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Osnabrück, Germany

Palm F.,Stadtisches Klinikum Ludwigshafen | Kraus M.,Klinikum | Safer A.,Universitatsklinikum Heidelberg | Wolf J.,Stadtisches Klinikum Ludwigshafen | And 2 more authors.
BMC Neurology | Year: 2014

Background: Cardioembolic stroke (CES) due to atrial fibrillation (AF) is associated with high stroke mortality. Oral anticoagulation (OAC) reduces stroke mortality, however, the impact of OAC-administration during hospital stay post ischemic stroke on mortality is unclear. We determined whether the timing of OAC initiation among other prognostic factors influenced mortality after CES.Methods: Within the Ludwigshafen Stroke Study (LuSSt), a prospective population-based stroke register, we analysed all patients with a first ever ischemic stroke or TIA due to AF from 2006 until 2010. We analysed whether treatment or non-treatment with OAC and initiation of OAC-therapy during and after hospitalization influenced stroke mortality within 500 days after stroke/TIA due to AF.Results: In total 479 patients had a first-ever ischemic stroke (n = 394) or TIA (n = 85) due to AF. One-year mortality rate was 28.4%. Overall, 252 patients (52.6%) received OAC. In 181 patients (37.8%), OAC treatment was started in hospital and continued thereafter. Recommendation to start OAC post discharge was given in 110 patients (23.0%) of whom 71 patients received OAC with VKA (14.8%). No OAC-recommendation was given in 158 patients (33.0%). In multivariate Cox regression analysis, higher age (HR 1.04; 95% CI 1.02-1.07), coronary artery disease (HR: 1.6; 95% CI 1.1-2.3), higher mRS-score at discharge (HR 1.24; 95% CI 1.09-1.4), and OAC treatment ((no OAC vs started in hospital (HR: 5.4; 95% CI 2.8-10.5), were independently associated with stroke mortality. OAC-timing did not significantly influence stroke mortality (started post discharge vs. started in hospital (HR 0.3; 95% CI 0.07-1.4)).Conclusions: OAC non-treatment is the main predictor for stroke mortality. Although OAC initiation during hospital stay showed a trend towards higher mortality, early initiation in selected patients is an option as recommendation to start OAC post hospital was implemented in only 64.5%. This rate might be elevated by implementation of special intervention programs. © 2014 Palm et al.; licensee BioMed Central Ltd.

Ferbert A.,Klinikum
Practical Neurology | Year: 2011

The posterior reversible encephalopathy syndrome is an increasingly recognised disorder. Most patients have several symptoms; seizures are the most frequent, often multiple or status epilepticus. A combination of seizures, visual disturbance and/or headache, in particular, should lead to an early brain MRI to reveal the typical pattern of bilateral hyperintensities on f uid attenuated inversion recovery imaging, predominantly in the parieto-occipital region. There seem to be many possible triggers, including abrupt arterial hypertension, impaired renal function, pregnancy, immunosuppressive therapies and various inf ammatory conditions. The clinical outcome is excellent, with recovery within a few days, while the MRI abnormalities resolve much more slowly. Little is known about the best management. Seizures do not normally progress to chronic epilepsy so antiepileptic drugs should be discontinued after about 3 months.

Background: In German the terms unconsciousness, coma, somnolence, stupor and sopor are used to describe a state of impaired consciousness partly due to historical reasons. In parallel the Glasgow Coma Scale (GCS) introduced in 1974 provides a better definition for the state of consciousness. Material and methods: In this study two different groups were evaluated: active emergency physicians and emergency medicine trainees. Using a questionnaire both groups were asked to describe the impaired consciousness terms and indicate a corresponding GCS value. In addition they were asked to define a predescribed state of consciousness justifying the need for intubation. Results: The active emergency physicians assigned coma and unconsciousness median GCS levels of 7 (5-8, interquartile range, IQR) and 9 (7-10 IQR), respectively, whereas trainees assigned mean GCS levels of 6.5 (5-8 IQR) and 8 (8-10 IQR), respectively. Of the participants 60% assumed that an unconscious patient, in contrast to the definition, does not show any defence signs to pain. Somnolence was assigned higher GCS values (median 11, 10-13 IQR) and 12, 10-13.5 IQR). Stupor and sopor were assessed to having GCS scores covering almost the complete range of values. Conclusions: The results showed that most participating physicians were not aware that coma and unconsciousness are synonyms. Moreover, this demonstrates that much uncertainty is associated with the terms somnolence, sopor and stupor. In order to describe altered levels of consciousness, particularly in trauma patients, restrictions should be placed on the terms impaired consciousness and unconsciousness with a parallel use of the numerical GCS scale. © Springer-Verlag 2012.

