Ten-year survival of esophageal cancer after an en-bloc esophagectomy.

BACKGROUND: Esophagectomy with gastric pull-up is the optimal treatment for patients with resectable esophageal cancer. Although the morbidity and mortality of an esophagectomy is reduced, the long-term outcome remains poor. The aim of this study was to evaluate the 10-year survival of a standardized multidisciplinary therapy concept for esophageal cancer. METHODS: Between 1989 and 1999, 114 patients were treated for esophageal cancer at the University of Essen. All patients underwent an en-bloc esophagectomy with systematic lymphadenectomy. Patients with locally advanced disease (stage III) received neoadjuvant therapy. All patients were followed-up for 10 years or more or until death. RESULTS: The 3-year survival was 35%, the 5-year survival 25%, and the 10-year survival was 18%. The recurrence rate was 44% with a median time of 13 months. There was no significant difference in survival between patients with locally advanced disease who received neoadjuvant therapy and patients with early disease (stadium I + II) who underwent surgery alone. Of the patients who achieved 10-year survival, 60% had locally advanced disease and received neoadjuvant therapy. CONCLUSION: Patients with locally advanced disease, managed by a multidisciplinary treatment strategy, achieved a similar long-term survival to patients with early disease (stadium I + II).

Prevention of pressure ulcer: interaction of body characteristics and different mattresses.

We analysed the effect of different body features on contact area, interface pressure and pressure distribution of three different mattresses. Thirty-eight volunteers (age ranged from 17 to 73 years, 23 females) were asked to lie on three different mattresses in a random order: I, standard hospital foam mattresses; II, higher specification foam mattresses (Viscorelax Sure® ); III, constant low pressure devices (CareMedx® , AirSystems). Measurements were performed in supine position and in a 90° left- and right-sided position, respectively, using a full-body mat (pressure mapping device Xsensor X2-Modell). Outcome variables were contact area (CA) in cm(2) , mean interface pressure (IP) in mmHg and pressure distribution (PD) estimated as rate of low pressures between 5 and 33 mmHg on each mattress in percent. Mean CA was lowest in the standard hospital foam mattresses and increased in the higher specification foam mattresses and was highest in the constant low pressure device (supine position: 491 ± 86 cm(2) , 615 ± 95 cm(2) , 685 ± 116 cm(2) ). Mean IP was highest in the standard hospital foam mattresses and lower but similar in the higher specification foam mattresses and the constant low pressure devices (supine position: 22·3 ± 1·5 mmHg, 17·6 ± 1·7 mmHg, 17·6 ± 2·2 mmHg). Models were estimated for CA, IP and PD including the independent variables height, weight and waist-to-hip-ratio (WHR). They show that body morphology seems to play a minor role for CA, IP and PD, but very thin and tall patients and very small and obese people might benefit from different mattresses. Our data show that CA increases with increasing specification of mattresses. Higher specification foam mattresses and constant low pressure devices show similar IP, but constant low pressure devices show a wider pressure distribution. Body morphology should be considered to optimise prevention for single patients.

Increasing pressure ulcer rates and changes in delivery of care: a retrospective analysis at a University Clinic.

AIM: To evaluate the relation between pressure ulcers and delivery of care. BACKGROUND: No decrease of pressure ulcer rates could be recognised in acute hospital care, despite intensive efforts in prevention. Furthermore, reports show increasing rates. DESIGN: Retrospective analysis of hospital data. METHODS: The study included all inpatients from year 1 (2003/2004) and 4 (2006/2007) of the interdisciplinary decubitus project. Information on ulcers was recorded at admission, discharge and in case of new events. We analysed the effect of age, length of stay, operation and intensive care episode. In logistic regression, we used the existence of ulcers and the appearance of new ulcers as dependent variables. RESULTS: Parallel to a decrease in the number of inpatients, age, length of stay and operation frequency rose between 2003 and 2007. Higher age, longer length of stay, operation, intensive care episode and year 4 raise the odds for ulcers in univariate and with exception of operation in multivariate analyses. With exception of operation and year 4, the same variables raise the odds for new ulcers, too. CONCLUSIONS: The increase of pressure ulcer frequency could be related to changes in delivery of care. The adverse event pressure ulcer will become more important in hospital care. RELEVANCE TO CLINICAL PRACTICE: There is no decrease in pressure ulcer rates, albeit enormous efforts in prevention. Hospital care has been facing changes in case mix. Age, length of stay and intensive care episodes are related to increasing ulcer rates at a University Clinic. Nursing management has to be aware of additional workload for pressure ulcer management in the future.

