[Mortality after high-risk surgery in Jehovah's Witness patients]. / Letalität nach operativen Risikoeingriffen bei Zeugen Jehovas.

BACKGROUND: Jehovah's Witness (JW) patients strictly refuse allogeneic blood transfusion for religious reasons. Nevertheless, JW also wish to benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The Northwest Hospital in Frankfurt am Main Germany is a confidential clinic of JW and performs approximately 100 surgical interventions per year on this patient group. MATERIAL AND METHODS: A retrospective analysis of closed medical cases performed in the years 2008-2018 at the Northwest Hospital aimed to clarify (1) the frequency of surgical procedures in JW patients associated with a statistical allogeneic transfusion risk (presence of preoperative anemia and/or in-house transfusion probability >10%) during this time period, (2) the degree of acceptance of strategies avoiding blood transfusion by JW and (3) the anemia-related postoperative mortality rate in JW patients. RESULTS: In the 11- year observation period 123 surgical procedures with a relevant allogeneic transfusion risk were performed in 105 JW patients. Anemia according to World Health Organization (WHO) criteria was present in 44% of cases on the day of surgery. Synthetic and recombinant drugs (tranexamic acid, desmopressin, erythropoetin, rFVIIa) were generally accepted, acute normovolemic hemodilution (ANH) in 92% and cell salvage in 96%. Coagulation factor concentrates extracted from human plasma and therefore generally refused by JW so far, were accepted by 83% of patients following detailed elucidation. Out of 105 JW patients 7 (6.6%) died during the postoperative hospital stay. In 4 of the 7 fatal cases the cause of death could be traced back to severe postoperative anemia. CONCLUSION: Given optimal management JW patients can undergo major surgery without an excessive risk of death. The 6.6% in-hospital mortality observed in this institution was in the range of the 4% generally observed after surgery in Europe. The majority of JW patients accepted a variety of blood conservation strategies following appropriate elucidation. This also included coagulation factor concentrates extracted from human plasma enabling an effective treatment of even severe bleeding complications. In this analysis postoperative hemoglobin concentrations below 6 g/dl in older JW patients were associated with a high mortality risk due to anemia.

[A comparison of special and traditional inpatient care of people with dementia]. / Besondere und traditionelle stationäre Betreuung demenzkranker Menschen im Vergleich.

Recent studies reveal that approximately two thirds of the residents in German nursing homes suffer from some type of moderate to severe dementia. In addition to cognitive impairments, other psychiatric symptoms and behavior problems frequently impact the quality of life of the affected residents, their fellow residents and the nursing staff. Novel concepts of nursing care for dementia patients with behavior problems have been developed against this backdrop, e. g. within the framework of the program of special care for dementia patients in Hamburg. A comprehensive course study (follow-up period: approximately six months) of a sample population of nursing home residents and consecutive admissions focused upon:the degree to which the quality of life and care for dementia patients in Hamburg differs according to the type of care given, i. e. segregative (domus philosophy), or partially segregative (integration philosophy), and the differences between the special care of dementia patients as provided in Hamburg, as opposed to the traditionally integrative care of dementia patients as practiced in the city of Mannheim. In order to gain the most complete picture possible-also for persons with severe cognitive impairments-information was collected primarily on the basis of the assessments made by qualified nursing staff. In the city of Hamburg there were advantages and disadvantages, respectively, between segregative care (domus philosophy) and partially segregative care (integration philosophy): the activity rates were higher for care in integrative than in domus environments, and could be maintained better over time. Moreover, the number of visits from relatives and their involvement in the nursing and social care was also higher for the integrative, as opposed to the domus setting. Among the residents of domus-care homes, however, significantly more biographical information was collected, and the proportion of dementia patients receiving gerontopsychiatric care also was higher. Dementia patients in these homes also received more psychotropic medication, with antidementia drugs and antidepressants being prescribed significantly more frequently and antipsychotic drugs less frequently.The comparison of the special dementia care available in Hamburg with the traditional, integrative care available to dementia patients in Mannheim revealed a number of visible indicators for the quality of life that point in favor of the model program in Hamburg. This is apparent in the more frequent expression of positive feelings, the greater number of activities fostering competency, the significant involvement of relatives and volunteers, the greater number of social contacts with the staff, fewer use of physical restraint, and better gerontopsychiatric care. Contradictory to our expectation, however, dementia patients cared for in the traditional setting exhibited fewer behavior problems over time than did their counterparts cared for within the framework of the Hamburg model.

Comparative analysis of biofeedback and physical therapy for treatment of urinary stress incontinence in women.

OBJECTIVE: To compare the effectiveness of an intensive group physical therapy program with individual biofeedback training for female patients with urinary stress incontinence. DESIGN: Randomized study of two therapeutic interventions consisting of a specific physical therapy program (PT) or biofeedback training (BF) daily for 4 wk, followed by a 2-mo, unsupervised home exercise program in both groups in an outpatient clinic of a large university hospital. Forty women, referred by gynecologists for nonoperative treatment of genuine stress incontinence of mild-to-moderate severity, were included. Measurements of daytime/nocturnal urinary frequency and subjective improvement of incontinence were the main outcome measures at initial presentation, after completion of the therapy program, and at follow-up after 3 mo. Standardized examinations of digital contraction strength, speculum tests, and manometric measurements were documented as secondary outcome measures. RESULTS: In the PT group, the daytime urination frequency decreased 22% after 4 wk of therapy and 19% after 3 mo (P < 0.05) from baseline. The nocturnal urination frequency was reduced by 66% after 4 wk of therapy and 62% after 3 mo (P < 0.001). In the BF group, the daily urination frequency decreased 10% after 4 wk of therapy and 5% after 3 mo (P > 0.05). The nocturnal urination frequency declined 36% after 4 wk of therapy and 66% after 3 months (P < 0.05). Subjective assessment after 3 mo showed that in the PT group, 28% of patients were free of incontinence episodes, 68% reported improved symptoms (incontinence episodes improved by >50%), and 4% were unchanged. In the BF group, 62% were free of incontinence episodes, and 38% were improved. Results of the digital contraction strength assessments, speculum tests, and manometric measurements showed statistically significant improvement in all variables in both groups after 3 months. CONCLUSION: Four weeks of both intensive group physical therapy or individual biofeedback training followed by an unsupervised home exercise program for 2 mo are effective therapies for female urinary stress incontinence and result in a significantly reduced nocturnal urinary frequency and improved subjective outcome. Only group physical therapy resulted in reduced daytime urinary frequency. BF therapy resulted in a better subjective outcome and higher contraction pressures of the pelvic floor muscles.