Browsing by Author "Bauer, M."

Finding predictors of the response to antidepressant therapy is a major goal of molecular psychiatry. The genes encoding the serotonin (SERT) and dopamine (DAT1) transporters are among the possible candidate genes modulating an individual's antidepressant response. In a naturalistic prospective cohort study with a total of 190 fully assessed patients, improvement of depression symptoms during the 3 weeks following initiation of antidepressant therapy was recorded using the 21-item Hamilton Depression Rating Scale (HDRS). The SLC6A3 3' UTR 40-bp variable number of tandem repeats (VNTR) and the SLC6A4 5' 44-bp insertion/deletion polymorphism were analyzed by polymerase chain reaction. There was a significantly smaller number of rapid responders among homozygous carriers of the DAT1 9-repeat allele (9/9) than among heterozygous (9/10) and homozygous (10/10) carriers of the 10-repeat allele (19 versus 37 versus 52%, respectively, P = 0.0037). Median decline in HDRS score was 35, 40, and 52% in patients with the 9/9, 9/10, and 10/10 genotypes, respectively (P = 0.013). The effect was found in all classes of medications (selective serotonin reuptake inhibitors (SSRIs), tricyclics, mirtazapine, venlafaxine) and statistically significant also within the subgroup of patients having received SSRIs. The serotonin promoter insertion/deletion genotype had no effect in the entire study group, but there was an insignificant trend of better response in the I/I and I/s carriers who received SSRIs or mirtazapine. In conclusion, the dopamine transporter VNTR polymorphism influenced rapid response to antidepressant therapy. Compared with homozygous carriers of the 10-repeat allele, carriers of the 9/10 genotype had an odds ratio ( OR) calculated by logistic regression analysis of 1.6 ( 95% CI 0.8-3.2) and carriers of the 9/9 genotype had an OR of 6.0 (1.5-24.4) for no or poor response. Further studies are required to confirm this clinical association and to elucidate the underlying mechanisms.

BACKGROUND Remote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients undergoing cardiac surgery, but uncertainty about clinical outcomes remains. METHODS We conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary end point was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90. RESULTS A total of 1403 patients underwent randomization. The full analysis set comprised 1385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary end point (99 patients [14.3%] in the RIPC group and 101 [14.6%] in the sham-RIPC group, P = 0.89) or of any of the individual components: death (9 patients [1.3%] and 4 [0.6%], respectively; P = 0.21), myocardial infarction (47 [6.8%] and 63 [9.1%], P = 0.12), stroke (14 [2.0%] and 15 [2.2%], P = 0.79), and acute renal failure (42 [6.1%] and 35 [5.1%], P = 0.45). The results were similar in the per-protocol analysis. No treatment effect was found in any subgroup analysis. No significant differences between the RIPC group and the sham-RIPC group were seen in the level of troponin release, the duration of mechanical ventilation, the length of stay in the intensive care unit or the hospital, new onset of atrial fibrillation, and the incidence of postoperative delirium. No RIPC-related adverse events were observed. CONCLUSIONS Upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery.

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management. A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin). For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI. In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

The quality assurance of care and patient safety, with increasing cost pressure and performance levels is of major importance in the high-risk and high cost area of the operating room (OR). Standard operating procedures (SOP) are an established tool for structuring and standardization of the clinical treatment pathways and show multiple benefits for quality assurance and process optimization. An internal project was initiated in the department of anesthesiology and a continuous improvement process was carried out to build up a comprehensive SOP library. In the first step the spectrum of procedures in anesthesiology was transferred to PDF-based SOPs. The further development to an app-based SOP library (Aesculapp) was due to the high resource expenditure for the administration and maintenance of the large PDF-based SOP collection and to deficits in the mobile availability. The next developmental stage, the SOP healthcare information assistant (SOPHIA) included a simplified and advanced update feature, an archive feature previously missing and notably the possibility to share the SOP library with other departments including the option to adapt each SOP to the individual situation. A survey of the personnel showed that the app-based allocation of SOPs (Aesculapp, SOPHIA) had a higher acceptance than the PDF-based developmental stage SOP form. The SOP management system SOPHIA combines the benefits of the forerunner version Aesculapp with improved options for intradepartmental maintenance and administration of the SOPs and the possibility of an export and editing function for interinstitutional exchange of SOPs.

