1
|
Sensen B, Nierhaus A, Kluge S. [Corticosteroids in intensive care medicine]. Dtsch Med Wochenschr 2024; 149:714-718. [PMID: 38781995 DOI: 10.1055/a-2128-5319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
In the case of septic shock, recent studies show benefits from a combination of hydrocortisone and fludrocortisone, but clear guideline recommendations are still lacking. For severe community-acquired pneumonia, early corticosteroid therapy is recommended. Corticosteroid therapy should not be used in influenza-associated community-acquired pneumonia. In contrast, a significantly lower 28-day mortality rate was observed for COVID-19 by the use of dexamethasone. Current guidelines also recommend the use of corticosteroids in Acute Respiratory Distress Syndrome. These recommendations are based primarily on studies that started steroid therapy early. However, many questions such as the type of corticosteroid, the timing and duration of therapy, and the dosage still remain unanswered.
Collapse
Affiliation(s)
- Barbara Sensen
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Axel Nierhaus
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| |
Collapse
|
2
|
Kurotschka PK, Bentivegna M, Hulme C, Ebell MH. Identifying the Best Initial Oral Antibiotics for Adults with Community-Acquired Pneumonia: A Network Meta-Analysis. J Gen Intern Med 2024; 39:1214-1226. [PMID: 38360961 PMCID: PMC11116361 DOI: 10.1007/s11606-024-08674-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/02/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The objective of this network meta-analysis was to compare rates of clinical response and mortality for empiric oral antibiotic regimens in adults with mild-moderate community-acquired pneumonia (CAP). METHODS We searched PubMed, Cochrane, and the reference lists of systematic reviews and clinical guidelines. We included randomized trials of adults with radiologically confirmed mild to moderate CAP initially treated orally and reporting clinical cure or mortality. Abstracts and studies were reviewed in parallel for inclusion in the analysis and for data abstraction. We performed separate analyses by antibiotic medications and antibiotic classes and present the results through network diagrams and forest plots sorted by p-scores. We assessed the quality of each study using the Cochrane Risk of Bias framework, as well as global and local inconsistency. RESULTS We identified 24 studies with 9361 patients: six at low risk of bias, six at unclear risk, and 12 at high risk. Nemonoxacin, levofloxacin, and telithromycin were most likely to achieve clinical response (p-score 0.79, 0.71, and 0.69 respectively), while penicillin and amoxicillin were least likely to achieve clinical response. Levofloxacin, nemonoxacin, azithromycin, and amoxicillin-clavulanate were most likely to be associated with lower mortality (p-score 0.85, 0.75, 0.74, and 0.68 respectively). By antibiotic class, quinolones and macrolides were most effective for clinical response (0.71 and 0.70 respectively), with amoxicillin-clavulanate plus macrolides and beta-lactams being less effective (p-score 0.11 and 0.22). Quinolones were most likely to be associated with lower mortality (0.63). All confidence intervals were broad and partially overlapping. CONCLUSION We observed trends toward a better clinical response and lower mortality for quinolones as empiric antibiotics for CAP, but found no conclusive evidence of any antibiotic being clearly more effective than another. More trials are needed to inform guideline recommendations on the most effective antibiotic regimens for outpatients with mild to moderate CAP.
Collapse
Affiliation(s)
- Peter K Kurotschka
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Michelle Bentivegna
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Cassie Hulme
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.
| |
Collapse
|
3
|
Müller-Plathe M, Osmanodja B, Barthel G, Budde K, Eckardt KU, Kolditz M, Witzenrath M. Validation of risk scores for prediction of severe pneumonia in kidney transplant recipients hospitalized with community-acquired pneumonia. Infection 2024; 52:447-459. [PMID: 37985643 PMCID: PMC10954831 DOI: 10.1007/s15010-023-02101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Risk scores for community-acquired pneumonia (CAP) are widely used for standardized assessment in immunocompetent patients and to identify patients at risk for severe pneumonia and death. In immunocompromised patients, the prognostic value of pneumonia-specific risk scores seems to be reduced, but evidence is limited. The value of different pneumonia risk scores in kidney transplant recipients (KTR) is not known. METHODS Therefore, we retrospectively analyzed 310 first CAP episodes after kidney transplantation in 310 KTR. We assessed clinical outcomes and validated eight different risk scores (CRB-65, CURB-65, DS-CRB-65, qSOFA, SOFA, PSI, IDSA/ATS minor criteria, NEWS-2) for the prognosis of severe pneumonia and in-hospital mortality. Risk scores were assessed up to 48 h after admission, but always before an endpoint occurred. Multiple imputation was performed to handle missing values. RESULTS In total, 16 out of 310 patients (5.2%) died, and 48 (15.5%) developed severe pneumonia. Based on ROC analysis, sequential organ failure assessment (SOFA) and national early warning score 2 (NEWS-2) performed best, predicting severe pneumonia with AUC of 0.823 (0.747-0.880) and 0.784 (0.691-0.855), respectively. CONCLUSION SOFA and NEWS-2 are best suited to identify KTR at risk for the development of severe CAP. In contrast to immunocompetent patients, CRB-65 should not be used to guide outpatient treatment in KTR, since there is a 7% risk for the development of severe pneumonia even in patients with a score of zero.
