Search

A B S T R A C T Background: Acute kidney injury (AKI) frequently occurs following transcatheter aortic valve implantation (TAVI) and has been related to a worse outcome. We investigated the importance of contrast medium composition, either iso-osmolar (IOCM) or low-osmolar (LOCM) and assessed predictors for AKI after TAVI. Methods and results: We assessed AKI in 203 TAVI patients treated mainly with trans-femoral implantation and analgosedation. A total of 100 patients received IOCM and 103 LOCM. AKI was defined according to the Valve Academic Research Consortium. Following TAVI, 39 patients (19.2%) developed AKI; 17.0% of the IOCM and 21.4% of the LOCM group (p = 0.43). The only independent predictor for AKI was baseline serum creatinine [odds ratio (OR) 0.26, 95% confidence interval (CI) 0.01–0.64, p = 0.002]. Patients with advanced AKI (stages 2 and 3) post-TAVI had significantly higher mortality at 2 years (log rank p < 0.001), whereas patients with AKI stage 1 had a similar long-term outcome to non-AKI patients. Conclusions: Following TAVI, we observed no difference in the occurrence of AKI between IOCM and LOCM. Baseline creatinine was the only independent predictor of AKI, and patients who developed advanced AKI had significantly higher mortality at 2 years.

Current guidelines consider severe systolic left ventricular dysfunction [ejection fraction (EF) ≤20 %; left ventricular dysfunction (LVD)] a contraindication for transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the efficacy and safety of TAVI in this extreme risk subset of patients.The study population (253 patients) was divided into two groups; the LVD group [21 patients with left ventricular ejection fraction (LVEF) ≤20 %] and the control group (232 patients with LVEF20 %). TAVI was generally performed transfemorally under analgosedation without mechanical circulatory support. Clinical and hemodynamic variables, as well as procedural and follow-up outcomes, were compared, and all events were defined according to the Valve Academic Research Consortium criteria for event definition. Mean EF in the LVD group was 18.3 ± 2.9 % compared to 50.9 ± 11.3 % in the control group. Patients in the LVD group were younger, more commonly males, had higher logistic EuroSCORE and lower mean aortic pressure gradients. Immediate procedural mortality was low and similar in both groups (0 vs. 2.2 % in the LVD and control group, respectively, p = 0.49). At 30 days, post-procedural vascular and bleeding complications as well as strokes were similar, but all-cause mortality was higher in the LVD group (14.3 vs. 3.4 %, p = 0.05). In the survivors of the LVD group, New York Heart Association functional class and LVEF significantly improved at 30 days and 6 months. Survival at 1 and 2 years was 70.2 vs. 86.0 % and 56.1 vs. 78.3 % in the LVD and control group, respectively (log-rank p = 0.03).TAVI without mechanical circulatory support appears feasible, safe and effective in patients with severe aortic stenosis and severe LVD, but short- and long-term mortality remain high. TAVI should be considered a viable treatment option in this subset of extremely compromised patients.

In general, the prevalence of diseases is low in primary care. Therefore, the positive predictive value of diagnostic tests is lower than in hospitals where patients are highly selected. In addition, the patients present with milder forms of disease; and many diseases might hide behind the initial symptom(s). These facts lead to diagnostic uncertainty which is somewhat inherent to general practice. This narrative review discusses different sources of and reasons for uncertainty and strategies to deal with it in the context of the current literature. Fear of uncertainty correlates with higher diagnostic activities. The attitude towards uncertainty correlates with the choice of medical speciality by vocational trainees or medical students. An intolerance of uncertainty, which still increases as medicine is making steady progress, might partly explain the growing shortage of general practitioners. The bio-psycho-social context appears to be important to diagnostic decision-making. The effect of intuition and heuristics are investigated by cognitive psychologists. It is still unclear whether these aspects are prone to bias or useful, which might depend on the context of medical decisions. Good communication is of great importance to share uncertainty with the patients in a transparent way and to alleviate shared decision-making. Dealing with uncertainty should be seen as an important core component of general practice and needs to be investigated in more detail to improve the respective medical decisions.

Ziel dieser Studie war es, einen Fragebogen zum Umgang mit diagnostischer Unsicherheit zu entwickeln und zu validieren. Die exploratorische Faktorenanalyse mit 228 Fragebögen ergab vier Skalen mit heterogener interner Konsistenz. Auch wurden mittels weiterer Fragebögen signifikante Korrelationen zwischen Persönlichkeitseigenschaften, der emotionalen Reaktion und dem Umgang mit diagnostischer Unsicherheit errechnet. Die zur Beantwortung des Fragebogens genannten Patientenfälle verdeutlichten die Vielseitigkeit von diagnostischer Unsicherheit im hausärztlichen Alltag. The aim was to develop a questionnaire to describe how general practitioners (GPs) deal with uncertainty to gain more insight into the decisional process. The association of personality traits with medical decision making was investigated additionally. The final questionnaire was administered to 228 GPs. Factorial validity was calculated with explorative factor analysis. The items could be assigned to four scales with varying internal consistency. Personality traits were associated with diagnostic reasoning and communication with patients. The case vignettes illustrated the versatility of uncertainty in daily practice.