Besides reliable efficacy and patient satisfaction, economic efficiency is becoming increasingly more important in postoperative pain management. The present study investigated the effectiveness of two pain pump systems and compared the running costs in treatment. In this study 40 patients received an interscalene catheter prior to shoulder surgery. Postoperative pain management was provided via an electronic pump with patient-controlled analgesia (PCA) or a mechanical pump without PCA. Patients kept a pain log. After treatment they were interviewed about their satisfaction with the pump. In addition drug consumption, nursing material, staff time for handling and maintenance of the pumps and preparation of medications pro re nata were assessed. Postoperative pain levels and patient satisfaction were comparable in both groups. Economically, the electronic pump was more cost-effective than the electronic model for a duration of treatment of 1 and 2 days. With treatment duration of 2 days the costs of both pumps were equivalent; however, the PCA feature of the electronic pump allowed a reduced intake of systemic analgesics on demand. Both pain pump systems provide equally effective pain management, while the electronic model caused less costs. Both pumps offer advantages and disadvantages that should be considered based on local circumstantial demands.

Background: Lithium has proven suicide preventing effects in the long-term treatment of patients with affective disorders. Clinical evidence from case reports indicate that this effect may occur early on at the beginning of lithium treatment. The impact of lithium treatment on acute suicidal thoughts and/or behavior has not been systematically studied in a controlled trial. The primary objective of this confirmatory study is to determine the association between lithium therapy and acute suicidal ideation and/or suicidal behavior in inpatients with a major depressive episode (MDE, unipolar and bipolar disorder according to DSM IV criteria). The specific aim is to test the hypothesis that lithium plus treatment as usual (TAU), compared to placebo plus TAU, results in a significantly greater decrease in suicidal ideation and/or behavior over 5 weeks in inpatients with MDE. Methods/Design: We initiated a randomized, placebo-controlled multicenter trial. Patients with the diagnosis of a moderate to severe depressive episode and suicidal thoughts and/or suicidal behavior measured with the Sheehan-Suicidality-Tracking Scale (S-STS) will be randomly allocated to add lithium or placebo to their treatment as usual. Change in the clinician administered S-STS from the initial to the final visit will be the primary outcome. Discussion: There is an urgent need to identify treatments that will acutely decrease suicidal ideation and/or suicidal behavior. The results of this study will demonstrate whether lithium reduces suicidal ideation and behavior within the first 5 weeks of treatment.

Background and goal: Forced by the current economical situation, German hospitals have to reconsider their clinical productivity. When caregivers introduce new therapeutic concepts medical quality should either be improved without increasing costs or when reducing costs medical quality should be maintained. In the surgical field postoperative shivering reduces both patient comfort and medical quality. We therefore investigated the clinical pathway prevention of shivering with dolasetron in a prospective, randomized, placebo-controlled analysis of cost-effectiveness. Material and methods. After written informed consent we randomized 40 patients scheduled for lumbar disc hernia repair or head and neck surgery into two groups: patients of group D received dolasetron 1 mg/kg body weight during surgery whereas patients of group K received 100 ml saline as placebo. Primary endpoints were the incidence of shivering, the length of stay in the postanesthesia care unit and process-associated costs. Secondary endpoint was the influence on perioperative thermoregulation. Results. We observed postanesthetic shivering in 5 patients belonging to group D in comparison to 15 patients receiving the placebo (p < 0.05). The length of stay in the postanesthesia care unit was shorter in patients allocated to dolasetron (mean +/- SD; group D: 43 +/- 16 min, group K 62 +/- 18 min, p < 0.05). There was a significant saving in process-associated personnel costs (personnel costs in group D EUR 41.26 +/- 14, personnel costs in group K EUR 53.15 +/- 15) but in contrast the process-associated material costs were significantly increased (group D EUR 17.16 +/- 3, group K EUR 0.73 +/- 1, p < 0.05). Conclusions. The optimization of the clinical process and medical quality induced by a prophylaxis against shivering and postoperative nausea and vomiting compensates for the increased use of pharmaceutical resources in our setting.