Collapse
Affiliation(s)
- Moritz Müller-Plathe
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Barthel
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
4
|
Söhl K, Wolf F, Kuniß N, Sommer M, Tetmeyer R, Bleidorn J, Böde M. [Evaluation of electronic medical records from general practices using the example of the diagnosis of community-acquired pneumonia: A qualitative feasibility study]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024; 185:54-63. [PMID: 38388279 DOI: 10.1016/j.zefq.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Data collected by general practitioners (GPs) may provide potential for health services research. In this study, we investigated if clinical questions can be answered with GPs' electronic medical records (EMRs) by means of diagnosing community-acquired pneumonia (CAP). METHOD Patients diagnosed with CAP, defined as ICD code J18.9, were identified in the fourth quarter of 2021. The data were derived from the EMR system (Medical Office®) of a central German association of 30 general practices, using three different approaches: 1. The integrated statistic tool was used to record whether patients were referred for radiological diagnostic confirmation. 2. Retrospectively, EMRs were evaluated manually by a doctor familiar with the EMR. 3. The raw data of the EMR system were extracted by automated export. The information obtained through the three types of access was compared. For each patient case, detailed comments on problems and specifics were documented and evaluated by qualitative content analysis (QCA) according to Mayring. RESULTS In total, 164 patients diagnosed with CAP were identified. The numbers of documented radiological diagnostic confirmations varied between data approaches: While the manual evaluation of the EMRs revealed 60 referred patients, the statistics tool identified 38 of these cases. The export of the raw data identified 58 referrals to radiography after adjustment. According to QCA, there was a high variation in applied diagnostics and time of diagnosis. Referrals for radiography were made both before and after coding of the diagnosis. In case of hospitalization, X-rays were usually performed during the inpatient stay. Laboratory tests were performed as an alternative to radiography. There was also a high variation in the documentation of risk factors and diagnostic certainty. DISCUSSION The statistics tool integrated into the EMR system is a quick way to perform simple queries but proved to be impracticable for complex questions. The EMRs provide detailed information but need to be evaluated manually. An automated data export from the raw data offers both detailed information and access to large volumes of data but requires complex preparation and appropriate IT expertise. CONCLUSION Based on the example of diagnosed CAP in a GP setting, the use of data extracted from an EMR system seems to be feasible to answer simple clinical questions. However, it is necessary to adapt the data export, and a comparison with a small number of manually evaluated cases is useful to achieve valid results.
Collapse
Affiliation(s)
- Kristina Söhl
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Dr. med. Kielstein Akademie, Erfurt, Deutschland.
| | - Florian Wolf
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Dr. med. Kielstein Akademie, Erfurt, Deutschland; Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Institut für Allgemeinmedizin, Jena, Deutschland
| | - Nadine Kuniß
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Dr. med. Kielstein Akademie, Erfurt, Deutschland; Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, FB Endokrinologie und Stoffwechselerkrankungen, Jena, Deutschland
| | - Michael Sommer
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Dr. med. Kielstein Akademie, Erfurt, Deutschland
| | - Rico Tetmeyer
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Bereich IT, Softwareentwicklung, Erfurt, Deutschland
| | - Jutta Bleidorn
- Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Institut für Allgemeinmedizin, Jena, Deutschland
| | - Monique Böde
- Dr. med. Kielstein Ambulante Medizinische Versorgung, Dr. med. Kielstein Akademie, Erfurt, Deutschland; Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Institut für Allgemeinmedizin, Jena, Deutschland
| |
Collapse
|
5
|
Schleenvoigt BT, Ankert J, Barten-Neiner G, Voit F, Suttorp N, Boesecke C, Hoffmann C, Stolz D, Pletz MW, Rohde G, Witzenrath M, Panning M, Essig A, Rupp J, Degen O, Stephan C. Pathogen spectrum of community acquired pneumonia in people living with HIV (PLWH) in the German CAPNETZ-Cohort. Infection 2024; 52:129-137. [PMID: 37423969 PMCID: PMC10811115 DOI: 10.1007/s15010-023-02070-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES The objective of this study was to identify the pathogen spectrum of community acquired pneumonia in people living with HIV (PLWH), and to compare it with a matched HIV negative group in order to reassess therapeutic strategies for PLWH. METHODS Seventy-three (n = 73) PLWH (median CD4 3-6 months before CAP: 515/µl; SD 309) with community acquired pneumonia (CAP) were matched with 218 HIV-negative CAP controls in a prospective study design. Pathogen identifications used blood culture, samples from the upper and lower respiratory tract (culture and multiplex PCR) and urinary pneumococcal and legionella antigen test. RESULTS Although the vaccination rate among PLWH with CAP was significantly higher (pneumococcal vaccination: 27.4 vs. 8.3%, p < 0.001; influenza vaccination: 34.2 vs. 17.4%, p = 0.009), pneumococci were found most frequently as pathogen among both PLWH (n = 19/21.3%) and controls (n = 34/17.2%; p = 0.410), followed by Haemophilus influenzae (PLWH, n = 12/13.5%, vs. controls, n = 25 / 12.6%; p = 0.850). Staphylococcus aureus was found equally in 20.2 and 19.2% in PLWH and controls, but infection or colonization could not be distinguished. Mortality during 6-month follow-up was significantly higher for PLWH (5/73, or 6.8%) versus controls (3/218, or 1.4%), however with lower case numbers than previously reported. Typical HIV-associated pathogens such as Pneumocystis jirovecii were found only exceptionally. CONCLUSIONS Our study underscores the persistent clinical burden of CAP for PLWH. From pathogen perspective, empirical antibiotic treatment for CAP in PLWH on antiretroviral therapy should cover pneumococci and Haemophilus influenzae and may be adopted from valid common recommendations.
