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Jung‐König, Mona ; Füllenbach, Christoph ; Murphy, Michael F. ; Manzini, Paola ; Laspina, Stefan ; Pendry, Kate ; Mühling, Jörg ; Wikman, Agneta ; Humbrecht, Catherine ; Rigal, Jean‐Christophe ; Lasocki, Sigismond ; Folléa, Gilles ; Seifried, Erhard ; Müller, Markus M. ; Geisen, Christof ; Aranko, Kari ; Zacharowski, Kai ; Meybohm, Patrick
Background and objectives: Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.
Materials and methods: To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.
Results: Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.
Conclusion: Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.
Neef, Vanessa ; König, Sven ; Monden, Daniel ; Dubinski, Daniel ; Benesch, Anika ; Raimann, Florian ; Piekarski, Florian ; Ronellenfitsch, Michael Wilfried ; Harter, Patrick Nikolaus ; Senft, Christian ; Meybohm, Patrick ; Hattingen, Elke ; Zacharowski, Kai ; Seifert, Volker ; Baumgarten, Peter
Transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity, mortality and prolonged hospital length of stay (LOS). This retrospective single center study aims to identify the clinical outcome of RBC transfusions on skull base and non-skull base meningioma patients including the identification of risk factors for RBC transfusion. Between October 2009 and October 2016, 423 patients underwent primary meningioma resection. Of these, 68 (16.1%) received RBC transfusion and 355 (83.9%) did not receive RBC units. Preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%; p = 0.0015). In transfused patients, postoperative complications as well as hospital LOS was significantly higher (p < 0.0001) compared to non-transfused patients. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anaesthesiologists (ASA) physical status score (p = 0.0247), tumor size (p = 0.0006), surgical time (p = 0.0018) and intraoperative blood loss (p < 0.0001). Kaplan-Meier curves revealed significant influence on overall survival by preoperative anaemia, RBC transfusion, smoking, cardiovascular disease, preoperative KPS ≤ 60% and age (elderly ≥ 75 years). We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. Further studies evaluating the impact of preoperative anaemia management for reduction of RBC transfusion are needed to improve the clinical outcome of meningioma patients.
Krüger, Caroline ; Schäfer, Ingmar ; Bussche, Hendrik van den ; Baehr, Michael ; Bickel, Horst ; Fuchs, Angela ; Gensichen, Jochen ; Maier, Wolfgang ; Riedel-Heller, Steffi Gerlinde ; König, Hans-Helmut ; Dahlhaus, Anne Maren ; Schön, Gerhard ; Weyerer, Siegfried ; Wiese, Birgitt ; Renteln-Kruse, Wolfgang von ; Langebrake, Claudia ; Scherer, Martin
Background: The elderly population deals with multimorbidity (three chronic conditions) and increasinged drug use with age. A comprehensive characterisation of the medication – including prescription and over-the-counter (OTC) drugs – of elderly patients in primary care is still insufficient.
Objectives: This study aims to characterise the medication (prescription and OTC) of multimorbid elderly patients in primary care and living at home by identifying drug patterns to evaluate the relationship between drugs and drug groups and reveal associations with recently published multimorbidity clusters of the same cohort.
Methods: MultiCare was a multicentre, prospective, observational cohort study of 3189 multimorbid patients aged 65 to 85 years in primary care in Germany. Patients and general practitioners were interviewed between 2008 and 2009. Drug patterns were identified using exploratory factor analysis. The relations between the drug patterns with the three multimorbidity clusters were analysed with Spearman-Rank-Correlation.
Results: Patients (59.3% female) used in mean 7.7 drugs; in total 24,535 drugs (23.7% OTC) were detected. Five drug patterns for men (drugs for obstructive pulmonary diseases (D-OPD), drugs for coronary heart diseases and hypertension (D-CHD), drugs for osteoporosis (D-Osteo), drugs for heart failure and drugs for pain) and four drug patterns for women (D-Osteo, D-CHD, D-OPD and drugs for diuretics and gout) were detected. Significant associations between multimorbidity clusters and drug patterns were detectable (D-CHD and CMD: male: ρ = 0.376, CI 0.322–0.430; female: ρ = 0.301, CI 0.624–0.340).
Conclusion: The drug patterns demonstrate non-random relations in drug use in multimorbid elderly patients and systematic associations between drug patterns and multimorbidity clusters were found in primary care.
