Göppingen, Germany
Göppingen, Germany

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Paulsen F.,University of Tübingen | Doerr S.,University of Tübingen | Wilhelm H.,University of Tübingen | Becker G.,Klinik Am Eichert | And 2 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2012

Purpose: To evaluate the effectiveness of fractionated stereotactic radiotherapy (SFRT) in the treatment of optic nerve sheath meningioma (ONSM). Methods and Materials: Between 1993 and 2005, 109 patients (113 eyes) with primary (n = 37) or secondary (n = 76) ONSM were treated according to a prospective protocol with SFRT to a median dose of 54 Gy. All patients underwent radiographic, ophthalmologic, and endocrine analysis before and after SFRT. Radiographic response, visual control, and late side effects were endpoints of the analysis. Results: Median time to last clinical, radiographic, and ophthalmologic follow up was 30.2 months (n = 113), 42.7 months (n = 108), and 53.7 months (n = 91), respectively. Regression of the tumor was observed in 5 eyes and progression in 4 eyes, whereas 104 remained stable. Visual acuity improved in 12, deteriorated in 11, and remained stable in 68 eyes. Mean visual field defects reduced from 33.6% (n = 90) to 17.8% (n = 56) in ipsilateral and from 10% (n = 94) to 6.7% (n = 62) in contralateral eyes. Ocular motility improved in 23, remained stable in 65, and deteriorated in 3 eyes. Radiographic tumor control was 100% at 3 years and 98% at 5 years. Visual acuity was preserved in 94.8% after 3 years and in 90.9% after 5 years. Endocrine function was normal in 90.8% after 3 years and in 81.3% after 5 years. Conclusions: SFRT represents a highly effective treatment for ONSM. Interdisciplinary counseling of the patients is recommended. Because of the high rate of preservation of visual acuity we consider SFRT the standard approach for the treatment of ONSM. Prolonged observation is warranted to more accurately assess late visual impairment. Moderate de-escalation of the radiation dose might improve the preservation of visual acuity and pituitary gland function. © 2012 Elsevier Inc.


Fischer M.,Klinik am Eichert | Kamp J.,University of Bonn | Garcia-Castrillo Riesgo L.,University of Cantabria | Robertson-Steel I.,Hywel Dda Health Board Unit 4 Merlins Court | And 3 more authors.
Resuscitation | Year: 2011

Aim: The aim of this prospective study was the comparison of four emergency medical service (EMS) systems-emergency physician (EP) and paramedic (PM) based-and the impact of advanced live support (ALS) on patients status in preclinical care. Methods: The EMS systems of Bonn (GER, EP), Cantabria (ESP, EP), Coventry (UK, PM) and Richmond (US, PM) were analysed in relation to quality of structure, process and performance when first diagnosis on scene was cardiac arrest (OHCA), chest pain or dyspnoea. Data were collected prospectively between 01.01.2001 and 31.12.2004 for at least 12 month. Results: Over all 6277 patients were included in this study. The rate of drug therapy was highest in the EP-based systems Bonn and Cantabria. Pain relief was more effective in Bonn in patients with severe chest pain. In the group of patients with chest pain and tachycardia ≥120beats/min, the heart rate was reduced most effective by the EP-systems. In patients with dyspnoea and SpO2<90% the improvement of oxygen saturation was most effective in Bonn and Richmond. After OHCA significant more patients reached the hospital alive in EMS systems with EPs than in the paramedic staffed (Bonn=35.6%, Cantabria=30.1%; Coventry=11.9%, Richmond=9.2%). The introduction of a Load Distributing Band chest compression device in Richmond improved admittance rate after OHCA (21.7%) but did not reach the survival rate of the Bonn EMS system. Conclusions: Higher qualification and greater training and experience of ALS unit personnel increased survival after OHCA and improved patient's status with cardiac chest pain and respiratory failure. © 2010 Elsevier Ireland Ltd.


