Reinhart W.H.,Kantonsspital Graubunden
Clinical Hemorheology and Microcirculation | Year: 2016
The hematocrit (Hct) determines the oxygen carrying capacity of blood, but also increases blood viscosity and thus flow resistance. From this dual role the concept of an optimum Hct for tissue oxygenation has been derived. Viscometric studies using the ratio Hct/blood viscosity at high shear rate showed an optimum Hct of 50-60 for red blood cell (RBC) suspensions in plasma. For the perfusion of an artificial microvascular network with 5-70μm channels the optimum Hct was 60-70 for high driving pressures. With lower shear rates or driving pressures the optimum Hct shifted towards lower values. In healthy, well trained athletes an increase of the Hct to supra-normal levels can increase exercise performance. These data with healthy individuals suggest that the optimum Hct for oxygen transport may be higher than the physiological range (35-40 in women, 39-50 in men). This is in contrast to clinical observations. Large clinical studies have repeatedly shown that a correction of anemia in a variety of disorders such as chronic kidney disease, heart failure, coronary syndrome, oncology, acute gastrointestinal bleeding, critical care, or surgery have better clinical outcomes when restrictive transfusion strategies are applied. Actual guidelines, therefore, recommend a transfusion threshold of 7-8g/dL hemoglobin (Hct 20-24) in stable, hospitalized patients. The discrepancy between the optimum Hct in health and disease may be due to factors such as decreased perfusion pressures (low cardiac output, vascular stenoses, change in vascular tone), endothelial cell dysfunction, leukocyte adhesion and others. © 2016 - IOS Press and the authors. All rights reserved.
Businger A.,St. Claraspital Basel |
Villiger P.,Kantonsspital Graubunden |
Sommer C.,Kantonsspital Graubunden |
Furrer M.,Kantonsspital Graubunden
Annals of Surgery | Year: 2010
Objective: To evaluate arguments given by board-certified surgeons in Switzerland for and against a career in surgery. Background data: Currently, the surgical profession in most Western countries is experiencing a labor shortage because of a declining interest in a surgical career among new graduates, a changed public opinion of medicine and its representatives, and as a consequence of the increasing influence of health economists and politicians on the professional independence of surgeons. Reports that focus primarily on the reasons that board-certified surgeons remain within the surgical profession are rare. Methods: Surgeons were asked to answer 2 questions concerning arguments for and against a career in surgery. Of 749 surgeons the arguments of 334 (44.6%) were analyzed using Mayring's content analysis. The surgeons were also asked whether they would choose medicine as a career path again. Results: The 334 participating surgeons provided 790 statements for and 981 statements against a career in surgery. Fifty-nine surgeons (17.7%) would not choose medicine as a career again. Mayring's content analysis of the statements yielded 10 categories with arguments both for and against a career in surgery. "Personal Experience in Daily Professional Life" (18.7%) was the top-ranked category in favor of a career in surgery, and "Specific Training Conditions" (20%) was the top-ranked category against the choice of such a career. Ordinal logistic regression showed that the category "Personal Experience in Daily Professional Life" (OR, 2.39; 95%CI, 1.13-5.07) was independently associated with again studying medicine, and the category "Work-life Balance" (OR, 0.37; 95%CI, 0.20-0.70) was associated with not studying medicine again. Conclusion: This qualitative study revealed unfavorable working conditions and regulations as surgeons' main complaints. It is concluded that new organizational frameworks and professional perspectives are required to retain qualified and motivated surgeons in the surgical profession. Copyright © 2010 by Lippincott Williams & Wilkins.
Cathomas R.,Kantonsspital Graubunden |
De Santis M.,Ludwig Boltzmann Research Institute |
Galsky M.D.,Mount Sinai School of Medicine
Hematology/Oncology Clinics of North America | Year: 2015
More than 50% of patients with advanced urothelial carcinoma are not eligible for the standard treatment with cisplatin-based chemotherapy. In general, cisplatin-ineligible patients with metastatic urothelial cancer experience poor outcomes with standard treatment, although substantial heterogeneity exists. Baseline variables associated with poor prognosis include borderline performance status, presence of visceral metastases, liver metastases, and low hemoglobin. Although no standard treatment has been defined for cisplatin-ineligible patients, recommendations regarding carboplatin-based combination chemotherapy versus single-agent chemotherapy versus best supportive care are typically based on performance status and renal function. The clinical development of novel agents is of considerable interest. © 2015 Elsevier Inc.
