Stadtisches Klinikum Munich GmbH

München, Germany

Stadtisches Klinikum Munich GmbH

München, Germany
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Hubert G.J.,Stadtisches Klinikum Munich GmbH | Muller-Barna P.,Neurology | Audebert H.J.,Charité - Medical University of Berlin
International Journal of Stroke | Year: 2014

TeleStroke has become an increasing means to overcome shortage of stroke expertise in underserved areas. This rapidly growing field has triggered a large amount of publications in recent years. We aimed to analyze recent advances in the field of telemedicine for acute stroke, with main focus on prehospital management, Stroke Unit treatment and network implementations in developing countries. Out of 260 articles, 25 were selected for this systematic review: 9 regarding prehospital management, 14 regarding Stroke Unit treatment and 2 describing a network in developing countries. Prehospital management showed that stroke recognition can start at the dispatch emergency call, important clinical information can be electronically transmitted to hospitals before admission and even acute treatment such as thrombolysis can be initiated in the prehospital field if ambulances are equipped with CT scan and point-of-care laboratory. Articles on remote clinical examination, telemedical imaging interpretation, trial recruitment and cost-effectiveness described various aspects of Stroke Unit treatment within TeleStroke networks, underlining reliability, safety and cost savings of these systems of care. Only one network was described to have been implemented in a developing/emerging nation. TeleStroke is a growing field expanding its focus to a broader spectrum of stroke care. It still seems to be underused, particularly in developing countries. © 2014 World Stroke Organization.

Muller-Barna P.,Stadtisches Klinikum Munich GmbH | Hubert G.J.,Stadtisches Klinikum Munich GmbH | Boy S.,University of Regensburg | Bogdahn U.,University of Regensburg | And 3 more authors.
Stroke | Year: 2014

BACKGROUND AND PURPOSE-: Stroke Unit care improves stroke prognosis and is recommended for all patients with stroke. In rural areas, population-wide implementation of Stroke Units is challenging. Therefore, the TeleMedical Project for integrative Stroke Care (TEMPiS) was established in 2003 as a TeleStroke Unit network to overcome this barrier in Southeast Bavaria/Germany. Evaluation of its implementation between 2003 and 2005 had revealed improved process quality and clinical outcomes compared with matched hospitals without TeleStroke Units. Data on sustainability of these effects are lacking. METHODS-: Effects on the stroke care of the local population were analyzed by using data from official hospital reports. Prospective registries from 2003 to 2012 describe processes and outcomes of consecutive patients with stroke and transient ischemic attack treated in TEMPiS hospitals. Quality indicators assess diagnostics, treatment, and outcome. Rates and timeliness of intravenous thrombolysis as well as data on teleconsultations and secondary interhospital transfers were reported over time. RESULTS-: Within the covered area, network implementation increased the number of patients with stroke and transient ischemic attack treated in hospitals with (Tele-)Stroke Units substantially from 19% to 78%. Between February 2003 and December 2012, 54 804 strokes and transient ischemic attacks were treated in 15 regional hospitals, and 31 864 teleconsultations were performed. Intravenous thrombolysis was applied 3331 stroke cases with proportions increasing from 2.6% to 15.5% of all patients with ischemic stroke. Median onset-to-treatment times decreased from 150 (interquartile range, 127-163) to 120 minutes (interquartile range, 90-160) and door-to-needle times from 80 (interquartile range, 68-101) to 40 minutes (interquartile range, 29-59). CONCLUSIONS-: TeleStroke Units can provide sustained high-quality stroke care in rural areas. © 2014 American Heart Association, Inc.

Early duodenal neuroendocrine neoplasms (dNENs) are being increasingly diagnosed. Non-functional dNENs in the bulb expressing gastrin are by far the most frequent entity. In the period from 2004 to 2012, 17 cases of 16 patients with NET in the duodenal bulb were evaluated. dNENs of the ampulla of Vater and functional dNEN/gastrinoma were not included due to possibly different malignant potentials. The average age of the patients was 65.7 years, the mean tumour size was 10.2mm, the maximum proliferation index Ki 67 was 5% (NET G2). In most cases the maximum depth of invasion was down to the submucosa. In cases of dNEN without risk factors (size up to 10 mm, G1 situation, no invasion of the muscularis propria, no angioinvasion) in 10 out of 11 cases (90.9%), endoscopic therapy was sufficient. In cases of existing risk factors, sole endoscopic treatment was only possible in 1 out of 5 cases (20%). In the absence of risk factors in the current follow-up period (mean: 36.7 months) no lymph node metastases were detected. In the presence of risk factors or indications for surgery we found an increase in the rate of lymph node metastases. Our own data indicate that in case of a G2 situation, a tumour size >10mm or infiltration of the muscularis propria the need for surgical treatment increases significantly for early non-functional dNENs in the duodenal bulb. A high-risk-/low-risk-concept for the endoscopic therapy for early non-functional dNEN has been established. © Georg Thieme Verlag KG Stuttgart, New York.