Collapse
Affiliation(s)
- Benjamin T Schleenvoigt
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany.
| | - Juliane Ankert
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
| | - Grit Barten-Neiner
- CAPNETZ STIFTUNG, Hannover, Germany
- Institute of Virology, University Medical Center-University of Freiburg, Freiburg, Germany
| | - Florian Voit
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- German Center for Lung Research (DZL), Berlin, Germany
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Christian Hoffmann
- ICH Study Center Hamburg, Hamburg, Germany
- University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Daiana Stolz
- Department of Pneumology, University Medical Center Freiburg, Freiburg, Germany
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
- CAPNETZ STIFTUNG, Hannover, Germany
| | - Gernot Rohde
- CAPNETZ STIFTUNG, Hannover, Germany
- Medical Department I, Department of Respiratory Medicine, Goethe University Hospital, Frankfurt/Main, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Martin Witzenrath
- CAPNETZ STIFTUNG, Hannover, Germany
- Department of Infectious Diseases, Respiratory and Critical Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Panning
- Institute of Virology, University Medical Center-University of Freiburg, Freiburg, Germany
| | - Andreas Essig
- Institute of Medical Microbiology and Hygiene, University Hospital of Ulm, Ulm, Germany
| | - Jan Rupp
- CAPNETZ STIFTUNG, Hannover, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel, Giessen, Germany
| | - Olaf Degen
- Outpatient Infectious Diseases Unit, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Stephan
- Medical Department II, Section Infectious Diseases, University Medical Center, Frankfurt am Main, Germany
| |
Collapse
|
6
|
Dietrich CF, Görg C, Horn R, Prosch H, Safai Zadeh E, Jenssen C. Ultrasound of the lung. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:582-599. [PMID: 37054729 DOI: 10.1055/a-2010-7282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The CME review is intended to explain and discuss the clinical value of lung ultrasound but also to enable a pragmatically oriented approach by analyzing the clinical aspect. This includes knowledge of the pre-test probability, the acuteness of the disease, the current clinical situation, detection and/or characterization, initial diagnosis or follow up assessment and the peculiarities of exclusion diagnosis. Diseases of the pleura and lungs are described using these criteria with their direct and indirect sonographic signs and the specific clinical significance of ultrasound findings. The importance and criteria of conventional B-mode, color Doppler ultrasound with or without spectral analysis of the Doppler signal and contrast-enhanced ultrasound are discussed as well.
Collapse
Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Christian Görg
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Germany
| | - Rudolf Horn
- Center da sandà Val Müstair, CH-7537 Sta. Maria
| | - Helmut Prosch
- Abteilung für Allgemeine Radiologie und Kinderradiologie, Medizinische Universität Wien, Austria
| | - Ehsan Safai Zadeh
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Germany
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch-Oderland, Strausberg/Wriezen, Germany
- Brandenburgisches Institut für Klinischen Ultraschall an der Medizinischen Hochschule Brandenburg, Neuruppin, Germany
| |
Collapse
|
7
|
Michels G, Schallenburger M, Neukirchen M. Recommendations on palliative care aspects in intensive care medicine. Crit Care 2023; 27:355. [PMID: 37723595 PMCID: PMC10506254 DOI: 10.1186/s13054-023-04622-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The timely integration of palliative care is important for patients suffering from various advanced diseases with limited prognosis. While a German S-3-guideline on palliative care exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for integration of palliative care into intensive care medicine is missing to date. METHOD Ten German medical societies worked on recommendations on palliative care aspects in intensive care in a consensus process from 2018 to 2023. RESULTS Based on the german consensus paper, the palliative care aspects of the respective medical disciplines concerning intensive care are addressed. The recommendations partly refer to general situations, but also to specific aspects or diseases, such as geriatric issues, heart or lung diseases, encephalopathies and delirium, terminal renal diseases, oncological diseases and palliative emergencies in intensive care medicine. Measures such as non-invasive ventilation for symptom control and compassionate weaning are also included. CONCLUSION The timely integration of palliative care into intensive care medicine aims to improve quality of life and symptom control and also takes into acccount the often urgently needed support for patients' highly stressed relatives.
Collapse
Affiliation(s)
- Guido Michels
- Department of Emergency Medicine, Hospital of the Barmherzige Brüder, Trier, Germany
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany.
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Heinrich-Heine-University Duesseldof, Düsseldorf, Germany
- Center of integrated oncology Aachen, Bonn, Cologne (CIO ABCD) Heinrich-Heine-University, Düsseldorf, Germany
| |
Collapse
|
8
|
Raupach D, Joean O, Fuge J, Welte T, Rademacher J. Point-of-care procalcitonin testing for lower respiratory tract infection in pulmonary outpatient care has limited value. Pneumologie 2023; 77:550-553. [PMID: 37315574 DOI: 10.1055/a-2095-3321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Lower respiratory tract infections (LRTI) are frequently the reasons for patients to visit their general practitioners or lung specialists; however, physicians tend to prescribe antibiotics less frequently than necessary. A readily available biomarker could help distinguish between viral and bacterial cause of LRTI. The primary objective of our study was to determine the diagnostic accuracy of point-of-care testing (POCT) of procalcitonin (PCT) in identifying bacterial pneumonia in outpatients with LRTI. All patients aged 18 years or older with signs and symptoms of LRTI who visited a respiratory physician were included in the study and their PCT levels were measured. In 110 patients enrolled in the study, three patients (2.7%) had PCT values above the threshold of 0.25 µg/L without proven bacterial infection, in contrast to seven patients with typical radiological signs of pneumonia without elevated POCT PCT levels. The AUC for PCT for the detection of pneumonia was 0.56 (p=0.685). POCT PCT showed limited specificity and sensitivity in distinguishing pneumonia from bronchitis or exacerbation of chronic respiratory diseases. PCT is a marker of severe bacterial infections and not suitable for milder infections in outpatient care.
Collapse
Affiliation(s)
- David Raupach
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
| | - Oana Joean
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
- BREATH, German Center for Lung Research, Hannover, Germany
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jessica Rademacher
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
| |
Collapse
|
9
|
Bessat C, Boillat-Blanco N, Albrich WC. The potential clinical value of pairing procalcitonin and lung ultrasonography to guide antibiotic therapy in patients with community-acquired pneumonia: a narrative review. Expert Rev Respir Med 2023; 17:919-927. [PMID: 37766614 DOI: 10.1080/17476348.2023.2254232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Lower respiratory tract infections (LRTIs) are among the most frequent infections and are prone to inappropriate antibiotic treatments. This results from a limited accuracy of diagnostic tools in identifying bacterial pneumonia. Lung ultrasound (LUS) has excellent sensitivity and specificity in diagnosing pneumonia. Additionally, elevated procalcitonin (PCT) levels correlate with an increased likelihood of bacterial infection. LUS and PCT appear to be complementary in identifying patients with bacterial pneumonia who are likely to benefit from antibiotics. AREAS COVERED This narrative review aims to summarize the current evidence for LUS to diagnose pneumonia, for PCT to guide antibiotic therapy and the clinical value of pairing both tools. EXPERT OPINION LUS has excellent diagnostic accuracy for pneumonia in different settings, regardless of the examiner's experience. PCT guidance safely reduces antibiotic prescription in LRTIs. The combination of both tools has demonstrated an enhanced accuracy in the diagnosis of pneumonia, including CAP in the ED and VAP in the ICU, but randomized controlled studies need to validate the clinical impact of a combined approach.
