Healthcare Effectiveness as a Wellbeing Factor. Workforce

Wellbeing of citizens is a multifactorial and a multi-aspect process. One of the key aspects is health. Despite the fact that health depends on the healthcare system on 15-20% only, it is vital to improve its efficiency. Authors highlight that, on the one hand, healthcare as social-economical system must be targeted on citizens’ health improvement, and on the other hand, it must obey economic processes. Modernization and reforming of healthcare system demand effectiveness increase of all types of resources in this context; but authors imply that the key ones are the workforce resources. A conducted monitoring of Russian Federation citizens’ health on several diseases as well as an evaluation of Russian Federation workforce resources usage through 2003-2013 (level of an institution (federal, regional, municipal), provision, staff ratio (physicians and nurses), its correspondence to staff schedule, qualifications level, etc. were used as the criteria) and also a comparison of federal districts healthcare system effectiveness (using Minmax method) did not show synonymous dynamics.Increase in staff usage effectiveness is a factor of healthcare system effectiveness raise, which is a factor of citizens wellbeing improving

Editorial - eHealth Solutions for the Integrated Healthcare

Information and communication technologies (ICT) bring a whole new dimension into the healthcare arena by introducing electronic media that open the door to the use of new methodologies. Today, ICT support electronic gathering, storage, processing, and exchange of information to treat disease, prevent illness, promote healthy lifestyle, manage patients with chronic illness, and many other applications [1, 2]. Electronic health (eHealth) has the ability to bridge gaps between patients and doctors, patients and relatives, doctors and administrative staff, and so on. Also, eHealth helps to overcome barriers by means that are significantly different from traditional healthcare solutions [3]. It has paved the way for the adoption of sophisticated forms of healthcare provision based on mobile devices and context-awareness, such as mobile health (mHealth) [4] and smart health (sHealth) [5], which require unprecedentedly complex integration strategies.The advances in healthcare and ICT serve the society as a whole (e.g., patients, healthcare professionals, relatives, and governments) and support the sustainability of healthcare systems. New health ICT systems offer opportunities to improve the effectiveness and efficiency of healthcare services through innovative approaches in clinical service delivery, personalized health, and public health, with a wide impact on the well-being of individuals. Clearly, the study of the integration of healthcare solutions based on ICT is a hot topic that deserves attention.Despite the well-known potential benefits of adopting eHealth solutions, approaches to ICT implementation used in other industries have had limited success in the healthcare sector. This is not surprising, especially if we take into account the complexity and nature of the healthcare ecosystem. Hence, the implementation of ICT in practice remains difficult and implies many challenges at different levels, involving patients, healthcare providers, and healthcare organizations [6]. Some of the most significant challenges for the adoption of eHealth (and its mHealth and sHealth derivations) are inherent to the complexity of the healthcare system. Take, for example, the interoperability problem, which is an old problem inherited from previous nonelectronic healthcare infrastructures that is also common in a variety of other domains [7]. Also, ethical issues such as privacy protection are a common problem that affects healthcare in general, but it is magnified by the use of ICT [8, 9]. Last but not least, the integration of new technologies based on artificial intelligence, smartphones, neural networks, and big data analysis (to name a few) into the healthcare sector poses magnificent challenges for the current healthcare system’s limitations, which the scientific community is struggling to overcome. In this sense, the feasibility of many applications, policies, and data concerning the costs, effects, and effectiveness of eHealth and telemedicine are at stake. There is a lack of research-based, empirically-tested models to progress towards large-scale use of ICT in the health sector.In this special issue, we have undertaken the task of collecting a set of articles that address some of the aforementioned challenges faced by current eHealth infrastructure and applications.Monitoring long-distance fast walking in daily activities is challenging due to the lack of specific scientific equipment. In the literature, most gait experiments are performed by walking on treadmills. Unfortunately, gait data acquired on treadmills are quite different from the real ones gotten on the ground. The article by W.