Scheich, Sebastian ; König, Rosalie ; Wilke, Anne ; Lindner, Sarah ; Reinheimer, Claudia ; Wichelhaus, Thomas Alexander ; Hogardt, Michael ; Kempf, Volkhard A. J. ; Kessel, Johanna ; Weber, Sarah ; Martin, Hans ; Bug, Gesine ; Serve, Hubert ; Steffen, Björn
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) offers potential cure to acute myeloid leukemia (AML) patients. However, infections with commensal bacteria are an important cause for non-relapse mortality (NRM). We have previously described the impact of multidrug-resistant organism (MDRO) colonization on the survival of allo-HSCT patients. In the aforementioned publication, according to consensus, we there did not consider the opportunistic gram-negative bacterium Stenotrophomonas maltophilia (S. maltophilia) to be an MDRO. Since rate of S. maltophilia colonization is increasing, and it is not known whether this poses a risk for allo-HSCT patients, we here analyzed here its effect on the previously described and now extended patient cohort. We report on 291 AML patients undergoing allo-HSCT. Twenty of 291 patients (6.9%) were colonized with S. maltophilia. Colonized patients did not differ from non-colonized patients with respect to their age, remission status before allo-HSCT, donor type and HSCT-comorbidity index. S. maltophilia colonized patients had a worse overall survival (OS) from 6 months up to 60 months (85% vs. 88.1% and 24.7% vs. 59.7%; p = 0.007) due to a higher NRM after allo-HSCT (6 months: 15% vs. 4.8% and 60 months: 40.1% vs. 16.2% p = 0.003). The main cause of mortality in colonized patients was infection (46.2% of all deaths) and in non-colonized patients relapse (58.8% of all deaths). 5/20 colonized patients developed an invasive infection with S. maltophilia. The worse OS after allo-HSCT due to higher infection related mortality might implicate the screening of allo-HSCT patients for S. maltophilia and a closer observation of colonized patients as outpatients.
Koeberle, Andreas ; Henkel, Arne ; Verhoff, Moritz ; Tausch, Lars ; König, Stefanie ; Fischer, Dagmar ; Kather, Nicole ; Seitz, Stefanie ; Paul, Michael ; Jauch, Johann ; Werz, Oliver
Age-related diseases, such as osteoarthritis, Alzheimer’s disease, diabetes, and cardiovascular disease, are often associated with chronic unresolved inflammation. Neutrophils play central roles in this process by releasing tissue-degenerative proteases, such as cathepsin G, as well as pro-inflammatory leukotrienes produced by the 5-lipoxygenase (5-LO) pathway. Boswellic acids (BAs) are pentacyclic triterpene acids contained in the gum resin of the anti-inflammatory remedy frankincense that target cathepsin G and 5-LO in neutrophils, and might thus represent suitable leads for intervention with age-associated diseases that have a chronic inflammatory component. Here, we investigated whether, in addition to BAs, other triterpene acids from frankincense interfere with 5-LO and cathepsin G. We provide a comprehensive analysis of 17 natural tetra- or pentacyclic triterpene acids for suppression of 5-LO product synthesis in human neutrophils. These triterpene acids were also investigated for their direct interference with 5-LO and cathepsin G in cell-free assays. Furthermore, our studies were expanded to 10 semi-synthetic BA derivatives. Our data reveal that besides BAs, several tetra- and pentacyclic triterpene acids are effective or even superior inhibitors of 5-LO product formation in human neutrophils, and in parallel, inhibit cathepsin G. Their beneficial target profile may qualify triterpene acids as anti-inflammatory natural products and pharmacological leads for intervention with diseases related to aging.
Kutter, Steffen ; Weiss, Manfred S. ; Wille, Georg ; Golbik, Ralph ; Spinka, Michael ; König, Stephan
The mechanism by which the enzyme pyruvate decarboxylase from yeast is activated allosterically has been elucidated. A total of seven three-dimensional structures of the enzyme, of enzyme variants or of enzyme complexes from two yeast species (three of them reported here for the first time) provide detailed atomic resolution snapshots along the activation coordinate. The prime event is the covalent binding of the substrate pyruvate to the side chain of cysteine 221, thus forming a thiohemiketal. This reaction causes the shift of a neighbouring amino acid, which eventually leads to the rigidification of two otherwise flexible loops, where one of the loops provides two histidine residues necessary to complete the enzymatically competent active site architecture. The structural data are complemented and supported by kinetic investigations and binding studies and provide a consistent picture of the structural changes, which occur upon enzyme activation.
Dávidová, Petra ; Müller, Michael ; Wenner, Yaroslava ; König, Clara ; Kenikstul, Ninel ; Kohnen, Thomas
Purpose: Filler injections for aesthetic purposes are very popular, but can have far-reaching and irreversible consequences. This report describes the course of a patient with devastating complications after glabellar hyaluronic acid injection, their pathomechanism, management and outcome.
