Patient-reported outcome measures obtained via E-Health tools ease the assessment burden and encourage patient participation in cancer care (PaCC Study).

Patient-reported outcome measures obtained via E-Health tools ease the assessment burden and encourage patient participation in cancer care (PaCC Study) BACKGROUND: E-health based patient-reported outcome measures (PROMs) have the potential to automate early identification of both nutrition status and distress status in cancer patients while facilitating treatment and encouraging patient participation. This cross-sectional study assessed the acceptability, accuracy, and clinical utility of PROMs collected via E-Health tools among patients undergoing treatment for stomach, colorectal, and pancreatic tumors. RESULTS: Eight-nine percent mostly, or completely, agreed that PROMs via tablets should be integrated in routine clinical care. Men were significantly more likely to require help completing the questionnaires than women (inv.OR= 0.51, 95% CI=(0.27, 0.95), p = 0.035). The level of help needed increased by 3% with each 1-year increase in age (inv. OR=1.03, 95% CI=(1.01, 1.06), p = 0.013). On average, a patient tended to declare weight which was 0.84 kg inferior to their true weight (Bland and Altman 95 % CI=(-3.9, 5.6); SD: 2.41) and a height which was 0.95 cm superior to their true height (Bland and Altman 95 % CI=(-5, 3.1); SD 2.08). Patient-reported nutrition status was significantly associated with the professionally generated assessment (95% CI=(2.27, 4.15), p < 0.001). As nutrition status declined, the distress score increased (95%CI=(0.88, 1.68), p < 0.001). Of the patients, 48.8% who were both distressed and malnourished requested supportive care to address their problems. CONCLUSION: Patient-reported assessments utilizing E-health tools are an accurate and efficient method to encourage patient participation in cancer care while simultaneously ensuring that regular assessment of psycho-social and nutritional aspects of care are efficiently integrated in the daily clinical routine.

[Cancer and nutrition - a paradigma shift]. / Krebs und Ernährung ­ ein Paradigmenwechsel.

Substantial international differences in the prevalence of cancer disease suppose that nutrition may be an important factor in the development of cancer. Many experts believe, that nutritional factors may contribute up to 35 % to the development of malignant tumors. Many patients have lost substantial body weight already at the time of the diagnosis of the disease as consequence of undernutrition and malnutrition, respectively. During the course of the disease the nutritional status often is deteriorating further. Caused by both the cancer disease itself and the treatment, loss of appetite, changes in taste, nausea and vomiting may additionally contribute to undernutrition. Undernutrition is a relevant factor for the outcome of the disease and for the tolerance of the treatment as well. Therefore, supporting the heavily impaired patients in nutritional intake is of paramount importance and an urgent task for physicians and nurses. In view of physiology, pathophysiology, genetics and molecular biology, metabolic processes in cancer are highly complex regulated and there is increasing evidence that a diet rich in fat and protein is favourable. This, however, implies a paradigma shift away from the "healthy" balanced diet rich in fruit, vegetable and complex carbohydrates. So far, the evidence based data of this new concept is, however, a controversial issue.

[Beware of unconspicious cerebro spinal fluid]. / Gefahrenquelle unauffälliger Liquorstatus.

Nowadays with a lot of diagnostic facilities it is also difficult to find the right diagnose of herpes encephalitis. The aim of this case report was to give an overview about strategies of diagnostic and therapy of the herpes encephalitis.

[Clinic-internal and -external factors of length of hospital stay]. / Klinikinterne und -externe Determinanten der Spitalaufenthaltsdauer.

In the context of forthcoming initiation of Diagnosis Related Groups (DRG) in Switzerland, the objective of the study was to find factors having an impact on the inpatient's length of hospital stay. The study was performed on two general-medical wards of the Kantonsspital Winterthur, where all admitted patients were included in the study over two months. The various periods of diagnostic and therapeutic management of the patients and all diagnostic and therapeutic measures plus the arrangements after hospitalization were recorded. The determinants influencing the length of hospital stay were classified in clinic-internal or -external. 124 inpatients entered the study. 91 (73.4%) had a length of hospital stay without delay, whereas 33 (26.6%) patients had an extended length of hospital stay. The cumulative length of hospital stay of all patients was 1314 days, whereof 216 days (16.4%) were caused by delays. 67 days were caused by clinic-internal (5.1%) and 149 days by clinic-external factors (11.3%). Delays were substantially more generated by clinic-internal than -external factors. Clinic-internal factors were mainly weekends with interruption of the diagnostic and therapeutic procedures, dead times waiting for diagnostic results and waiting times for consultations. Clinic-external factors were caused by delayed transfer in nursing homes or rehabilitation institutions, waiting for family members for the backhaul and by indetermination of the patient. Also factors relating to the patients' characteristics had an influence on the length of hospital stay. Summing up, a substantial part of the length of hospital stay was caused by delays. However, the many different clinic-internal factors complicate solutions to lower the length of hospital stay. Moreover, factors that cannot be influenced such as waiting for microbiological results, contribute to extended length of hospital stay. Early scheduling of post-hospital arrangements may lower length of hospital stay. Moreover, when cantonal restriction falls away in 2012, patients may be transferred to rehabilitation institutions more rapidly. Also the insurance companies may possibly strengthen their organisation and thus may meet the costs more quickly.