-F. Wang et al. “Study on Tripping Risks in Fast Walking through Cadence-Controlled Gait Analysis” approaches this problem by performing all walking tests intended to reveal important clues for tripping risks in fast walking in a flat and straight pathway. The results show that fast walking with bigger strides and lower cadence is the best way to keep safety on ordinary ground.Similarly, the monitoring of vital signs is a very active research area. In the article “Analysis of a Pulse Rate Variability Measurement Using a Smartphone Camera,” A. Bánhalmi et al. approach the problem of using off-the-shelf technology (e.g., smartphones) to gather biometric data efficiently and reliably. More specifically, the authors analyse the possibility of using a smartphone camera to measure the pulse rate variability of patients. Their experiments show that photoplethysmography has high accuracy and does not differ more from ECG than ECG channels themselves. This study opens the door to simplified remote monitoring of the heart function.In a related topic, haemovigilance is attracting attention. It is the set of surveillance procedures covering the entire blood transfusion chain, from the donation and processing of blood and its components, through to their provision and transfusion to patients, and including their follow-up [10]. In the article “The Evolving Role of Information Technology in Haemovigilance Systems,” A. Ramoa et al. study 23 haemovigilance organizations in their use of information systems. They find an increasing number of these organizations choosing web-based solutions to take care of haemovigilance. There are still some nonelectronic notification systems, but they lack in data completeness and consistency. The authors support the development of electronic haemovigilance systems and conclude that national haemovigilance systems could benefit from international guidelines for their implementation and maintenance.There are a number of approaches to develop functionalities for medical decision support systems, which involve some extra efforts from users, thus limiting the spread of such systems in practice. V. L. Malykh and S. V. Rudetskiy provide a review of general approaches to decision support systems development based on nonreduced big clinical data in their article “Approaches to Medical Decision-Making Based on Big Clinical Data.” The article discusses different approaches to building a medical decision support system based on big data. The authors sought to abstain from any data reduction and apply universal teaching and big data processing methods independent of disease classification standards. The paper assesses and compares the accuracy of recommendations among three options: case-based reasoning, simple single-layer neural network, and probabilistic neural network. Further, the paper substantiates the assumption regarding the most efficient approach to solving the specified problem.In a similar research line, knowledge-based systems can notably improve the management of distributed eHealth systems, where communication and understanding between medical professionals and different tasks become essential. Usually, medical texts are full of references to medical entities, which could be utilized by knowledge-based medical decision support systems. However, the diverse and ambiguous nature of linguistic ME forms are challenging and hinder automatic medical entities recognition and linking, hence requiring tedious work to annotate data and define features. Xu et al. propose an unsupervised framework for recognizing and linking medical entities mentioned in Chinese online medical texts. Their solution is the first complete unsupervised solution