Assisted Peritoneal Dialysis

The number of patients depending on dialysis therapies increases worldwide. The home-based dialysis modalities offer some advantages especially for elderly patients. In the case of peritoneal dialysis (PD), the life quality is superior compared to in-center hemodialysis (HD), and other advantages are existent. Due to the effect that a lot of elderly PD patients are frail, a concept covering the different modalities of PD must include the assistance at home or the living environment (assisted PD) for the bag exchanges that often cannot be performed reliably by elderly and frail patients by themselves. Nowadays, we have enough data to safely offer assisted peritoneal dialysis (aPD) in a cost-saving manner. Putting all these aspects together, aPD is a safe and in some countries widely used modality. The issue of reimbursement and education of home nurse staff must be solved. However, for elderly and frail patients, aPD offers a change to use the advantages of PD for these population, and on a local level, the provider should seek ways to establish aPD programs

The Practice of Medicine in the Age of Information Technology

Regarding the practice of medicine, we have to face the chances and challenges of all aspects of e-Health; however, the term “digitalization” is broader and spanning all aspects. However, the digitalization of medicine offers solutions for pressing problem. We know the factors that lead to excellence in medicine. Without the right amount of experiences based on a solid ground of knowledge, no excellence is achievable. The problem, nowadays, is that due to restriction of working hours, to the goals of life (“life-work-balance”) and the restrictions of Generation Y, almost no education in medicine is spanning the needed 10,000 h experiences in practical medicine for excellence. Therefore, we will see the fading of medical excellence, if we could not establish other systems. A solution can be searched in decision-support systems. However, a requirement before is the need of a digitalization of all health data. We surely do not have enough evidences for all aspects of the practice of medicine, the intuition is fading away and therefore, we have to look around for other solutions. Big data generated by the digitalization of all health data could be the problem solver. In combination, IT will help to improve the quality of care

Durchlaufzeiten in der Zentralen Notaufnahme – eine Prinzipal-Agenten-Analyse

Fast die Hälfte (42%) aller Patienten eines Krankenhauses durchläuft die Notaufnahme [31]. Die Reduktion langer Wartezeiten, verursacht u.a. durch Prozessineffizienzen [26], verspricht daher gerade in der Zentralen Notaufnahme (ZNA) besonders hohe Optimierungspotenziale. In der Literatur werden verschiedene Ineffizienzen genannt, z.B. „Verschwinden“ der Patienten in der Radiologie [5] oder social loafing [22]. Der vorliegende Beitrag vermutet Informationsasymmetrien zwischen den beteiligten Akteuren als Ursache. Vorgestellt wird eine Analyse der ZNA mittels der Prinzipal-Agenten-Theorie und das Design einer empirischen Untersuchung zum Nachweis der Reduktion von Informationsasymmetrien und der Durchlaufzeiten durch ein Monitoring System

TIMP-2 and IGFBP7 in human kidney biopsies in renal disease

ABSTRACT Background Tissue inhibitor of matrix metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) are markers of tubular stress and urinary [TIMP-2]*[IGFBP7] is an established biomarker for risk assessment of acute kidney injury. There are no studies of expression profiles or localization of these markers in human renal tissue with confirmed renal disease. Methods We analysed 37 kidney biopsies of patients with renal disease and 10 non-diseased control biopsies for TIMP-2 and IGFBP7 expression using immunohistochemistry. Changes in glomerular morphology were evaluated by a semi-quantitative glomerulosclerosis score (GSI) and tubular interstitial changes were graded by the tubular injury score (TSI) using periodic acid–Schiff-stained paraffin sections. Interstitial fibrosis and tubular atrophy (IF/TA) were graded according to the Banff classification. Urinary [TIMP-2]*[IGFBP7] was collected at the time of biopsy. Results TIMP-2 and IGFBP7 had significantly greater expression in kidney biopsies from patients with renal disease compared with control tissue, especially in the tubular compartment. Here, IGFBP7 was detected in proximal and distal tubules while TIMP-2 was predominantly localized in the collecting ducts. Renal injury significantly correlated with staining intensity for TIMP-2 and IGFBP7: GSI weakly correlated with glomerular TIMP-2 (r = 0.36) and IGFBP7 (r = 0.35) and TSI correlated with tubular TIMP-2 (r = 0.41) and IGFBP7 (r = 0.43). Urinary [TIMP-2]*[IGFBP7] correlated weakly with the histopathological damage score but not with glomerular and tubular expression. Conclusion Our findings underline the role of TIMP-2/IGFBP7 as an unspecific marker of renal injury that is already in use for early detection of acute kidney injury. </jats:sec

