Intensivmedizin im Zeichen des demographischen Wandels: Aktuelle Inanspruchnahme ausgewählter Therapiemodalitäten und Abschätzung des zukünftigen Versorgungsbedarfes

Der demographische Wandel und die damit verbundene fortschreitende Alterung der Bevölkerung stellen die wesentlichen Säulen der sozialen und gesundheitlichen Sicherungssysteme vor große Herausforderungen. Besonders im Gesundheitssystem wird sich die steigende Zahl älterer Patienten bemerkbar machen, welche ohnehin schon einen großen Teil der Ressourcen in Anspruch nehmen. Im stationären Bereich kommen somit auch auf die Intensivmedizin große Veränderungen zu. So ist die Intensivmedizin schon jetzt eine der ressourcenintensivsten Disziplinen im Krankenhaussektor und könnte in Zukunft vor einen noch höheren Ressourcenbedarf gestellt werden, was eine Abschätzung der Folgen des demographischen Wandels für die Intensivstation unabdingbar macht. Ziel der Arbeit war es zum einen, etwaige Therapieunterschiede zwischen männlichen und weiblichen Patienten verschiedener Altersgruppen in der Intensivmedizin zu ermitteln und zum anderen, den künftigen Versorgungsbedarf auf Grundlage der gewonnen Kenntnisse unter Hinzunahme von Bevölkerungsprognosedaten und unter Berücksichtigung unterschiedlicher Szenarien zur Entwicklung der Morbidität abzuschätzen. Hierzu wurden elektronische Patientenakten der Operativen Intensivstation der Universitätsmedizin Mannheim und Bevölkerungsprognosedaten der Stadt Mannheim herangezogen. Mit der Antibiotikatherapie, der Beatmung und Nierenersatzverfahren wurden drei für die Intensivmedizin typische Therapiemodalitäten ausgewählt und zwischen männlichen und weiblichen Patienten verschiedener Altersgruppen, bzw. im Falle der Nierenersatzverfahren zwischen beatmeten und nicht beatmeten Patienten hinsichtlich Behandlungshäufigkeit und -intensität in einer retrospektiven Analyse verglichen. Die Ergebnisse wurden in einem Projektionsmodell mit drei verschiedenen demographischen Prognosen für die Stadt Mannheim und vier ausgewählten Szenarien zur künftigen Entwicklung der Morbidität verknüpft. In der retrospektiven Analyse konnte gezeigt werden, dass bereits jetzt einige Unterscheide in der Therapie verschiedener Altersgruppen existieren. Zwar ist die jeweilige Intensität der einmal eingesetzten Therapie nicht immer unterschiedlich, jedoch zeigen sich oftmals Unterschiede in den Behandlungshäufigkeiten, die insbesondere bei männlichen Patienten höher war als bei weiblichen. Zudem wurde deutlich, dass bei fortschreitender demographischer Alterung sowie einer Morbiditätsentwicklung etwa im Sinne der Theorie des Dynamischen Gleichgewichts ein höherer Anteil insbesondere von beatmeten Patienten auf der Intensivstation zu erwarten ist. Zudem wäre ein weiterhin wachsender Anteil insbesondere älterer, männlicher Patienten wahrscheinlich, welche einen vergleichsweise hohen Ressourcenbedarf haben. Dies würde letztlich eine Kapazitätserweiterung um zusätzliche Betten unumgänglich machen, um den wahrscheinlich zu erwartenden Versorgungsbedarf decken zu können. Das hier entwickelte Rechenmodell zur Abschätzung des künftigen Ressourcenbedarfes auf Basis elektronischer Patientenakten, Bevölkerungsprognosedaten und Theorien zur weiteren Morbiditätsentwicklung stellt ein realitätsnahes und leicht zu übertragenes Modell dar, mit dessen Hilfe die Folgen des demographischen Wandels auch auf anderen Intensivstationen abgeschätzt werden können

Indirect consequences of extreme weather and climate events and their associations with physical health in coastal Bangladesh: a cross-sectional study