[Antioxidant vitamin supplementation in the prevention of cardiovascular disease]. / Antioxidanzien und Vitamine in der Prävention von kardiovaskulären Erkrankungen.

Oxidative stress, in particular oxidative modification of LDL-cholesterol, appears to be of great importance in the pathogenesis of atherosclerosis. Various observational epidemiological studies have suggested that antioxidant vitamin intake is associated with reduced cardiovascular morbidity and mortality. Also, experimental studies in animals have demonstrated that antioxidant vitamins slow the progression of atherosclerosis. However, prospective controlled clinical trials have failed to demonstrate a benefit of antioxidant vitamin supplementation in primary or secondary prevention of cardiovascular disease. Thus, the use of antioxidants and vitamin supplements as a preventive or therapeutic intervention can not be recommended.

[Eating and drinking during aging]. / Essen und Trinken.

The retirement is a good moment in life to mirror one's health behaviour in regard to eating habits and physical activity. Based on the literature we recommend the Mediterranean "diet" in all ages. This diet is characterized by the intake of fresh fruit, vegetables, cereals, olive oil, fish, little meat, legumes, spices and herbs such as basil and garlic. A glass wine a day is legitimate. In increasing age total energy needs are decreasing. Therefore the energy intake has to be adjusted. Caloric restriction per se is a powerful means to reduce cardiovascular morbidity and mortality. However, not only the eating habits but also the entire lifestyle are important factors to influence cardiovascular mortality. Thus, the "low risk factors", i.e. Mediterranean diet, moderate alcohol consumption, physical activity and non-smoking must be controlled to improve health. In the HALE project the control of these factors reduced over-all mortality by 65 percent!

[Nutritional support for critically ill and dying patients]. / Ernährung Schwerkranker und Sterbender.

There is evidence in the literature that oral nutritional supplements, total enteral and parenteral nutrition can expand life expectancy and improve quality of life in patients suffering from undernutrition. In the present review, we outline whether these treatments regimens are also effective in severely ill patients. Moreover, the usefulness of nutritional interventions in patients sick unto death, e.g. by stroke, cancer or dementia, is broadly discussed. The controversy about terminal dehydration is shortly reviewed.

[Diabetic ketoacidosis and hyperosmolar hyperglycemia. 24 consecutive cases]. / Diabetische Ketoazidose und hyperosmolare Hyperglykämie - 24 konsekutive Fälle -

BACKGROUND: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia (HH) remain life-threatening complications of diabetes mellitus. Herein, we evaluated a standardized protocol for the therapy of acute hyperglycemic crises. PATIENTS AND METHODS: Retrospective study of patients treated in a medical intensive care unit for acute and severe hyperglycemia. Therapy was standardized according to internal guidelines effective for all treating physicians. RESULTS: 24 diabetic patients (11 men, 13 women, age 54 +/- 16 years, 11 DKA, 13 HH) were included into this study. All except one patient in the DKA-group had diabetes mellitus type 1. All patients with HH had diabetes mellitus type 2. Patients with DKA were significantly younger and complained more often about nausea and vomiting compared to the HH-group. Infections were the major cause for acute hyperglycemia followed by non-compliance. The arterial pH-value in the DKA-group was lower than in the HH-group (7,07 +/- 0,12 vs. 7,36 +/- 0,05). The length of stay in the intensive care unit was 1,8 +/- 1,2 days in patients with DKA and 2,2 +/- 1,2 days in patients with HH. The length of stay in the hospital was 11,5 +/- 5,9 days in patients with DKA and 18,3 +/- 10,9 days in patients with HH. No patient died during hospitalization. CONCLUSION: This study emphasizes the relevance of standardized written guidelines for the therapy of acute hyperglycemic crises in diabetic patients.

Acute metabolic acidosis decreases muscle protein synthesis but not albumin synthesis in humans.