Redel A.,University of Wurzburg | Redel A.,University of Regensburg | Stumpner J.,University of Wurzburg | Smul T.M.,University of Wurzburg | And 5 more authors.
Journal of Cardiothoracic and Vascular Anesthesia | Year: 2013

Objectives: Nitric oxide synthases (NOSs) mediate the first window of anesthetic-induced preconditioning (APC). The authors tested the hypothesis that endothelial NOS (eNOS) mediates the first window and inducible NOS (iNOS) mediates the second window of APC. Design: Randomized, prospective, blinded laboratory investigation. Setting: Experimental laboratory. Participants: Mice. Interventions: Mice were subjected to a 45-minute coronary artery occlusion (CAO) and a 180-minute reperfusion. C57BL/6 mice received desflurane, 1.0 minimum alveolar concentration, for 30 minutes or 12, 24, 48, or 96 hours before CAO. In eNOS-/- and iNOS-/- mice, desflurane was given 30 minutes and 48 hours before CAO. In the control groups, no desflurane was administered. Myocardial infarct size (IS) was determined after staining with Evans blue and triphenyltetrazolium chloride. Measurements and Main Results: The second window of APC was detectable at 48 hours but not at 12, 24, and 96 hours after preconditioning. In the control groups, IS was not different among the wild-type (50 ± 10%), eNOS-/- (52 ± 14%), and iNOS -/- (46 ± 10%) mice. The IS decreased significantly (p < 0.05) when desflurane was administered 30 minutes (10 ± 6%) or 48 hours (16 ± 7%) before CAO in wild-type mice, 48 hours (21 ± 13%) before CAO in eNOS-/- mice, and 30 minutes (13 ± 6%) before CAO in iNOS-/- mice. Desflurane given 30 minutes before CAO in eNOS -/- mice (60 ± 10%) and 48 hours before CAO in iNOS -/- mice (48 ± 21%) did not decrease the IS significantly compared with controls. Conclusions: Endothelial NOS and iNOS work independently to mediate the first and second windows of APC, respectively. Endothelial NOS is not necessary to trigger the second window of APC. © 2013 Elsevier Inc.

von Minckwitz G.,German Breast Group | Konecny G.E.,University of California at Los Angeles | Conrad U.,St. Barbara Hospital | Fett W.,Hematologic Oncologic Practice | And 16 more authors.
Annals of Oncology | Year: 2011

Background: The objective of this study was to compare the effect of dose-intensified neoadjuvant chemotherapy with that of standard epirubicin plus cyclophosphamide followed by paclitaxel in combination with or without darbepoetin on survival in primary breast cancer. Patients and methods: A total of 733 patients received either four cycles of neoadjuvant epirubicin 90 mg/m 2 plus cyclophosphamide 600 mg/m 2 every 3 weeks followed by four cycles of paclitaxel 175 mg/m 2 every 3 weeks (EC→T), or three cycles of epirubicin 150 mg/m 2 every 2 weeks followed by three cycles of paclitaxel 225 mg/m 2 every 2 weeks followed by three cycles of combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (E dd→T dd→CMF). The patients were randomly assigned to receive darbepoetin or none. The primary objective was to demonstrate a superior disease-free survival (DFS) of E dd→T dd→CMF compared with EC/T. Results: Estimated 3-year DFS was 75.8% with EC/T versus 78.8% with E dd→T dd→CMF [hazard ratio (HR) 1.14; P = 0.37] and overall survival (OS) 88.4% versus 91.5% (HR 1.26; P = 0.237). Three-year DFS was 74.3% with darbepoetin versus 80.0% without (HR 1.31; P = 0.061) and OS 88.0% versus 91.8% (HR 1.33; P = 0.139). Patients with a pathologically documented complete response [pathological complete response (pCR)] had a significantly better DFS compared with those without achieving a pCR (estimated 3-year DFS: 89.2% versus 74.9%; HR 2.27; P = 0.001). Conclusion: Neoadjuvant dose-intensified chemotherapy compared with standard chemotherapy did not improve DFS, whereas the addition of darbepoetin might have detrimental effects on DFS. © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.

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