Collapse
Affiliation(s)
- Cécile Bessat
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases & Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| |
Collapse
|
10
|
Safai Zadeh E, Alhyari A, Kroenig J, Görg C, Trenker C, Dietrich CF, Findeisen H. B-mode ultrasound and contrast-enhanced ultrasound for evaluation of pneumonia: A pictorial essay. Australas J Ultrasound Med 2023; 26:100-114. [PMID: 37252619 PMCID: PMC10225008 DOI: 10.1002/ajum.12332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Due to their often peripheral pleural-based location, pneumonias can be visualised by B-mode ultrasound. Therefore, sonography can be used as an alternative imaging modality to chest X-ray in suspected cases of pneumonia. Depending on the clinical background of the patient, and various underlying pathological mechanisms, a heterogeneous pattern of pneumonia is seen in both B-mode lung ultrasound and contrast-enhanced ultrasound. Here, we describe the spectrum of sonographic manifestations of pneumonic/inflammatory consolidation on B-mode lung ultrasound and contrast-enhanced ultrasound.
Collapse
Affiliation(s)
- Ehsan Safai Zadeh
- Interdisciplinary Centre of Ultrasound Diagnostics, Gastroenterology, Endocrinology, Metabolism and Clinical InfectiologyUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| | - Amjad Alhyari
- Interdisciplinary Centre of Ultrasound Diagnostics, Gastroenterology, Endocrinology, Metabolism and Clinical InfectiologyUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| | - Johannes Kroenig
- Department of Pulmonary and Critical Care MedicineUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| | - Christian Görg
- Interdisciplinary Centre of Ultrasound Diagnostics, Gastroenterology, Endocrinology, Metabolism and Clinical InfectiologyUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| | - Corinna Trenker
- Haematology, Oncology and ImmunologyUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| | | | - Hajo Findeisen
- Interdisciplinary Centre of Ultrasound DiagnosticsUniversity Hospital Giessen and Marburg, Philipps University MarburgMarburgGermany
| |
Collapse
|
11
|
Passon SG, Schmidt AR, Wittmann M, Velten M, Baehner T. Evaluation of continuous ampicillin/sulbactam infusion in critically ill patients. Life Sci 2023; 320:121567. [PMID: 36907327 DOI: 10.1016/j.lfs.2023.121567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
Continuous infusion (CI) of beta-lactam-antibiotics may improve pharmacodynamics in critically ill patients, but resulting concentrations have not been studied. Therapeutic drug monitoring is increasingly used to ensure antibiotic concentration. The aim of this study is to evaluate therapeutic ampicillin/sulbactam concentrations of a continuous infusion regimen. METHODS Medical records of all patients admitted to ICU between January 2019 and December 2020 were retrospectively reviewed. Each patient received a 2/1 g ampicillin/sulbactam loading dose, followed by a continuous infusion of 8/4 g per 24 h. Ampicillin serum concentrations were measured. Main outcomes were reaching of plasma concentrations breakpoint defined by minimum inhibitory concentration (MIC at 8 mg/l) and 4-fold MIC (MIC at 32 mg/l) during steady state of CI. RESULTS In 50 patients a total of 60 concentration measurements were performed. The first concentration was measured after a median of 29 h (IQR 21-61 h). Mean ampicillin concentration was 62.6 ± 39.1 mg/l. Furthermore, serum concentrations exceeded the defined MIC breakpoint in all measurements (100 %) and were above the 4-fold MIC in 43 analyses (71.1 %). However, patients suffering from acute kidney injury exhibited significant higher serum concentrations (81.1 ± 37.7 mg/l vs. 38.2 ± 24.8 mg/l; p < 0.001). Also, there was a negative correlation between ampicillin serum concentrations and GFR (r = -0.659; p < 0.001). CONCLUSION The described dosing regimen for ampicillin/sulbactam is safe with respect to the defined MIC breakpoints for ampicillin, and continuous subtherapeutic concentration is unlikely. However, with impaired renal function drug accumulation occurs, and with increased renal clearance, drug levels can be below the 4-fold MIC breakpoint.
Collapse
Affiliation(s)
- S G Passon
- Department of Anesthesiology and Intensive Care Medicine, St. Nikolaus Stiftshospital Andernach, Germany
| | - A R Schmidt
- Division of Pediatric Cardiac Anesthesia, Stanford University - School of Medicine, Palo Alto, CA, USA
| | - M Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
| | - M Velten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany.
