What Matters to Patients with Alzheimer's Disease and Their Care Partners? Implications for Understanding the Value of Future Interventions.

Alzheimer's Disease (AD) is the most common cause of dementia. Recent thinking portrays AD as a continuum consisting of three stages: an asymptomatic preclinical period, a mild cognitive impairment phase, and dementia, which can be further classified as mild, moderate or severe. While many studies explore the cognitive and functional aspects of AD, fully understanding AD pathophysiology, as well as the potential value of pharmacological and psycho-social interventions, requires a deeper understanding of patient and care partner priorities, particularly in the early stages where such interventions may have the greatest impact in slowing or delaying progression. Available studies highlight a diverse range of patient and care partner priorities, including impacts on their emotions, moods, and social lives. These priorities have not been systematically incorporated in the clinical and value assessments of potential interventions. We propose approaches to better understand the humanistic impact of AD including conducting additional research into the impacts of interventions from the point of view of patients and care partners, expanding notions of 'value' and improving health system capacity for diagnosis.

Radiological management of postoperative lymphorrhea.

PURPOSE: Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated. METHOD: A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI. RESULTS: Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated. CONCLUSION: The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.

[Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]. / "Resuscitative endovascular balloon occlusion of the aorta" (REBOA) : Aktuelles zu Material, Indikationen und Grenzen: ein Überblick.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) describes an endovascular procedure in which a blocking balloon is introduced into the aorta to reduce bleeding situated distal to the balloon and simultaneously to improve cardiac and cerebral oxygenation. OBJECTIVE: Presentation of the REBOA technique, the possible indications, the required material and possible complications of the procedure. MATERIAL AND METHODS: Non-systematic review of the currently available literature. RESULTS: The REBOA procedure is an adjunct to achieve hemodynamic stabilization in patients with traumatic hemorrhage and ruptured aortic aneurysms. The complication rate of the procedure is approximately 5%, whereby access complications are the most common; however, fatal complications are also possible. CONCLUSION: A balloon block of the aorta is well established in the treatment of ruptured aortic aneurysms. There is growing evidence that REBOA is a minimally invasive alternative to open surgical cross-clamping of the aorta by thoracotomy for the treatment of patients with polytrauma and hemorrhagic shock due to abdominal or visceral bleeding. Due to the development of new balloon catheters, which can be placed without stiff guidewires and require smaller sheath diameters, REBOA is also discussed for treatment of postoperative abdominal or gynecological bleeding or as a possible adjunct to cardiopulmonary resuscitation for nontraumatic cardiac arrest.

Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair.

Endovascular treatment of thoracic and thoracoabdominal aortic diseases is accompanied by a risk of spinal ischemia in 1-19% of patients, depending on the entity and extent of the disease. The use of perioperative drainage of cerebrospinal fluid is one of the invasive measures to reduce the occurrence of this severe complication. This article reviews the incidence of spinal ischemia, its risk factors, the evidence for carrying out cerebrospinal fluid drainage and its modern use by means of an automated, pressure controlled system (LiquoGuard®7).

Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection.

PURPOSE: Soft tissue sarcomas (STS) of the retroperitoneum and the lower limb with invasion of major blood vessels are very rare malignancies. This study analyses the outcome of patients with vascular replacement during resection of STS of the retroperitoneum and the lower extremity with either arterial or concomitant arterial and venous infiltration. METHODS: Patients with vascular replacement during resection of sarcoma of the retroperitoneum and the lower extremity between 1990 and 2014 were included in this retrospective single center study. Patients with a sole infiltration of a major vein were excluded. The follow up was obtained from medical records, the general practitioner and a clinical examination whenever possible. The main endpoints were survival, graft patency and the rate of major amputations. RESULTS: Fourty seven patients were included in this study. Twenty patients have received an operation for a retroperitoneal STS, twenty seven for a STS of the lower extremity. The median follow-up was 24.5 months. The median survival was 113 months with a median tumor-free survival of 25 months. The two-year patency for arterial bypasses in the retroperitoneum and the lower extremity was 88% and 66%, respectively. Limb salvage rate was 89%. CONCLUSIONS: Invasion of major blood vessels is no contraindication for a resection of a STS in the retroperitoneum and the lower extremity, but it is accompanied by a high postoperative morbidity. Since surgical resection is the only curative therapy in these patients, it should also be offered to patients with infiltration of major blood vessels.

[Metformin-induced lactic acidosis : Severe symptoms with difficult diagnostics]. / Metformininduzierte Laktatacidose : Schweres Krankheitsbild mit schwieriger Diagnosestellung.