Underutilization of information and knowledge in everyday medical practice: Evaluation of a computer-based solution

<p>Abstract</p> <p>Background</p> <p>The medical history is acknowledged as the <it>sine qua non </it>for quality medical care because recognizing problems is pre-requisite for managing them. Medical histories typically are incomplete and inaccurate, however. We show here that computers are a solution to this issue of information gathering about patients. Computers can be programmed to acquire more complete medical histories with greater detail across a range of acute and chronic issues than physician histories.</p> <p>Methods</p> <p>Histories were acquired by physicians in the usual way and by a computer program interacting directly with patients. Decision-making of what medical issues were queried by computer were made internally by the software, including determination of the chief complaint. The selection of patients was from admissions to the Robert-Bosch-Hospital, Stuttgart, Germany by convenience sampling. Physician-acquired and computer-acquired histories were compared on a patient-by-patient basis for 45 patients.</p> <p>Results</p> <p>The computer histories reported 160 problems not recorded in physician histories or slightly more than 3.5 problems per patient. However, physicians but not the computer reported 13 problems. The data show that computer histories reported problems across a range of organ systems, that the problems detected by computer but not physician histories were both acute and chronic and that the computer histories detected a significant number of issues important for preventing further morbidity.</p> <p>Conclusion</p> <p>A combination of physician and computer-acquired histories, in non-emergent situations, with the latter available to the physician at the time he or she sees the patient, is a far superior method for collecting historical data than the physician interview alone.</p

Under-recognition of Acute Kidney Injury after Cardiac Surgery in the ICU Impedes Early Detection and Prevention

Background: Acute kidney injury (AKI) is associated with high morbidity and mortality; therefore, prevention is important. The aim of this study was to systematically assess AKI incidence after cardiac surgery as documented in clinical routine compared to the real incidence because AKI may be under-recognized in clinical practice. Further, its postoperative management was compared to Kidney Disease: Improving Global Outcomes (KDIGO) recommendations because recognition and adequate treatment represent the fundamental cornerstone in the prevention and management of AKI. Methods: This retrospective single-center study included n = 100 patients who underwent cardiac surgery with cardiopulmonary bypass. The coded incidence of postoperative AKI during intensive care unit stay after surgery was compared to the real AKI incidence. Furthermore, conformity of postoperative parameters with KDIGO recommendations for AKI prevention and management was reviewed. Results: We found a considerable discrepancy between coded and real incidence, and conformity with KDIGO recommendations was found to be relatively low. The coded incidence was significantly lower (n = 12 vs. n = 52, p < 0.05), representing a coding rate of 23.1%. Regarding postoperative management, 90% of all patients had at least 1 episode with mean arterial pressure <65 mm Hg within the first 72 h. Furthermore, regarding other preventive parameters (avoiding hyperglycemia, stopping angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, avoiding contrast media, and nephrotoxic drugs), only 10 patients (20.8%) in the non-AKI group and in 5 (9.6%) subjects in the AKI group had none of all the above potential AKI-promoting factors. Conclusions: AKI recognition in everyday clinical routine seems to be low, especially in lower AKI stages, and the current postoperative management still offers potential for optimization. Possibly, higher AKI awareness and stricter postoperative management could already achieve significant effects in prevention and treatment of AKI