Perioperative Betreuung von Palliativpatienten durch den Anästhesisten

Anästhesisten betreuen Palliativpatienten in unterschiedlichsten Situationen. Nicht nur auf Intensivstationen, in der Notfallmedizin und in der Schmerztherapie muss mit diesen Patienten gerechnet werden, sondern auch im Operationssaal. Obwohl die Beteiligung der Anästhesie an der Palliativmedizin schon intensiv erforscht wurde, fehlen ausführliche Erkenntnisse über Palliativpatienten unter anästhesiologischer Betreuung im Operationssaal. Prämedikation und Narkoseführung bei palliativen Patienten stellen besondere Anforderungen an den Anästhesisten. Palliativpatienten leiden an unterschiedlichen Symptomen, wie Schmerzen, Atemnot oder Übelkeit, die behandlungsbedürftig sind. Diese Behandlung kann im Zeitraum vor, während und nach dem Eingriff idealerweise vom Anästhesisten angeboten werden, da dieser sowohl die Narkose durchführt als auch das entsprechende Fachwissen zum Umgang mit den beschriebenen Symptomen mitbringt. Diese Studie wurde durchgeführt, um die Häufigkeit, die Demographie und das Outcome palliativer Patienten unter anästhesiologischer Betreuung einzuschätzen. Fast jeder sechzigste Patient in anästhesiologischer Betreuung war bereits vor dem Eingriff als palliativ klassifizierbar. Insgesamt handelt es sich bei jedem fünfundvierzigsten Eingriff um einen Palliativpatienten. Die an ihnen durchgeführten Eingriffe waren häufiger nicht-elektiv, dringlich und außerhalb der regulären Arbeitszeiten als bei einem vergleichbaren nicht-palliativen Patientenkollektiv. Die häufigsten Symptome, an denen die Palliativpatienten litten, waren Schmerzen, gastrointestinale Symptome, Ernährungsprobleme und pulmonale Probleme. Das Bewusstsein für diese Patientengruppe muss geschärft werden, damit diese Patienten rechtzeitig erkannt und adäquat behandelt werden können. Der palliative Status des Patienten sollte als ‚palliativ‘ auf dem Untersuchungsbogen bei der anästhesiologischen Untersuchung vermerkt werden. Bei Prämedikation und Narkoseführung kann der Anästhesist dann besonders aufmerksam auf die besonderen Anforderungen bei dieser Patientengruppe eingehen. Die Symptomkontrolle und die Erkennung von therapeutischen Einschränkungen wie Patientenverfügungen und DNR-Ordern sollten im Voraus erkannt, mit dem Patienten besprochen und geplant werden. Um die Rechte des Patienten nicht zu verletzten, ist es wichtig, sich schon vor dem Eingriff mit dem Patientenwillen auseinanderzusetzen und alle betreuenden Ärzte und die Angehörigen des Patienten darüber zu informieren

A five-year perspective on the situation of haemorrhagic fever with renal syndrome and status of the hantavirus reservoirs in Europe, 2005-2010

Hantavirus infections are reported from many countries in Europe and with highly variable annual case numbers. In 2010, more than 2,000 human cases were reported in Germany, and numbers above the baseline have also been registered in other European countries. Depending on the virus type human infections are characterised by mild to severe forms of haemorrhagic fever with renal syndrome. The member laboratories of the European Network for diagnostics of Imported Viral Diseases present here an overview of the progression of human cases in the period from 2005 to 2010. Further we provide an update on the available diagnostic methods and endemic regions in their countries, with an emphasis on occurring virus types and reservoirs

European survey on laboratory preparedness, response and diagnostic capacity for crimean-congo haemorrhagic fever, 2012

Crimean-Congo haemorrhagic fever (CCHF) is an infectious viral disease that has (re-)emerged in the last decade in south-eastern Europe, and there is a risk for further geographical expansion to western Europe. Here we report the results of a survey covering 28 countries, conducted in 2012 among the member laboratories of the European Network for Diagnostics of 'Imported' Viral Diseases (ENIVD) to assess laboratory preparedness and response capacities for CCHF. The answers of 31 laboratories of the European region regarding CCHF case definition, training necessity, biosafety, quality assurance and diagnostic tests are presented. In addition, we identifi

CME: Radiojodbehandlung des Schilddrüsenkarzinoms

Die papillären und follikulären Schilddrüsenkarzinome bilden ca. 90% aller Schilddrüsentumore und werden als differenzierte Karzinome usammengefasst. Sie haben eine gute Prognose, Rezidive sind jedoch nicht selten. Ihre Fähigkeit der Jodaufnahme wird für die Radiojodtherapie ausgenutzt. Die Radiojodablation wird postoperativ zur Elimination von Restgewebe und sensitivem Staging eingesetzt (Abb. 1). Durch die komplette Ablation der Schilddrüse wird das Rezidivrisiko gesenkt. Des Weiteren kann Thyreoglobulin als Tumormarker sensitiv eingesetzt werden. Als Radiojodtherapie wird die Metastasentherapie bezeichnet. Ein Sonderfall stellt das papilläre Mikrokarzinom dar, bei der in der Regel eine Lobektomie ausreicht

18F-FDG PET/CT based spleen to liver ratio associates with clinical outcome to ipilimumab in patients with metastatic melanoma