Prevalence of pressure ulcers in hospitalized patients in Germany in 2005: data from the Federal Statistical Office.

OBJECTIVE: Using the National Statistics ('DRG-Statistik') published by the Federal Statistical Office, we analyzed prevalences of pressure ulcers coded as principal or as additional diagnosis separately and describe differences in ulcer characteristics. PATIENTS AND METHODS: Age-adjusted prevalence and tables for gender and age distribution of pressure ulcers separately for the principal diagnosis and for additional diagnoses were provided by the Federal Statistical Office. RESULTS: In 2005, about 16 million patients were treated as full-time patients in German hospitals. 9,941 (0.06%) were referred with pressure ulcer as principal diagnosis and 191,040 (1.19%) had at least one additional diagnosis pressure ulcer. People >65 years of age had the highest risk for pressure ulcers (per 100,000 population principal diagnosis: females 52 and males 37; additional diagnosis: females 1,076 and males 947). Up to 80% of those who had the principal diagnosis pressure ulcer had ulcers grade 3 and 4, whereas 60% of the pressure ulcers documented as additional diagnosis were grade 1 and 2 (p < 0.001). The most frequent localizations of pressure ulcers were the ischium, the sacrum and the heel. In patients <65 years of age with the principal diagnosis pressure ulcer, the mortality rate is <0.1%. In the older age groups it increases gradually up to 10% in the 8th decade of life. CONCLUSION: Pressure ulcers are still a relevant problem in Germany. Although patients 65 years and older are at the highest risk, all age groups are affected. Younger people seem to struggle with different problems compared to older people.

Reliability and validity of pressure ulcer diagnosis and grading: an image-based survey.

BACKGROUND: The reliability and validity of pressure ulcer diagnosis and grading are major methodological issues in studies and reports on pressure ulcer frequency. OBJECTIVES: The aim of the study was to estimate the reliability and validity of pressure ulcer diagnosis and grading within the interdisciplinary pressure ulcer project of the University Clinics of Essen, Germany. DESIGN: Fifty images of wounds from the foot/heel region and 50 images of wounds from the buttock/hip region were classified using a 4-grade scale. A gold standard was established by consensus of two senior physicians. SETTINGS: The images were assessed PC-based, independently by each rater. PARTICIPANTS: Five nursing experts and two physicians participated. METHODS: Mean simple Kappa and per cent agreement were calculated to assess reliability and validity. RESULTS: Mean simple Kappa values showed a moderate interrater agreement for grading and a fair interrater agreement for diagnosis. The percentage of agreements was highest for pressure ulcer diagnosis in the buttock/hip region with 90.5% and lowest for pressure ulcer grading in the buttock/hip region with 63.5%. No differences could be found between nurses and physicians. CONCLUSIONS: The differentiation between pressure ulcers and other skin lesions is rather difficult. It is important to assign the lower grade when the available information does not definitely support the higher grade. The level of agreement found was intermediate in the range of published results. A substantial level of agreement should be obtainable through further standardisation and training. Future studies should control for dependency in the assessment situation and dispense with the category "uncertain".

Problem focused integration of information, quality and process management with empirical research: The example of the Essen Interdisciplinary Pressure Ulcer Project.