NF-{kappa}B is a key regulator of innate and adaptive immunity and is implicated in the pathogenesis of AKI. The cell type-specific functions of NF-{kappa}B in the kidney are unknown; however, the pathway serves distinct functions in immune and tissue parenchymal cells. We analyzed tubular epithelial-specific NF-{kappa}B signaling in a mouse model of ischemia-reperfusion injury (IRI)-induced AKI. NF-{kappa}B reporter activity and nuclear localization of phosphorylated NF-{kappa}B subunit p65 analyses in mice revealed that IRI induced widespread NF-{kappa}B activation in renal tubular epithelia and in interstitial cells that peaked 2-3 days after injury. To genetically antagonize tubular epithelial NF-{kappa}B activity, we generated mice expressing the human NF-{kappa}B super-repressor I{kappa}B{alpha}{delta}N in renal proximal, distal, and collecting duct epithelial cells. Compared with control mice, these mice exhibited improved renal function, reduced tubular apoptosis, and attenuated neutrophil and macrophage infiltration after IRI-induced AKI. Furthermore, tubular NF-{kappa}B-dependent gene expression profiles revealed temporally distinct functional gene clusters for apoptosis, chemotaxis, and morphogenesis. Primary proximal tubular cells isolated from I{kappa}B{alpha}{delta}N-expressing mice and exposed to hypoxia-mimetic agent cobalt chloride exhibited less apoptosis and expressed lower levels of chemokines than cells from control mice did. Our results indicate that postischemic NF-{kappa}B activation in renal tubular epithelia aggravates tubular injury and exacerbates a maladaptive inflammatory response.

Hintergrund: Diagnostische Unsicherheit ist vor allem im hausärztlichen Bereich ein zentrales Thema. Als erste Ansprechpartner der Patienten werden Hausärzte häufig mit unspezifischen Symptomen konfrontiert. Darüber hinaus findet die tägliche Arbeit im sogenannten Niedrigprävalenzbereich[zum vollständigen Text gelangen Sie über die oben angegebene URL], 49. Kongress für Allgemeinmedizin und Familienmedizin

Significant aortic regurgitation (AR) has been reported in 20% of patients undergoing transfemoral aortic valve implantation (TAVI) and has been associated with increased mortality. Depending on the population included and the type of implanted prosthesis, several anatomical and procedural factors have been linked with increased risk of post-TAVI AR. While the impact of patients' gender on this complication, is still contradictory. We sought to assess the impact of patients' gender on the risk of significant AR after TAVI.We included 323 consecutive patients (136 men) who underwent transfemoral implantation of either self-expandable or balloon-expandable prostheses for treatment of symptomatic aortic stenosis.After TAVI 52 patients (16.1%) had AR grade ≥ 2/4 as evaluated by angiography. They were more frequently male (59.6% vs. 40.4%, P = 0.005), received self-expandable (94.2% vs. 63.5%, P0.001) and bigger size prostheses (28 ± 1.9 vs. 27.3 ± 2.1 mm, P = 0.028) and had reduced left ventricular ejection fraction (45.3% ± 14.2% vs. 51.2% ± 13%, P = 0.003) compared to patients with AR grade2/4 (N. = 271). In multivariate analysis, men (OR 2.13 [95% CI, 1.08-4.18]) and prosthesis type (OR 13.17 [95% CI, 3.24-57.97]) were identified as independent predictors of AR grade ≥ 2/4.Alongside with the implantation of self-expandable aortic prosthesis, male gender independently increases the risk of significant AR in patients undergoing TAVI. The question if this finding is related to gender biology itself or to gender-related aggregation of subtle anatomic characteristics needs further investigations.

Background Diagnostic reasoning in primary care setting where presented problems and patients are mostly unselected appears as a complex process. The aim was to develop a questionnaire to describe how general practitioners (GPs) deal with uncertainty to gain more insight into the decisional process. The association of personality traits with medical decision making was investigated additionally. Methods Raw items were identified by literature research and focus group. Items were improved by interviewing ten GPs with thinking-aloud-method. A personal case vignette related to a complex and uncertainty situation was introduced. The final questionnaire was administered to 228 GPs in Germany. Factorial validity was calculated with explorative and confirmatory factor analysis. The results of the Communicating and Dealing with Uncertainty (CoDU) – questionnaire were compared with the scales of the ‘Physician Reaction to Uncertainty’ (PRU) questionnaire and with the personality traits which were determined with the Big Five Inventory (BFI-K). Results The items could be assigned to four scales with varying internal consistency, namely ‘communicating uncertainty’ (Cronbach alpha 0.79), ‘diagnostic action’ (0.60), ‘intuition’ (0.39) and ‘extended social anamnesis’ (0.69). Neuroticism was positively associated with all PRU scales ‘anxiety due to uncertainty’ (Pearson correlation 0.487), ‘concerns about bad outcomes’ (0.488), ‘reluctance to disclose uncertainty to patients’ (0.287), ‘reluctance to disclose mistakes to physicians’ (0.212) and negatively associated with the CoDU scale ‘communicating uncertainty’ (−0.242) (p