for Chinese medical text with both medical entity recognition and linking, which has considerable value in many applications such as medical knowledge-based construction and expansion, semantic comprehension of medical text, and medical Q&A systems.Interacting with healthcare systems and applications is an emerging topic that deserves special attention when dealing with disabled people. The article “Projection mapping user interface for disabled people” by J. Gelšvartas et al. seeks to help improve user interfaces for people with motoric or speech disabilities through projection mapping. This technique makes possible to create a natural augmented reality information presentation environment. The authors provide a detailed description of a camera-projector system calibration procedure. The described system performs tabletop object detection and automatic projection mapping. The proposed system was tested with real users and, overall, the interface was evaluated positively by the system users, which in most cases were able to learn how to use the system very quickly. The article clearly opens ways for new ideas to produce support systems for motoric or speech disabled people.Last but not least, the constant aging of the population raises a new set of problems for eHealth systems. In coming years, age-related and degenerative diseases will become the main burden for public health systems. Lauraitis et al. address the problem of identifying Huntington’s disease (HD) at its early stage, so that elder patients could benefit from future medical interventions that may help delaying the progress of the disease. They created a computerized behavioural model, which allows predicting an impaired reaction condition for HD patients. The model is embodied in a mobile application available on smartphones and tablet PCs, which allows predicting the functional capacity level of subjects by performing an on-screen touch-based test, thus providing a low-cost alternative to the currently used HD symptom assessment procedures.The integration of eHealth solutions is far from simple, and it must capture the attention of the healthcare research community for the next years. The adoption of new mobile and context-aware technologies will multiply the benefits for patients and doctors but, at the same time, it will increase the complexity of the eHealth systems and it will be associated to major challenges. In this special issue, we have gathered some relevant examples of research studies that have put their efforts towards this direction. Notwithstanding, there is a lot of unused potential in information systems to support eHealth and its mHealth and sHealth derivations.It has become clear that technology is not the limiting factor for future progress in healthcare. On the contrary, the main limitations come from the lack of innovativeness of ICT use and the lack of incentives from users and communities to adopt new technology-based solutions for the integrated healthcare. We hope that these limitations will be solved in the next years and that the articles collected in this special issue will contribute with their grain of sand to the overall improvement of healthcare systems worldwide.</p

Synergy between medical informatics and bioinformatics: facilitating genomic medicine for future health care

Medical Informatics (MI) and Bioinformatics (BI) are two interdisciplinary areas located at the intersection between computer science and medicine and biology, respectively. Historically, they have been separated and only occasionally have researchers of both disciplines collaborated. The completion of the Human Genome Project has brought about in this post genomic era the need for a synergy of these two disciplines to further advance in the study of diseases by correlating essential genotypic information with expressed phenotypic information. Biomedical Informatics (BMI) is the emerging technology that aims to put these two worlds together in the new rising genomic medicine. In this regard, institutions such as the European Commission have recently launched several initiatives to support a new combined research agenda, based on the potential for synergism of both disciplines. In this paper we review the results the BIOINFOMED study one of these projects funded by the E