Grasner J.-T.,University of Kiel | Meybohm P.,University of Kiel | Lefering R.,Witten/Herdecke University | Wnent J.,University of Kiel | And 9 more authors.
European Heart Journal | Year: 2011

AimsReturn of spontaneous circulation (ROSC) following cardiopulmonary resuscitation from cardiac arrest (CA) depends on numerous variables. The aim of this study was to develop a score to predict the initial resuscitation outcomethe RACA (ROSC after cardiac arrest) score.Methods and resultsBased on 5471 prospectively registered out-of-hospital CAs patients between 1998 and 2008 within the German Resuscitation Registry, calculation of the RACA score was performed by multivariate logistic regression analysis with ROSC as the outcome variable. The probability of ROSC was defined as 1/(1 e-X), where X is the weighted sum of independent factors. Additional 2218 patients documented between 2009 and 2010 were used for validation of the RACA score. The following independent variables were found to have a significant positive () or negative (-) impact on the probability of ROSC: male gender (-0.2); age <80 years (-0.2); witnessing by lay people (0.6) and by professionals (0.5); asystole (-1.1); location at doctors office (1.2), medical institution (0.5), public place (0.3) and nursing home (-0.3); presumable aetiology of hypoxia (0.7), intoxication (0.5) and trauma (-0.6); and time until professionals arrival (-0.04 per minute). In a validation cohort, observed ROSC (43.8) did not differ from predicted ROSC (43.7).ConclusionThe RACA score represents a simple tool and enables comparison between observed and predicted ROSC rates based on readily available variables after CA. Thereby, the RACA score may contribute to preclinical quality assessment and may help analysing the effects of different (post)-resuscitation strategies. © 2011 The Author.


Perrone-Filardi P.,University of Naples Federico II | Achenbach S.,Friedrich - Alexander - University, Erlangen - Nuremberg | Mhlenkamp S.,University of Duisburg - Essen | Reiner Z.,University of Zagreb | And 7 more authors.
European Heart Journal | Year: 2011

Cardiovascular events remain one of the most frequent causes of mortality and morbidity worldwide. The majority of cardiac events occur in individuals without known coronary artery disease (CAD) and in low-to intermediate-risk subjects. Thus, the development of improved preventive strategies may substantially benefit from the identification, among apparently intermediate-risk subjects, of those who have a high probability for developing future cardiac events. Cardiac computed tomography and myocardial perfusion scintigraphy (MPS) by single photon emission computed tomography may play a role in this setting. In fact, absence of coronary calcium in cardiac computed tomography and inducible ischaemia in MPS are associated with a very low rate of major cardiac events in the next 35 years. Based on current evidence, the evaluation of coronary calcium in primary prevention subjects should be considered in patients classified as intermediate-risk based on traditional risk factors, since high calcium scores identify subjects at high-risk who may benefit from aggressive secondary prevention strategies. In addition, calcium scoring should be considered for asymptomatic type 2 diabetic patients without known CAD to select those in whom further functional testing by MPS or other stress imaging techniques may be considered to identify patients with significant inducible ischaemia. From available data, the use of MPS as first line testing modality for risk stratification is not recommended in any category of primary prevention subjects with the possible exception of first-degree relatives of patients with premature CAD in whom MPS may be considered. However, the Working Group recognizes that neither the use of computed tomography for calcium imaging nor of MPS have been proven to significantly improve clinical outcomes of primary prevention subjects in prospective controlled studies. This information would be crucial to adequately define the role of imaging approaches in cardiovascular preventive strategies. © 2009 The Author.


Mahabadi A.A.,University of Duisburg - Essen | Achenbach S.,Friedrich - Alexander - University, Erlangen - Nuremberg | Burgstahler C.,University of Tübingen | Dill T.,Sana Kliniken Dusseldorf | And 8 more authors.
Radiology | Year: 2010

For selected indications, coronary computed tomographic (CT) angiography is an established clinical technology for evaluation in patients suspected of having or known to have coronary artery disease. In coronary CT angiography, image quality is highly dependent on heart rate, with heart rate reduction to less than 60 beats per minute being important for both image quality and radiation dose reduction, especially when single-source CT scanners are used. β-Blockers are the first-line option for short-term reduction of heart rate prior to coronary CT angiography. In recent years, multiple β-blocker administration protocols with oral and/or intravenous application have been proposed. This review article provides an overview of the indications, efficacy, and safety of β-blockade protocols prior to coronary CT angiography with respect to different scanner techniques. Moreover, implications for radiation exposure and left ventricular function analysis are discussed. © RSNA, 2010.