Beier D, Brzoska P, Khan MH. Indirect consequences of extreme weather and climate events and their associations with physical health in coastal Bangladesh: a cross-sectional study. Global Health Action. 2015;8(1): 29016.Background: Bangladesh is one of the countries in the world which is most prone to natural disasters. The overall situation is expected to worsen, since extreme weather and climate events (EWCE) are likely to increase in both frequency and intensity. Indirect consequences caused in the events' aftermath widen the range of possible adverse health outcomes. Objective: To assess the association of indirect consequences of EWCE and physical health. Design: We used recent cross-sectional self-reported data from 16 coastal villages in Bangladesh. A total of 980 households were surveyed using a structured questionnaire. The outcome of physical health was categorized into three groups, reflecting the severity of reported diseases by the respective source of treatment as a proxy variable (hospital/clinic for severe disease, other source/no treatment for moderate disease, and no disease). The final statistical analysis was conducted using multinomial logistic regression. Results: Severe diseases were significantly associated with drinking water from open sources [odds ratio (OR): 4.26, 95% confidence interval (CI): 2.25-8.09] and tube wells (OR: 2.39, 95% CI: 1.43-4.01), moderate harm by river erosion (OR: 6.24, 95% CI: 2.76-14.11), food scarcity (OR: 1.98, 95% CI: 1.16-3.40), and the perception of increased employment problems (OR: 2.19, 95% CI: 1.18-4.07). Moderate diseases were significantly associated with moderate harm by river erosion (OR: 2.65, 95% CI: 1.28-5.48) and fully experienced food scarcity (OR: 1.75, 95% CI: 1.16-2.63). For both categories, women and the elderly had higher chances for diseases. Conclusions: Indirect consequences of EWCE were found to be associated with adverse health outcomes. Basic needs such as drinking water, food production, and employment opportunities are particularly likely to become threatened by EWCE and, thus, may lead to a higher likelihood of ill-health. Intervention strategies should concentrate on protection and provision of basic needs such as safe drinking water and food in the aftermath of an event

Is antibacterial treatment intensity lower in elderly patients? A retrospective cohort study in a German surgical intensive care unit

Background: Demographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs). Antibacterial treatment is an important, often life-saving, aspect of intensive care but burdened by the associated antimicrobial resistance risk. Elderly patients are simultaneously at greater risk of infections and may be more restrictively treated because, generally, treatment intensity declines with age. We therefore described utilization of antibacterials in ICU patients older and younger than 80 years and examined differences in the intensity of antibacterial therapy between both groups. Methods: We analysed 17,464 valid admissions from the electronic patient data management system of our surgical ICU from April 2006 – October 2013. Antibacterial treatment rates were defined as days of treatment (exposed patient days) relative to patient days of ICU stay and calculated for old and young patients. Rates were compared in zero-inflated Poisson regression models adjusted for patients’ sex, mean SAPS II- and TISS-scores, and calendar years yielding adjusted rate ratios (aRRs). Rate ratios exceeding 1 represent higher rates in old patients reflecting greater treatment intensity in old compared to younger patients. Results: Observed antibacterial treatment rates were lower in patients 80 years and older compared to younger patients (30.97 and 39.73 exposed patient days per 100 patient days in the ICU, respectively). No difference in treatment intensity, however, was found from zero-inflated Poisson regression models permitting more adequate consideration of patient days with low treatment probability: for all antibacterials the adjusted rate ratio (aRR) was 1.02 (95%CI: 0.98–1.07). Treatment intensities were higher in elderly patients for penicillins (aRR 1.37 (95%CI: 1.26–1.48)), cephalosporins (aRR 1.20 (95%CI: 1.09–1.31)), carbapenems (aRR 1.35 (95%CI: 1.20–1.50)), fluoroquinolones (aRR 1.17 (95%CI: 1.05–1.30), and imidazoles (aRR 1.34 (95%CI: 1.23–1.46)). Conclusions: Elderly patients were generally less likely to be treated with antibacterials. This observation, however, did not persist in patients with comparable treatment probability. In these, antibacterial treatment intensity did not differ between younger and older ICU patients, for some antibacterial classes treatment intensity was even higher in the latter. Patient-level covariates are instrumental for a nuanced evaluation of age-effects in antibacterial treatment in the ICU

Malignancy rates in Crohn's disease patients with perianal fistula: A German retrospective cohort study

