Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study.

BACKGROUND: Appropriate utilization of vancomycin is important to attain therapeutic targets while avoiding clinical failure and the development of antimicrobial resistance. Our aim was to observe the use of vancomycin in an intensive care population, with the main focus on achievement of therapeutic serum concentrations (15-20 mg/l) and to evaluate how this was influenced by dose regimens, use of guidelines and therapeutic drug monitoring. METHODS: A prospective observational study was carried out in the intensive care units at two tertiary hospitals in Norway. Data were collected from 83 patients who received vancomycin therapy, half of these received continuous renal replacement therapy. Patients were followed for 72 h after initiation of therapy. Blood samples were drawn for analysis of trough serum concentrations. Urine was collected for calculations of creatinine clearance. Information was gathered from medical records and electronic health records. RESULTS: Less than 40% of the patients attained therapeutic trough serum concentrations during the first 3 days of therapy. Patients with augmented renal clearance had lower serum trough concentrations despite receiving higher maintenance doses and more loading doses. When trough serum concentrations were outside of therapeutic range, dose adjustments in accordance to therapeutic drug monitoring were made to less than half. CONCLUSION: The present study reveals significant challenges in the utilization of vancomycin in critically ill patients. There is a need for clearer guidelines regarding dosing and therapeutic drug monitoring of vancomycin for patient subgroups.

[Factors Influencing Participation in Financial Incentive Programmes of Health Insurance Funds. Results of the Study 'German Health Update']. / Einflussfaktoren für die Teilnahme an Bonusprogrammen der gesetzlichen Krankenversicherung. Ergebnisse der Studie "Gesundheit in Deutschland aktuell".

AIM OF THE STUDY: The statutory health insurance can offer their insured incentive programmes that will motivate for healthy behaviour through a financial or material reward. This study will show results about what factors influence financial incentive programme participation (BPT) including all sorts of statutory health insurance funds and taking into account gender differences. METHODS: For the cross-sectional analysis, data were used from 15,858 participants in the study 'Germany Health Update' (GEDA) from 2009, who were insured in the statutory health insurance. The selection of potential influencing variables for a BPT is based on the "Behavioural Model for Health Service Use" of Andersen. Accordingly, various factors were included in logistic regression models, which were calculated separately by gender: predisposing factors (age, education, social support, and health awareness), enabling factors (income, statutory health insurance fund, and family physician), and need factors (smoking, fruit and vegetable consumption, sports, body mass index, and general health status). RESULTS: In consideration of all factors, for both sexes, BPT is associated with age, health awareness, education, use of a family physician, smoking, and sports activities. In addition, income, body mass index, and diet are significant in women and social support and kind of statutory health insurance fund in men. It is found that predisposing, enabling and need factors are relevant. CONCLUSIONS: Financial incentive programmes reach population groups with greatest need less than those groups who already have a health-conscious behaviour, who receive a reward for this. In longitudinal studies, further research on financial incentive programmes should investigate the existence of deadweight effects and whether incentive programmes can contribute to the reduction of the inequity in health.

[Health of children and adolescents in single-parent, step-, and nuclear families: results of the KiGGS study: first follow-up (KiGGS Wave 1)]. / Gesundheit von Kindern und Jugendlichen in Eineltern-, Stief- und Kernfamilien : Ergebnisse der KiGGS-Studie - Erste Folgebefragung (KiGGS Welle 1).

