Organ transplantation as an option to overcome end-stage diseases is common in countries with advanced healthcare systems and is increasingly provided in emerging and developing countries. A review of the literature points to sex- and gender-based inequity in the field with differences reported at each step of the transplant process, including access to a transplantation waiting list, access to transplantation once waitlisted, as well as outcome after transplantation. In this review, we summarize the data regarding sex- and gender-based disparity in adult and pediatric kidney, liver, lung, heart, and hematopoietic stem cell transplantation and argue that there are not only biological but also psychological and socioeconomic issues that contribute to disparity in the outcome, as well as an inequitable access to transplantation for women and girls. Because the demand for organs has always exceeded the supply, the transplant community has long recognized the need to ensure equity and efficiency of the organ allocation system. In the spirit of equity and equality, the authors call for recognition of these inequities and the development of policies that have the potential to ensure that girls and women have equitable access to transplantation.

Midday and nadir salivary cortisol appear superior to cortisol awakening response in burnout assessment and monitoring.

Burnout and work-related stress symptoms of anxiety disorder and depression cause prolonged work absenteeism and early retirement. Hence, reliable identification of patients under risk and monitoring of treatment success is highly warranted. We aimed to evaluate stress-specific biomarkers in a population-based, "real-world" cohort (burnouts: n = 40, healthy controls: n = 26), recruited at a preventive care ward, at baseline and after a four-month follow up, during which patients received medical and psychological treatment. At baseline, significantly higher levels of salivary cortisol were observed in the burnout group compared to the control group. This was even more pronounced in midday- (p < 0.001) and nadir samples (p < 0.001) than for total morning cortisol secretion (p < 0.01). The treatment program resulted in a significant reduction of stress, anxiety, and depression scores (all p < 0.001), with 60% of patients showing a clinically relevant improvement. This was accompanied by a ~30% drop in midday cortisol levels (p < 0.001), as well as a ~25% decrease in cortisol nadir (p < 0.05), although not directly correlating with score declines. Our data emphasize the potential usefulness of midday and nadir salivary cortisol as markers in the assessment and biomonitoring of burnout.

Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years.

BACKGROUND: The project "Quality Assurance in Ambulatory Psychotherapy in Bavaria" (QS-PSY-BAY) focuses on the quality assurance of outpatient psychotherapy (OPT) in Germany in terms of symptom reduction and cost reduction under naturalistic conditions. In this study, we examined the effectiveness of psychotherapy in terms of pre-post cost reduction. METHOD: The health-care costs of N = 22,294 insurants over a 5-year period were examined in a naturalistic longitudinal design. Six participating health insurance funds provided data on costs related to inpatient treatment, outpatient treatment, drugs, and hospitalization and work disability days. RESULTS: We found that the average annual total costs for inpatient and outpatient treatments as well as drug costs and work disability days increased from the second to the first year before OPT. Besides a large and significant reduction of work disability days (41.8%), hospitalization days (27.4%), and inpatient costs (21.5%) from the first year before versus the first year following OPT, we found evidence for long-term effects: the number of work disability days in the second year after OPT was lower (23.8%), and drug costs were higher than in the second year before OPT (41.5%). CONCLUSION: We conclude that OPT as a part of the health insurance system is an investment which can pay off in the future especially in terms of lower inpatient costs and work disability.

[Role of Institutional Review Boards for multi-centre studies in national health services research - a cross-sectional study of the effort to obtain secondary ethical approvals for the DACAPO study]. / Die Rolle von Ethikkommissionen für die nationale Versorgungsforschung - eine Querschnittsstudie des Aufwandes zur Erlangung von Sekundärvoten anhand der DACAPO-Studie.

BACKGROUND: Health services research (HSR) is of fundamental importance for the continuous improvement of preventive, diagnostic or therapeutic measures. The conduct of multi-centre HSR studies requires that ethical approval by Institutional review boards (IRB's) is obtained. We documented the effort, the complexity and the man power necessary to obtain secondary ethical approval for a national HSR in Germany ("Surviving the Acute Respiratory Distress Syndrome" [DACAPO-study]). METHODS: Having obtained a primary ethical approval by the IRB of Regensburg University, the time, correspondence, necessity for amendments, corrections, or additional costs by 34 IRB's for 64 participating study centers was documented. RESULTS: The complete obtainment was found to be time consuming and associated with a high workload and man power. A time span of seven month was needed to receive votes from all IRB's. The median time span was 25,5 days (25 %/75 % percentile 13 and 42 days, respectively). Requirements in terms of corrections or amendments were inhomogeneous and frequent changes were necessary. There were additional fees for secondary votes of 4328,40 €. Total costs for the study center Regensburg were 21.193,40 € (2,6 % of the grant volume). CONCLUSION: Obtaining all ethical approvals for a multi-centre observational HSR study in Germany is complex and time consuming. Various and inhomogeneous formalities may delay the plan and realization of HSR. A Homogenization and simplification of the procedure of ethics votes should be discussed.