| | - T Baehner
- Department of Anesthesiology and Intensive Care Medicine, St. Nikolaus Stiftshospital Andernach, Germany; Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
| |
Collapse
|
12
|
Fischer C, Knüsli J, Lhopitallier L, Tenisch E, Meuwly MG, Douek P, Meuwly JY, D’Acremont V, Kronenberg A, Locatelli I, Mueller Y, Senn N, Boillat-Blanco N. Pulse Oximetry as an Aid to Rule Out Pneumonia among Patients with a Lower Respiratory Tract Infection in Primary Care. Antibiotics (Basel) 2023; 12:496. [PMID: 36978363 PMCID: PMC10044291 DOI: 10.3390/antibiotics12030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Guidelines recommend chest X-rays (CXRs) to diagnose pneumonia and guide antibiotic treatment. This study aimed to identify clinical predictors of pneumonia that are visible on a chest X-ray (CXR+) which could support ruling out pneumonia and avoiding unnecessary CXRs, including oxygen saturation. A secondary analysis was performed in a clinical trial that included patients with suspected pneumonia in Swiss primary care. CXRs were reviewed by two radiologists. We evaluated the association between clinical signs (heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, abnormal auscultation, and oxygen saturation < 95%) and CXR+ using multivariate analysis. We also calculated the diagnostic performance of the associated clinical signs combined in a clinical decision rule (CDR), as well as a CDR derived from a large meta-analysis (at least one of the following: heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, or abnormal auscultation). Out of 469 patients from the initial trial, 107 had a CXR and were included in this study. Of these, 26 (24%) had a CXR+. We found that temperature and oxygen saturation were associated with CXR+. A CDR based on the presence of either temperature ≥ 37.8 °C and/or an oxygen saturation level < 95% had a sensitivity of 69% and a negative likelihood ratio (LR-) of 0.45. The CDR from the meta-analysis had a sensitivity of 92% and an LR- of 0.37. The addition of saturation < 95% to this CDR increased the sensitivity (96%) and decreased the LR- (0.21). In conclusion, this study suggests that pulse oximetry could be added to a simple CDR to decrease the probability of pneumonia to an acceptable level and avoid unnecessary CXRs.
Collapse
Affiliation(s)
- Chloé Fischer
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - José Knüsli
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | | | - Estelle Tenisch
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Marie-Garance Meuwly
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Pauline Douek
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Valérie D’Acremont
- Digital Global Health Department, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Andreas Kronenberg
- Medix General Practice, 3010 Bern, Switzerland
- Institute for Infectious Diseases, University Bern, 3010 Bern, Switzerland
| | - Isabella Locatelli
- Department of Education, Research, and Innovation, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| |
Collapse
|
13
|
Seeger A, Rohde G. [Community-acquired pneumonia]. Dtsch Med Wochenschr 2023; 148:335-341. [PMID: 36878234 DOI: 10.1055/a-1940-8944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
RISK FACTORS FOR SEVERE COURSES The CRB-65 score is recommended as a risk predictor, as well as consideration of unstable comorbidities and oxygenation. GROUPING OF COMMUNITY-ACQUIRED PNEUMONIA Community-acquired pneumonia is divided into 3 groups: mild pneumonia, moderate pneumonia, severe pneumonia. Whether there is a curative vs palliative treatment goal should be determined early. DIAGNOSTIC RECOMMENDATION An X-ray chest radiograph is recommended to confirm the diagnosis, also in the outpatient setting if possible. Sonography of the thorax is an alternative, asking for additional imaging if negative. Streptococcus pneumoniae remains the most common bacterial pathogen. THERAPY Community-acquired pneumonia continues to be associated with high morbidity and lethality. Prompt diagnosis and prompt initiation of risk-adapted antimicrobial therapy are essential measures. However, in times of COVID-19, as well as the current influenza and RSV epidemic, purely viral pneumonias must also be expected. At least with COVID-19, antibiotics can often be avoided. Antiviral and anti-inflammatory drugs are used here. POST-ACUTE COURSE Patients after community-acquired pneumonia have increased acute and long-term mortality due to cardiovascular events in particular. The focus of research is on improved pathogen identification, a better understanding of the host response with the potential of developing specific therapeutics, the role of comorbidities, and the long-term consequences of the acute illness.
Collapse
Affiliation(s)
- Alexander Seeger
- Med. Klinik 1 - Schwerpunkt Pneumologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Gernot Rohde
- Med. Klinik 1 - Schwerpunkt Pneumologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| |
Collapse
|
14
|
Bernhard M, Keymel S, Krüger S, Pin M. [Acute dyspnea]. Dtsch Med Wochenschr 2023; 148:253-267. [PMID: 36848889 DOI: 10.1055/a-1817-7578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
ACUTE DYSPNEA The leading symptom "acute dyspnea" and the causal underlying diseases have a high risk potential for an unfavorable course of treatment with a high letality. This overview of possible causes, diagnostic procedures and guideline-based therapy is intended to help implement a targeted and structured emergency medical care in the emergency department. The leading symptom "acute dyspnea" is present in 10% of prehospital and 4-7% of patients in the emergency department. The most common conditions in the emergency department with the leading symptom "acute dyspnea" are heart failure in 25%, COPD in 15%, pneumonia in 13%, respiratory disorders in 8%, and pulmonary embolism in 4%. In 18% of cases, the leading symptom "acute dyspnea" is sepsis. The in-hospital letality is high and amounts to 9%. In critically ill patients in the non-traumatologic resuscitation room, respiratory disorders (B-problems) are present in 26-29%. In addition to cardiovascular disease, noncardiovascular disease may underlie "acute dyspnea" and requires differential diagnostic consideration. A structured approach can contribute to a high degree of certainty in the clarification of the leading symptom "acute dyspnea".