On the basis of data from KiGGS Wave 1, the following manuscript investigates potential differences in the health status of children and adolescents aged 3-17 years according to the family form they live in: nuclear, single-parent, or stepfamily (n = 10,298). Additionally, we investigate whether differences persist after controlling for age, gender, living area, parental social status, and getting along in the family. Parent-rated health, chronic diseases, emotional or behavior problems, health-related quality of life, and daily consumption of fruits and vegetables were analyzed (prevalence, odds ratios). While the parent-rated health was independent of the family form, the prevalence of the other outcomes differed significantly according to the family form. Emotional or behavior problems were measured more often among children and adolescents growing up in single-parent families (OR 1.62; 95% CI 1.17-2.26) or stepfamily households (OR 2.36; 95% CI 1.63-3.41) than among those growing up in nuclear families, after adjusting for age, gender, living area, social status, and getting along in the family. Additionally, children and adolescents from single-parent families had chronic diseases (OR 1.53; 95% CI 1.20-1.96) more often than their counterparts who lived together with both parents. Compared with those growing up in nuclear families, children and adolescents from stepfamilies showed a greater risk of lower health-related quality of life (OR 2.91; 95% CI 1.76-4.80) and of lower daily consumption of fruits and vegetables (OR 1.30; 95% CI 1.01-1.67). The results indicate the importance of the family context for the health of children and adolescents.

[Factors influencing the prevalence and duration of breastfeeding in Germany: results of the KiGGS study: first follow up (KiGGS Wave 1)]. / Einflussfaktoren auf Verbreitung und Dauer des Stillens in Deutschland : Ergebnisse der KiGGS-Studie - Erste Folgebefragung (KiGGS Welle 1).

Breastfeeding is the natural way of feeding infants in the first months of their lives and has been proven to have health benefits for both infants and mothers. Breastfeeding initiation and duration are affected by social, demographic and health factors. The aim of this study was to describe the current rates of breastfeeding initiation and duration in Germany, and to identify potential factors that underline these rates. Additionally, results are compared with the KiGGS basic (2003-2006; birth cohorts 1996-2002) study in order to reveal the development in the trends of breastfeeding initiation and duration in Germany. The KiGGS wave 1 (2009-2012) includes data on the breastfeeding behavior of mothers of 4410 children aged between 0 and 6 years (birth cohorts 2002-2012). Altogether, 82% (95% confidence interval 79.8-84.2 %) of children were ever breastfed, and the average breastfeeding duration was 7.5 months (7.2-7.8). There was a slight increase in the breastfeeding initiation in Germany over the last several years. Breastfeeding initiation among children aged 0-6 years increased by 4% points compared to 0- to 6-year-olds (birth cohorts 1996-2002) from the KiGGS basic study. The breastfeeding duration stayed unchanged. The breastfeeding behavior was mainly related to the age of the mother at birth, the mother's education level, smoking during pregnancy, and multiple or premature birth. Despite the overall increasing trend in breastfeeding initiation, there is still a growing need for breastfeeding promotion and support for young and less educated mothers, mothers who smoke during pregnancy, and also for mothers with premature babies or multiple births.

[Participation in health behaviour change programmes: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Teilnahme an verhaltenspräventiven Maßnahmen: Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

Health behaviour change programmes to promote healthy behaviours are aimed at, among other things, counteracting the emergence of widespread non-communicable diseases. Which population groups use these programmes? This analysis is based on data from DEGS1, which was conducted from 2008-2011. People aged 18-79 years were asked about their participation in programmes in the last 12 months in the fields of nutrition, physical activity and relaxation (n = 7,807). The analysis was stratified by sex, age, socioeconomic status (SES), and type of statutory health insurance fund. A total of 16.6 % of respondents participate in at least one programme for behaviour change, with women using these programmes significantly more frequently, indeed twice as often, as men (22.1 % versus 11 %). The older population participates more often than younger age groups. Women and men with low SES use the programmes significantly less frequently than those with middle or high SES. Women who are insured by the AOK health insurance group have a significantly lower rate of participation than women insured by any other statutory health insurance fund. Overall participation has almost doubled since the "German National Health Interview and Examination Survey 1998" (9.1 %). Further efforts are necessary to reach population groups with low participation rates. An English full-text version of this article is available at SpringerLink as supplemental.

