Die Bedeutung einfacher Parameter zur Beurteilung des metabolischen Risikos bei chirurgischen Patienten - Einfluss auf die Klinik- und Langzeitletalität

Einleitung: Geeignete einfache Parameter zur Erkennung ernährungsmedizinischer Risikopatienten sind in der Chirurgie weiterhin in der Diskussion. Patienten und Methoden: In einer prospektiven Untersuchung wurden im Jahr 2000 1000 konsekutive allgemein- und viszeralchirurgische Patienten des Klinikum St. Georg Leipzig bei der stationären Aufnahme auf ihren Ernährungsstatus untersucht. Eine schwere Mangelernährung wurde beim Vorliegen eines der folgenden Kriterien definiert: BMI <18.0 kg/m² Gewichtsverlust >10% in den letzten 3 bis 6 Monaten Serum-Albumin <30g/l (bei fehlenden Anzeichen für eine Leber- oder Nierenfunktionseinschränkung) Ergebnisse: Bei 86 Patienten (8.6%) fand sich eine schwere Mangelernährung. Bei 33 Patienten (38.4%) lag eine maligne Erkrankung vor. Nur 14 (16.3%) der Patienten waren allein durch den BMI <18kg/m² aufgefallen, 47 (54.7%) allein durch Gewichtsverlust und 11 (12.8%) allein durch ein erniedrigtes Serum-Albumin. Kein Patient erfüllte alle Kriterien. 8 Patienten (9.3%) verstarben während des stationären Aufenthaltes, insgesamt 16 (18.6%) innerhalb der ersten 6 Monate. In den darauffolgenden Jahren bis 2007 waren 50 Patienten (58.1%) – mit Alterskorrektur 40 (46.5%) verstorben. Die stationäre Letalität lag 4-5x höher als die Referenzwerte des statistischen Bundesamts im entsprechenden Zeitraum. Schlussfolgerung: Es konnte gezeigt werden, dass mit einfachen ernährungsmedizinischen Parametern chirurgische Risikopatienten definiert werden können. Die untersuchten Parameter sind 2006 mit geringer Modifikation in die Definition des “severe nutritional risk“ der Europäischen Gesellschaft für klinische Ernährung und Metabolismus (ESPEN) eingegangenen. Die so identifizierten Patienten bedürfen einer über die Phase der stationären Behandlung hinausreichenden ernährungsmedizinischen Behandlung.Purpose: In order to identify surgical patients with nutritional risk appropriate parameters are a matter of discussion. Patients and Methods: In the year 2000 1000 general surgical patients of the community hospital St. Georg Klinikum Leipzig prospectively and consecutively underwent assessment of nutritional status. Severe malnutrition was defined in case of presence of at least one of the following criteria: BMI 10% within the last 3 to 6 months, serum albumin <30g/l (no hepatic or renal dysfunction). Results: 86 patients (8.6%) were identified according to the criteria of severe malnutrition. 33 patients (38.4%) suffered from malignancy. 14 patients (16.3%) were identified only by a BMI <18kg/m², 47 (54.7%) only by weight loss, and 11 (12.8%) only by low serum albumin. No patient met all criteria. 8 patients (9.3%) died during hospital stay, 16 (18.6%) during the first six months, and up to 2007 50 (58.1%) – corrected for age 40 (46.5%). Hospital mortality was 4-5 times higher than the official statistical reference data for Germany for this time period. Conclusion: The data clearly show, that surgical metabolic risk patients can be easily identified. In 2006, the parameters were taken with a slight modification (BMI <18.5kg/m² for the definition of “severe nutritional risk“ of the European Society for Clinical Nutrition and Metabolism (ESPEN). These patients obviously require special nutritional care longer than the hospital stay

Analysis for purchasing and financing productive equipment: staff study.; Management Services technical study, no. 4

https://egrove.olemiss.edu/aicpa_guides/1168/thumbnail.jp

Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study

Background Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0- to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years. Methods We conducted a cross-sectional study including 594 children aged 6-month- 6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children’s stool and conducted a survey with children’s caregivers. We employed the hierarchical logistic regression model to explore the predictors of stunting among 25–72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6–24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers’ height, the overall duration of breastfeeding, birthweight, child’s history of diarrhea and mean socio-economic score. Results The prevalence of stunting was significantly higher among the 6–24 months old children (13.3%) compared to the children aged 25–72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6–24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother’s height significantly decreased the odds of stunting among the children 25–72- months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups. Conclusions The study results highlight the significance of mother’s height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region

Adapting continuing medical education for post-conflict areas: assessment in Nagorno Karabagh - a qualitative study