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Immune-mediated hemolytic anemia and immune-mediated thrombo-cytopenia in dogs, a prospective study (1997 - 1999)

1.Einleitung und Literaturteil 2\. Material und Methoden 3\. Eigene Ergebnisse 4\. Diskussion 5\. Zusammenfassung und Summary 6\. Anhang LiteraturverzeichnisVI. Zusammenfassung In dieser prospektiven Studie wurden alle Patienten mit immunbedingter Thrombozytopenie (ITP) und immunhamolytischer Anamie (IHA), die innerhalb von 2 Jahren (Januar 1997-Januar 1999) in der Klinik fur kleine Haustiere der FU Berlin vorgestellt wurden, im Hinblick auf Symptome, Diagnostik und Krankheitsverlauf ausgewertet. Immunbedingte Thrombozytopenie: Eine Thrombozytopenie mit Tc-Zahlen &lt; 150.000/µl wurde bei insgesamt 268 Hunden festgestellt, davon hatten 15 Hunde (5,6 %) eine primare ITP (pITP). Die Diagnose pITP wurde aufgrund des Vorliegens einer Thrombozytopenie, dem Ausschluß anderer Erkrankungen sowie dem positiven Nachweis Tc-gebundener Antikorper gestellt. Insgesamt waren Hunde 11 verschiedener Rassen erkrankt. Mehrfach vertreten waren Cockerspaniel (n=3) und Golden Retriever (n=3). Das Alter zu Erkrankungsbeginn lag zwischen 0,5 und 10,0 Jahren (&amp;#61638; 7,3 Jahre). Vier Tiere waren mannlich, 10 weiblich und 1 weiblich kastriert. 12 Hunde zeigten Anzeichen einer erhohten Blutungsneigung, wie Petechien in Haut und Schleimhauten (n=10), Zahnfleischbluten (n=4), Melana (n=3), Ekchymosen (n=1) und Epistaxis (n=1). Die Tc-Zahlen lagen zwischen 0 - 74.000 /µl (&amp;#61638; 10.400/µl), 93 % der Hunde hatten Tc-Zahlen &lt; 30.000/µl. Das mittlere Plattchenvolumen (MPV) wurde bei 6 Hunden bestimmt und schwankte zwischen 5,6 und 9,1 fl (&amp;#61638; 7,4 fl; Normalbereich 3,9-6,1 fl). Eine Anamie mit Hkt &lt; 35 % lag bei 5 Hunden vor. In der Rontgen- und Ultraschalluntersuchung wurde bei 7 Hunden eine Splenomegalie, bei einem eine Hepatomegalie und bei 2 Hunden eine Hepatosplenomegalie festgestellt. Die Patienten wurden mit Prednisolon (n=9), Prednisolon/Azathioprin (n=3) und Prednisolon/Azathioprin/Vincristin (n=3) behandelt. Erster Anstieg der Tc- Zahlen uber 50.000/µl wurde bei 13 Hunden nach 2-11 Tagen (&amp;#61638; 4,4 Tage) festgestellt. Bei einem Hund stiegen die Tc-Zahlen nie uber 25.000/µl, ein Patient hatte bereits initial Tc-Zahlen &gt; 50.000/µl. Funf Hunde mit kontinuierlichem Tc-Anstieg konnten nur einen begrenzten Zeitraum (9-38 Tage, &amp;#61638; 20,4 Tage) beobachtet werden. Nach telefonischer Auskunft der Besitzer waren diese Patienten ca. ein Jahr nach Ende der Studie noch am Leben. Unter Medikamentation erlitten 2 Hunde, nach Absetzen aller Medikamente zeigten ebenfalls 2 Hunde ein Rezidiv. Die Rezidivrate bei 15 Hunden betrug somit 27 %. Betrachtet man nur die 10 uber einen langeren Zeitraum (59 ý 588 Tage, &amp;#61638; 234 Tage) kontrollierten Patienten, so betrug die Rezidivrate 40 %. Funf Hunde erfuhren wahrend des Behandlungszeitraumes (59 ý208 Tage) kein Rezidiv und hatten nach Absetzen der Medikamente (48-580 Tage, &amp;#61638; 356 Tage) oder unter anhaltend niedriger Prednisolonbehandlung (59-119 Tage) Tc-Zahlen im Referenzbereich. Ein Hund wurde wegen Pankreatitis und DIC euthanasiert. Die Letalitatsrate betrug damit 6,7 %. Bei 17 Hunden mit Grundkrankheit (Tc-Zahlen 1.400-119.000/µl, &amp;#61638; 31.200/µl) und positivem Nachweis Tc-gebundener Antikorper wurde die Verdachtsdiagnose sITP gestellt. Als Grundkrankheiten lagen Ehrlichiose (4), Ehrlichiose/Babesiose (1), Ehrlichiose/Polyarthritis (1), Babesiose (2), Babesiose/Leishmaniose (2), Lymphom (2), Abszeß (1), Prostatitis (1), Lebertumor (1) und Milztumor (1) vor; bei einem Hund trat die Thrombozytopenie nach einer Bluttransfusion auf. Neben der Behandlung der Grundkrankheit wurden 3 Hunde (Ehrlichiose 2, Ehrlichiose/Polyarthritis 1) auch immunsuppressiv behandelt. Ein positives Testergebnis Tc-gebundener Antikorper war demnach nicht spezifisch fur eine pITP und andere Ursachen fur eine ITP bedurfen der sorgfaltigen Abklarung. Der Nachweis Tc-gebundener Antikorper war bei 17 Hunden (Tc-Zahlen 2.700-110.000/µl, &amp;#61638; 48.900/µl) mit Grundkrankheit (Milztumor/Hamangiosarkom 4, DIC 3, lymphatische Leukamie 2, Hamophilie 2, Lymphom unter Chemotherapie 1, Cumarinintoxikation 1, Milzhamatome 1 und Milztorsion 1) negativ. Bei 2 Hunden mit negativem Testresultat, die bereits 1 bzw. 4 Wochen