Strebel R.T.,Kantonsspital Graubunden
Andrology | Year: 2013
Data supporting the widespread use of antibiotics in patients with chronic scrotal pain syndrome (CSPS) are not available. Therefore, the aim of this study was to investigate the presence of bacteria in the genitourinary tract in patients presenting with CSPS. From July 2005 to July 2007 we prospectively enrolled patients presenting with CSPS in our outpatient clinic. The evaluation consisted of a detailed patient's history, physical examination and ultrasound examination of the scrotum. A blood and urinalysis, a Meares-Stamey four-glass test for bacterial cultures and PCR testing for Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis and Neisseria gonorrhoeae as well as a semen culture were performed. We assessed the symptom severity with the chronic epididymitis symptom index (CESI) score according to Nickel et al. (J Urol 2002, 167:1701; based on the NIH-CPSI). A total of 55 eligible men (median age 34 years) with CSPS were enrolled in the study. The median CESI score was 17 (range 4-26). The majority of patients (n = 39; 71%) were seen by a general practitioner or an urologist before. Of these, 25 patients (64%) were treated with antibiotics and 26 (67%) with non-steroidal anti-inflammatory drugs, respectively. A significant bacterial colony count in at least one specimen was detected in 21 of 55 patients (38%). The predominantly detected microorganisms were an Alpha-haemolytic Streptococcus (11 patients) and coagulase-negative staphylococci (10 patients). Thus, only in 12 of 55 (22%) patients isolated bacteria were considered to be of clinical relevance. No factor or condition predictive for a bacterial aetiology for CSPS could be identified. In our microbiological assessment of patients presenting with CSPS we found no evidence for the widely held belief that CSPS is predominantly the result of a chronic bacterial infection. We therefore conclude that the widespread use of antibiotic agents in the treatment of patients with CSPS is not justified. © 2012 American Society of Andrology and European Academy of Andrology.
Jeker R.,Kantonsspital Graubunden
Therapeutische Umschau | Year: 2013
Hypersplenism is characterized by a significant reduction in one or more of the cellular elements of the blood in the presence of normocellular or hypercellular bone marrow and splenomegaly. The incidence of hypersplenism in patients with cirrhosis and portal hypertension is high. In rare cases the hyperslenism is symptomatic with bleeding disorders or hemolytic anemia. In this situation the splenectomy is the therapy of choice. The arterial partial embolisation is a good alternative procedure in patients with high risk of operation. © 2013 Verlag Hans Huber, Hogrefe AG, Bern.
Acklin Y.P.,Kantonsspital Graubunden |
Stoffel K.,University of Western Australia |
Sommer C.,Kantonsspital Graubunden
Injury | Year: 2013
Background: Locking-plate osteosynthesis is a well-established treatment option for proximal humerus fractures. The standard approach is delta-pectoral, but few data using the minimally invasive antero-lateral delta-split approach exist. The aim of the study was to prospectively evaluate shoulder function and radiological outcome after a minimally invasive antero-lateral delta-split approach. Materials and methods: From December 2007 to October 2010, 124 patients with proximal humerus fractures were treated with locking-plate osteosynthesis using a minimally invasive antero-lateral delta-split approach. Complete prospective clinical and radiographic data were available for 97 patients for a minimum 1-year follow-up period. Results: After a follow-up period of 18 ± 6 months, the patients achieved a mean absolute Constant score of the injured shoulder of 75 ± 11, equalling 91% of the contralateral shoulder Constant score (p < 0.01). Implant-related complications (e.g., screw perforation) were observed in seven patients (7.2%), and avascular necrosis occurred in eight patients (8.2%). Damage to the ventral branch of the axillary nerve was recorded in four cases (4%) without any clinical consequences. The mean delay between trauma and surgery was 0.5 days. The procedures were performed by a total of 16 surgeons who required an average of 73 ± 27 min of OR time and 108 ± 121 s of fluoroscopy time. Conclusions: Minimally invasive osteosynthesis using angle-stable implants for proximal humerus fractures demonstrated good functional results. Compared to the literature, this minimally invasive procedure resulted in a shorter operation time and may have reduced the avascular necrosis rate. Level of evidence: Level IIb, monocentric prospective cohort study. © 2012 Elsevier Ltd.
Reinhart W.H.,Kantonsspital Graubunden
Clinical Hemorheology and Microcirculation | Year: 2013
Platelets play a key role in primary hemostasis and in the pathogenesis of atherosclerosis and atherothrombotic events such as stroke and myocardial infarction. When a plaque ruptures, platelets adhere to the underlying collagen matrix, become activated and aggregate, which may lead to vascular occlusions. Hemorheological aspects are intimately involved in this process. The assessment of this platelet function in vitro is difficult and has not reached the stage of routine use. Inhibition of platelet aggregation is the corner stone of any treatment of vascular disease. It is achieved mainly by to mechanisms, inhibition of thromboxane formation by acetylsalicylic acid, and with ADP receptor antagonists such as clopidogrel. Newer agents are being developed with the difficult mission to inhibit platelet aggregation more efficiently, and simultaneously reduce the risk of bleeding. © 2013 - IOS Press and the authors. All rights reserved.