Chronic metabolic acidosis induces negative nitrogen balance by either increased protein breakdown or decreased protein synthesis. Few data exist regarding effects of acute metabolic acidosis on protein synthesis. We investigated fractional synthesis rates (FSRs) of muscle protein and albumin, plasma concentrations of insulin-like growth factor-I (IGF-I), thyroid-stimulating hormone (TSH), and thyroid hormones (free thyroxin [fT(4)] and triiodothyronine [fT(3)]) in seven healthy human volunteers after a stable controlled metabolic period of 5 days and again 48 hours later after inducing metabolic acidosis by oral ammonium chloride intake (4.2 mmol/kg/d divided in six daily doses). Muscle and albumin FSRs were obtained by the [(2)H(5)ring]phenylalanine flooding technique. Ammonium chloride induced a significant decrease in pH (7.43 +/- 0.02 versus 7.32 +/- 0.04; P < 0.0001) and bicarbonate concentration (24.6 +/- 1.6 versus 16.0 +/- 2.7 mmol/L; P < 0.0001) within 48 hours. Nitrogen balance decreased significantly on the second day of acidosis. The FSR of muscle protein decreased (1.94 +/- 0.25 versus 1.30 +/- 0.39; P < 0.02), whereas the FSR of albumin remained constant. TSH levels increased significantly (1.1 +/- 0.5 versus 1.9 +/- 1.1 mU/L; P = 0.03), whereas IGF-I, fT(4), and fT(3) levels showed no significant change. We conclude that acute metabolic acidosis for 48 hours in humans induces a decrease in muscle protein synthesis, which contributes substantially to a negative nitrogen balance. In contrast to prolonged metabolic acidosis of 7 days, a short period of acidosis in the present study did not downregulate albumin synthesis.

Determination of plasma volume by indocyanine green--validation of the method and use in patients after cardiopulmonary bypass.

OBJECTIVE: Validation of plasma volume (PV) determination by indocyanine green (ICG) in comparison to the gold-standard method with radioiodinated albumin, and investigation of the effect of commonly used plasma expanders (albumin, hydroxyethyl starch, and polygelatine) on PV in the early postoperative phase in patients undergoing cardiac surgery. DESIGN: Prospective clinical study. SETTING: Department of medicine and intensive care unit at a university hospital. PATIENTS AND PARTICIPANTS: Ten healthy volunteers and 21 patients after elective open-heart surgery. MEASUREMENTS AND RESULTS: PV of subjects was measured by i.v. injecting 5 microCi [125I]albumin (I-ALB). One hour later, PV was determined by a peripheral i. v. injection of 0.25 mg/kg body weight ICG (ICG1). In five subjects PV was measured repeatedly by ICG (ICG2) 1 h after ICG1. Mean PV of I-ALB and ICG1 or ICG2 showed consistent results. Further, we investigated central vs peripheral intravenous injection of ICG in six patients after open-heart surgery compared to [125I]albumin. There was no difference between mean PV measured by [125I]albumin and peripheral ICG (P = 0.40). PV determined by central injection of ICG was significantly higher than by the other methods. In 15 patients PV was determined by [125I]albumin. Thereafter, patients were randomly divided into three groups. Group ALB was infused with 1.75 ml/kg body weight human albumin 20%, group HAES with 5.25 ml/kg body weight hydroxyethyl starch 6%, and group HAEM with 7.0 ml/kg body weight polygelatine 3.5%. PV was measured 1 h and 4 h after infusion by ICG. There were no significant changes in PV between the groups. CONCLUSIONS: PV determination by peripheral i. v. injection of ICG produced reliable and consistent results when a reactive hyperaemia was produced by a tourniquet prior to injection. Therefore, central venous injection of ICG may not be prerequisite for precise measurements of PV. The expected acute increase in PV after infusion of commonly used plasma expanders after cardiac surgery was not found.

Enhanced synthesis of albumin and fibrinogen at high altitude.

The acute effects of active and passive ascent to high altitude on plasma volume (PV) and rates of synthesis of albumin and fibrinogen have been examined. Measurements were made in two groups of healthy volunteers, initially at low altitude (550 m) and again on the day after ascent to high altitude (4,559 m). One group ascended by helicopter (air group, n = 8), whereas the other group climbed (foot group, n = 9), so that the separate contribution of physical exertion to the response could be delineated. PV was measured by dilution of (125)I-labeled albumin, whereas synthesis rates of albumin and fibrinogen were determined from the incorporation of isotope into protein after injection of [ring-(2)H(5)]phenylalanine. In the air group, there was no change in PV at high altitude, whereas, in the foot group, there was a 10% increase in PV (P < 0.01). Albumin synthesis (mg. kg(-1). day(-1)) increased by 13% in the air group (P = 0.058) and by 32% in the foot group (P < 0.001). Fibrinogen synthesis (mg. kg(-1). day(-1)) increased by 40% in the air group (P = 0.068) and by 100% in the foot group (P < 0.001). Hypoxia and alkalosis at high altitude did not differ between the groups. Plasma interleukin-6 was increased modestly in both groups but C-reactive protein was not changed in either group. It is concluded that increases in PV and plasma protein synthesis at high altitude result mainly from the physical exercise associated with climbing. However, a small stimulation of albumin and fibrinogen synthesis may be attributable to hypobaric hypoxia alone.