Collapse
|
15
|
Schaub C, Barnsteiner S, Schönenberg L, Bloch N, Dräger S, Albrich WC, Conen A, Osthoff M. Antibiotic treatment durations for common infectious diseases in Switzerland: comparison between real-life and local and international guideline recommendations. J Glob Antimicrob Resist 2023; 32:11-17. [PMID: 36572147 DOI: 10.1016/j.jgar.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/16/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Shortening the duration of antibiotic therapy (DAT) for common infectious diseases may be an effective strategy to tackle antimicrobial resistance. Shorter DAT has been proven safe and effective for community-acquired pneumonia (CAP), cellulitis, and cholangitis. METHODS In a retrospective multicentre quality-control study, medical records of 770 patients hospitalized with CAP, cellulitis, and cholangitis at three tertiary care hospitals in Switzerland during 2017-2018 were randomly selected. Appropriateness of antibiotic treatment duration was assessed according to international and local guidelines. RESULTS Records of 271, 260, and 239 patients with CAP, cellulitis, and cholangitis were included, respectively. Median DAT was seven days (interquartile range [IQR] 6-9), ten days (IQR 8-13), and nine days (IQR 6-13) in CAP, cellulitis, and cholangitis, respectively. DAT longer than recommended by local and international guidelines was observed in 32% and 37% of CAP patients, 23% and 70% of cellulitis patients, and 33% and 37% of cholangitis patients, respectively. Positive blood cultures (odds ratio [OR] = 2.42 (95% confidence interval [CI] 1.33-4.34]), infectious diseases consultation (OR = 1.79 [95% CI 1.05-2.78]), impaired renal function (OR = 0.99 [95% CI 0.98-1.00] per 1 ml/min / 1.73 m2 increase in estimated glomerular filtration rate) and a higher degree of inflammation on admission (OR = 1.0 [95% CI 1.001-1.005] per 10 mg/L increase in C-reactive protein) were independently associated with a DAT longer than recommended in international guidelines. CONCLUSIONS DAT exceeded recommendations in a significant proportion of patients with mostly community-acquired infections.
Collapse
Affiliation(s)
- Cédéric Schaub
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Stefanie Barnsteiner
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ladina Schönenberg
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Nando Bloch
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sarah Dräger
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Anna Conen
- Department of Infectious Diseases and Infection Prevention, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland.
| |
Collapse
|
16
|
Betz V, van Ackeren V, Scharsack E, Stark B, Müller CT, Loske G. [Intrathoracic negative pressure therapy of pleural empyema using an open-pored drainage film]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:349-360. [PMID: 36754892 PMCID: PMC10042902 DOI: 10.1007/s00104-022-01800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 02/10/2023]
Abstract
INTRODUCTION We report our initial experience with intrathoracic negative pressure therapy (ITNPT) in the stage-adjusted therapy of pleural empyema (PE) based on a case series. MATERIALS AND METHODS ITNPT represents a further development in negative pressure therapy that is designed to be used in the thoracic cavity. After thoracic surgical open debridement, an intrathoracic negative pressure dressing was inserted. The drainage elements used were a thin open-pore double-layer drainage film (OF) with open-pore polyurethane foams (PUF). Only the OF was placed in direct contact with the lung parenchyma. Negative pressure was generated using an electronic pump (continuous suction, -75 mm Hg). In revision thoracotomies, ITNPT was stopped or continued depending on local findings. RESULTS 31 patients with stage II and III pleural empyemas were treated. ITNPT was administered at the time of primary procedure (n = 17) or revision (n = 14). ITNPT was given over a duration of m = 10 days (2-18 days), change interval m = 4 d (2-6 d). The application of intrathoracic negative pressure dressings was performed m = 3.5 (1-6) times. The empyema cavity continuously reduced in size and was cleansed by the suction. The OF has a minimum intrinsic volume with maximum absorption surface. Once negative pressure is established, there is no intrathoracic dead volume and the parenchyma can expand. DISCUSSION The protective material properties of OF make ITNPT suitable for the treatment of pleural empyema. Targeted local intrathoracic drainage of the septic focus is a possible adjunct to surgery. The treatment regimen requires surgical dressings to be changed repeatedly. The method is suitable for the treatment of complex stage II and III pleural empyemas. CONCLUSION The OF can be used as an intrathoracic drainage element for ITNPT in pleural empyema. This new application option expands the range of indications for negative pressure therapy.
Collapse
Affiliation(s)
- Viktoria Betz
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland.
| | - Vera van Ackeren
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Ernst Scharsack
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Bettina Stark
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Christian Theodor Müller
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Gunnar Loske
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus gGmbH, Alfredstr. 9, 22087, Hamburg, Deutschland
| |
Collapse
|
17
|
Westhoff M. [Exacerbation of COPD and pharmacological therapy]. MMW Fortschr Med 2023; 165:56-64. [PMID: 36759478 DOI: 10.1007/s15006-022-2243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland.
| |
Collapse
|
18
|
Gröning I, Friebe M, Rothstein D, Bernhard M. Die Bedeutung von Laborleistungen in Notaufnahmen nach G‑AEP-Kriterien und beim Leitsymptom Dyspnoe. Notf Rett Med 2023. [DOI: 10.1007/s10049-022-01115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
19
|
Brehm TT, Hennigs A. [Seasonal Influenza - Update on Epidemiology, Prevention and Therapy]. Dtsch Med Wochenschr 2022; 147:1456-1464. [PMID: 36318908 DOI: 10.1055/a-1838-9223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Infection control measures and travel restrictions implemented during the COVID-19 pandemic have limited the transmission of seasonal influenza viruses as well. It must be assumed that after these public health measures have largely been lifted, influenza activity will sharply increase in the coming influenza season. Anticipating the potentially high number of cases, the co-circulation of influenza viruses and SARS-CoV-2, efforts to increase vaccination rates against both infectious diseases must be given more attention.