Reinhart W.H.,Kantonsspital Graubunden |
Lubszky S.,Kantonsspital Graubunden |
Thony S.,AO Research Institute Davos |
Schulzki T.,Kantonsspital Graubunden
Toxicology in Vitro | Year: 2014
An intercalation of a drug in the outer half of the membrane lipid bilayer leads to echinocytosis, an intercalation in the inner half to stomatocytosis. We have used the shape transforming capacity of RBCs as a model to analyse the membrane interaction potential of various neurotropic drugs. Chlorpromazine, clomipramine, citalopram, clonazepam, and diazepam induced a reversible stomatocytosis, phenytoin induced echinocytosis, while the anticonvulsants levetiracetam, valproic acid and phenobarbital had no effect. This diversity of RBC shape transformations suggests that the pharmacological action is not linked to the membrane interaction. We conclude that this simple RBC shape transformation assay could be a useful tool to screen for potential drug interactions with cell membranes. © 2014.
Maevis V.,University of Bonn |
Mey U.,Kantonsspital Graubunden |
Schmidt-Wolf G.,University of Bonn |
Schmidt-Wolf I.G.H.,University of Bonn
Blood Cancer Journal | Year: 2014
Hairy cell leukemia (HCL) is part of the low-grade non-Hodgkin lymphoma family and represents approximately 2% of all leukemias. Treatment with splenectomy and interferon-α historically belonged to the first steps of therapeutic options, achieving partial responses/remissions (PR) in most cases with a median survival between 4 and 6 years in the 1980s. The introduction of the purine analogs (PA) pentostatin and cladribine made HCL a well-treatable disease: overall complete response rates (CRR) range from 76 to 98%, with a median disease-free survival (DFS) of 16 years a normal lifespan can be reached and HCL-related deaths are rare. However, insufficient response to PA with poorer prognosis and relapse rates of 30-40% after 5-10 years of follow-up may require alternative strategies. Minimal residual disease can be detected by additional examinations of bone marrow specimens after treatment with PA. The use of immunotherapeutic monoclonal antibodies (mAB) like rituximab as a single agent or in combination with a PA or more recently clinical trials with recombinant immunotoxins (RIT) show promising results to restrict these problems. Recently, the identification of the possible disease-defining BRAF V600E mutation may allow the development of new therapeutic targets. © 2014 Macmillan Publishers Limited.
Staerkle R.F.,Kantonsspital Graubunden |
Villiger P.,Kantonsspital Graubunden
British Journal of Surgery | Year: 2011
Background: Patient-oriented questionnaires are indispensable in the assessment of surgical outcome. The psychometric properties of a brief multidimensional instrument were examined in patients with inguinal hernia undergoing surgery. Methods: Fifty-one patients (mean(s.d.) age 50·6(17·4) years; 48 men) participated. The following questionnaire properties were assessed for the Core Outcome Measures Index adapted for patients with hernia (COMI-hernia) and the EuroQol: practicability, floor and ceiling effects, test-retest reliability (over 2 weeks), construct validity (by comparison with other relevant scales) and responsiveness 9 months after surgery as standardized response mean (SRM). Results: The questionnaires were easy to implement and well accepted by the patients. Ceiling effects at baseline were 2 per cent for the COMI-hernia, 8 per cent for EuroQol - visual analogue scale (EQ-VAS) and 35 per cent for EuroQol - Five Dimensions (EQ-5D); no instrument showed floor effects. The reproducibility of individual COMI-hernia items was good, with test-retest differences within one grade ranging from 41 of 45 for 'social/work disability' to 44 of 45 for 'general quality of life'. The intraclass correlation coefficients were moderately high for COMI-hernia (0·74) and EQ-VAS (0·77), but low for EQ-5D (0·43). COMI-hernia scores correlated in the expected manner with related scales (r = 0·42-0·72, P < 0·050). COMI-hernia was the most responsive instrument (SRM 1·42). Conclusion: The COMI-hernia and EQ-VAS general health scale represent reliable, valid and sensitive tools for assessing multidimensional outcome in patients with inguinal hernia undergoing surgical treatment. Copyright © 2010 British Journal of Surgery Society Ltd.