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Venous reperfusion as well as double-lumen cannulae for extracorporeal gas exchange (ECMO) are usually inserted via the right internal jugular vein. The supraclavicular approach to the right or left subclavian vein could serve as a possible alternative. The aim of this analysis was to compare feasibility, complications, and performance of supraclavicular and jugular cannulation, respectively.We retrospectively analysed charts and registry data of patients undergoing veno-venous ECMO. Twenty-four patients underwent jugular cannulation and 11 patients underwent supraclavicular cannulation. Ten patients underwent femoro-jugular and 5 patients underwent femoro-supraclavicular ECMO. Double lumen cannulae were inserted via the jugular approach in 14 patients and via the supraclavicular approach in 6 patients.No cannulation associated complications but for a single minor bleeding from the insertion site of a supraclavicular double lumen cannula were recorded. Performance of the extracorporeal circuit was comparable between jugular and supraclavicular groups but for a more pronounced oxygenation effect in the supraclavicular double-lumen group due to higher blood flows via larger (24F) cannulae.The supraclavicular approach seems safe and equivalent to jugular cannulation and could serve as a valid alternative. Copyright © 2017 by the American Society for Artificial Internal Organs

Metastatic melanoma is a highly aggressive disease. Recent progress in immunotherapy (IT) and targeted therapy (TT) has led to significant improvements in response and survival rates in metastatic melanoma patients. The current project aims to determine the benefit of the introduction of these new therapies in advanced melanoma across several regions of Switzerland. This is a retrospective multicenter analysis of 395 advanced melanoma patients treated with standard chemotherapy, checkpoint inhibitors, and kinase inhibitors from January 2008 until December 2014. The 1-year survival was 69% (n=121) in patients treated with checkpoint inhibitors (IT), 50% in patients treated with TTs (n=113), 85% in the IT+TT group (n=66), and 38% in patients treated with standard chemotherapy (n=95). The median overall survival (mOS) from first systemic treatment in the entire study cohort was 16.9 months. mOS of patients treated either with checkpoint or kinase inhibitors (n=300, 14.6 months) between 2008 and 2014 was significantly improved (P<0.0001) compared with patients treated with standard chemotherapy in 2008–2009 (n=95, 7.4 months). mOS of 61 patients with brain metastases at stage IV was 8.1 versus 12.5 months for patients without at stage IV (n=334), therefore being significantly different (P=0.00065). Furthermore, a significant reduction in hospitalization duration compared with chemotherapy was noted. Treatment with checkpoint and kinase inhibitors beyond clinical trials significantly improves the mOS in real life and the results are consistent with published prospective trial data. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Mari A.,Vienna University Hospital
Current Opinion in Urology | Year: 2017

PURPOSE OF REVIEW: To review and summarize the current literature of the implications of obesity on nononcological urological surgery. We conducted a comprehensive search of the current literature with emphasis on the published literature in the last 18 months. RECENT FINDINGS: Over time, obese patients have become a more common encounter in clinical practice. Obesity represents a considerable operative challenge and has been linked to a higher rate of postoperative complications. Data regarding surgery for incontinence are inconsistent. Nevertheless, the success rates in obese women are high, and complication rates are relatively low with comparable results to nonobese women. In renal surgery, percutaneous nephrolithotomy and minipercutaneous nephrolithotomy are feasible, well tolerated, and effective even in obese patients. However, certain precautions and availability of proper instruments are necessary. SUMMARY: Although randomized clinical data are lacking and the results of many studies are inconsistent, evidence supports the feasibility and safety of different nononcological urological interventions in obese patients. Moreover, the success rates and the overall complication rates seem to be comparable to nonobese patients with some exceptions. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