Collapse
Affiliation(s)
- Thomas Theo Brehm
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf
| | - Annette Hennigs
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf
| |
Collapse
|
20
|
Bahrs C, Moeser A. Antibiotic Stewardship und Pneumonie. ZEITSCHRIFT FÜR PNEUMOLOGIE 2022. [PMCID: PMC9514178 DOI: 10.1007/s10405-022-00474-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Die Pneumonie ist eine sehr häufige und potenziell tödliche Erkrankung. Es werden 3 Entitäten (ambulant erworbenen = CAP, nosokomial erworben = HAP und Pneumonie unter Immunsuppression) unterschieden von denen insbesondere die CAP und die HAP für die Umsetzung von Antibiotic Stewardship(ABS)-Strategien, den rationalen Umgang mit Antibiotika, gut geeignet sind. Die Durchführung einer mikrobiologischen Diagnostik vor Start einer Antibiotikatherapie bei Pneumonie, die stationär behandelt werden muss, wird stark empfohlen. Eine Risikostratifizierung der Patienten und der Schweregrad der Erkrankung sind entscheidend für die kalkulierte Antibiotikaauswahl und die Applikationsform. Bei COVID-19-Patienten ohne septischen Schock kann aufgrund der niedrigen Rate von bakteriellen Superinfektionen auf eine empirische Antibiotikatherapie verzichtet werden. Eine Reevaluation der Antibiotikatherapie nach 48–72 h mit gezielter Deeskalation unter Beachtung der Klinik und Mikrobiologie, Absetzen bei Fehlindikation und die Begrenzung der Therapiedauer sind essenzielle ABS-Strategien zur Optimierung des klinischen Outcomes bei CAP und HAP mit dem Ziel, die Antibiotikaresistenzentwicklung sowie die Toxizität für den Patienten möglichst gering zu halten. Der Einsatz von Biomarkern wie Procalcitonin kann in bestimmten Situationen ein frühzeitiges Absetzen der Therapie begünstigen oder die Diagnose einer bakteriellen Superinfektion bei COVID-19 unterstützen.
Collapse
Affiliation(s)
- Christina Bahrs
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena – Friedrich-Schiller-Universität, Am Klinikum 1, 07747 Jena, Deutschland
- Universitätsklinik für Innere Medizin I, Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Währinger Gürtel 18–20, 1090 Wien, Österreich
| | - Anne Moeser
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena – Friedrich-Schiller-Universität, Am Klinikum 1, 07747 Jena, Deutschland
| |
Collapse
|
21
|
Kahan AC. [59/m-Community-acquired pneumonia, hypoxemic respiratory insufficiency : Preparation course anesthesiological intensive care medicine: case 13]. DIE ANAESTHESIOLOGIE 2022; 71:74-77. [PMID: 35925162 DOI: 10.1007/s00101-022-01136-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- A-C Kahan
- Universitätsklinikum Augsburg, Augsburg, Deutschland.
| |
Collapse
|
22
|
Point-of-Care Ultrasound for Tuberculosis Management in Sub-Saharan Africa-A Balanced SWOT Analysis. Int J Infect Dis 2022; 123:46-51. [PMID: 35811083 DOI: 10.1016/j.ijid.2022.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/21/2022] Open
Abstract
Point-of-care ultrasound (POCUS) is an increasingly accessible skill, allowing for the decentralization of its use to non-specialist healthcare workers to guide routine clinical decision making. The advent of ultrasound-on-a-chip has transformed the technology into a portable mobile health device. Due to its high sensitivity to detect small consolidations, pleural effusions and sub pleural nodules, POCUS has recently been proposed as a sputum-free likely triage tool for tuberculosis (TB). To make an objective assessment of the potential and limitations of POCUS in routine TB management, we present a Strengths, Weaknesses, Opportunities & Threats (SWOT) analysis based on a review of the relevant literature and focusing on Sub-Saharan Africa (SSA). We idenitified numerous strengths and opportunities of POCUS for TB management e.g.; accessible, affordable, easy to use & maintain, expedited diagnosis, extra-pulmonary TB detection, safer pleural/pericardial puncture, use in children/pregnant women/PLHIV, targeted screening of TB contacts, monitoring TB sequelae, and creating AI decision support. Weaknesses and external threats such as operator dependency, lack of visualization of central lung pathology, poor specificity, lack of impact assessments and data from Sub-Saharan Africa must be taken into consideration to ensure that the potential of the technology can be fully realized in research as in practice.
Collapse
|
23
|
Management of patients with SARS-CoV-2 infections with focus on patients with chronic lung diseases (as of 10 January 2022) : Updated statement of the Austrian Society of Pneumology (ASP). Wien Klin Wochenschr 2022; 134:399-419. [PMID: 35449467 PMCID: PMC9022736 DOI: 10.1007/s00508-022-02018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/17/2022] [Indexed: 12/15/2022]
Abstract
The Austrian Society of Pneumology (ASP) launched a first statement on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in May 2020, at a time when in Austria 285 people had died from this disease and vaccinations were not available. Lockdown and social distancing were the only available measures to prevent more infections and the breakdown of the health system. Meanwhile, in Austria over 13,000 patients have died in association with a SARS-CoV‑2 infection and coronavirus disease 2019 (COVID-19) was among the most common causes of death; however, SARS-CoV‑2 has been mutating all the time and currently, most patients have been affected by the delta variant where the vaccination is very effective but the omicron variant is rapidly rising and becoming predominant. Particularly in children and young adults, where the vaccination rate is low, the omicron variant is expected to spread very fast. This poses a particular threat to unvaccinated people who are at elevated risk of severe COVID-19 disease but also to people with an active vaccination. There are few publications that comprehensively addressed the special issues with SARS-CoV‑2 infection in patients with chronic lung diseases. These were the reasons for this updated statement. Pulmonologists care for many patients with an elevated risk of death in case of COVID-19 but also for patients that might be at an elevated risk of vaccination reactions or vaccination failure. In addition, lung function tests, bronchoscopy, respiratory physiotherapy and training therapy may put both patients and health professionals at an increased risk of infection. The working circles of the ASP have provided statements concerning these risks and how to avoid risks for the patients.