Horer S.,Stadtisches Klinikum Munich GmbH | Schulte-Altedorneburg G.,Stadtisches Klinikum Munich GmbH | Haberl R.L.,Stadtisches Klinikum Munich GmbH
Cerebrovascular Diseases | Year: 2011

Background: Transient ischemic attack (TIA) patients are at high risk of short-term stroke, myocardial infarction and vascular death. Stroke risk is reduced by immediate treatment initialization. Stroke unit treatment is recommended for TIA patients. We established an outpatient TIA clinic to address the question whether outpatient evaluation of suspected TIA is safe. Methods: TIA workup included cerebral imaging, duplex sonography, transcranial Doppler screening for patent foramen ovale, electrocardiography, blood tests, ABCD 2 score and ankle-brachial index within one day. TIA patients received secondary prophylaxis immediately. TIA patients fulfilling predefined criteria for high early stroke risk (ABCD 2 score ≥4 points and TIA within 72 h, symptomatic stenosis, newly detected atrial fibrillation, recurrent TIA) were referred to the stroke unit. The remaining patients were discharged home. 90-day telephone follow-up was obtained. Results: 123 consecutive patients with suspected TIA (53 male, age 59 ± 17.2 years) were prospectively evaluated. TIA or minor stroke was diagnosed in 69 (56%), and TIA mimics in 54 (44%) patients. Median time from symptom onset to presentation was 48 h (1 h to 3 months). Patients with TIA/minor stroke presented significantly more frequently with ABCD 2 score ≥4 points (p = 0.021). Twelve patients (9.8%) were admitted to the stroke unit. There were 2 strokes during follow-up. The stroke rate was 1.6% within all patients, and 2.9% within the subgroup of patients with TIA/minor stroke, compared to 5.7% predicted by the ABCD 2 score. Other vascular end points were not found. Conclusion: Based on risk stratification, outpatient evaluation of TIA is safe. TIA mimics are frequent. Copyright © 2011 S. Karger AG, Basel.

With its differing courses of illness diabetes mellitus represents a complex clinical entity. The clinical appearance of a diabetes illness can, in the case of classical symptoms, can be unambiguous and directing, in many cases, such as, e.g., for type 2 diabetes, it may remain undetected for a longer time. Aggravating this situation, there are numerous endocrinological diseases that can be associated with an impaired glucose tolerance or a diabetes mellitus type 2 or, respectively, a diabetes mellitus type 1. Since in many cases these diseases are complex with regard to their clinical picture, diagnostics and therapy, the accompanying existence of a diabetes mellitus i soften not taken into consideration. In the present article we exemplarily describe the more important endocrinological diseases that can be accompanied by an impaired glucose tolerance/diabetes mellitus.

Heitland W.,Stadtisches Klinikum Munich GmbH
Chirurg | Year: 2012

Cryptoglandular anal fistula: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. Anal fissures: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation. © 2012 Springer-Verlag Berlin Heidelberg.

Other types of diabetes include diabetes forms which are induced by diseases of the pancreas or liver as well as drug-induced diabetes. In this context endocrine disorders as the cause of secondary diabetes are of special clinical interest: On the one hand a chronically insufficient metabolic control of diabetes can change endocrine parameters (e.g. thyroid hormone, growth hormone), while on the other hand acute imbalance of glucose control in diabetic patients could be induced by endocrine diseases. Hyperthyroidism in diabetics leads to increased insulin resistance and reduced insulin secretion, resulting in pronounced hyperglycemia. In contrast, hypothyroidism leads to increased insulin sensitivity and greater risk of hypoglycemia, especially in insulin-dependent diabetes. Pathologically increased growth hormone secretion and diseases of the adrenal gland may have pronounced effects on glucose metabolism. Given the known association between type 1 diabetes and other autoimmune endocrinopathies (polyglandular autoimmune syndrome, PAS), annual screening for these patients and their near relatives is recommended. © Springer-Verlag 2010.

Muller-Barna P.,Sta Dtisches Klinikum Munich GmbH | Schwamm L.H.,Massachusetts General Hospital | Haberl R.L.,Sta Dtisches Klinikum Munich GmbH
Current Opinion in Neurology | Year: 2012

Purpose of review: This review provides a comprehensive overview of the management of acute stroke within the framework of telestroke services. Recent findings: The remote neurological examination using high quality videoconferencing coupled with remote review of neuroimaging has gained acceptance and proved its reliability in various publications. Telestroke networks confirmed the safety and efficiency of telethrombolysis, with an increase in the rate of thrombolysis in recent years. The analysis of a telestroke network in Europe showed improved outcomes in a cohort of ischemic stroke patients. Summary: At the beginning of the millennium, telestroke networks started to develop. Ten years later, there is a collection of about 40 various networks in North America and Europe performing teleconsultations on a regular basis. Telestroke is not a new therapeutic modality, but rather a set of tools to enable more efficient delivery of acute stroke care and to improve the quality of stroke care in neurologically underserved areas. Depending on the level of available regional resources, telestroke networks can support affiliated hospitals by implementing measures that improve the quality of stroke management such as regional campaigns, stroke units and stroke teams, medical education and programs encouraging the usage of guidelines. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

The phenomena of auto-positive end-expiratory pressure (auto-PEEP) and hyperinflation in patients under mechanical ventilation have been known for over 40 years. In this context, airway obstruction, insufficient expiration times and inadequate respiratory pressures play important roles. The negative effects of auto-PEEP and hyperinflation are complex and include barotrauma, impairment of hemodynamics, asynchrony between patient and ventilator and dyspnea. In addition to the definition of signs of hyperinflation and the underlying pathophysiology, this article describes the relevant methods applicable at the bedside for determination of auto-PEEP and air trapping. The most important steps to prevent hyperinflation in mechanically ventilated patients are also explained. © 2016 Springer-Verlag Berlin Heidelberg

Malnutrition is an often underestimated problem in the ICU. Adequate nutritional therapy is able to diminish or reverse the deleterious effects of malnutrition. Traditionally, the enteral route is preferred as a more physiologic approach to clinical nutrition. During prolonged critical illness energy uptake via enteral nutrition is often limited by gastrointestinal intolerance. Supplemental parenteral nutrition may be able to decrease the energy deficit in these patients and be therefore a therapeutic approach to improving the patients' outcome. © 2011 Springer-Verlag.

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