Schmidt R.,University of Mannheim | Rupp-Heim G.,Klinik am Eichert | Dammann F.,Klinik am Eichert | Ulrich C.,Klinik am Eichert | Nothwang J.,Klinik am Eichert
Tumori | Year: 2011

Aims and background. Preoperative embolization of vertebral metastases has been shown to lower intraoperative blood loss. Nevertheless, excessive up to life-threatening blood loss can occur despite embolization.We therefore decided to evaluate possible parameters for predicting significant blood loss in a surgically homogeneous group of patients with vertebral metastases. Methods. Patients with vertebralmetastases of the thoracic and thoracolumbar spine who underwent preoperative embolization were included. All patients had existing or impending neurological deficit as the main indication for direct metastasis reduction. The parameters evaluated were the technical feasibility of embolization, vascularization grade ofmetastasis, success of embolization, tumor type in relation to blood loss, and interval between embolization and surgery. Results. Twenty-seven patients fullfilled the inclusion criteria. Technically complete embolization was feasible in 14 patients (52%) and fully successful embolization was obtained in 10 patients (37%). Eighty-three percent of the renal cell carcinomas were hypervascularized, but also 67% of the breast carcinoma patients had hypervascularized tumors. No permanent complications occurred during embolization, but two patients had pain and another two experienced a transient burning sensation. A significant difference in intraoperative blood loss was only found between patients achieving partially or fully successful embolization in the subgroup of hypervascularized grade III metastases. Conclusions. The success of embolization in the group of hypervascularized grade III metastases was the only predictor for the extent of blood loss in our study. Due to the inaccuracy of predicting high blood loss in general all possible precautions for excessive blood loss should be taken despite preoperative embolization. Further randomized studies to determine the indications and results of embolization seem desirable. Free full text available at www.tumorionline.it.


Lukas R.-P.,Intensive Care and Pain Medicine University Hospital Muenster | Grasner J.T.,University of Kiel | Seewald S.,University of Lübeck | Lefering R.,Witten/Herdecke University | And 4 more authors.
Resuscitation | Year: 2012

Aims: Investigating the effects of any intervention during cardiac arrest remains difficult. The ROSC after cardiac arrest score was introduced to facilitate comparison of rates of return of spontaneous circulation (ROSC) between different ambulance services. To study the influence of chest compression quality management (including training, real-time feedback devices, and debriefing) in comparison with conventional cardiopulmonary resuscitation (CPR), a matched-pair analysis was conducted using data from the German Resuscitation Registry, with the calculated ROSC after cardiac arrest score as the baseline. Methods and results: Matching for independent ROSC after cardiac arrest score variables yielded 319 matched cases from the study period (January 2007-March 2011). The score predicted a 45% ROSC rate for the matched pairs. The observed ROSC increased significantly with chest compression quality management, to 52% (P= 0.013; 95% CI, 46-57%). No significant differences were seen in the conventional CPR group (47%; 95% CI, 42-53%). The difference between the observed ROSC rates was not statistically significant. Conclusions: Chest compression quality management leads to significantly higher ROSC rates than those predicted by the prognostic score (ROSC after cardiac arrest score). Matched-pair analysis shows that with conventional CPR, the observed ROSC rate was not significantly different from the predicted rate. Analysis shows a trend toward a higher ROSC rate for chest compression quality management in comparison with conventional CPR. It is unclear whether a single aspect of chest compression quality management or the combination of training, real-time feedback, and debriefing contributed to this result. © 2012 Elsevier Ireland Ltd.