mit Glukokortikoiden vorbehandelt wurden, konnte keine Grundkrankheit festgestellt werden. Bei den 42 gesunden Kontrollhunden war der Nachweis Tc-gebundener Antikorper negativ. Immunhamolytische Anamie: Bei 352 Hunden wurde eine Anamie mit Hkt &lt; 35 % festgestellt. Davon waren 15 Hunde (4,3 %) an primarer IHA (pIHA) erkrankt. Die Diagnose pIHA wurde aufgrund von positivem Coombs-Test (n=13), makroskopischer Objekttrageragglutination (n=15), Spharozyten (n=10), dem Auschluß anderer Erkrankungen und dem Ansprechen auf die immunsuppressive Therapie gestellt. Bei 2 Hunden, die nicht immunsuppressiv vorbehandelt waren, war der Coombs-Test negativ. Hier stutzte sich die Diagnose auf die makroskopische Objekttrageragglutination (n=2), Spharozyten (n=1), dem Ansprechen auf die immunsuppressive Therapie (n=2) und auf den Ausschluß anderer Erkrankungen (n=2). Die Hunde gehorten 6 verschiedenen Rassen an, 6 waren Mischlingshunde. Mehrfach vertreten waren Cockerspaniel (n=2) und Bobtail (n=2). Das Erkrankungsalter lag zwischen 1-10 Jahren (&amp;#61638; 5,3 Jahre). 9 Tiere waren mannlich oder mannlich-kastriert, 6 Hunde weiblich oder weiblich- kastriert. Der Hkt bei Erstvorstellung lag zwischen 10 ý 23 % (&amp;#61638; 16,6 %), wobei 10 Hunde (66 %) eine schwere Anamie mit Hkt &lt; 20 % aufwiesen. Neun Hunde hatten auch eine Thrombozytopenie (Tc-Zahlen 11.800-143.000/µl), davon 3 wegen DIC. Die differenzierten Coombs-Test-Ergebnisse (n=12) ergaben eine Beteiligung von IgG (n=7), IgG + C3 (n=4) und IgG + IgM + C3 (n=1). Ein Hund hatte ein unspezifisch positives Coombs-Testergebnis. Von 7 Patienten wurden die Titer von IgG bestimmt, die zwischen 1:40 und 1:1280 lagen. Die C3-Titer lagen zwischen 1:20-1:40. Es bestand kein Zusammenhang zwischen Antikorperklasse und Titerhohe des Coombs-Testes und dem Verlauf und der Schwere der Erkrankung. Die korrigierten Retikulozytenzahlen lagen zwischen 0 ý 23,6 % (&amp;#61638; 4,0 %), wobei mit Retikulozytenzahlen &lt; 1,0 % die Anamie bei 5 Hunden bei Erstvorstellung nicht regenerativ war. Eine Serumbilirubinerhohung mit Werten zwischen 0,7 ý 33 mg/dl (&amp;#61638; 4,6 mg/dl) wiesen 11 Hunde auf. An extravaskularer Hamolyse litten 14, an intravaskularer Hamolyse ein Hund. Eine Erhohung unterschiedlicher Leberenzyme (AP, ALT, AST, GLDH) lag bei 12 Tieren, eine DIC bei 3 Hunden vor. In der Rontgen- und Ultraschalluntersuchung zeigten 7 Hunde eine Splenomegalie, 4 eine Hepatomegalie und 2 Tiere eine Hepatosplenomegalie. Die immunsuppressive Therapie erfolgte mit Prednisolon (n=6), Prednisolon/Azathioprin (n=8) und Prednisolon/Cyclophosphamid (n=1). Bei je einem Hund mit Prednisolon/Azathioprin-Behandlung wurde das Azathioprin durch Cyclophosphamid bzw. Ciclosporin ersetzt. Vier Hunde konnten nur einen kurzen Zeitraum (10-39 Tage, &amp;#61638; 19 Tage) verfolgt werden und zeigten einen Hkt-Anstieg &gt; 25 % in der 2. (n=2), 3. (n=1) bzw. 4. Woche. Diese Hunde waren am Ende der Studie nach telefonischer Auskunft noch am Leben. Funf Hunde starben bzw. wurden in der Anfangsphase der Erkrankung euthanasiert. Sechs Hunde wurden langerfristig beobachtet (10-89 Wochen, &amp;#61638; 32,7 Wochen). Sie zeigten in der 2. (n=4) bzw. 3. Woche (n=2) einen Hkt-Anstieg &gt; 25 %. Unter Medikamentation erlitten 2 Patienten, nachdem sie 12 bzw. 20 Wochen unter Therapie standen, einen Ruckfall. Der eine Patient wurde mit respiratorischen Symptomen euthanasiert. Der 2. Patient erholte sich vom dem Rezidiv, war 34 Wochen in Behandlung und wies 10 Wochen nach dem Ende der Studie stabile Hkt-Werte auf. Damit lag die Rezidivrate unter 15 Hunden mit pIHA bei 13 %. Betrachtet man nur die langerfristig betreuten Hunde (n=6), so ergab sich eine Rezidiv-rate von 33 %. Einer der langerfristig untersuchten Hunde war 25 Wochen in Behandlung, zeigte kontinuierlichen Hkt-Anstieg und wies 64 Wochen nach Absetzen der Medikamente stabile Hkt-Werte auf. Weitere 3 der langerfristig kontrollierten Hunde zeigten kontinuierlichen Hkt-Anstieg und standen am Ende der Studie noch unter Medikamenten. Insgesamt uberlebten 6 Hunde die Erkrankung nicht. Das ergab eine Letalitatsrate von 40 %. Eine sIHA wurde bei 7 Hunden (Hkt 17-28 %; &amp;#61638; 23,6 %) aufgrund eines positiven Coombs-Tests vermutet. Die Patienten waren an Leishmaniose (n=2), Leishmaniose/Babesiose, Ehrlichiose, Lebernekrose und Leberzellkarzinom (je n=1) erkrankt oder standen unter Medikamenten (Phenobarbital, n=1). Alle Patienten mit sIHA zeigten eine unterschiedlich ausgepragte Objekttrageragglutination, die bei einem Patienten bei 4°C makroskopisch persistierte. Bei 2 Tieren fanden sich Spharozyten im Blutausstrich. Bei 25 Hunden (Hkt 11-35 %, &amp;#61638; 22,1 %) mit pITP (8), Babesiose (3), Ehrlichiose (3), chronischer Niereninsuffizienz (3), gastrointestinalen Tumoren (3), Hamophilie (2), hamorrhagischer Gastroenteritis (1), lympho- plasmazellularer Enteritis (1) und lymphatischer Leukamie (1) war das Coombs- Test-Ergebnis negativ. Immunbedingte Thrombozytopenie und immunhamolytische Anamie (Evansý Syndrom): Bei 9 Hunden lag neben einer pITP zusatzlich eine pIHA vor. Insgesamt waren 5 Hunde 3 verschiedener Rassen (Cockerspaniel und Riesenschnauzer, je n=2) und 4 Mischlingshunde erkrankt. Das Alter zu Erkrankungsbeginn lag zwischen 2 und 14 Jahren (&amp;#61638; 7,3 Jahre). 5 Tiere waren mannlich, 3 weiblich und eines weiblich-kastriert. Anzeichen einer erhohten Blutungsneigung wie Melana (n=2), Petechien in Haut und Schleimhauten, Ekchymosen, Hamatome, blutigen Durchfall und blutigen Scheidenausfluß (je n=1) zeigten 5 Hunde. Die Tc-Zahlen lagen zwischen 10.000-143.000/µl (&amp;#61638; 46.900/µl); bei 5 Hunden lagen sie &lt; 30.000/µl. Der Nachweis Tc-gebundener Antikorper war bei allen 9 Hunden positiv. Das MPV wurde bei 5 Hunden bestimmt und lag zwischen 1,8 und 5,3 fl (&amp;#61638; 3,3 fl). Alle 9 Hunde waren anamisch; eine schwere Anamie Hkt &lt; 20 % wiesen 6 Tiere auf. Eine makroskopische Objekttrageragglutination zeigten alle 9, Spharozyten wiesen 5 Hunde auf. Mit dem Coombs-Test wurden die Antikorperklassen IgG (n=8) und IgG + C3 (n=1) nachgewiesen. Alle Patienten zeigten eine extravaskulare Hamolyse. Die korrigierte Retikulozytenzahl lag zwischen 0,4 ý 6,8 % (&amp;#61638; 2,6 %); bei einem Hund war die Anamie nicht regenerativ. Eine Serumbilirubinerhohung wiesen 2 Hunde auf. In der Rontgen- und Ultraschalluntersuchung zeigten 5 Hunde eine Splenomegalie und 2 eine Hepatosplenomegalie. Die immunsuppressive Therapie erfolgte mit Prednisolon (n=2) und Prednisolon/Azathioprin (n=7), wobei bei einem Hund nach Tc-Abfall und nachfolgend fehlendem Tc-Anstieg das Azathioprin gegen Ciclosporin ausgetauscht wurde. Erster Anstieg der Tc-Zahlen uber 50.000/µl wurde bei 7 Hunden 2-6 Tage (&amp;#61638; 3,4 Tage) nach Therapiebeginn beobachtet. Zwei Hunde hatten bereits Tc-Zahlen uber 50.000/µl. Einen Hkt-Ansteig zeigten alle Hunde in der 1. (n=1), 2. (n=6) und 3. (n=2) Behandlungswoche. Ein Patient konnte nur 13 Tage verfolgt werden. Es fehlen samtliche Daten uber den Verlauf. Unter Medikamentation erlitten 3 Hunde nach 16, 84 und 119 Tagen einen Tc- Abfall. Bei 2 Hunden erfolgte gleichzeitig ein Hkt-Abfall. Bei dem 3. Patienten erfolgte ein Hkt-Abfall zeitlich versetzt (18 Wochen) nach dem Tc- Abfall. 235 Tage nach Absetzen der Medikamente erlitt ein Patienten einen Tc- und Hkt-Abfall. Damit lag die Rezidivrate (Tc- bzw. Hkt-Abfall) bei 50 %. Diese 4 Hunde mit Rezidiven und 3 Tiere mit kontinuierlichem Tc- und Hkt- Anstieg standen am Ende der Studie noch unter Therapie. Ein Patient mit kontinuierlichem Tc-und Hkt-Anstieg wurde wegen Harninkontinenz beim Haustierarzt euthanasiert. Die Letalitatsrate lag bei 11 %.VII. Summary: Immune-mediated hemolytic anemia and immune-mediated thrombo- cytopenia in dogs, a prospective study (1997 ý1999) In this prospective study all patients with immune-mediated thrombocytopenia (ITP) and immune-hemolytic anemia (IHA), which were presented within two years (January 1997 - January 1999) at the Clinic for Small Animals, Free University of Berlin, were studied and clinical findings, diagnostics and treatment results were evaluated. Immune-mediated thrombocytopenia Thrombocytopenia (&lt; 150,000/µl) was observed in 268 dogs, primary ITP was diagnosed in 15 of these dogs (5,6 %). The diagnosis pITP was based on low platelet counts, exclusion of other diseases and a positive platelet-bound antibody test result and response to immunosuppressive therapy. The dogs belonged to 11 different breeds, Cocker Spaniels (n=3) and Golden Retrievers (n=3) were overrepresented. The age when first signs of disease were noted, ranged from 0.5 ý 10.0 years (mean 7.3 years). Four dogs were male, 10 female and 