Perioperative hypothermia is a common complication of general anesthesia and occurs in up to 50 % of patients during ear, nose and throat (ENT) surgery. In this prospective, randomized controlled study the hypothesis that a new conductive warming blanket (BarrierA (R) EasyWarmA (R), Molnlycke Health Care Erkrath, Germany) is better in reducing the incidence of perioperative hypothermia in ENT surgery than insulation with a conventional hospital duvet alone was tested. After approval of the local ethics committee and written informed consent 80 patients with a planned procedure time between 1 and 3 h were recruited. Anesthesia was induced and maintained using propofol, remifentanil and rocuronium and the core temperature was measured using an esophageal temperature probe. Patients in the study group were warmed at least 30 min prior to induction of anesthesia using the novel warming blanket (BarrierA (R) EasyWarmA (R)) and patients in the control group were insulated with a standard hospital duvet. Data were tested using Fisher's exact test, Student's t-test or the Mann-Whitney U-test as appropriate. Time-dependent changes in core temperature were evaluated using repeated measures analysis of variance (ANOVA) and post hoc Scheff,'s test. Results are expressed as mean +/- SD or as median and interquartile range (IQR) as appropriate. A p < 0.05 was considered to be statistically significant. The ANOVA did not identify a significantly higher core temperature in the study group at any time point. Furthermore, Fisher's exact test showed no differences in the incidence of intraoperative (12 out of 29 versus 10 out of 32 patients, p = 0.44) or postoperative hypothermia (12 out of 29 versus 9 out of 32 patients, p = 0.30) between the groups. No adverse effects were observed. In the studied patient group the new conductive warming blanket (BarrierA (R) EasyWarmA (R)) showed no superiority compared to conventional thermal insulation alone.

The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental. The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures. Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing information on dosage, pharmacological interactions, side effects and contraindications of medications. The major challenges for quality and risk management, for the heads of departments and the executive board is the implementation and support of the described actions and a sustained guidance of the staff involved in the modification management process. The global trigger tool is suitable for improving transparency and objectifying the frequency of medical errors.

Supraglottic airway devices (SGAD) have become more important in airway management over the past years and an objective comparison of the available devices is in order. In a prospective study the four SGADs LMA-Classic (TM)(cLMA), LMA-ProSeal (TM) (PLMA), Ambu AuraOnce (TM) and Intersurgical i-gel (TM) were compared in groups of 40 patients in ambulatory surgery, with respect to the feasibility of positioning, leak tightness, patient comfort and airway morbidity. The seal test of the airway devices was carried out with a specially constructed pneumotachograph. Adequate placement on the first attempt was achieved in 92.5% with the cLMA, 85% with the PLMA, 92.5% with the AuraOnce (TM) and 82.5% with the i-gel (TM) (p > 0.05). There were no clinically relevant differences in mean insertion times: cLMA 13.8 s (+/- 3.4 s), PLMA 13 s (+/- 3.2 s), AuraOnce (TM) 11.2 s (+/- 2.7 s; p < 0.05) and 13.9 s (+/- 3.6 s) with the i-gel (TM). A tight seal at a constant oropharyngeal pressure of 15 cmH(2)O was achieved in 85% of the cases (34 cases) with the cLMA, 90% (36 cases) with the PLMA, 97.5% (39 cases) with the AuraOnce and 72.5% (29 cases) with the i-gel (TM) (p < 0.05). A tight seal at a constant oropharyngeal pressure of 20 cmH(2)O was seen in 62.5% with the cLMA, 60% with the PLMA, 67.5% with the AuraOnce (TM) and in 50% with the i-gel (TM) of the cases (p > 0.05). Airway morbidity was not observed in any group. Significantly more patients complained of a sore throat after using the cLMA (p < 0.05). The tested SGADs were comparable with regard to ease of insertion, insertion times and airway morbidity. Considering leak tightness and patient comfort the PLMA and the AuraOnce fared better with regard to tightness of seal and patient comfort.

Background: The aim of this study was to examine how human resources and costs of acute pain services (APS) are documented and covered. Methods: Heads of German anaesthesia departments were invited to participate in an online survey addressing human resources planning as well as provision of personnel and cost of supplies of their APS. Results: Answffs were received from 342 departments (response rate 38%), 80% (n=247) of the hospitals had an APS. Physicians for APS were included in the personnel planning in 24% of the hospitals, nursing staff in 50%. Personnel costs were most often covered by the budget of the anaesthesiology department 1(82%), considerably less by the nursing directorate (16%), an intra-hospital cost allocation (9%), shared between departments (6%), as a cost-centre (2%), or by external sponsorship (1%). 'In addition, the cost of supplies was generally covered by. the department of anaesthesia (drugs 85%, consumables 96%, pumps 93%, and maintenance costs 93%). Only 21% of APS documented the exact costs. 91% of the APS had no separate burden centre. Cost-type accounting was done for drugs in 10%, for consumables in 13%, for pumps in 18%, for, personnel expenses for catheter placement in 3%, and for postoperative care of the catheters or patient-controlled analgesia pumps in 5% of cases. Conclusions: Although many hospitals provide an APS, 75 and 50 percent of them did not foresee positions for doctors and nursing staff in their personnel planning, respectively. Personnel and supply costs were mostly covered by the department of anaesthesiology. There was a lack of documentation to explain the actual efforts and costs. For transparent financing of APS, a documentation of the actual efforts and costs would be of importance.