BACKGROUND Patients with inflammatory bowel disease are at increased risk of colorectal and extra-intestinal cancer. However, the overall cancer risk in patients with Crohn's disease (CD) with perianal fistulas (PF) (CPF) and those with CD without PF (non-PF CD) is unclear. OBJECTIVE To describe the prevalence and incidence of cancer in patients with CPF and non-PF CD, and to estimate incidence rate ratio (IRR) of cancer between CPF and non-PF CD groups. METHODS A retrospective cohort study was conducted using the German InGef (Institute for Applied Health Research Berlin) research database. Patients with a CD record and PF from 1 January 2013 to 31 December 2014 were identified and followed up from 1 January 2015 until the first occurrence of cancer, end of health insurance contributing data, death, or end of study period (31 December 2020). Prevalence of any type of cancer including patients with CD diagnosed with cancer in the selection period and incidence of cancer excluding patients with CD diagnosed with cancer in the selection period were calculated. RESULTS In total, 10,208 patients with CD were identified. Of 824 patients with CPF (8.1%), 67 had had a malignancy (6-year period crude malignancy prevalence 8.13% [95% confidence interval (CI) 6.36%-10.21%]), which was lower than patients with non-PF CD (19.8% [95% CI 19%-20.6%]). Incidence (per 100,000 person-years) in patients with CPF was 1184 (95% CI 879-1561) and in non-PF CD was 2365 (95% CI 2219-2519). There was no significant difference in the adjusted IRR of cancer for the CPF group compared with the non-PF CD group (0.83 [95% CI 0.62-1.10]; p = 0.219). CONCLUSION There was no significant difference in the incidence of any cancer in patients with CPF compared with non-PF CD. However, patients with CPF had a higher numerical risk of cancer than the general German population

ilastik: interactive machine learning for (bio)image analysis

We present ilastik, an easy-to-use interactive tool that brings machine-learning-based (bio)image analysis to end users without substantial computational expertise. It contains pre-defined workflows for image segmentation, object classification, counting and tracking. Users adapt the workflows to the problem at hand by interactively providing sparse training annotations for a nonlinear classifier. ilastik can process data in up to five dimensions (3D, time and number of channels). Its computational back end runs operations on-demand wherever possible, allowing for interactive prediction on data larger than RAM. Once the classifiers are trained, ilastik workflows can be applied to new data from the command line without further user interaction. We describe all ilastik workflows in detail, including three case studies and a discussion on the expected performance

Modelling human choices: MADeM and decision‑making

Research supported by FAPESP 2015/50122-0 and DFG-GRTK 1740/2. RP and AR are also part of the Research, Innovation and Dissemination Center for Neuromathematics FAPESP grant (2013/07699-0). RP is supported by a FAPESP scholarship (2013/25667-8). ACR is partially supported by a CNPq fellowship (grant 306251/2014-0)

Epidemiology and health care utilization of patients suffering from Huntington’s disease in Germany: real world evidence based on German claims data

Background: Huntington’s disease (HD) is a rare, genetic, neurodegenerative and ultimately fatal disease with no cure or progression-delaying treatment currently available. HD is characterized by a triad of cognitive, behavioural and motor symptoms. Evidence on epidemiology and management of HD is limited, especially for Germany. This study aims to estimate the incidence and prevalence of HD and analyze the current routine care based on German claims data. Methods: The source of data was a sample of the Institute for Applied Health Research Berlin (InGef) Research Database, comprising data of approximately four million insured persons from approximately 70 German statutory health insurances. The study was conducted in a retrospective cross-sectional design using 2015 and 2016 as a two-year observation period. At least two outpatient or inpatient ICD-10 codes for HD (ICD-10: G10) during the study period were required for case identification. Patients were considered incident if no HD diagnoses in the 4 years prior to the year of case identification were documented. Information on outpatient drug dispensations, medical aids and remedies were considered to describe the current treatment situation of HD patients. Results: A 2-year incidence of 1.8 per 100,000 persons (95%-Confidence interval (CI): 1.4–2.4) and a 2-year period prevalence of 9.3 per 100,000 persons (95%-CI: 8.3–10.4) was observed. The prevalence of HD increased with advancing age, peaking at 60–69 years (16.8 per 100,000 persons; 95%-CI: 13.4–21.0) and decreasing afterwards. The most frequently observed comorbidities and disease-associated symptoms in HD patients were depression (42.9%), dementia (37.7%), urinary incontinence (32.5%), extrapyramidal and movement disorders (30.5%), dysphagia (28.6%) and disorders of the lipoprotein metabolism (28.2%). The most common medications in HD patients were antipsychotics (66.9%), followed by antidepressants (45.1%). Anticonvulsants (16.6%), opioids (14.6%) and hypnotics (9.7%) were observed less frequently. Physical therapy was the most often used medical aid in HD patients (46.4%). Nursing services and speech therapy were used by 27.9 and 22.7% of HD patients, respectively, whereas use of psychotherapy was rare (3.2%). Conclusions: Based on a representative sample, this study provides new insights into the epidemiology and routine care of HD patients in Germany, and thus, may serve as a starting point for further research