Issues of information management, quality management, process management, and empirical research are often seen independently from each other. In the Essen interdisciplinary pressure ulcer project, they were integrated to establish a synergy between quality of care, economics and research. The electronic documentation of events and supplementary information was done with the hospital wide patient administration system. Feedback and automatically requests were used for quality improvement. Codes for reimbursement are generated from the clinical documentation. Research studies had been based on the routine documentation. Prerequisite was the cooperation of all relevant groups, nurses, physicians, informaticians, theoreticians and medical controller. In the future, it will be necessary to extend the approach to other relevant nursing problems and to replace the redundant documentation (paper-based as well as electronic) by an electronic health record.

Percutaneous repair of abdominal aortic pseudoaneurysm by catheter-based delivery of thrombin.

PURPOSE: To present a case in which thrombin was injected percutaneously to treat an aortic pseudoaneurysm. CASE REPORT: A 63-year-old man developed a large pseudoaneurysm in the abdominal aorta after surgical fenestration and patch aortoplasty for acute type B aortic dissection with malperfusion syndrome. Transcatheter delivery of 1500 units of thrombin resulted in complete thrombosis of the pseudoaneurysm sac. No complications occurred. Twelve months after the procedure, the pseudoaneurysm was completely resolved on computed tomography. CONCLUSION: Thrombin continues to prove its safety and efficacy for the treatment of pseudoaneurysms at numerous anatomical sites, including the abdominal aorta.

Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease.

Despite advances in medical and surgical treatment, acute as well as chronic diseases of the thoracic aorta are still associated with a high mortality. For the descending thoracic aorta, endovascular stent-graft placement competes with surgical therapy for clinical outcome. From July 1999 till December 2004, a total of 84 patients (64 +/- 14 years) with aortic disease of the descending thoracic aorta were treated. Nine patients had acute (AAD) and 35 chronic aortic dissection (AD), 16 had thoracic aortic aneurysms (TAA), 21 had penetrating aortic ulcer (PAU), and 3 patients had traumatic dissection (trans). Initial clinical status was assessed using the American Society of Anesthesiologists (ASA) classification. Fifty-three patients were in class 2, 16 in class 3, 8 in class 4, and 7 in class 5. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia. Technical success was obtained in 81/84 patients (96%). Within 30 days, seven patients (8%) died, four of them due to aortic rupture. In 14 patients, additional stent-grafts had to be implanted due to type I endovascular leakage (n = 5) or additional entry site adding up to a total of 107 implanted stent-grafts. During a follow-up period of 21 +/- 18 months, 17 additional patients died (22%). In 10 patients, death was disease- or procedure-related (13%). This long-term mortality depended on the underlying disease and was highest in the group with TAA (45%) followed by AAD (38%) and AD (18%). Patients in ASA class 4 and 5 had a significantly worse outcome. No aortic-related death occurred among patients with PAU or traumatic transsections. Overall, there was only one transient neurological deficit. Endovascular stent-graft placement has acceptable results in the treatment of patients with disease of the descending thoracic aorta. The outcome strongly depends on the underlying aortic pathology and the clinical health status of the patients. Randomized trials are necessary in order to establish the exact value of this new therapeutic option.

Resection of residual disease in patients with metastatic gastrointestinal stromal tumors responding to treatment with imatinib.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Long-term survival of patients with metastatic disease has only been observed in patients with completely resected disease. Recently, the tyrosine kinase inhibitor imatinib has been found to yield responses in the majority of patients with metastatic GIST suggesting improved resectability in responding patients. Combined treatment approaches including resective surgery after imatinib treatment in patients with advanced metastatic disease have rarely been explored. We report a series of 90 patients with metastatic GIST in whom treatment with imatinib enabled 12 patients with mostly recurrent and extensive disease to be considered for resection of residual disease. In 11 of these patients, complete resection could be achieved. Viable tumor cells were found in all but one resected specimens suggesting that despite favorable radiological or clinical responses, imatinib is unlikely to induce pathological complete responses. Until more mature data from prospective trials are available, these data suggest that an early aggressive surgical approach should be considered for all patients with metastatic GIST. Further trials investigating a combined surgical and pre/postoperative treatment with imatinib in patients with advanced metastatic GIST are warranted.