Background Immune checkpoint blockade such as ipilimumab and anti-PD1 monoclonal antibodies have significantly improved survival in advanced melanoma. Biomarkers are urgently needed as a majority of patients do not respond, despite treatment-related toxicities. We analysed pre-treatment 18F-fluorodeoxyglucose positron emission tomography/computerised tomography (FDG PET/CT) parameters to assess its correlation with patient outcome. Methods This retrospective study evaluated pre-treatment FDG PET/CT scans in a discovery cohort of patients with advanced melanoma treated with ipilimumab or anti-PD1. Pre-treatment scans were assessed for maximum tumoral standardised uptake value (SUVmax), metabolic tumour volume (MTV) and spleen to liver ratio (SLR). Progression-free survival (PFS) and overall survival (OS) were characterised and modelled using univariable and multivariable analyses. Correlation of SLR and OS was validated in an independent cohort. Blood parameters and stored sera of patients from the discovery cohort was analysed to investigate biological correlates with SLR. Results Of the 90 evaluable patients in the discovery cohort: 50 received ipilimumab monotherapy, 20 received anti-PD1 monotherapy, and 20 patients received ipilimumab followed by anti-PD1 upon disease progression. High SLR > 1.1 was associated with poor PFS (median 1 vs 3 months; HR 3.14, p = 0.008) for patients treated with ipilimumab. High SLR was associated with poor OS after ipilimumab (median 1 vs 21 months; HR 5.83, p = 0.0001); as well as poor OS after first line immunotherapy of either ipilimumab or anti-PD1 (median 1 vs 14 months; HR 3.92, p = 0.003). The association of high SLR and poor OS after ipilimumab was validated in an independent cohort of 110 patients (median 2.3 months versus 11.9 months, HR 3.74). SLR was associated with poor OS in a multi-variable model independent of stage, LDH, absolute lymphocyte count and MTV. Conclusions Pre-treatment Spleen to liver ratio (SLR) > 1.1 was associated with poor outcome after ipilimumab in advanced melanoma. This parameter warrants prospective evaluation

Visualization of parathyroid hyperplasia using 18F-fluorocholine PET/MR in a patient with secondary hyperparathyroidism

Several imaging modalities exist for the detection of parathyroid adenomas in patients with primary hyperparathyroidism. Unlike solitary parathyroid adenoma, parathyroid hyperplasia in patients with secondary hyperparathyroidism hitherto is difficult to assess with any imaging modality. Our case of a young patient with chronic kidney failure illustrates that F-fluorocholine PET/MR might be an imaging tool suitable for the diagnosis and presurgical assessment of parathyroid hyperplasia

Palliative patients under anaesthesiological care: a single-centre retrospective study on incidence, demographics and outcome

Background While anesthesiologist’s involvement in palliative care has been widely researched, extensive data on palliative patients under anesthesiological care in the operating room is missing. This study was performed to assess the incidence, demographics, and outcome of palliative patients under anesthesiological care. Methods We conducted a single-center retrospective chart review of all palliative patients under anesthesiological care at a university hospital in 1 year. Patients were classified as palliative if they fulfilled all predefined criteria (a) incurable, life-threatening disease, (b) progression of the disease despite therapy, (c) advanced stage of the disease with limited life-expectancy, (d) receiving or being in need of a specific palliative therapy. Demographics, periprocedural parameters, symptoms at evaluation, and outcome were determined using different medical records. Results Of 17,580 patients examined, 276 could be classified as palliative patients (1.57 %). Most contacts with palliative patients occurred in the operating room (68.5 %). In comparison to the non-palliative patients, procedures in palliative patients were significantly more often urgent or emergency procedures (39.1 % vs. 27.1 %., P < 0.001), and hospital mortality was higher (18.8 % vs. 5.0 %, P < 0.001). Preprocedural symptoms varied, with pain, gastrointestinal, and nutritional problems being the most prevalent. Conclusions Palliative patients are treated by anesthesiologists under varying circumstances. Anesthesiologists need to identify these patients and need to be aware of their characteristics to adequately attend to them during the periprocedural period

Human Parvovirus B19 NS1 Protein Modulates Inflammatory Signaling by Activation of STAT3/PIAS3 in Human Endothelial Cells▿

The pathogenic mechanism by which parvovirus B19 may induce inflammatory cardiomyopathy (iCMP) is complex but is known to involve inflammatory processes, possibly including activation of JAK/STAT signaling. The nonstructural B19 protein NS1 acts as a transactivator triggering signaling cascades that eventually lead to activation of interleukin 6 (IL-6). We examined the impact of NS1 on modulation of STAT signaling in human endothelial cells (HMEC-1). The NS1 sequences were identified from B19 DNA isolated from the myocardia of patients with fatal iCMP. B19 infection as well as NS1 overexpression in HMEC-1 cells produced a significant upregulation in the phosphorylation of both tyrosine705 and serine727 STAT3 (P < 0.05). The increased STAT3 phosphorylation was accompanied by dimerization, nuclear translocation, and DNA binding of pSTAT3. In contrast, NS1 expression did not result in increased STAT1 activation. Notably, the expression levels of the negative regulators of STAT activation, SOCS1 and SOCS3, were not altered by NS1. However, the level of PIAS3 was upregulated in NS1-expressing HMEC-1 cells. Analysis of the transcriptional activation of target genes revealed that NS1-induced STAT3 signaling was associated with upregulation of genes involved in immune response (e.g., the IFNAR1 and IL-2 genes) and downregulation of genes associated with viral defense (e.g., the OAS1 and TYK2 genes). Our results demonstrate that B19 NS1 modulates the STAT/PIAS pathway. The NS1-induced upregulation of STAT3/PIAS3 in the absence of STAT1 phosphorylation and the lack of SOCS1/SOCS3 activation may contribute to the mechanisms by which B19 evades the immune response and establishes persistent infection in human endothelial cells. Thus, NS1 may play a critical role in the mechanism of viral pathogenesis in B19-associated iCMP