Thoraxchirurgische Resektion des Lungenkarzinoms beim alten Menschen – bedingt der demografische Wandel ein Umdenken?

ZusammenfassungDurch den in Deutschland herrschenden demografischen Wandel verschiebt sich die Alterspyramide immer mehr nach oben. Als älter gilt laut WHO ein Mensch zwischen dem 61. und dem 75. Lebensjahr. Als alt werden Menschen ab 76 Jahren bezeichnet. Für die Beantwortung der Frage, ob und in welchem Ausmaß ein alter Patient aufgrund seiner Komorbiditäten thoraxchirurgisch operabel ist, gibt es bislang keine systematische Klassifizierung. In den meisten Fällen scheint für diese Entscheidung die Erfahrung und Einschätzung des Operateurs ausschlaggebend zu sein. Patienten und Methoden Die Datenanalyse erfolgte im Zeitraum von 01. 2016–01. 2018 anhand der Daten des Deutschen Thoraxregisters (Projekt-ID:2017–03), das unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) aufgebaut wurde. Insgesamt wurden 1357 Patienten eingeschlossen, von denen 658 ein histologisch nachgewiesenes Lungenkarzinom im Stadium I-II hatten. Diese wurden in drei Gruppen unterteilt; Gruppe I (< 65 Jahre), Gruppe II (65– ≤ 75 Jahre) und Gruppe III (> 75 Jahre).Wir konnten zeigen, dass Gruppe III, die der > 75-jährigen Patienten, im Wesentlichen keine erhöhten postoperativen Komplikationsraten hatten (Alle = 48,00 %; Gr. I = 40,90 %; Gr. II = 53,00 %; Gr. III = 52,90 %) und sogar bei einigen speziellen Komplikationen besser abschnitt, als die Gruppe der 65 bis ≤ 75-jährigen Patienten. (z. B. postoperative Pneumonie Gruppe II = 19,20 %, Gruppe III = 12,90 %).Die Mortalität lag bei den Patienten der Gruppen I–III, die in Zentren des Deutschen Thoraxregisters operiert wurden (Alle = 1,70 %, Gr. I = 1,90 %; Gr. II = 1,70 %; Gr. III = 1,30 %), insgesamt niedriger als im bundesdeutschen Durchschnitt (Alle = 1,99 %; Gr. I = 1,23 %; Gr. II = 2,18 %; Gr. III = 3,78 %). Insbesondere die alten Patienten der Gruppe III wiesen hierbei den größten Unterschied auf.Weiterhin konnten wir feststellen, dass im Gegensatz zu anderen deutschen Zentren und Kliniken, der größte Teil der anatomischen Resektionen in den Zentren des Deutschen Thoraxregisters minimalinvasiv per VATS (Video-assisted Thoracoscopic Surgery) durchgeführt wurde. Diskussion Auf Grundlage dieser Erhebungen stellte sich uns die Frage, ob die alten Patienten der Gruppe III (> 75jährigen) in Deutschland in der Regel einer leitliniengerechten Therapie zugeführt wurden. Zwar gibt es eine Selektion der Patienten in Gruppe III in den Zentren des Deutschen Thoraxregisters, dennoch ist unser Appell, dass nach Abwägung der individuellen Risiken und nach objektiven Kriterien auch diese Patientengruppe deutschlandweit der onkologischen Therapie der Wahl (Goldstandard) zugeführt werden sollte. Hierunter verstehen wir unbedingt die anatomische Resektion mit einem minimal invasiven Zugang per VATS. Das Risiko einer postoperativen Komplikation auf Grund des Alters darf nicht die alleinige Entscheidungsgrundlage gegen eine Resektion sein.

Trajectories of Recovery after Atrial Fibrillation Ablation

Ablation procedures are common for patients with atrial fibrillation (AF), yet evidence is limited about patient perceptions of their recovery following ablation. We sought to expand understanding of this recovery process. Twenty participants undergoing their first AF ablation completed semi-structured interviews prior to ablation (baseline) and at one, three, and six months post AF ablation. Pre-procedure education is modeled after education used for other ablation procedures, preparing patients to expect a single recovery trajectory. We identified two recovery trajectories that varied in speed of symptom resolution: sustained improvement and pseudo improvement. Recovery was slower than expected in both trajectories. Moreover, returning to desired activity levels consistently lagged behind other symptom resolution by approximately two months. A more accurate understanding of what patients experience post-ablation, as illustrated in these findings, serves as a beginning step to alter patient education prior to AF ablation to better prepare individuals for the recovery process.