Pressure ulcers in secondary care: incidence, prevalence, and relevance.

OBJECTIVE: To compare point and period prevalence rates. DESIGN: Descriptive, cohort, cross-sectional survey. PARTICIPANTS: From a cohort of 25,075 cases, information on pressure ulcer status on admission was recorded for 20,283 cases. From 3237 selected cases, the pressure ulcer team made 2234 assessments. MAIN OUTCOME MEASURES: Point prevalence, period prevalence, and incidence rates. MAIN RESULTS: The cohort showed a period prevalence rate of 1.4% and an incidence rate of 0.6%. Patients with a pressure ulcer were older, were more likely to have had surgery, had longer hospital stays, and had a higher cost weight. The cross-sectional survey revealed a point prevalence rate of 5.3%. Patients within the cross-sectional survey had longer lengths of stay, were more likely to have had surgery, and presented a higher cost weight in comparison with the cohort. CONCLUSIONS: In an unselected hospital sample one can expect a period prevalence rate of 2% and a point prevalence rate of 10%. As demonstrated by the present study, differences between the 2 prevalence measurements are mainly due to the confounding of point prevalence rates by length of stay. Length of stay determines the probability of inclusion in a cross-sectional study and should be considered in pressure ulcer trials in the future.

Severe acute pancreatitis: nonsurgical treatment of infected necroses.

OBJECTIVES: In acute pancreatitis, infection of necrosis is associated with a substantial mortality of 15% to >50% even if immediate necrosectomy, the recommended standard treatment, is performed, mainly because of the patients' critical systemic and unstable local conditions at the time of manifestation of infection. We investigated whether this dreaded complication can be managed conservatively. METHODS: We evaluated 88 consecutive patients with severe (APACHE II score, > or =11; Ranson score, > or =4) acute necrotizing pancreatitis who received ICU treatment including early antibiotic prophylaxis. Twenty-eight patients were included who developed infection of necroses, verified by fine needle aspiration, 19 +/- 6 days after admission. No patient received urgent surgery; rather, in all patients, nonsurgical therapy was continued after adapting the antibiotic regimen to bacteriology. In the further course, 12 patients were excluded due to refractory local complications eventually requiring surgical treatment 36 +/- 14 days after diagnosis of infection. RESULTS: Sixteen patients (APACHE II score: 18.1 [11-33]; Ranson score, 5.9 [4-10]) were managed with medical treatment alone. Six patients recovered without further complications; 10 patients (62%) developed single or multiple organ failure, and 2 died (mortality, 12%). CONCLUSION: These data suggest that in patients with acute necrotizing pancreatitis and infected necroses, surgery can be avoided without compromising prognosis and outcome.

Primary failure of arteriovenous fistulae in auto-immune disease.

BACKGROUND/AIM: Chronic haemodialysis depends on an arteriovenous fistula. Primary failure of vascular access is a common problem which is mainly related to thrombosis. As ambulatory surgery is common, it is mandatory to identify patients with a high thrombophilic risk to allow better prevention (anticoagulation) and direct re-intervention after thrombosis. The purpose of this study was to determine thrombophilic risk factors for primary access failure in order to identify patients at risk before the operation. METHODS: We performed a retrospective study on 62 chronic haemodialysis patients who received permanent vascular access. We evaluated established risk factors for chronic access failure as well as the number of earlier shunt operations in these patients. RESULTS: The patients predominantly suffered from auto-immune diseases. The frequency of a successful first vascular access was above average (92.5%). We identified four major risk factors for primary access failure: number of previous vascular access thromboses (p < 0.01; R = 0.96), pre-existing thrombophilic risk factors (p < 0.01), pre-operative fibrinogen (p < 0.02), and vasculitis (p < 0.01). CONCLUSIONS: We identified four risk factors which allowed an individual risk evaluation. Among the factors investigated, the activity of the auto-immune disease was the most striking. Our data suggest not to perform a vascular access during an active period of vasculitis.