How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.

Demographic changes in Germany are leading towards a decrease of the population from the current 82 million to 74 million in the year 2050. As a consequence the shortage of qualified staff will be aggravated and intensifying recruiting efforts will increase competition among employers. An alternative is to utilize the potential of jobholders older than 55 years, the so-called generation 55 +. However, little is known about the hospital workforce generation 55 +. An internet search was conducted using google.de, yahoo.de and altavista.de for "generation 55 + and medicine" and "demographics, personnel and hospital" In Medline/pubmed a search was conducted for the key words "aging workforce" (949 sources) and in combination with AND "doctors" (134 sources), "demographic changes", "staff" (794 sources) as well as for "generation 55 + AND doctors" (312 sources). Finally, sources from reputable public institutions and academic medical societies were analyzed. The data were sorted by main categories and relevance for hospitals. Statistical analysis was done mainly using descriptive measures. From initially more than 530,000 sources, a total of 289 studies and reports on the topic were plotted. There was no evidence for a negative correlation between age and work ability or fitness. Jobholders senior to 55 years can be divided into the "economic miracle generation" and into the so-called baby-boomers. Both groups have differences in values, communication needs and leadership requirements. They jointly prefer direct communication and seek appreciation for their experience on the job. Generation 55 + is not asking for an upscaled position in hospitals. They expect respect and appreciation for their sound experience of work and life. Generation 55 + wants to be integrated and sought after. Keeping these employees fit, motivated and qualified is a sound approach to fight the foreseeable shortage of qualified staff in hospitals.

There is a significant shortage of highly qualified personnel in medicine, especially skilled doctors and nurses. This shortage of qualified labor has led to competition between hospitals. Analyzing the circumstances of the competition, nurses and doctors of the so-called generation Y are of importance. Recruitment and retention of these staff members will become a critical success factor for hospitals in the future. An internet search was conducted using the key words "generation Y and medicine, demography, personnel and hospitals". A search in Medline/pubmed for scientific studies on the topics of labor shortage was performed using the key words "personnel, shortage doctors, generation X, baby boomer, personnel and demographic changes, staff". Finally, sources from public institutions and academic medical societies were analyzed. The data were sorted by main categories and relevance for hospitals. Statistical analysis was done using descriptive measures. The analysis confirmed the heterogeneous and complex flood of information on the topic demography and generation. A comparison of the generations showed that they can be separated into baby boomers (born 1946-1964 live to work), generation X (born 1965-1980 work to live) and generation Y (born 1981 and after, live while working). Members of generation Y "live while working" are oriented to competence and less with hierarchies. They exchange information using modern communication methods and within networks. Internet and computers are part of their daily routine. Employees of generation Y challenge leadership in hospitals by increasing the demands. However, generation Y can significantly increase professionalization and competitiveness for hospitals.

The development of new molecular and neurobiological methods, computer-assisted quantification techniques and neurobiological investigation methods which can be applied to the human brain, all have evoked an increased demand for post-mortem tissue in research. Psychiatric disorders are considered to be of neurobiological origin. Thus far, however, the etiology and pathophysiology of schizophrenia, depression and dementias are not well understood at the cellular and molecular level. The following will outline the consensus of the working group for neuropsychiatric brain banking organized in the Brainnet Europe II, on ethical guidelines for brain banking, clinical diagnostic criteria, the minimal clinical data set of retrospectively analyzed cases as well as neuropathological standard investigations to perform stageing for neurodegenerative disorders in brain tissue. We will list regions of interest for assessments in psychiatric disorder, propose a dissection scheme and describe preservation and storage conditions of tissue. These guidelines may be of value for future implementations of additional neuropsychiatric brain banks world-wide.