[Prevalence of smoking in the adult population of Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Verbreitung des Rauchens in der Erwachsenenbevölkerung in Deutschland: Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

Although various tobacco control measures have been implemented in Germany in the recent years, smoking is still widespread and constitutes a considerable health risk for the population. According to the data of the German Health Interview and Examination Survey for Adults (DEGS1), which was conducted by Robert Koch Institute from 2008 to 2011, 29.7% of the 18 to 79-year old population smokes (women = 26.9%, men = 32.6%). The proportion of women and men who smoke 20 or more cigarettes a day amounts to 6.0% and 10.6% respectively. Smoking is mostly widespread among young adults, as well as among persons with low social status who are also overrepresented among the heavy smokers. Comparison with data from previous health surveys indicates that the proportion of smokers has reduced slightly over the last 10 years. An English full-text version of this article is available at SpringerLink as supplemental.

[Prevalence of hysterectomy in women 18 to 79 years old: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Prävalenz von Hysterektomien bei Frauen im Alter von 18 bis 79 Jahren: Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

In many countries, hysterectomy is one of the most frequently performed surgical procedures in gynaecology. The aim of this study is to analyse the prevalence of hysterectomy in Germany by socio-demographic factors and factors of (reproductive) health. Analyses are based on data from the "German Health Interview and Examination Survey for Adults (DEGS1)", which is part of the health monitoring of the Robert Koch Institute (RKI). The prevalence of hysterectomy among participating women (18-79 years old) was 17.5% (n = 689). Most women (49.1%) were 40-49 years old when surgery was performed. 6.1% of hysterectomised women had cancer of the uterus or ovaries, and 19.7% underwent a simultaneous oophorectomy. There were significant differences in the prevalence of hysterectomy regarding social status, place of residence in 1988, number of live births, and body weight. DEGS1 is the first study showing the prevalence of hysterectomy in a representative sample of the German population. More detailed analyses of the DEGS data, among other data sources, are needed to evaluate the importance of the described associations and to assess trends. An English full-text version of this article is available at SpringerLink as supplemental.

[Socioeconomic status and health: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Sozioökonomischer Status und Gesundheit : Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

The analysis focuses on the connection between socioeconomic status (SES) and five health outcomes in the 18 to 79-year-old population of Germany. It uses data from the "German Health Interview and Examination Survey for Adults" (DEGS1) which the Robert Koch Institute conducted in the period from 2008 to 2011 (n=8152). Socioeconomic status is recorded via a multidimensional index which includes information on education attainment, occupational status and household income. The results show that persons with a low socioeconomic status have a self-rated health status which is worse than that of persons with a medium or high socioeconomic status, and that they have diabetes more frequently. They also have a higher risk of depressive symptoms, obesity and physical inactivity. The results illustrate that health chances and the risk of illness are still very socially uneven distributed, thus emphasising the significance of political interventions to reduce health inequalities. An English full-text version of this article is available at SpringerLink as supplemental.

Mortality of 2009 pandemic influenza A(H1N1) in Germany.

The mortality in Germany caused by the 2009 pandemic influenza A(H1N1) seems to have been one of the lowest in Europe. We provide a detailed analysis of all 252 fatal cases of confirmed infection with the pandemic virus notified between 29 April 2009 and 31 March 2010. The overall mortality was 3.1 (95% confidence interval (CI): 2.7 to 3.5) per one million inhabitants. We observed an increase in the case fatality rate of notified cases over time; notified cases aged 60 years or older had the highest case fatality rate (2.16%; 95% CI: 1.61 to 2.83; odds ratio: 5.4; p<0.001; reference group: 35­59 years). The median delay of four days (interquartile range (IQR): 2­7) between symptom onset and antiviral treatment was significantly longer in fatal cases than for non-fatal cases (median: two days (IQR: 1­3; p<0.001). Analysis of the underlying medical conditions of fatal cases, based on the observed frequency of the conditions in the general population, confirms the risk for fatal outcome, which is most notably due to immunosuppression, diabetes and respiratory diseases. Our results suggest that early treatment might have had an impact on overall mortality. Identification of risk groups for targeted intervention to prevent fatalities needs to take into account the distribution of underlying conditions in the population.

