Prognostische Bedeutung pleuraler Defekte in der Lunge bei Patienten mit tiefer Beinvenenthrombose: Eine prospektive sonographische Studie bei 211 Patienten

Einleitung: Die klinische Diagnose einer Lungenembolie (LE) wird lediglich in 20-30% vor dem Tode diagnostiziert, d.h. zwei Drittel aller Lungenembolien werden vom Kliniker nicht diagnostiziert. Die Pulmonalisarterienangiographie war lange Zeit der diagnostische Goldstandard in der Diagnostik der LE. Aktuell hat die Spiral-Computertomographie die Pulmonalisarterien- angiographie abgelöst. Die Sonographie wird in den "Leitlinien" nicht erwähnt. Aufgrund akustisch-physikalischer Gegebenheiten an der Lunge kommt es zu einer fast vollständigen Reflexion der Schallwellen. Die Pleura stellt sich sonographisch als "echoreiches scharfes Reflexband" dar. Nach Verschluß einer peripheren Subarterie kommt es durch Sauerstoffmangel zu einem Zusammenbruch der Surfactant-Produktion und Einstrom von interstitieller Flüssigkeit und Erythrozyten in den Alveolarraum (Hämorrhagie). Sonographisch erkennt man "pleurale Defekte". Der Embolus selbst ist sonographisch nicht darstellbar. Bei zentralen großen Embolien wird die Lungenperipherie über Kolleteralen der a. bronchiales versorgt. Durch Defragmentierung des zentralen Embolus und Ausschwemmung thrombotischen Materials in die Peripherie entstehen oft Hämorrhagien, die mit der Sonographie erkannt werden. Ziel der Arbeit: Prüfung des diagnostischen Stellenwertes der Sonographie in der Diagnose einer Pulmonalarterienembolie durch Nachweis pleuraler Defekte sowie Prüfung der klinischen/prognostischen Bedeutung dieser pleuralen Defekte. Patienten und Methode: In die Studie wurden n = 211 Patienten mit einer sonographisch diagnostizierten tiefen Beinvenenthrombose (TBVT) aufgenommen. Anschließend wurden alle Patienten prospektiv sonographisch am Thorax untersucht. Die Patienten wurden in 3 Gruppen aufgeteilt: 1. klinisch asymptomatisch für eine LE; 2. klinisch symptomatisch für eine LE; 3. klinisch symptomatisch für eine LE mit intensivmedizinischer Betreuung. Ergebnisse: 1. Bei 40,3% der Patienten der 1. Gruppe wurden "pleurale Defekte" diagnostiziert, die mit peripheren Signalembolien vereinbar sind. Der Vergleich der Überlebenskurven Patienten mit/ohne pleurale Defekte war gleich und statistisch nicht relevant. Schlußfolgerung: "Pleurale Defekte" (Signalembolien) bei klinisch asymptomatischen Patienten für eine LE mit TBVT haben keine klinische Bedeutung. 2. 82% der Patienten mit klinischen Verdacht auf eine LE hatten "pleurale Defekte", im Sinne einer LE. Die Ergebnisse sind mit anderen Studien vergleichbar. 3. 22% der Patienten des gesamten Patientenkollektivs wurden nicht entsprechend den allgemeinen Leitlinien zur Behandlung einer TBVT oder LE behandelt. Der Vergleich der Überlebenskurven regelrecht/nicht regelrechte Behandlung war statistisch signifikant

Performance of different data sources in identifying adverse drug events in hospitalized patients

Purpose: The incidence of adverse drug events (ADE) is an important parameter in determining the quality of medical care. We identified the probability that a specific data source would identify ADEs in patients on the oncology ward, that could be assigned to one substance. Methods: We captured all medical adverse events (AE) from five different data sources. Each AE was determined to be drug-related according to the WHO criteria and classified according to the severity, category, and causality of the ADE. Results: The study recorded 129 patients with 252 hospitalizations over a 5-month period. A total of 3,341 medical events were captured and resulted in 1,121 ADEs. In 122 patients, at least one ADE (95%) was observed. Only 39 hospitalizations were believed not to have an ADE (15%). No ADE was captured by all data sources. The patient record captured 550, the nursing record 569, the laboratory tests 387, the questionnaire 63, and the event monitoring during grand rounds 141 ADEs. Only the nursing record and the laboratory tests had a significantly different probability of observing indicative ADEs. Conclusion: For all AEs reported in the data sources, physicians and nurses were the best source for ADEs. Data sources differed in identifying indicative ADEs and were influenced by specific patient parameter

Comparative evaluation of three clinical decision support systems: prospective screening for medication errors in 100 medical inpatients