Background: One of the major challenges in the current century is the increasing number of post-conflict states where infrastructures are debilitated. The dysfunctional health care systems in post-conflict settings are putting the lives of the populations in these zones at increased risk. One of the approaches to improve such situations is to strengthen human resources by organizing training programmes to meet the special needs in post-conflict zones. Evaluations of these training programmes are essential to assure effectiveness and adaptation to the health service needs in these conditions. Methods: A specialized qualitative evaluation was conducted to assess and improve a post-conflict continuing medical education (CME) programme that was conducted in Nagorno Karabagh. Qualitative research guides were designed for this post-conflict zone that included focus group discussions with physician programme participants and semi-structured in-depth interviews with directors of hospitals and training supervisors. Results: Saturation was achieved among the three participating groups in the themes of impact of participation in the CME and obstacles to application of obtained skills. All respondents indicated that the continuing medical education programme created important physician networks absent in this post-conflict zone, updated professional skills, and improved professional confidence among participants. However, all respondents indicated that some skills gained were inapplicable in Nagorno Karabagh hospitals and clinics due to lack of appropriate medical equipment, qualified supporting human resources and facilities. Conclusion: The qualitative research methods evaluation highlighted the fact that the health care human resources training should be closely linked to appropriate technologies, supplies, facilities and human resources available in post-conflict zones and identified the central importance of creating health professional networks and professional confidence among physicians in these zones. The qualitative research approach most effectively identifies these limitations and strengths and can directly inform the optimal adjustments for effective CME planning in these difficult areas of greatest need

Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans

RATIONALE: Purpura fulminans in adults is a rare but devastating disease. Its pathophysiology is not well known. OBJECTIVES: To understand the pathophysiology of skin lesions in purpura fulminans, the interplay between circulating blood and vascular alterations was assessed. METHODS: Prospective multicenter study in four intensive care units. Patients with severe sepsis without skin lesions were recruited as control subjects. MEASUREMENTS AND MAIN RESULTS: Twenty patients with severe sepsis and purpura fulminans were recruited for blood sampling, and skin biopsy was performed in deceased patients. High severity of disease and mortality rates (80%) was observed. Skin biopsies in purpura fulminans lesions revealed thrombosis and extensive vascular damage: vascular congestion and dilation, endothelial necrosis, alteration of markers of endothelial integrity (CD31) and of the protein C pathway receptors (endothelial protein C receptor, thrombomodulin). Elevated plasminogen activating inhibitor-1 mRNA was also observed. Comparison with control patients showed that these lesions were specific to purpura fulminans. By contrast, no difference was observed for blood hemostasis parameters, including soluble thrombomodulin, activated protein C, and disseminated intravascular coagulation markers. Bacterial presence at the vascular wall was observed specifically in areas of vascular damage in eight of nine patients tested (including patients with Streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, and Pseudomonas aeruginosa infection). CONCLUSIONS: Thrombi and extensive vascular damage with multifaceted prothrombotic local imbalance are characteristics of purpura fulminans. A "vascular wall infection" hypothesis, responsible for endothelial damage and subsequent skin lesions, can be put forward

Mast Cells Granular Contents Are Crucial for Deep Vein Thrombosis in Mice

Rationale: Deep vein thrombosis (DVT) and its complication pulmonary embolism have high morbidity reducing quality of life and leading to death. Cellular mechanisms of DVT initiation remain poorly understood. Objective: We sought to determine the role of mast cells (MCs) in DVT initiation and validate MCs as a potential target for DVT prevention. Methods and Results: In a mouse model, DVT was induced by partial ligation (stenosis) of the inferior vena cava. We demonstrated that 2 strains of mice deficient for MCs were completely protected from DVT. Adoptive transfer of in vitro differentiated MCs restored thrombosis. MCs were present in the venous wall, and the number of granule-containing MCs decreased with thrombosis. Pharmacological depletion of MCs granules or prevention of MC degranulation also reduced DVT. Basal plasma levels of von Willebrand factor and recruitment of platelets to the inferior vena cava wall after DVT induction were reduced in MC-deficient mice. Stenosis application increased plasma levels of soluble P-selectin in wild-type but not in MC-deficient mice. MC releasate elevated ICAM-1 (intercellular adhesion molecule-1) expression on HUVEC (human umbilical vein endothelial cells) in vitro. Topical application of compound 48/80, an MC secretagogue, or histamine, a Weibel–Palade body secretagogue from MCs, potentiated DVT in wild-type mice, and histamine restored thrombosis in MC-deficient animals. Conclusions: MCs exacerbate DVT likely through endothelial activation and Weibel–Palade body release, which is, at least in part, mediated by histamine. Because MCs do not directly contribute to normal hemostasis, they can be considered potential targets for prevention of DVT in humans