Observations: A healthy, 43-year-old woman underwent her first hyaluronic acid injection in the glabella and went blind on her left eye immediately thereafter. Massaging of the injection area and observation were performed, before she presented with swelling of the left forehead and upper lid, ptosis, complete ophthalmoplegia and blindness in our hospital. Immediate massaging of the globe and systemic therapy including acetylsalicylic acid, tinzaparin sodium and cortisone was initiated and hyaluronidase injections in the injection area were performed. In the further course, the patient developed necrotic and hemorrhagic skin and mucosal lesions, lagophthalmos, anterior and posterior segment ischemia and globe hypotonia with consecutive globe deformation. In the follow-up of 2.5 months, lid swelling, lagophthalmos and ptosis resolved and keratopathy improved but blindness, skin lesions and strabismus with reduced eye motility were still present and madarosis and early enophthalmos were detected.
Conclusions and Importance: The outcome of ophthalmic artery occlusion after hyaluronic acid filler injection is poor. Sufficient knowledge about facial anatomy, the implementation of filler injections and the management of complications is essential for the practitioner. The patient should be clarified about potential and even rare risks of these procedures.
Sonntag, Michael ; Konnopka, Alexander ; Leichsenring, Falk ; Salzer, Simone ; Beutel, Manfred ; Herpertz, Stephan ; Hiller, Wolfgang ; Hoyer, Jürgen ; Joraschky, Peter ; Nolting, Björn ; Pöhlmann, Karin ; Stangier, Ulrich ; Strauß, Bernhard ; Willutzki, Ulrike ; Wiltink, Jörg ; Leibing, Eric ; König, Hans-Helmut
Objective: The aim of the study was to analyse the psychometric properties of the EQ-5D in patients with social phobia.
Methods: We used a sample of 445 patients with social phobia with five measurement points over a 30 month period. The discriminative ability of the EQ-5D was analysed by comparing the patients' responses with the general population and between different disease severity levels. For test-retest reliability we assessed the level of agreement in patients' responses over time, when there was no change in the Liebowitz Social Anxiety Scale (LSAS). Construct validity was analysed by identifying correlations of the EQ-5D with more specific instruments. For responsiveness we compared the means of EQ VAS/EQ-5D index anchored on improved (deteriorated) health status and computed effect sizes as well as a receiver operating characteristic (ROC) curve.
Results: Compared to the general population, patients with social phobia reported more problems in the dimensions "usual activities", "pain/discomfort", and "anxiety/depression" and less problems in "mobility" and "self-care". The EQ-5D was able to distinguish between different disease severity levels. The test-retest reliability was moderate (intraclass correlation coefficient > 0.6). Correlations between the EQ-5D and other instruments were mostly small except for correlations with Beck Depression Inventory. The EQ-5D index seemed to be more responsive than the EQ VAS, but with only medium effect sizes (0.5 < effect size < 0.8) in the British EQ-5D index and only significant in patients with improved health status. The ROC analysis revealed no significant results.
Conclusions: The EQ-5D was moderately reliable and responsive in patients with improved health status. Construct validity was limited.
Trial registration: Current controlled trials ISRCTN53517394.
Neef, Vanessa ; König, Sven ; Monden, Daniel ; Ronellenfitsch, Michael Wilfried ; Harter, Patrick Nikolaus ; Senft, Christian ; Meybohm, Patrick ; Hattingen, Elke ; Zacharowski, Kai ; Seifert, Volker ; Baumgarten, Peter
Background: Transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity, mortality and prolonged hospital length of stay (LOS). This retrospective single center study aims to identify the impact of RBC transfusions on skull-base and non-skull-base meningioma patients including the identification of risk factors for RBC transfusion.
Methods: From October 2009 - October 2016 we retrospectively analyzed 423 primary meningioma patients undergoing surgery for primary meningioma resection our department.
Results: Of these 423 patients, 68 (16.1%) received RBC transfusion and 355 (83.9%) did not receive RBC units. Preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%; p = 0.0015). In transfused patients, postoperative complications as well as hospital LOS was significantly higher (p < 00001) compared to non-transfused patients. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anesthesiologists (ASA) physical status score (p = 0.0247), tumor size (p = 0.0006), surgical time (p = 0.0018) and intraoperative blood loss (p < 0.001). Kaplan-Meier curves revealed significant influence on overall survival by preoperative anaemia, RBC transfusion, smoking, cardiovascular disease, preoperative KPS ≤ 60% and age (elderly ≥ 75 years).
Conclusion: We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. Further studies evaluating the impact of preoperative anaemia management for reduction of RBC transfusion are needed to improve clinical outcomes of meningioma patients.