Discrepancy rates of preliminary and final reports for after-hours pediatric teleradiology interpretations

Background Children’s hospitals often do not have a high enough volume to justify providing radiologist staffing overnight, leading to hospitals employing teleradiology services to offer preliminary reports. There is limited literature related to discrepancies between preliminary teleradiology pediatric radiologists and final interpretations. Purpose The purpose of this study is to examine discrepancy rates for teleradiologists preliminarily interpreting pediatric exams at a children’s hospital. Material and Methods Eight thousand seven hundred seventy-eight consecutive preliminary reports issued by pediatric teleradiologists were reviewed. The hospital utilized a system in which local onsite radiologists rated the preliminary reports of teleradiologists following the interpretations as part of standard operating procedure. Discrepancies were also rated according to whether the discrepancy was actionable (judged to alter patient management by the final rater) or not. Rates were stratified by modality, preliminary teleradiologist reader, and final rater and compared to each using a normal approximation. The mean discrepancy rates were compared using a z test for proportions. Linear regression was applied to the effect of years of radiologist experience on the total and actionable discrepancy rates. Results The overall actionable discrepancy rate was 1.6%, similar to inter-observer discrepancy rates reported in other studies. There were no significant differences in the actionable discrepancy rates among teleradiologists. There was no correlation between years of experience and discrepancy rate for either the teleradiologists or the final raters. Conclusion Pediatric subspecialty teleradiologists issue reports that mirror discrepancy rates typical of radiologists who issue reports for emergent adult studies. Years of radiologist experience is not a predictor of discrepancy rate.

Repeat Head CT for Neurologically Stable Patients With Mild Traumatic Subarachnoid Hemorrhage During Interfacility Transfer and Follow-Up Does Not Alter Patient Care

Purpose: To evaluate the impact of repeat head computed tomography (CT) during (1) interfacility transfer and (2) inpatient and/or outpatient follow-up on management, cost-effectiveness, and radiation dose in neurologically stable patients with mild traumatic subarachnoid hemorrhage (tSAH). Material and Methods: This is a single-center retrospective study evaluating patients with mild tSAH presenting between January 2017 and July 2019. A total of 101 and 140 patients met the eligibility criteria for the first and second subgroups, respectively. Common inclusion criteria were isolated mild tSAH, Glasgow Coma Scale between 13 and 15, and neurological stability. Additional inclusion criteria for the first subgroup were availability of brain imaging at the outside institution prior to transfer and the second subgroup was the availability of follow-up imaging. Results: In the first subgroup, 76.20% of patients had stable SAH, 18.80% had reduced SAH, while 5% had an interval increase in SAH. None required any surgical intervention. Additional per-patient mean radiation exposure was 1.77 ± 0.26 mSv. In the second subgroup, all 140 patients had complete resolution of tSAH. One patient had a new tiny subdural hemorrhage, which subsequently resolved on follow-up. The additional mean radiation exposure was 2.47 ± 1.29 mSv. A total of 256 avoidable CT scans were performed resulting in excess health care costs of about US$531 696. Conclusion: In neurologically stable isolated tSAH patients, repeat brain imaging during interfacility transfer and inpatient and/or outpatient follow-up do not alter patient management despite increased health care costs and radiation burden.

Do reflex comments on laboratory reports alter patient management?

Introduction Laboratory comments appended on clinical biochemistry reports are common in the UK. Although popular with clinicians and the public, there is little evidence that these comments influence the clinical management of patients. Methods We provided reflex automated laboratory comments on all primary care lipid results including, if appropriate, recommendation of direct referral to the West Midlands Familial Hypercholesterolaemia service (WMFHS). Over a two-year period, the number GP referrals from the Wolverhampton City Clinical Commissioning Group (CCG) to the WMFHS were compared with four comparator CCGs of similar population size, who were not provided with reflex laboratory comments. Results Over the study period, the WMFHS received more referrals from Wolverhampton GPs (241) than any other comparator CCG (range 8–65) and greater than the combined referrals (172) from all four comparator CCGs. Conclusion Targeted reflex laboratory comments may influence the clinical management of patients and may have a role in the identification of individuals with familial hypercholesterolaemia.

Sugammadex: routine use vs restrictive use

Worldwide, the use of sugammadex for the reversal of neuromuscular blocking agents worldwide is restricted. This article reflects on how more liberal use of sugammadex might alter patient experience, anaesthetic delivery and surgical techniques.

KCNQ gene family members act as both tumor suppressors and oncogenes in gastrointestinal cancers

We present evidence that KCNQ genes are drivers and suppressors of gastrointestinal (GI) cancer in humans. The KCNQ family of genes encode for subunits of a potassium channel complex involved in membrane polarisation and little is known about their role in cancer. We use human cancer data and a multidisciplinary computational-based approach including structural modelling and simulation, coupled with in vitro experiments to show that KCNQ1 is a tumor suppressor, and KCNQ3 and KCNQ5 are oncogenic across human GI cancers. We link the expression of KCNQ genes to WNT signalling, EMT, and survival and propose that mutation/copy number alteration of KCNQ genes can significantly alter patient prognosis in GI cancers.