1 female-spayed. Clinical signs of hemorrhage were observed in 12 dogs: petechiae (n=10), gingival bleeding (n=4), melaena (n=3), ecchymoses (n=1) and epistaxis (n=1). Platelet counts ranged from 0 ý 74,000/µl (mean 10,400/µl), 93 % of the dogs had platelet counts &lt; 30,000/µl. The mean platelet volume (MPV) measured in 6 dogs ranged from 5.6 to 9.1 fl (mean 7.4 fl; reference range 3.9-6.1 fl). Five dogs were anemic (Hematocrit &lt; 35 %). Radiography and ultrasonography revealed splenomegaly in 7 dogs, hepatomegaly in 1 and hepatosplenomegaly in 2 dogs. The patients were treated with prednisolone (n=9), prednisolone/azathioprine (n=3) and prednisolone/azathioprine/vincristine (n=3). An increase of platelet counts above 50,000/µl was noted in 13 dogs after 2 to 11 days (mean 4.4 days). In 1 dog, platelet counts never exceeded 25,000/µl during course of disease, 1 dog had an initial platelet count &gt; 50,000/µl. In 5 dogs with increasing platelet counts the follow-up period was short (9 to 38 days, mean 20.4 days). All of these dogs were alive approximately 1 year after the end of the study. Two dogs showed a decrease in platelet counts under therapy, 2 dogs after finishing drug ther-apy. Recurrence rate was 27 % for all patients, and 40 % if only the 10 patients, which were followed for a longer period (59 to 588 days, mean 234 days), were included. Five dogs showed no recurrence of disease under therapy (59 to 208 days) and had platelet counts in the normal range after finishing therapy (48 to 580 days, mean 356 days) or under immunosuppressive therapy. One dog was euthanized due to pancreatitis and DIC. The mortalitiy rate was 6.7 %. An underlying disease was diagnosed in 17 dogs (platelet counts 1,400 to 119,000/µl, mean 31,200/ µl) with a positive platelet-bound antibody test result suggesting a secondary ITP (sITP). Twelve of the 17 dogs had an infectious disease (babesiosis, ehrlichiosis, leishmaniasis, abscess, prostatits), 4 had neoplasia (lymphoma, liver or splenic tumor) and 1 dog developed thrombocytopenia after a blood transfusion. In 9 of 12 dogs with infections platelet counts increased after treatment of the underlying disease, 3 dogs with ehrlichiosis also received prednisone. The platelet-bound antibody test was negative in 15 dogs (platelet-numbers 11,000-110,000/µl, mean 54,300/µl) with splenic tumor/hemangiosarcoma (4), DIC (3), lymphatic leukemia (2), hemophilia (2), lymphoma under chemotherapy (1), rodenticide intoxication (1), splenic hematoma (1), and splenic torsion (1). In 42 healthy control dogs the platelet-bound antibody test was negative. Immune-mediated hemolytic anemia 352 dogs were anemic (Hematocrit, Hct &lt; 35 %), 15 of these dogs (4.3 %) had a primary immune-mediated anemia (pIMHA). The diagnosis pIMHA was based on a positive Coombsý test (n=13), macroscopic slide agglutination (n=15), spherocytes (n=10), exclusion of other diseases and response to immunosuppressive treatment. In 2 dogs the Coombsý test was negative. In these dogs the diagnosis pIMHA was based on slide agglutination (n=2), spherocytes (n=1), response to immunosuppressive treatment (n=2) and exclusion of other diseases (n=2). The dogs belonged to 6 different breeds, 6 dogs were mixed-breed. The Cocker Spaniel (n=2) and bobtail (n=2) were overrepresented. At the time of first presentation the dogs were between 1 to 10 years (mean 5.3 years) old. Nine animals were male or male-castrated, 6 female or female-castrated. The Hct ranged from 10 to 23 % (mean 17 %); 10 dogs had a severe anemia with a Hct &lt; 20 %. Nine dogs were thrombopenic (patelet counts from 11,800 to 143,000/µl), 3 due to DIC. The antibody classes of the differentiated Coombsý test (n=12) were IgG (n=7), IgG + C3 (n=4), and IgG + IgM + C3 (n=1). An undifferentiated Coombsý test was performed in one dog (positive result). The IgG titres were determined for 7 patients. The IgG titers ranged from 1:40 to 1:1280, the C3 titres from 1:20 to 1:40. No correlation was found between antibody class and antibody titer of the Coombsý test and the course and severity of the disease. The corrected reticulocyte counts ranged from 0 to 23.6 % (mean 4.0 %); in 5 dogs with reticulocyte counts &lt; 1.0 % the anemia was non-regenerative at the time of first presentation. Eleven dogs had elevated serum bilirubin levels (0.7 to 33 