The expenditure of computer-related worktime using clinical decision support systems in chronic pain therapy.

BACKGROUND: Estimate the expenditure of computer-related worktime resulting from the use of clinical decision support systems (CDSS) to prevent adverse drug reactions (ADR) among patients undergoing chronic pain therapy and compare the employed check systems with respect to performance and practicability. METHODS: Data were collected retrospectively from 113 medical records of patients under chronic pain therapy during 2012/2013. Patient-specific medications were checked for potential drug-drug interactions (DDI) using two publicly available CDSS, Apotheken Umschau (AU) and Medscape (MS), and a commercially available CDSS AiDKlinik® (AID). The time needed to analyze patient pharmacotherapy for DDIs was taken with a stopwatch. Measurements included the time needed for running the analysis and printing the results. CDSS were compared with respect to the expenditure of time and usability. Only patient pharmacotherapies with at least two prescribed drugs and fitting the criteria of the corresponding CDSS were analyzed. Additionally, a qualitative evaluation of the used check systems was performed, employing a questionnaire asking five pain physicians to compare and rate the performance and practicability of the three CDSSs. RESULTS: The AU tool took a total of 3:55:45 h with an average of 0:02:32 h for 93 analyzed patient regimens and led to the discovery of 261 DDIs. Using the Medscape interaction checker required a total of 1:28:35 h for 38 patients with an average of 0:01:58 h and a yield of 178 interactions. The CDSS AID required a total of 3:12:27 h for 97 patients with an average time of analysis of 0:01:59 h and the discovery of 170 DDIs. According to the pain physicians the CDSS AID was chosen as the preferred tool. CONCLUSIONS: Applying a CDSS to examine a patients drug regimen for potential DDIs causes an average extra expenditure of work time of 2:09 min, which extends patient treatment time by 25 % on average. Nevertheless, the authors believe that the extra expenditure of time employing a CDSS is outweighed by their benefits, including reduced ADR risks and safer clinical drug management.

[Non-completion of insurance-funded outpatient psychotherapy: frequency, risk factors, outcome]. / Abbrüche antragspflichtiger ambulanter Psychotherapien: Häufigkeit, Risikofaktoren, Outcome.

OBJECTIVE: Because premature discontinuation of psychotherapy limits the effectiveness of the interventions, in a naturalistic design we examined the prevalence, predictors, and outcome of premature discontinuation. METHODS: The sample included N = 584 patients with various mental disorders. Risk factors were identified using regression analysis. As outcome Patient Health Questionnaire scales were considered. We compared pre and post averages as well as post averages of premature discontinuation versus regular termination. RESULTS: Risk factors were: female and/or unemployed patient, low patient and/or therapist ratings regarding therapy success, and extraordinarily high therapist ratings of the therapeutic alliance. Despite premature discontinuation we found significant reductions of depression, anxiety, somatic symptoms, and stress (ES = 0.30, …, 0.44). Compared to regular termination though, patients with premature discontinuation were more impaired at last measurement (ES = 0.17, …, 0.37). CONCLUSION: Not each premature discontinuation is a psychotherapeutic failure. Warning signals for looming premature discontinuation are low ratings of therapy success while psychotherapeutic treatment.

[Management of critically ill patients in the resuscitation room. Different than for trauma?]. / Schockraummanagement kritisch erkrankter Patienten. Anders als beim Trauma?

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.

Identifying environmental health priorities in underserved populations: a study of rural versus urban communities.

OBJECTIVES: Understanding and effectively addressing persistent health disparities in minority communities requires a clear picture of members' concerns and priorities. This study was intended to engage residents in urban and rural communities in order to identify environmental health priorities. Specific emphasis was placed on how the communities: defined the term environment; their perceptions of environmental exposures as affecting their health; specific priorities in their communities; and differences in urban versus rural populations. STUDY DESIGN: A community-engaged approach was used to develop and implement focus groups and compare environmental health priorities in urban versus rural communities. METHODS: A total of eight focus groups were conducted: four in rural and four in urban communities. Topics included: defining the term environment; how the environment may affect health; and environmental priorities within their communities, using both open discussion and a predefined list. Data were analysed both qualitatively and quantitatively to identify patterns and trends. RESULTS: There were important areas of overlap in priorities between urban and rural communities; both emphasized the importance of the social environment and shared a concern over air pollution from industrial sources. In contrast, for urban focus groups, abandoned houses and their social and physical sequelae were a high priority while concerns about adequate sewer and water services and road maintenance were high priorities in rural communities. CONCLUSIONS: This study was able to identify environmental health priorities in urban versus rural minority communities. In contrast to some previous risk perception research, the results of this study suggest prioritization of tangible, known risks in everyday life instead of rare, disaster-related events, even in communities that have recently experienced devastating damage from tornadoes. The findings can help inform future efforts to study, understand and effectively address environmental issues, and are particularly relevant to developing effective community-based strategies in vulnerable populations.

