Aktualisierte Kurzfassung der Leitlinien zur Pr?vention, Diagnostik und Therapie der nosokomial erworbenen Pneumonie

ZusammenfassungHintergrund:  Die nosokomiale Pneumonie gehört zu den häufigsten nosokomialen Infektionen und ist die häufigste auf der Intensivstation. Die nosokomiale Pneumonie ist mit einer signifikanten Mortalität und Morbidität assoziiert, und ihr Auftreten verschlechtert die Prognose des Patienten deutlich. Nach der Definition der DRGs auch im deutschen Krankenhaussystem ist die nosokomiale Pneumonie überwiegend Sache des Krankenhauses und kann somit nicht nur das Ergebnis der Patientenbehandlung, sondern auch das finanzielle Ergebnis des Krankenhauses beeinträchtigen.Ziel:  In diesem Sinne kommt vor allem der Prävention, aber auch der Diagnostik und der schweregradadaptierten Therapie eine ganz entscheidende Bedeutung zu. Die hier vorgelegte aktualisierte Kurzfassung der Leitlinien zur Prävention, Diagnostik und Therapie der nosokomial erworbenen Pneumonie soll helfen, das Problem noch bewusster zu machen und gleichzeitig durch ein praxisnahes Arbeitsblatt die Dokumentation auf der Intensivstation zu erleichtern.* An der Ausarbeitung dieses Textes waren außerdem beteiligt: S. Ewig, Bochum, M. Trautmann, Stuttgart, und darüber hinaus J. Barth, Halle; K. Dalhoff, Lübeck; B. Grabein, München; M. Kresken, Bonn; E. Müller, Trier; T. Schaberg, Rotenburg a. d. W.; B. Wiedemann, Bonn, und K. Brodt, Frankfurt a. M.; G. Höffken, Dresden; H. Lode, Berlin; J. Meyer, Duisburg; U. Ullmann, Kiel; K. S. Unertl, Tübingen.     

Gefitinib in definitive management of esophageal or gastroesophageal junction cancer: a retrospective analysis of two clinical trials

The role of epidermal growth factor receptor inhibition in resectable esophageal/gastroesophageal junction (E/GEJ) cancer is uncertain. Results from two Cleveland Clinic trials of concurrent chemoradiotherapy (CCRT) and surgery are updated and retrospectively compared, the second study differing only by the addition of gefitinib (G) to the treatment regimen. Eligibility required a diagnosis of E/GEJ squamous cell or adenocarcinoma, with an endoscopic ultrasound stage of at least T3, N1, or M1a (American Joint Committee on Cancer 6th). Patients in both trials received 5‐fluorouracil (1000 mg/m²/day) and cisplatin (20 mg/m²/day) as continuous infusions over days 1–4 along with 30 Gy radiation at 1.5 Gy bid. Surgery followed in 4–6 weeks; identical CCRT was given 6–10 weeks later. The second trial added G, 250 mg/day, on day 1 for 4 weeks, and again with postoperative CCRT for 2 years. Preliminary results and comparisons have been previously published. Clinical characteristics were similar between the 80 patients on the G trial (2003–2006) and the 93 patients on the no‐G trial (1999–2003). Minimum follow‐up for all patients was 5 years. Multivariable analyses comparing the G versus no‐G patients and adjusting for statistically significant covariates demonstrated improved overall survival (hazard ratio [HR] 0.64, 95% confidence interval [CI] = 0.45–0.91, P = 0.012), recurrence‐free survival (HR 0.61, 95% CI = 0.43–0.86, P = 0.006), and distant recurrence (HR 0.68, 95% CI = 0.45–1.00, P = 0.05), but not locoregional recurrence. Although this retrospective comparison can only be considered exploratory, it suggests that G may improve clinical outcomes when combined with CCRT and surgery in the definitive treatment of E/GEJ cancer.     