mg/dl, mean 4.6 mg/l). Fourteen dogs had extravascular, one dog intravascular hemolysis. Serum activity of several liver enzymes (AP, ALT, AST, GLDH) were elevated in 12 dogs. Based on radiography and ultrasonography, 7 dogs had splenomegaly, 4 hepatomegaly and 2 had hepatosplenomegaly. The dogs were treated with different immunosuppressive drugs: prednisolone (n=6), prednisolone/azathioprine (n=8) and prednisolone/cyclophosphamide (n=1). In 2 dogs, azathioprine was replaced by cyclophosphamide or cyclosporine. In four dogs, the course of disease could be followed only for a short time (10 to 39 days, mean 19 days). A rise of the Hct &gt; 25 % was noted in the second (n=2), the third (n=1) or the fourth (n=1) week after beginning therapy. All of these dogs were still alive at the end of the study. Five dogs died or were euthanized before an increase of the Hct was noted. Six dogs were followed for a longer period (10 to 89 weeks, mean 32.7 weeks). A Hct rise &gt; 25 % was noted in the second (n=4) or the third (n=2) week. Two dogs had recurrence of disease 12 or 20 weeks after beginning of therapy. One dog was euthanized with respiratory symptoms. The other patient was treated for 34 weeks, 10 weeks after finishing therapy the Hct was stable. The rate of recurrence was 13 %. The recurrence rate was 33 %, however, if only dogs were included that could be followed for a longer period. One dog was treated for 25 weeks, 64 weeks after finishing therapy the Hct was stable. Three dogs with increasing or normal Hct still received immunosuppressive drugs at the end of the study. Overall 6 dogs died or were euthanized. The mortalitiy rate was 40 %. In 7 dogs (Hct 17 to 28 %, mean 24 %) with a positive Coombsý test, secondary IMHA (sIMHA) was suggested. The patients suffered from leishmaniasis (n=2), leishmaniasis/babesiosis (n=1), ehrlichiosis (n=1), liver necrosis (n=1), liver cell carcinoma (n=1) or received drugs (phenobarbital n=1). All dogs with sIMHA showed slide agglutination, which persisted in one dog at 4 °C. Two dogs had spherocytes. In 25 anemic dogs (Hct 11 to 35 %, mean 22 %) with pITP (n=8), babesiosis (n=3), ehrlichiosis (n=3), chronic renal insufficiency (n=3), gastrointestinal tumor (n=3), hemophilia (n=2), hemorrhagic gastroenteritis (n=1), lymphoplasmacellular enteritis (n=1), and lymphatic leukemia (n=1) the Coombsý test was negative. Immune-mediated thrombocytopenia and immune-mediated hemolytic anemia (Evansý Syndrom) A pITP and pIMHA was diagnosed in 9 dogs. The dogs belonged to 3 different breeds and 4 were mixed-breed. The age when first signs of disease were noted ranged from 2 ý 14 years (mean 7.3 years). Five of the dogs were male, 3 female and 1 female-spayed. Five dogs showed an increased bleeding tendency with melaena (n=2), petechiae and ecchymoses, hematoma, hemorrhagic diarrhoe and bloody vaginal discharge (each n=1). The platelet counts ranged from 10,000 ý 143,000/µl (mean 46,900/µl). Five dogs had platelet counts &lt; 30,000/µl. The results of the platelet-bound antibody test were positive in all 9 dogs. The MPV measured in 5 dogs ranged from 1.8 to 5.3 fl (median 3.3 fl). All 9 dogs were anemic. Six dogs had a severe anemia with a Hct &lt; 20 %. Nine of the dogs showed macroscopic slide agglutination, five dogs had spherocytes. The antibody classes of the differentiated Coombsý test were IgG (n=8) and IgG + C3 (n=1). All patients showed an extravascular hemolysis. The corrected reticulocyte counts ranged from 0.4 to 6.8 % (mean 3.5 %), in one dog the anemia was non-regenerative. Two dogs had elevated serum bilirubin levels. Based on radiography and ultrasonography, 5 dogs had a splenomegaly and 2 had a hepatosplenomegaly. The patients were treated with prednisolone (n=2), prednisolone/azathioprine (n=7) and in 1 dog azathioprine was replaced by cyclosporine. An increase of platelet counts above 50,000/µl was noted in 7 dogs after 2-6 days (mean 3.4 days). A rise of Hct was noted in 9 dogs in the first (n=1), the second (n=6) or the third (n=2) week after beginnig of treatment. In one dog, the course of disease could be followed only for a short time (13 days). This dog was lost for follow-up. Three dogs, that still received immunosuppressive treatment at the end of the study showed a decrease in platelet counts after 16, 84 and 119 days. Two dogs had a d