Ambulatory care of children treated with anticonvulsants - pitfalls after discharge from hospital.

BACKGROUND: Anticonvulsants require special consideration particularly at the interface from hospital to ambulatory care. PATIENTS AND METHOD: Observational study for 6 months with prospectively enrolled consecutive patients in a neuropediatric ward of a university hospital (age 0-<18 years) with long-term therapy of at least one anticonvulsant. Assessment of outpatient prescriptions after discharge. Parent interviews for emergency treatment for acute seizures and safety precautions. RESULTS: We identified changes of the brand in 19/82 (23%) patients caused by hospital's discharge letters (4/82; 5%) or in ambulatory care (15/82; 18%). In 37/76 (49%) of patients who were deemed to require rescue medication, no recommendation for such a medication was included in the discharge letters. 17/76 (22%) of the respective parents stated that they had no immediate access to rescue medication. Safety precautions were applicable in 44 epilepsy patients. We identified knowledge deficits in 27/44 (61%) of parents. CONCLUSION: Switching of brands after discharge was frequent. In the discharge letters, rescue medications were insufficiently recommended. Additionally, parents frequently displayed knowledge deficits in risk management.

Socioeconomic status, severity of disease and level of family members' care in adult surgical intensive care patients: the prospective ECSSTASI study.

BACKGROUND: Low socioeconomic status (SES) is associated with increased mortality from cardiovascular disease, cancer and trauma. However, individual-level prospective data on SES in relation to health outcomes among critically ill patients admitted to intensive care units (ICU) are unavailable. METHODS: In a cohort of 1,006 patients at a 24-bed surgical ICU of an academic tertiary care facility in Germany, we examined levels of SES in relation to disease severity at admission, time period of mechanical ventilation, length of stay and frequency of phone calls and visits by next-of-kin. FINDINGS: Patients with low SES had higher risk for Sequential Organ Failure Assessment (SOFA) score greater or equal to 5 [multivariate-adjusted odds ratio (OR) 1.49; 95% confidence interval (CI) 0.95-2.33; p = 0.029] and a trend for higher risk for Simplified Acute Physiology Score (SAPS II) greater or equal to 31 (OR 1.28; 95% CI 0.80-2.05; p = 0.086) at admission as compared with patients with high SES. When compared with men with high SES, those with low SES had greater risk for ICU treatment ≥ 5 days (multivariate-adjusted OR 1.99; 95% CI 1.06-3.74; p = 0.036) and showed a trend for a low number of visits from next-of-kin (<0.5 visits per day) (OR 1.85; 95% CI 0.79-4.30; p = 0.054). In women such associations could not be demonstrated. INTERPRETATION: Socioeconomic status is inversely related to severity of disease at admission and to length of stay in ICU, and positively associated with the level of care by next-of-kin. Whether relations differ by gender requires further examination.

Knowledge levels of pharmaceutical sales representatives in pain therapy: a descriptive questionnaire-based study.

PURPOSE: Pain is a common physiological reaction. The development and sale of medication against pain is a main focus of pharmaceutical companies, with total sales of prescription analgesics amounting to US$50 billion in 2009. In this market, advertising is necessary. One way to market both new and old drugs is through direct physician-to-pharmaceutical sales representative (PSR) contact. PSRs see themselves ideally as equal partners to the physicians they advise, thereby setting high standards for themselves. In this setting, PSRs should therefore have an adequate knowledge of pain therapy. The aim of this study was to evaluate whether these standards can be met by PSRs working in the area of pain medicine in terms of their level of education and knowledge of pain topics. METHODS: We distributed 114 questionnaires that were divided into demographic and knowledge sections. Of these, 90 questionnaires (79%) were returned completed. Since there is no complete list of PSRs working in pain medicine in Germany, we could not draw a representative sample for our study. RESULTS: We collected general demographic data on PSRs as well as on their educational backgrounds. Analysis of the completed questionnaires revealed that there was a high requirement for PSRs to acquire further education in pain therapy. In the knowledge section, PSRs were asked to rate a total of 70 statements on pain therapy as to whether they were true or false. The mean total of correctly rated statements was 48 (69%). CONCLUSIONS: Based on the results, we conclude that most PSRs do not meet their ideal high standards of being equal partners to the specialist physicians they visit. More education is needed to achieve this goal.

Intramedullary leg lengthening with a motorized nail.