OBJECTIVE: The aim of this study was to evaluate if an early rehabilitation program for survivors of critical illness improves functional recovery, reduces length of stay, and reduces hospital costs. DESIGN: This was a prospective randomized controlled trial. Fifty-three consecutive survivors of critical illness were included in the study. After discharge from the intensive care unit, the intervention group received an early rehabilitation program, and the standard-care group received physical therapy as ordered by the primary care team. Length of stay at the general ward after transfer from the intensive care unit was recorded. In addition, Early Rehabilitation Barthel Index, visual analog scale for pain, 3-minute walk test, Beck Depression Inventory, State-Trait Anxiety Inventory, and Medical Research Council scale were used. RESULTS: In the per-protocol analysis, length of stay at the general ward was a median 14 days (interquartile range [IQR], 12–20 days) in the early rehabilitation and 21 days [IQR, 13–34 days) in the standard-care group. This significant result could not be confirmed by the intention-to-treat analysis (16 days [IQR, 13–23 days] vs. 21 days [IQR, 13–34 days]). Secondary outcomes were similar between the groups. Hospital costs were lower in the intervention group. No adverse effects were detected. CONCLUSIONS: An early rehabilitation program in survivors of critical illness led to an earlier discharge from the hospital, improved functional recovery, and was also cost-effective and safe. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at CME OBJECTIVES: Upon completion of this article, the reader should be able to (1) delineate the benefits of early rehabilitation on a general medicine ward after an intensive care unit stay, (2) recognize the safety of appropriately implemented early rehabilitation, and (3) incorporate early rehabilitation on the general medical ward as applicable. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Adams D.H.,Mount Sinai School of Medicine | Rosenhek R.,Vienna University Hospital | Falk V.,University of Zürich
European Heart Journal | Year: 2010

Degenerative mitral valve disease often leads to leaflet prolapse due to chordal elongation or rupture, and resulting in mitral valve regurgitation. Guideline referral for surgical intervention centres primarily on symptoms and ventricular dysfunction. The recommended treatment for degenerative mitral valve disease is mitral valve reconstruction, as opposed to valve replacement with a bioprosthetic or mechanical valve, because valve repair is associated with improved event free survival. Recent studies have documented a significant number of patients are not referred in a timely fashion according to established guidelines, and when they are subjected to surgery, an alarming number of patients continue to undergo mitral valve replacement. The debate around appropriate timing of intervention for asymptomatic severe mitral valve regurgitation has put additional emphasis on targeted surgeon referral and the need to ensure a very high rate of mitral valve repair, particularly in the non-elderly population. Current clinical practice remains suboptimal for many patients, and this review explores the need for a 'best practice revolution' in the field of degenerative mitral valve regurgitation. © The Author 2010.

Ball E.M.,The University of Shimane | Ball E.M.,Vienna University Hospital
Rheumatology (Oxford, England) | Year: 2014

OBJECTIVES: The aims of this study were to investigate the extent of MRI-determined joint disease (erosion and synovitis) in SLE and to link this to autoantibody profiles known to be relevant to SLE, including ACPA, RF and anti-RA33 antibodies.METHODS: Contrast-enhanced MRI of the hand and wrist was performed in 34 symptomatic SLE patients and in 15 RA patients with similar disease duration. Images were scored by two observers using the OMERACT rheumatoid arthritis MRI scoring (RAMRIS) system. Findings were correlated with clinical examination and autoantibody status.RESULTS: Erosions were present at the wrist in 93% of SLE patients and at the MCP joints in 61% of SLE patients. Despite the high prevalence of MRI-determined erosion, only 8.8% of SLE patients were ACPA positive, although these patients had a higher burden of erosive disease. There was no positive correlation with anti-RA33 titres and erosion scores in the SLE patients, but there was a negative correlation with anti-RA33 titres and total bone oedema scores in the SLE patients. Ninety-three per cent of SLE patients had at least grade 1 synovitis at one or more MCP joints, and wrist joint synovitis was present in all the SLE patients.CONCLUSION: An MRI-determined joint erosive phenotype is common in SLE, even in ACPA-negative cases. The conventional radiographic observation that anti-RA33 is not positively associated with erosion in patients with RA was also found to be the case in SLE patients. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email:

Druml W.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2014

Purpose of review Acute kidney injury (AKI) is a frequent and serious event associated with a high rate of complications, with an increased risk of progression to multiple organ dysfunction and excessive 'attributable' mortality. AKI affects all physiologic functions and organ systems with interrelated mechanisms, including the 'classical' consequences of the uremic state, the inflammatory nature of AKI per se and resulting systemic effects, the modulating effect of AKI in the presence of an (inflammatory) underlying disease process and the multiple untoward effects induced by renal replacement therapy (RRT) and anticoagulation. Recent findings A rapidly increasing body of evidence is clarifying these systemic effects that are the reflection of a broad common pathology that ultimately results in an 'augmented' inflammation and impairment of immunocompetence. This includes the release of cytokines and inflammatory mediators, increase in oxidative stress, activation of various immune cells, neutrophil extravasation, generalized endothelial injury, increased vascular permeability and tissue oedema formation. Summary These systemic phenomena associated with AKI induce distant organ injury affecting all organ systems with clinically the most relevant effects being exerted on the lungs, the intestines and liver and the heart and predispose the progression to multiple organ dysfunction syndrome and death. Currently available renal replacement therapy modalities are incapable of compensating for these systemic consequences of AKI. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Valentin A.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2010

Purpose of review Intensive care patients are per definition at risk for an unfavourable outcome while at the same time being exposed to the risks of a very complex and invasive process of care. This review addresses this extrinsic risk with respect to causative factors and strategies for risk reduction. Recent findings A growing amount of evidence shows that the actual risk of an unfavourable outcome in critically ill patients depends on the quality of the process of care. Several domains have been identified in which changes in infrastructure, process, and culture can result in a substantial risk reduction and increased patient safety. Important examples refer to work environment and workload of intensive care professionals, safety climate, information flow, and continuity of care. Recent studies have demonstrated that routine procedures in intensive care are amenable to considerable improvement. Summary This review discusses recent findings related to the reduction of risk in critically ill patients with respect to the process of intensive care medicine and the conditions under which that care is provided. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Hoke M.,Vienna University Hospital
Swiss medical weekly | Year: 2011

Dental status and oral hygiene are associated with progression of atherosclerosis in patients with carotid stenosis. It remains unclear whether dental disease is a risk factor for mortality in these patients. We evaluated the bearing of dental disease on mortality among patients with asymptomatic carotid atherosclerosis. Three World Health Organization-validated indices in 411 patients with asymptomatic carotid atherosclerosis were evaluated, measuring DMFT (decayed, missing, filled teeth) for dental status, CPITN (community periodontal index for treatment needs) for periodontal status and SLI (Silness-Löe Index) for oral hygiene respectively. Patients were prospectively followed for median 6.2 years (IQR 5.8 to 6.6 years) for all-cause mortality. During follow-up, 107 (26%) deaths occurred (74 cardiovascular causes). DMFT and SLI, but not CPITN, showed a significant and gradual association with mortality. For continuous variables, the adjusted hazard ratios (HR) for death were 1.06 (95% CI 1.0 to 1.12; p = 0.04) for DMFT, and 1.43 (95% CI, 1.01 to 2.03; p = 0.04) for SLI respectively. Edentulousness was a significant risk factor for death (adjusted HR 1.99, 95% CI, 1.18 to 3.02; p = 0.008). Dental status and oral hygiene were associated with mortality in patients with carotid atherosclerosis regardless of conventional cardiovascular risk factors.

Valentin A.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2013

PURPOSE OF REVIEW: The very complex process of intensive care is accompanied by a not unexpected accumulation of risk for error and adverse events. The present review addresses strategies to decrease care errors in several domains of daily intensive care practice. RECENT FINDINGS: Strategies to decrease care errors now focus on a systematic approach by identifying latent system failures and change the design of the care process in such a way that inevitable human errors are prevented or their consequences are mitigated. Recent examples refer to the standardization of processes, adaptation to cognitive limitations of human beings, optimization of working conditions, and the increasing use of supporting information technologies. The development of a safety climate constitutes a key element and apparently contributes to reduction of medical errors in ICUs. SUMMARY: The present review discusses recent approaches aimed to decrease care errors in ICUs. A growing body of evidence demonstrates that a system based approach with the change of process characteristics and the development of a safety climate is most essential in the effort to increase patient safety. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins.

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