Komplizierte intraabdominelle Infektionen: Erreger, Resistenzen

Intra-abdominal infections are generally the result of invasion and multiplication of enteric bacteria in the wall of a hollow viscus within the abdomen to produce peritonitis or abscess. When the infection extends into the peritoneal cavity or another normally sterile region of the abdominal cavity, the infection is described as a ?complicated“ intra-abdominal infection. Treatment of patients with complicated intra-abdominal infections involves antimicrobial therapy, generally in conjunction with an appropriate and timely surgical source control. Nearly all intra-abdominal infections are caused by multiple microorganisms that constitute the intestinal flora (aerobes and facultative and obligate anaerobes, with Enterobacteriaceae, enterococci and Bacteroides fragilis isolated most frequently). The emergence of drug resistance (e.g. ESBL-producing Enterobacteriaceae or resistant enterococci and staphylococci) poses a substantial threat to patients with surgical infections. Especially in patients with nosocomially acquired infections inadequate empiric antibiotic treatment is associated with treatment failure and death. In patients at risk broader spectrum antibiotic regimens with coverage of resistant Gram-negative bacilli and anaerobes and Gram-positive bacteria such as enterococci (including VRE) and staphylococci should be considered.     

Hemodynamic profile of intravenous fenoldopam in patients with hypertensive crisis

Summary Fenoldopam, a newly developed intravenous dopaminergic DA₁ receptor agonist, was used in an open, prospective study for blood pressure control in 12 patients presenting with hypertensive crisis. At a dose of 0.2–0.5 g kg^–1 min^–1 fenoldopam decreased systolic blood pressure from 209±13 to 151±17 mmHg and diastolic blood pressure from 114±10 to 78±10 mmHg. Blood pressure was controlled in all 12 patients within 5–50 min. In none of the patients did rebound hypertension occur upon termination of the study medication, nor was any adverse event reported. Major hemodynamic changes induced by fenoldopam were a decrease in total peripheral resistance from 1853±611 to 1193±368 and in pulmonary vascular resistance from 252±170 to 180±74 dyne s^–1 cm^–5. In patients with high left ventricular filling pressure at study pulmonary capillary wedge pressure decreased while the stroke volume index and mixed venous oxygen saturation increased under fenoldopam. Thus, fenoldopam appears to be a rapid-acting, well-tolerated, and highly effective intravenous substance for the treatment of severe hypertension.     

Atrial fibrillation in patients of a medical clinic--a marker for multi-morbidity and unfavorable prognosis

Out of 724 patients admitted to the medical department of a community teaching hospital during three months 110 (14.5%) had electrocardiographically documented atrial fibrillation (AF). 56% had chronic and 44% intermittent AF. Only 66% of patients with AF suffered from diseases generally accepted as cause of AF, 29% had cardiovascular and pulmonary risk factors, 5% had lone AF. AF was already known in 66% of patients, in 21% AF was documented at the first time, only 14% were admitted because of AF, although AF was clearly the cause of symptoms in an additional 11%. The mean age of patients with AF (72 years) was higher than that of patients without AF. 95% of patients with AF suffered from more than one cardiovascular or pulmonary disease or risk factor (mean index of diseases of 3.2). Hospital mortality of patients with AF was much higher than mean total hospital mortality (19 vs 7.7) except in patients with lone AF. We conclude that AF is a marker of multimorbidity and bad prognosis in patients of general internal medicine.     

Partielle spezifische refraktionen von polymethylmethacrylat und polystyrol. II. Eine methode zur endgruppenanalyse

Specific refraction and its dispersion applied to polymer homologous series are investigated as a method for analysis of endgroups. Employing polymethylmethacrylate and polystyrene polymerized with dibenzoyl peroxide, it is illustrated that this method is successfull in drawing conclusions as well upon the kind as the number of endgroups per molecule, provided (1) that specific refractions and dispersions of the endgroups and the chain are different and (2) that no exaltation effects interfere.