Implementation of the European health interview survey (EHIS) into the German health update (GEDA).

BACKGROUND: This methodological paper describes the integration of the 'European Health Interview Survey wave 2' (EHIS 2) into the 'German Health Update' 2014/2015 (GEDA 2014/2015-EHIS). METHODS: GEDA 2014/2015-EHIS is a cross-sectional health survey. A two-stage stratified cluster sampling approach was used to recruit persons aged 15 years and older with permanent residence in Germany. Two different modes of data collection were used, self-administered web questionnaire and self-administered paper questionnaire. The survey instrument implemented the EHIS 2 modules on health status, health care use, health determinants and social background variables and additional national questions. Data processing was conducted according to the quality and validation rules specified by Eurostat. RESULTS: In total, 24,824 questionnaires were completed. The response rate was 27.6%. The two-stage cluster sample method seems to have been successful in achieving a sample with high representativeness. The final micro data file was inspected, approved and certified by Eurostat. Access to micro data of the EHIS 2 can be provided by Eurostat via research contract and to the GEDA 2014/2015-EHIS public use file by the Research Data Centre of the Robert Koch Institute. First EHIS 2 results are available at the Eurostat website. CONCLUSIONS: Integrating a multinational health survey into an existing national health monitoring system was a challenge in Germany. The national survey methodology for conducting the survey had to be further developed in order to meet the overarching goal of harmonizing the health information from national statistical offices and public health research institutes across the European Union. The harmonized EHIS 2 data source will profoundly impact international public health research in the near future. The next EHIS wave 3 will be conducted around 2019.

[Urosepsis]. / Urosepsis.

Septicemia as a result of urinary infection is a serious condition, almost always caused by gram-negative bacteria. The bacterial toxins have a profound influence on haemostasis, microcirculation, and cardiac anf respiratory function. This article contains a brief review of aetiology, pathogenesis, pathophysiology, diagnostic work-up and treatment of this life-threatening condition. As soon as specimens from urine and blood are sent for bacteriological examination, intravenous antibiotics are given. It is essential that free drainage of urine from both kidneys is established by means of a bladder catheter, retrograde catheterization or percutaneous nephrostomy. The development of septic shock is a life-threatening condition which should be treated in an intensive care unit with continuous monitoring of vital parameters.

Septicaemia in granulocytopenic patients caused by multiresistant diphtheroid rods. A study of two cases.

Two cases of septicaemia in granulocytopenic patients are reported. Both were caused by multiresistant aerobic (JK-group) diphtheroid rods. The bacterial isolates were resistant to all commonly used antibacterial agents but showed good sensitivity to vancomycin and rifampicin. These agents should be included in the routine sensitivity testing of such isolates and diphtheroids should always be reported by the routine laboratory for granulocytopenic patients.

[Myocarditis and pericarditis in connection with Campylobacter jejuni infection]. / Myokarditt og perikarditt i forbindelse med infeksjon med Campylobacter jejuni.

We describe a case of myo/pericarditis related to infection with C. jejuni. The microbe was repeatedly isolated from faeces and the patient had specific IgA, IgM and IgG antibodies, detected in serum samples by means of a DIG-ELISA method. The condition is rare and the pathogenesis unclear. The case described may be the result of a primary infection or a reactive immune response.

[Infections in intensive care units. A challenge for the specialist of infectious diseases?]. / Infeksjoner i intensivavdelingen. En utfordring for infeksjonsmedisineren?