Schuster M.,Charité - Medical University of Berlin | Neumann C.,Charité - Medical University of Berlin | Neumann K.,Charité - Medical University of Berlin | Braun J.,Charité - Medical University of Berlin | And 4 more authors.
Anesthesia and Analgesia | Year: 2011

BACKGROUND: Short-term case cancellation causes frustration for anesthesiologists, surgeons, and patients and leads to suboptimal use of operating room (OR) resources. In many facilities, >10% of all cases are cancelled on the day of surgery, thereby causing major problems for OR management and anesthesia departments. The effect of hospital type and service type on case cancellation rate is unclear. METHODS: In 25 hospitals of different types (university hospitals, large community hospitals, and mid- to small-size community hospitals) we studied all elective surgical cases of the following subspecialties over a period of 2 weeks: general surgery, trauma/orthopedics, urology, and gynecology. Case cancellation was defined as any patient who had been scheduled to be operated on the next day, but cancelled after the finalization of the OR plan on the day before surgery. A list of possible cancellation reasons was provided for standardized documentation. RESULTS: A total of 6009 anesthesia cases of 82 different anesthesia services were recorded during the study period. Services in university hospitals had cancellation rates 2.23 (95% confidence interval [CI] = 1.49 to 3.34) times higher than mid- to small-size community hospitals 12.4% (95% CI = 11.0% to 13.8%) versus 5.0% (95% CI = 4.0% to 6.2%). Of the surgical services, general surgical services had a significantly (1.78, 95% CI = 1.25 to 2.53) higher cancellation rate than did gynecology services-11.0% (95% CI = 9.7% to 12.5%) versus 6.6% (95% CI = 5.1% to 8.4%). CONCLUSIONS: When benchmarking cancellation rates among hospitals, comparisons should control for academic institutions having higher incidences of case cancellation than nonacademic hospitals and general surgery services having higher incidences than other services. Copyright © 2011 International Anesthesia Research Society.


Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.


Wnent J.,University of Lübeck | Seewald S.,University of Lübeck | Heringlake M.,University of Lübeck | Brauer K.,University of Lübeck | And 6 more authors.
Critical Care | Year: 2012

Introduction: Between 1 and 31% of patients suffering out-of-hospital cardiac arrest (OHCA) survive to discharge from hospital. International studies have shown that the level of care provided by the admitting hospital determines survival for patients suffering from OHCA. These data may only be partially transferable to the German medical system where responders are in-field emergency medical physicians. The present study determines the influence of the emergency physician's choice of admitting hospital on patient outcome after OHCA in a large urban setting.Methods: All data for patients collected in the German Resuscitation Registry for the city of Dortmund during 2007 and 2008 were analyzed. Patients under 18 years of age, with traumatic mechanism, and with incomplete charts were excluded. Admitting hospitals were divided into two groups: those without the capability for percutaneous coronary intervention (PCI), and those with PCI capability. Data were analyzed by multivariate statistics, taking into account the effects of mild therapeutic hypothermia treatment and PCI capability of the admitting hospital with respect to the neurological status upon hospital discharge.Results: Between 2007 and 2008 a total of 1,109 cardiopulmonary resuscitation attempts were registered for the city of Dortmund, of which 889 could be included in our study. Return of spontaneous circulation was achieved in 360 of 889 patients (40.5%). In total, 282 of 889 patients displayed return of spontaneous circulation during transport to the hospital (31.7%); 152 were transported with ongoing cardiopulmonary resuscitation (17.1%). Of the total 434 patients admitted to hospital, 264 were admitted to hospitals without PCI capability and 170 to hospitals with PCI capability. Multivariate analysis demonstrated a significant influence on patient discharge with good neurological status for those admitted to PCI hospitals (odds ratio 3.14 (95% confidence interval 1.51 to 6.56)), independent of receiving mild therapeutic hypothermia and/or PCI. Compared with patients admitted to hospitals without PCI capability, significantly more patients in PCI hospitals were discharged alive (41% vs. 13%, P < 0.001) and remained alive 1 year after the event (28% vs. 6%, P < 0.001).Conclusions: The choice of admitting hospital for patients suffering OHCA significantly influences treatment and outcome. This influence is independent of PCI performance and of mild therapeutic hypothermia. Further analysis is required to determine the possible parameters determining patient outcome. © 2012 Wnent et al.; licensee BioMed Central Ltd.

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