[Recurrent Clostridium difficile enterocolitis]. / Rezidivierende Clostridium-difficile-Enterokolitis.

Pseudomembranous enterocolitis generally occurs after antibiotic treatment. The standard treatment is oral metronidazol or vancomycin. Nevertheless, relapses of Clostridium difficile enterocolitis are observed in 10-25% of cases. Factors associated with recurrences include endogenous reinfection by spore formation, selective IgG1 or IgA deficiency or infection with mutated strains of Clostridium difficile. Recurrent Clostridium difficile enterocolitis may be treated with repeat oral vancomycin combined with Sacchoromyces boulardii, with intravenous immunoglobulin for severe colitis.

[Conservative management of spontaneous splenic rupture as a complication of infectious mononucleosis: two case reports and literature review]. / Konservatives Management bei spontaner Milzruptur als Komplikation einer Mononucleosis infectiosa: zwei Fallberichte und Literaturübersicht.

We report on conservative management of 2 patients with spontaneous splenic rupture associated with infectious mononucleosis. Both patients had an unremarkable hospital course and were discharged within 7 days of admission. Resolution of the haematoma was followed by ultrasound monitoring during the hospital stay. A literature review to 1999 shows that approximately 45 patients with serologically proven infectious mononucleosis have suffered spontaneous rupture of the spleen. Spontaneous splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Although splenectomy has been advocated in the past as the definitive therapy, we recommend that non-surgical management be considered in haemodynamically stable patients, to avoid the complications of splenectomy (e.g. post-splenectomy sepsis).

[Percutaneous endoscopic gastrostomy (PEG) for palliative decompression drainage in inoperable ileus]. / Perkutane endoskopische Gastrostomie (PEG) zur palliativen Entlastungsdrainage bei inoperablem Ileus.

Bowel obstruction, causing repetitive vomiting and reduced quality of life, is a common complication in patients with intraabdominal malignancies. Conservative treatment with nasogastric tubes is limited by patient discomfort. Antisecretory drug treatment with octreotide may be insufficient. We describe the application of percutaneous endoscopic gastrostomy (PEG) in 3 terminally ill cancer patients as simple and effective method for decompression in the upper gastrointestinal tract.

[Obesity: principles of drug therapy]. / Adipositas: Grundlagen--medikamentöse Therapie.

Obesity is a major global public health problem. In many instances, a combination of diet modification, increased physical activity and behavior therapy fail or are insufficient for sustained weight loss. In these situations, drug therapy may be helpful. However, drug treatment of obesity resulted in unexpected devastating events in recent years. In the late sixties, aminorex caused an epidemic of pulmonary hypertension with high mortality rates. Dexfenfluramine and phentermine were also associated with the development of pulmonary hypertension and with alarming reports of cardiac valvular abnormalities. Therefore, these drugs were withdrawn from the market. Newer drugs, like sibutramine, a serotonin and norepinephrine reuptake inhibitor, and orlistat, a specific lipase inhibitor, reduce body weight significantly compared to placebo. In combination with a hypocaloric diet, weight loss of three to ten kilos can be achieved. Pharmacotherapy is limited to patients with a body mass index greater than 30 kg/m2, if non-pharmacological treatment programs have failed. The drugs should be prescribed under strict medical surveillance only.

[Late sequelae of early summer meningoencephalitis]. / Spätfolgen nach Frühsommer-Meningoenzephalitis.

The incidence of tick-borne encephalitis varies widely in different geographic regions due to local difference in the rate of infected vectors (Ixodes ricinus) transmitting tick-borne encephalitis virus. In the Cantonal Hospital Winterthur a large number of cases are hospitalised due to endemic areas with infected ticks nearby. From 1976 until 1996 132 patients with tick-borne encephalitis were hospitalised (an average of 7 patients per year), compared with 535 cases (41 per year) in the whole of Switzerland during a similar period (1984-1992). While previously tick-borne encephalitis was considered to be a harmless illness with complete recovery, a postencephalitic syndrome after tick-borne encephalitis has recently been reported. Since the prevalence of sequelae differs in these publications, the aim of this study was to investigate sequelae in a Swiss population which had suffered from tick-borne encephalitis. We retrospectively analysed the patients with tick-borne encephalitis hospitalised in the years 1987-1996, to determine the clinical and functional outcome. A few weeks after discharge from hospital, 73% patients still had complaints, and one year later 56%. 32 patients were observed over 5 years and 31% still had some disability. After tick-borne encephalitis 10% of patients did not recover the same quality of life as before. The symptoms most frequently reported were fatigue, concentration deficits and impairment of memory. Objective neurological deficits were rare. Our results correspond well with experience in other countries and demonstrate the substantial morbidity of tick-borne encephalitis. We recommend therefore vaccination against tick-borne encephalitis, an effective measure with a low complication rate.