Die minimalisierte versus konventionelle extrakorporale Zirkulation bei minimalinvasiven klappenchirurgischen Eingriffen

Die Herz-Lungen-Maschine wird seit ihrer Entwicklung 1954 in der Herzchirurgie eingesetzt. Durch sie sind viele herzchirurgische Eingriffe überhaupt erst möglich geworden. Zusätzlich wird ein übersichtliches und ruhiges Operationsfeld bereitet, ohne Unterbrechung der notwendigen Blutversorgung des Patienten während der Operation. Dabei ist sie Fluch und Segen zugleich, denn die extrakorporale Zirkulation kann mit einer Reihe unerwünschter Komplikationen einhergehen. Zusammengefasst werden diese als Postperfusionssyndrom beschrieben, einer Unterart des Systemic Inflammatory Response Syndrome (SIRS) und können sich klinisch in unterschiedlicher Weise manifestieren. Ein möglicher Grund hierfür ist der Kontakt zwischen körpereigenem Blut und der künstlichen Oberfläche verschiedener Komponenten der Herz-Lungen-Maschine. Weiterhin werden der Verdünnungseffekt aufgrund der notwendigen Vorfüllung (Primingvolumen) sowie der nicht unerhebliche Blut-Luft-Kontakt für das SIRS verantwortlich gemacht. Um die schädigenden Einflüsse zu reduzieren, ist man bestrebt, minimierte Systeme zu entwickeln, die eine deutliche Reduktion der Fremdoberfläche, des Blut-Luft-Kontaktes und des Primingvolumens aufweisen. Die Anwendung des minimierten Systems ließ sich im klinischen Einsatz trotz höherer Anforderungen sowohl an den Operateur als auch an den Kardiotechniker nahezu komplikationslos gestalten; die Sicherheit eines minimierten HLM-Systems ist bei gleichen intraoperativen Zeiten gegeben. Die Auswertung zeigte eine signifikant stärkere Hämodilution mit Anstieg der inflammatorischen Zytokine sowie eine erhöhte koagulatorische Aktivität, begleitet von erhöhter Fibrinolyse, in der Gruppe der konventionellen HLM, während eine gleichermaßen starke Hämolyse auftrat. Ebenso ist die eintretende Myokardschädigung vergleichbar. Das Syndrom des postoperativen Delirs tritt bei Patienten, welche mit einer konventionellen Herz-Lungen- Maschine operiert wurden, signifikant häufiger auf. Insgesamt kann also festgestellt werden, dass der Einsatz einer minimalisierten Herz-Lungen-Maschine zu einer Reduktion des mechanischen Traumas der Erythrozyten, der inflammatorischen Immunantwort, der neurologischen Komplikationen und einer Beeinträchtigung der Gerinnung führt. Die Patienten der Gruppe der minimalinvasiven Herz-Lungen-Maschine zeigten einen signifikant kürzeren Aufenthalt auf der Intensivstation sowie eine kürzere gesamtstationäre Verweildauer. Die minimalinvasive Herz-Lungen-Maschine hat somit ihren klinischen Vorteil in der von uns untersuchten Kohorte bewiesen

Development and validation of a multivariable risk prediction model for serious infection in patients with psoriasis receiving systemic therapy

BACKGROUND: Patients with psoriasis are often concerned about the risk of serious infection associated with systemic psoriasis treatments. OBJECTIVES: To develop and externally validate a prediction model for serious infection in patients with psoriasis within 1 year of starting systemic therapies. METHODS: The risk prediction model was developed using the British Association of Dermatologists Biologic Interventions Register (BADBIR), and the German Psoriasis Registry PsoBest was used as the validation dataset. Model discrimination and calibration were assessed internally and externally using the C-statistic, the calibration slope and the calibration in the large. RESULTS: Overall 175 (1·7%) out of 10 033 participants from BADBIR and 41 (1·7%) out of 2423 participants from PsoBest developed a serious infection within 1 year of therapy initiation. Selected predictors in a multiple logistic regression model included nine baseline covariates, and starting infliximab was the strongest predictor. Evaluation of model performance showed a bootstrap optimism-corrected C-statistic of 0·64 [95% confidence interval (CI) 0·60-0·69], calibration in the large of 0·02 (95% CI -0·14 to 0·17) and a calibration slope of 0·88 (95% CI 0·70-1·07), while external validation performance was poor, with C-statistic 0·52 (95% CI 0·42-0·62), calibration in the large 0·06 (95% CI -0·25 to 0·37) and calibration slope 0·36 (95% CI -0·24 to 0·97). CONCLUSIONS: We present the first results of the development of a multivariable prediction model. This model may help patients and dermatologists in the U.K. and the Republic of Ireland to identify modifiable risk factors and inform therapy choice in a shared decision-making process