Purpose: Clinical decision support systems (CDSS) are promoted as powerful screening tools to improve pharmacotherapy. The aim of our study was to evaluate the potential contribution of CDSS to patient management in clinical practice. Methods: We prospectively analyzed the pharmacotherapy of 100 medical inpatients through the parallel use of three CDSS, namely, Pharmavista, DrugReax, and TheraOpt. After expert discussion that also considered all patient-specific clinical information, we selected apparently relevant alerts, issued suitable recommendations to physicians, and recorded subsequent prescription changes. Results: For 100 patients with a median of eight concomitant drugs, Pharmavista, DrugReax, and TheraOpt generated a total of 53, 362, and 328 interaction alerts, respectively. Among those we identified and forwarded 33 clinically relevant alerts to the attending physician, resulting in 19 prescription changes. Four adverse drug events were associated with interactions. The proportion of clinically relevant alerts among all alerts (positive predictive value) was 5.7, 8.0, and 7.6%, and the sensitivity to detect all 33 relevant alerts was 9.1, 87.9, and 75.8% for Pharmavista, DrugReax and TheraOpt, respectively. TheraOpt recommended 31 dose adjustments, of which we considered 11 to be relevant; three of these were followed by dose reductions. Conclusions: CDSS are valuable screening tools for medication errors, but only a small fraction of their alerts appear relevant in individual patients. In order to avoid overalerting CDSS should use patient-specific information and management-oriented classifications. Comprehensive information should be displayed on-demand, whereas a limited number of computer-triggered alerts that have management implications in the majority of affected patients should be based on locally customized and supported algorithm

Optimized Distillation Profiles for Heavy-Light Spectroscopy

It has been demonstrated that distillation profiles can be employed to build optimized quarkonium interpolators for spectroscopy calculations in lattice QCD. We test their usefulness for heavy-light systems on (3+1)-flavor ensembles with mass-degenerate light and a charm quark in the sea in preparation for a future $D\bar{D}$-scattering analysis. The additional cost of light inversions naturally leads to the question if knowledge of optimal profiles can be used to avoid superfluous computations. We show such optimal profiles for different lattice sizes and pion masses and discuss general trends. Furthermore, we discuss the handling of momenta in this framework

Plasma Factor XIII Activity in Patients with Disseminated Intravascular Coagulation

The objective of this study was to investigate the correlation between factor XIII (FXIII) activity and disseminated intravascular coagulation (DIC) parameters and also to evaluate the clinical usefulness of DIC diagnosis. Citrated plasma from eighty patients with potential DIC was analyzed for FXIII activity. The primary patient conditions (48 male and 32 female, mean age, 51 years) were malignancy (n = 29), infection (n = 25), inflammation (n = 6), heart disease (n = 3), thrombosis (n = 2), injury (n = 2), and other miscellaneous conditions (n = 13). FXIII testing was performed using the CoaLinkTM FXIII Incorporation Assay Kit (PeopleBio Inc.). Among 80 patients who were suspected to have DIC based on clinical analysis, 46 (57.5%) fulfilled the overt DIC criteria (DIC score > = 5) according to the International Society of Thrombosis and Haemostasis. FXIII levels in the plasma were significantly decreased in overt DIC compared to non-overt DIC patients (mean 75.1% and 199.7% respectively, p < 0.0001). Interestingly, we found a significant inverse correlation between DIC scores and FXIII activity. In addition, FXIII activity significantly correlated with other hemostatic markers that included platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, and D-dimer. FXIII levels were significantly lower in patients with liver or renal dysfunction. In conclusion, FXIII cross-linking activity measurements may have differential diagnostic value as well as predictive value in patients who are suspected to have DIC

Treatment of Marburg and Ebola hemorrhagic fevers: A strategy for testing new drugs and vaccines under outbreak conditions.

The filoviruses, Marburg and Ebola, have the dubious distinction of being associated with some of the highest case-fatality rates of any known infectious disease-approaching 90% in many outbreaks. In recent years, laboratory research on the filoviruses has produced treatments and vaccines that are effective in laboratory animals and that could potentially drastically reduce case-fatality rates and curtail outbreaks in humans. However, there are significant challenges in clinical testing of these products and eventual delivery to populations in need. Most cases of filovirus infection are recognized only in the setting of large outbreaks, often in the most remote and resource-poor areas of sub-Saharan Africa, with little infrastructure and few personnel experienced in clinical research. Significant political, legal, and socio-cultural barriers also exist. Here, we review the present research priorities and environment for field study of the filovirus hemorrhagic fevers and outline a strategy for future prospective clinical research on treatment and vaccine prevention

Academic Impact of a Public Electronic Health Database: Bibliometric Analysis of Studies Using the General Practice Research Database

BACKGROUND: Studies that use electronic health databases as research material are getting popular but the influence of a single electronic health database had not been well investigated yet. The United Kingdom's General Practice Research Database (GPRD) is one of the few electronic health databases publicly available to academic researchers. This study analyzed studies that used GPRD to demonstrate the scientific production and academic impact by a single public health database. METHODOLOGY AND FINDINGS: A total of 749 studies published between 1995 and 2009 with 'General Practice Research Database' as their topics, defined as GPRD studies, were extracted from Web of Science. By the end of 2009, the GPRD had attracted 1251 authors from 22 countries and been used extensively in 749 studies published in 193 journals across 58 study fields. Each GPRD study was cited 2.7 times by successive studies. Moreover, the total number of GPRD studies increased rapidly, and it is expected to reach 1500 by 2015, twice the number accumulated till the end of 2009. Since 17 of the most prolific authors (1.4% of all authors) contributed nearly half (47.9%) of GPRD studies, success in conducting GPRD studies may accumulate. The GPRD was used mainly in, but not limited to, the three study fields of "Pharmacology and Pharmacy", "General and Internal Medicine", and "Public, Environmental and Occupational Health". The UK and United States were the two most active regions of GPRD studies. One-third of GRPD studies were internationally co-authored. CONCLUSIONS: A public electronic health database such as the GPRD will promote scientific production in many ways. Data owners of electronic health databases at a national level should consider how to reduce access barriers and to make data more available for research