There is an obvious need for teamwork between different specialists on the diagnosis and treatment of patients in an intensive care unit. The infectious disease specialist must contribute by establishing definite and quick diagnosis of infections and by employing an adequate and sensible antibiotic policy for successful treatment. The local microbiological flora should be kept at an acceptable level of resistance to antibiotics, and preventive measures should be chosen carefully. To achieve this goal, extensive knowledge on antibiotics and microbial epidemiology is essential.

[Serious streptococcal infections of the head and neck region]. / Alvorlige streptokokkinfeksjoner i øre-nese-halsområdet.

This article describes the four cases of serious infections caused by Streptococcus pyogenes in the head and neck. Three patients presented with invasive infections of the soft tissues in the neck and one with epiglottitis. Two patients fulfilled the criteria for toxic streptococcal shock syndrome. The incidence of severe streptococcal disease is increasing in Norway, which emphasizes the importance of an aggressive attitude when diagnosing and treating atypical throat infections.

Effect of fibroblast interferon and recombinant gamma interferon on zymosan-induced nitroblue tetrazolium reduction in mouse peritoneal macrophages.

Mouse peritoneal macrophages (MPM) were cultivated with a fibroblast interferon (IFN) preparation or recombinant gamma-IFN (rIFN-alpha) for 1, 24 or 48 h. The zymosan-induced reduction of nitroblue tetrazolium (NBT) in these MPM was then measured. Fibroblast IFN enhanced the NBT reducing capacity of MPM when the incubation period was 1 h. When the incubation period was extended to 48 h, a suppressed NBT reduction by fibroblast IFN treated MPM was recorded. The influence of rIFN-alpha on MPM with regard to NBT reduction was minor. Only when the MPM were treated with a moderate dose of rIFN-alpha (10 U/ml) for 48 h was an enhanced NBT reduction recorded.

[Bilateral pulmonary infiltrations in patients admitted to an intensive care unit]. / Bilaterale lungefortetninger hos pasienter i medisinsk overvåkingsavdeling.

Diffuse pulmonary infiltrates are commonly found in hypoxic respiratory failure. We have reviewed 16 patients admitted to our medical intensive care unit over a period of 21 months, of whom seven died in hospital. Only patients requiring ventilatory support (CPAP or mechanical ventilation) for respiratory failure due to non-cardiogenic causes were included. All patients met the criteria for the diagnosis of ARDS. Three patients suffered from Wegener's granulomatosis, three from Pneumocystis carinii pneumonia, three from bacterial pneumonia, and two from pneumonia. Staphylococcal septicemia, SLE, sarcoidosis, cancer-associated hemolytic-uremic syndrome and ARDS of unknown etiology were each found in one patient. We discuss diagnosis and treatment of such patients on the basis of our experience.

[Yellow staphylococci with borderline resistance to methicillin]. / Gule stafylokokker med nedsatt meticillinfølsomhet.

Over the last four years there has been an increase in the incidence of borderlineresistant Staphylococcus aureus isolated from bacteriological samples at the Ullevål University Hospital, Department of Medical Microbiology. Several severe infections caused by these bacteria have been noticed in the Department of Infectious Diseases at Ullevål University Hospital. From December 1994 to April 1997, 24 patients suffering from this type of S. aureus infection were examined with regard to clinical and microbiological outcome. 15 of the patients had hospital-acquired infections, and all except one had acquired the infection in Norway. 13 of the patients had at least one predisposing factor, 50% had received antibiotics (mainly cefalosporins) beforehand. Three of the 24 patients died from the infection. We discuss etiology, identification of groups at risk and management of the infection.

[Clinical wound botulism in injecting drug addicts]. / Klinisk sårbotulisme hos sprøytenarkomane.

Wound botulism among drug abusers was first described in the USA in 1982. From 1988 to 1995, 46 laboratory confirmed cases were reported in California. The condition occurred for the first time in Norway in 1997 when three cases of suspected wound botulism among drug users who injected heroin subcutaneously or intramuscularly were reported. Two of these cases are presented here with neurophysiological findings and differential diagnosis.