BACKGROUND AND PURPOSE: In the last decade, intramedullary limb lengthening has become a viable alternative to traditional external systems. We retrospectively analyzed the use of an intramedullary motorized nail (Fitbone) in a consecutive series of 32 patients. PATIENTS AND METHODS: During the period September 2006 to December 2008, 32 consecutive patients with a median age of 17 (IQR: 15-19) years were treated with a fully implantable, motorized intramedullary lengthening device (Fitbone). The median leg length discrepancy was 35 (IQR: 30-44) mm at the femur (n = 21) and 28 (IQR: 25-30) mm at the tibia (n = 11). RESULTS: Leg lengthening was successful in 30 of 32 cases, with no residual relevant discrepancy (± 5 mm). No intraoperative complications were observed. The consolidation index was significantly different (p = 0.04) between femoral lengthening (mean 35 days/cm) and tibial lengthening (mean 48 days/cm) but did not depend on age older/younger than 16 or previous operations at the affected site. 3 problems, 3 obstacles, and 4 complications (3 minor, 1 major) were encountered in 8 patients, 5 of which were implant-associated. INTERPRETATION: This technique even allows correction in patients with multiplanar deformities. Compared to external devices, intramedullary systems provide comfort and reduce complication rates, give improved cosmetic results, and lead to fast rehabilitation since percutaneous, transmuscular fixation is prevented. This results in reasonable overall treatment costs despite the relatively high costs of implants.

Prevention of coronary heart disease in primary medical care in Poland: results from the LIPIDOGRAM study.

AIMS: To determine: (1) achievement of cholesterol therapy goals in patients receiving lipid-lowering drugs in Polish primary care between the years 2004 and 2006; (2) the characteristics of patients that are associated with attainment of these goals. DESIGN: Cross-sectional study in randomly selected Polish primary care practices. METHOD: 5248 patients aged over 30 years in 2004 and 5386 patients in 2006, who were taking cholesterol-lowering treatment took part in the study. Physicians recorded demographic and medical history data using a standardized questionnaire, including weight and height, and collected blood samples of patients to determine their cholesterol level. RESULTS: 18.5% of patients attained their optimal goals of therapy (total cholesterol, TC; low-density lipoprotein cholesterol, LDL-C) in 2004 compared to 25.2% in 2006 (p < 0.001). In both 2004 and 2006, more patients achieved their target levels for LDL-C than for TC and statins were the most commonly used medication (85% and 91%, respectively). Male sex, smoking, and higher education were the strongest correlates of the therapeutic outcome. The odds ratio of achieving cholesterol therapy goals in men, non-smokers, and university graduates was estimated at 1.51, 0.70, 1.38 in 2004 and 1.50, 0.73, 1.34 in 2006, respectively. CONCLUSION: There was a measurable improvement in the effectiveness of hypercholesterolaemia treatment between 2004 and 2006 but the majority of patients remain inadequately treated, with goals not being achieved. There is a need to raise the standard of lipid-lowering management in Poland.

[Personnel planning in the emergency department. Optimized patient care round the clock]. / Personalplanung in der zentralen Notaufnahme. Optimierte Patientenversorgung rund um die Uhr.

In recent years the number of interdisciplinary emergency departments (ED) at hospitals in Germany has increased. The model of decentralized first contact units for each medical discipline has been abandoned, last but not least due to economic considerations. While decentralized units could be staffed with personnel from each discipline there is much controversy surrounding the question of which kind of doctor is best suited for a centralized ED. The development of programs providing the necessary qualification for German ED physicians in the future by working groups of several specialties is still nascent and has not yet produced concrete results. However, even without these special training programs, the management of critically ill or severely injured patients in the ED is paramount. The smooth operation of centralized EDs is therefore important. Therefore, taking into account economical aspects, qualification and number of available personnel, this article introduces a staffing concept as a rational basis for an optimized patient management in centralized EDs in Germany. Taking the patient characteristics, the specific treatment modalities and the number of admissions to the ED into account, this paper will determine treatment time per patient and the necessary number of physicians, as well as an optimized staffing model for EDs.

[Expectations of relatives concerning palliative home care]. / Erwartungen Angehöriger an die spezialisierte arnbulante Palliativversorgung.

BACKGROUND: Palliative home care gains in importance in Germany. In addition to administering pain and symptom control for patients a "Palliative Care Team" (PCT) tries to address the patients' psychosocial and spiritual needs. METHODS: Retrospective analysis of caregiving relatives' expectations of the support by a PCT. RESULTS: Most relatives expected a sufficient pain therapy and support of the PCT. Additionally they wished for further outreach afterthe death of the patient. CONCLUSION: Palliative homecare is perceived as a helpful supporting factor by the care-giving relatives of palliative patients.