In general, the prevalence of diseases is low in primary care. Therefore, the positive predictive value of diagnostic tests is lower than in hospitals where patients are highly selected. In addition, the patients present with milder forms of disease; and many diseases might hide behind the initial symptom(s). These facts lead to diagnostic uncertainty which is somewhat inherent to general practice. This narrative review discusses different sources of and reasons for uncertainty and strategies to deal with it in the context of the current literature. Fear of uncertainty correlates with higher diagnostic activities. The attitude towards uncertainty correlates with the choice of medical speciality by vocational trainees or medical students. An intolerance of uncertainty, which still increases as medicine is making steady progress, might partly explain the growing shortage of general practitioners. The bio-psycho-social context appears to be important to diagnostic decision-making. The effect of intuition and heuristics are investigated by cognitive psychologists. It is still unclear whether these aspects are prone to bias or useful, which might depend on the context of medical decisions. Good communication is of great importance to share uncertainty with the patients in a transparent way and to alleviate shared decision-making. Dealing with uncertainty should be seen as an important core component of general practice and needs to be investigated in more detail to improve the respective medical decisions.

Einleitung: Die Plastizität von Nervenzellen ist Grundlage jeglichen Lernens. Geschwindigkeit und Ausmaß dieser plastischen Reorganisation unterliegen neben den Faktoren Motivation und Aufmerksamkeit auch dem Alter. In den letzten Jahren wurden passive Lernprotokolle entwickelt, die durch aufmerksamkeitsunabhängige Stimulation eines Hautareals Reorganisationen neuronaler Netzwerke im somato-sensorischen Kortex induzieren. Die Folge ist eine Diskriminationssteigerung des zuvor stimulierten Hautareals. Ziel: In dieser Studie sollten mit Hilfe der passiven Stimulation neue Erkenntnisse über den Einfluss des Alters auf die kortikale Reorganisationsfähigkeit bei Kindern und Jugendlichen gewonnen werden. Erwartet wurde eine Abnahme kortikaler Reorganisationsfähigkeit mit zunehmendem Probandenalter. Ferner galt es, mögliche Korrelationen zwischen dem Maß der Reorganisationsfähigkeit und höheren kognitiven Leistungen aufzuzeigen. Methoden: 67 Schüler im Alter von 8 bis 20 Jahren nahmen an der Studie teil. Sie wurden an der Zeigefingerbeere sowohl auf ihre native als auch auf ihre stimulationsgesteigerte Diskriminationsfähigkeit untersucht. Zur Abbildung höherer kognitiver Leistungen wurden zum einen Schulleistungen, zum anderen das Abschneiden in Intelligenztests erfasst. Ergebnisse: Durch die passive Stimulation verbesserte sich die Diskriminationsfähigkeit der Gesamtstudienpopulation signifikant um 18,25 %. Korrelationsanalysen zwischen dem Alter bzw. den höheren kognitiven Leistungen und dem Diskriminationsgewinn blieben ohne Signifikanz. Schlussfolgerungen: Entgegen der eingangs formulierten Grundhypothese konnte keine Einflussnahme des Alters auf das Reorganisationsmaß im somato-sensorischen Kortex belegt werden; ebenso wenig wurde ein Zusammenhang des Reorganisationsmaßes mit höheren kognitiven Leistungen ersichtlich; dieser ist aber möglich.

After contact with a rabies-infected rabbit, 31 Persons were submitted to complete vaccination treatment with duck embryo vaccine, comprising of injections of 1.0 ml each every fast night and two booster injections of 1.0 ml each, which were administered 10 and 20 days, respectively, after the end of the 14 days' vaccination series. After performance of intracutaneous and ophthalmic tests, 18 children received heterologous rabies immunserum (Behring) in a dose of 0.2 ml per kg of body weight before the beginning of the vaccination series. Six weeks after the start of the vaccination series neutralizing and complement-fixing antibodies (rate of conversion 100 per cent) were detected in all patients. The mean titre of neutralizing antibodies (mouse test 200 LD 50 Fixed virus, strain CVS) amounted to 1:140, that of complement-fixing antibodies to 1:41. Severe incompatibility reactions were not observed. Outpatient treatment with duck embryo vaccine therefore seems to be fully justified.