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Wiedermann C.J.,Central Hospital of Bolzano | Joannidis M.,Innsbruck Medical University
Intensive Care Medicine | Year: 2014

Purpose: To systematically review clinical and preclinical data on hydroxyethyl starch (HES) tissue storage. Methods: MEDLINE (PubMed) was searched and abstracts were screened using defined criteria to identify articles containing original data on HES tissue accumulation. Results: Forty-eight studies were included: 37 human studies with a total of 635 patients and 11 animal studies. The most frequent indication for fluid infusion was surgery accounting for 282 patients (45.9 %). HES localization in skin was shown by 17 studies, in kidney by 12, in liver by 8, and in bone marrow by 5. Additional sites of HES deposition were lymph nodes, spleen, lung, pancreas, intestine, muscle, trophoblast, and placental stroma. Among major organs the highest measured tissue concentration of HES was in the kidney. HES uptake into intracellular vacuoles was observed by 30 min after infusion. Storage was cumulative, increasing in proportion to dose, although in 15 % of patients storage and associated symptoms were demonstrated at the lowest cumulative doses (0.4 g kg-1). Some HES deposits were extremely long-lasting, persisting for 8 years or more in skin and 10 years in kidney. Pruritus associated with HES storage was described in 17 studies and renal dysfunction in ten studies. In one included randomized trial, HES infusion produced osmotic nephrosis-like lesions indicative of HES storage (p = 0.01) and also increased the need for renal replacement therapy (odds ratio, 9.50; 95 % confidence interval, 1.09-82.7; p = 0.02). The tissue distribution of HES was generally similar in animals and humans. Conclusions: Tissue storage of HES is widespread, rapid, cumulative, frequently long-lasting, and potentially harmful. © 2013 Springer-Verlag Berlin Heidelberg and ESICM.

Mayr R.,University of Regensburg | Pycha A.,Central Hospital of Bolzano | Burger M.,University of Regensburg
European Urology Focus | Year: 2016

We briefly describe the perioperative management of patients with metabolically active adrenal tumors. The potential intraoperative and postoperative complications that occur in patients with an adrenal tumor are reviewed with emphasis on recognition, treatment, and prevention. © 2015 European Association of Urology.

Wiedermann C.J.,Central Hospital of Bolzano | Joannidis M.,Innsbruck Medical University
Swiss Medical Weekly | Year: 2012

BACKGROUND: Hydroxyethyl starch (HES) is in widespread clinical use for volume therapy with colloids. According to the most recent meta-analysis performed in 2010, published studies are of poor quality and report too few events to reliably estimate the benefits or risks of administering 6% HES 130/0.4. As results from new trials, reporting on a large number of events became available in 2011 and 2012, an updated meta-analysis was performed. METHODS: Randomised controlled trials comparing the effects of 6% HES 130/0.4 with other colloid or crystalloid solutions were analysed for pooled effect size on mortality in eligible studies published up to 20 February 2012. RESULTS: Overall, 13 studies reporting 1,131 participants met the inclusion criteria. The weight of evidence contributed by the two new trials was 51.3%. The pooled relative risk (RR) for mortality increased to 1.14 with a 95% confidence interval (CI) of 0.89 to 1.46. Publication bias favoring HES 130/0.4 was present (p = 0.038). Adjustment for the observed publication bias increased the RR for mortality to 1.25 (CI, 0.98 to 1.58; p = 0.069). No heterogeneity was found (I2, 0%; CI, 0% to 32%; p = 0.81). CONCLUSIONS: Large-scale trials should help more precisely to determine the effect of HES 130/0.4 on mortality. In the interim, best current evidence suggests a trend toward higher mortality among HES 130/0.4 recipients.

Bellmann R.,Innsbruck Medical University | Feistritzer C.,Innsbruck Medical University | Wiedermann C.J.,Central Hospital of Bolzano
Clinical Pharmacokinetics | Year: 2012

Background: Intravenously infused hydroxyethyl starch (HES) can be found in urine, plasma and tissues.HES remaining in plasma and tissues is thought to increase the risk of clinical complications.HES solutions of lower molecular weight and substitution have been developed to increase urinary excretion and reduce plasma persistence. However, their effect on tissue uptake of HES has not been investigated in human subjects. Objective: Our objective was to test the hypothesis that lower molecular weight and substitution decrease tissue uptake of HES. Data sources: Computer searches were performed of MEDLINE; EMBASE; the Cochrane Library; meeting abstract databases in surgery, anaesthesiology and intensive care; ClinicalTrials.gov; and Google. Supplementary sources were reference lists and electronic tables of journal contents. No time period or language restrictions were imposed. Study Selection: Clinical studies were eligible for inclusion in the meta-analysis, if data were reported both for cumulative urinary excretion ofHES over 24 hours after infusion and for plasmaHES concentration at 24 hours. Data Extraction: Data were extracted on 24-hour urinary excretion of HES, 24-hour HES plasma concentration, plasma volume, HES molecular weight and substitution, study design, type and demographics of subjects, indication for fluid infusion, andHES infusion regimen. Tissue uptake ofHES was computed as the difference between the infused dose and the sum of urinary excretion and residual plasma HES at 24 hours. Data Synthesis: Twenty-five clinical studies totalling 287 subjects were included. Tissue uptake of lowmolecular- weight HES (≤200 kD) was 42.3%(95% confidence interval [CI] 39.6, 45.0) compared with 24.6% (CI 17.8, 31.4) for high-molecular-weight HES (p< 0.001). Similarly, tissue uptake of lower-substitution HES (≤0.5) was 42.4% (CI 39.5, 45.3) versus 26.6% (CI 19.6, 33.6) for higher-substitution HES (pp< 0.001). Among the three most often investigated singleHES solutions, tissue uptake of 130/0.4 (42.6%;CI 35.0, 50.2) and HES 200/0.5 (43.3%; CI 39.4, 47.2) closely coincided, whereas uptake of HES 450/0.7 (22.2%; CI 14.8, 29.6) was lower (p = 0.001 and p<0.001, respectively). Conclusions: This meta-analysis did not support the hypothesis that lower molecular weight and substitution decrease tissue uptake of HES. Further clinical studies of HES tissue uptake are needed. © 2012 Adis Data Information BV. All rights reserved.

Grozinger M.,RWTH Aachen | Smith E.S.,RWTH Aachen | Conca A.,Central Hospital of Bolzano
Wiener Klinische Wochenschrift | Year: 2015

Background: Quite a few patients with severe mental diseases do not respond sufficiently to psychopharmacology and psychotherapy. For some of these, electroconvulsive therapy (ECT) offers a promising alternative. Erroneously, the method is being perceived as old fashioned by the lay public, but also by many doctors. Therefore, this overview aims at all colleagues who in their role as multipliers, referring physicians or ECT specialists can reduce the likelihood of mental disease to become chronic. Methods: During the last decades, numerous international medical societies including the Austrian and the German Association for Psychiatry (ÖGPP and DGPPN) have pointed to the importance of ECT as a modern medical intervention. Our overview is based on these guidelines and statements. Additionally selective literature searches have been conducted concerning some key aspects. Results: Due to its excellent efficacy, ECT is an important option in the treatment of severe mental disease. Technological innovations and continued development in the psychiatric environment determined the evolution from the electroshock of the 1930s to the ECT of today. This process led to reduced side effects and a stronger patient-oriented praxis. Conclusions: ECT is a modern, highly effective and safe treatment of severe mental diseases with comparatively few side effects. The method should not be used as a last resort but in an evidence-based way. Patients should be informed timely and adequately about the therapeutic option. © 2015, Springer-Verlag Wien.

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