Attitudes towards asylum seekers: Understanding differences between rural and urban areas

This paper examines spatial differences in the attitudes of the public towards asylum seekers using data from the British Social Attitudes Survey. Initial analysis reveals some statistically significant variations across geographical areas, with people living in London, the South East of England and Scotland displaying the most tolerant views. The spatial variations are then further investigated by considering differences between rural and different types of urban areas. The estimation of regression models enables a range of socio-demographic influences on attitudes to be examined including whether an individual is a foreign national, belongs to ethnic minority group and possesses a higher education qualification. Members of each of these groups are more concentrated in urban areas, especially London, thus accounting for part of the observed differentials. However, even after controlling for these and other factors, some significant differences remain between rural and some urban areas, especially large cities. We discuss potential explanations and conclude that having opportunities for meaningful social contact with asylum seekers and other immigrants is a key factor underlying some of the unexplained rural-urban differences in attitudes. Given increasing diversity in rural areas, it is recommended that policy makers and civil society organisations concerned about the impacts of negative attitudes on social and community cohesion should invest resources in creating opportunities for meaningful social contact between different groups

Perception and Impact of COVID-19 Pandemic in Psoriasis Patients: Data from the German PsoBest and the CoronaBest Registries

María José Valencia López,1,* Brigitte Stephan,1,* Anna Meineke,1 Sandra Wolf,1 Diamant Thaci,2 Ulrich Mrowietz,3 Valerie Andrees,1 Stephan Jeff Rustenbach,1 Kristian Reich,1 Linus Thalmann,1 Henriette Bogena,1 Petra Staubach,4 Ralph Michael von Kiedrowski,5 Matthias Augustin1 1Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; 2Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany; 3Psoriasis-Center, Department of Dermatology, University Medical Center Schleswig-Holstein, Kiel, Germany; 4Department of Dermatology and Allergy, University Medical Center Mainz, Mainz, Germany; 5Dermatological Practice Selters, Selters, Germany*These authors contributed equally to this workCorrespondence: Matthias Augustin, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, Hamburg, 20246, Germany, Tel +49 040 7410 55428, Fax +49 040 7410 55348, Email [email protected]: Limited data are available characterizing the impact of the SARS-CoV-2 pandemic on psoriasis care for patients in Germany.Objective: To analyze patient perception and impact of the pandemic on well-being and psoriasis management of German patients with moderate-to-severe psoriasis or psoriasis arthritis under systemic therapies.Methods: The CoronaBest registry captures events of SARS-CoV-2 infections and analyzes the impact of the pandemic on patients with psoriasis or psoriasis arthritis. In June 2020, and independently in February 2022, patients with psoriasis or psoriasis arthritis received a standardized questionnaire for current treatment, protective measures, well-being, and individual risks for COVID-19, among others.Results: Included were 4,194 patients in 2020 (mean age of 47.7 years and 41.8% women) and 4,818 patients in 2022 (mean age of 56.4 and 42.9% women). Treatment discontinuations were observed in 2.7% and 1.7% of patients in 2020 and 2022, respectively. In the vast majority of the cases (> 92%), no additional measures were taken concerning the management of psoriasis treatments in either 2020 or 2022. Those patients with changes reported most frequently: telephone calls instead of face-to-face visits (80.2%, in 2020 vs 40.5% in 2022) or more frequent controls (27.1%, 2020 vs 22.0%, 2022). A majority (66.7%, 2020, and 70.6%, 2022) did not perceive the virus as a considerable threat. The proportion of patients feeling well informed about COVID-19 by physicians increased from 42.6% in 2020 to 51.8% in 2022. About 81.1% of patients in 2020 and 67.5% in 2022 stated that their overall personal condition was not affected due to the pandemic. Physicians attributed no special risk of contracting SARS-CoV-2 in most of the patients.Conclusion: A high rate of systemic treatment persistence and awareness of risks and protective measures indicate that health care for psoriasis largely followed current national and international recommendations during the COVID-19 pandemic.Keywords: psoriasis, COVID-19, SARS-CoV-2, pandemic, patient perception, risk factor

Factors Associated with Receiving Biologics or Classic Systemic Therapy for Moderate-to-Severe Psoriasis: Evidence from the PSONET Registries.

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