Metformin-induced lactic acidosis is a rare but severe disease for the individual patients. A case of a 64-year-old patient with diabetes mellitus type 2 suffering from this disease is presented where metformin accumulation was caused by prerenal acute kidney failure. The clinical evaluation up to the final diagnosis, the pathophysiology and the appropriate therapy are presented in detail. Additionally, the current guidelines regarding the perioperative management of metformin administration are summarized. The case described aims to direct attention to the rare but, nevertheless, severe symptoms of metformin-induced lactic acidosis.

[Rare aortic diseases: infections, tumors, congenital anomalies]. / Seltene Aortenerkrankungen: Infektionen, Tumoren, angeborene Fehlbildungen.

Congenital malformations, tumors and aortic infections are rare and mostly asymptomatic. Unspecific clinical symptoms may cause delayed verification of the underlying disease. Contrast enhanced computer tomography- and magnetic resonance angiography are important sectional imaging methods for diagnostic completion. Consistent guidelines concerning diagnosis and therapy of rare aortic diseases are non-existent. Aortic tumors must be resected by open surgery, aortic infections in general require medical treatment and anomalies, if indicated, are treated more and more by endovascular or hybrid procedures. Therefore, it is recommended to treat these entities in an interdisciplinary approach in specialized aortic centers.

Evolving attitudes to Alzheimer's disease among the general public and caregivers in Europe: findings from the IMPACT survey.

Understanding and appreciating the awareness of, and attitudes towards, Alzheimer's disease (AD) in the general public is of paramount importance to those charged with the development of health care policy. Furthermore, it is essential that this policy be formulated with consideration given to both the attitudes of the general population and to those within society more directly affected by AD; namely, the caregivers of patients with the disease. In the IMPACT survey, approximately 1000 members of the general public and 250 caregivers in 5 European countries (France, Germany, Italy, Spain, and the United Kingdom) completed a 30-minute, Web-based questionnaire. In this article, we compare and contrast the attitudes and opinions of these populations in an attempt to define specific themes. Indeed, caregivers were more concerned about consequences of growing old and were more fearful of AD than general public respondents, although a high proportion in both groups acknowledged the significant impact of the disease. Similarly, although most respondents in the 2 groups recognised that early signs and symptoms of AD are difficult to detect, caregivers were more skeptical of the abilities of both primary physicians and specialists to detect these early signs and symptoms. In terms of treatment, caregivers were less convinced of the effectiveness of treatment beyond the early stages of AD and more likely to agree that current treatments are associated with side effects. Respondents in both groups had a negative view of their government's investment in AD, but caregivers, particularly those in France, Spain and the United Kingdom, were more likely to feel that their government acts as a barrier to treatment. Some survey respondents from the 2 groups also had a negative view of their governments' attempts to raise awareness of AD and make its treatment a high priority. Overall, comparison of responses from these 2 groups suggests that caregivers' personal experiences of AD profoundly affect their attitudes and perceptions surrounding the disease.

Influence of the histologic and cytologic grade and the clinical and postsurgical stage on the rate of endometrial carcinoma detection by cervical cytology.

The influence of postsurgical stage, histologic grade and cytologic grade of the tumor on the rate of detection of endometrial carcinoma by cervical smear was examined in a retrospective study. Cervical smears from 220 patients with endometrial carcinoma seen in the years between 1965 and 1981 were reevaluated for the presence of normal, suspicious or frankly malignant endometrial cells. The smears were positive in 33.2% of the patients, suspicious in 25.5% and negative in 40%. In three cases (1.4%), the smear was technically inadequate. Positive or suspicious smears indicated the presence of a higher grade as well as a higher stage of the lesion. In this material, the presence of normal endometrial cells as an indicator of endometrial disease, as emphasized in the literature, proved useless since normal endometrial cells without accompanying malignant cells were not seen in a single case. It appears that the reason for the lower rate of detection of low-grade endometrial carcinoma is the complete absence of any exfoliation in these lesions.

Justification and implementation of an oncology pharmacist practitioner in an HMO setting.

The role of an oncology pharmacist practitioner in an outpatient clinic is described. The clinic provides cancer treatment and follow-up to approximately 60 to 80 patients per day. The hospital pharmacy department, the director of the medical oncology service, and the oncology nurse specialist presented a proposal to the clinic administration for the employment of a full-time pharmacist. Previously, the clinic nursing staff prepared all chemotherapeutic agents. The oncology pharmacist now prepares between 35 to 75 chemotherapy drug doses per day. As a result, nurses are able to devote more time to direct patient care. Through the application of inventory management, clinic drug costs have been reduced. In addition, patients undergoing chemotherapy no longer have to wait for their prescriptions since the oncology pharmacist calls them to the outpatient pharmacy. A valuable service has been introduced tht not only benefits the clinic personnel, but also assures that the patients receive the highest standards of care.