Collapse
|
24
|
Wild J, Siegrist B, Hobohm L, Münzel T, Schwanz T, Sagoschen I. Short and Concise Peer-to-Peer Teaching—Example of a Successful Antibiotic Stewardship Intervention to Increase Iv to Po Conversion. Antibiotics (Basel) 2022; 11:antibiotics11030402. [PMID: 35326866 PMCID: PMC8944614 DOI: 10.3390/antibiotics11030402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/05/2022] Open
Abstract
Antibiotic stewardship (ABS) programs aim to combine effective treatment with minimized antibiotic-related harms. Common ABS interventions are simple and effective, but their implementation in daily practice is often difficult. The aim of our study was to investigate if a single, short, peer-to-peer teaching intervention (junior doctor to junior doctor) during clinical routine can successfully improve antibiotic prescriptions. We performed a quasi-experimental before–after study on a regular care cardiology ward at a large academic medical center in Germany. We evaluated antibiotic use metrics retrospectively and calculated defined daily doses (DDD) with the anatomical therapeutic chemical/DDD classification system of the World Health Organization. We hypothesize that the over-representative use of intravenous administration is a potentially modifiable target, which can be proven by antibiotic use metrics analysis. After a single peer-to-peer teaching session with a focus on indications for iv to po conversion, the normalized percentage of intravenous compared to oral administration significantly decreased (from 86.5 ± 50.3% to 41.4 ± 70.3%). Moreover, after the intervention, antibiotics with high oral bioavailability were no longer administered intravenously at all during the following quarter. Our results indicate that even a single peer-to-peer training session is highly effective in improving the iv to po conversion rate in the short term.
Collapse
Affiliation(s)
- Johannes Wild
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Correspondence:
| | - Bettina Siegrist
- Department of Pharmacy, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
| | - Thomas Schwanz
- Institute of Medical Microbiology and Hygiene, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Ingo Sagoschen
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
| |
Collapse
|
25
|
Glöckner V, Pletz MW, Rohde G, Rupp J, Witzenrath M, Barten-Neiner G, Kolditz M. Early post-discharge mortality in CAP: frequency, risk factors and a prediction tool. Eur J Clin Microbiol Infect Dis 2022; 41:621-630. [PMID: 35137301 PMCID: PMC8934328 DOI: 10.1007/s10096-022-04416-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/31/2022] [Indexed: 12/02/2022]
Abstract
There are few data on mortality after discharge with community-acquired pneumonia (CAP). Therefore, we evaluated risk factors for 30-day post-discharge mortality after CAP. We included all patients of the prospective multi-national CAPNETZ study between 2002 and 2018 with (1) hospitalized CAP, (2) survival until discharge, and (3) complete follow-up data. The study endpoint was death within 30 days after discharge. We evaluated risk factors including demographics, comorbidities, admission CAP severity, and laboratory values and treatment-related factors in uni- and multivariable analyses. A total of 126 (1.6%) of 7882 included patients died until day 30 after discharge, corresponding to 26% of all 476 deaths. After multivariable analysis, we identified 10 independent risk factors: higher age, lower BMI, presence of diabetes mellitus, chronic renal or chronic neurological disease (other than cerebrovascular diseases), low body temperature or higher thrombocytes on admission, extended length of hospitalization, oxygen therapy during hospitalization, and post-obstructive pneumonia. By addition these factors, we calculated a risk score with an AUC of 0.831 (95%CI 0.822–0.839, p < 0.001) for prediction of post-discharge mortality. Early post-discharge deaths account for ¼ of all CAP-associated deaths and are associated with patient- and CAP-severity-related risk factors. Additional studies are necessary to replicate our findings in independent cohorts. Study registration: NCT 02139163.
Collapse
Affiliation(s)
- Verena Glöckner
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus of TU Dresden, Fetscherstr. 74, Dresden, 01307, Germany
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - Gernot Rohde
- Medical Department I, Department of Respiratory Medicine, Goethe University Hospital, Frankfurt/Main, Germany.,CAPNETZ STIFTUNG, Hannover, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel, Giessen, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Pulmonary Medicine, and Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Grit Barten-Neiner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Munich, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus of TU Dresden, Fetscherstr. 74, Dresden, 01307, Germany.
| | | |
Collapse
|
26
|
No evidence of harmful effects of steroids in severe exacerbations of COPD associated with influenza. Infection 2022; 50:699-707. [PMID: 35091985 PMCID: PMC8799421 DOI: 10.1007/s15010-021-01743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/10/2021] [Indexed: 11/05/2022]
Abstract
Purpose Methods Results Conclusion Supplementary Information
Collapse
|
27
|
Briegel I, Trautnitz M, Behr J. [Rare Cause of Lung Tumour - Pulmonary Infection with Hafnia alvei: A Case Report]. Pneumologie 2022; 76:499-502. [PMID: 35008123 DOI: 10.1055/a-1718-2521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
If a malignant disease is suspected, rapid diagnosis of suspicious pulmonary masses is required. In the presented case, malignancy was repeatedly not proven. Only the test-appropriate antibiotic treatment of an intestinal germ that was initially assessed as an impurity brought the therapeutic success with total remission. In our case the treatment with broad-spectrum penicillin piperacillin/tazobactam was ineffective and only the gyrase inhibitors ciprofloxacin and levofloxacin brought therapeutic success.
Collapse
|
28
|
Rolles B, Wessels I, Doukas P, Kotelis D, Rink L, Vieri M, Beier F, Jacobs M, Gombert A. Retrospective observational study evaluating zinc plasma level in patients undergoing thoracoabdominal aortic aneurysm repair and its correlation with outcome. Sci Rep 2021; 11:24348. [PMID: 34934131 PMCID: PMC8692510 DOI: 10.1038/s41598-021-03877-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/06/2021] [Indexed: 01/08/2023] Open
Abstract
Thoracoabdominal aortic aneurysm (TAAA) repair is related to a relevant morbidity and in-hospital mortality rate. In this retrospective observational single-center study including serum zinc levels of 33 patients we investigated the relationship between zinc and patients’ outcome following TAAA repair. Six patients died during the hospital stay (18%). These patients showed significantly decreased zinc levels before the intervention (zinc levels before intervention: 60.09 µg/dl [survivors] vs. 45.92 µg/dl [non-survivors]). The post-interventional intensive care SOFA-score (Sepsis-related organ failure assessment) (at day 2) as well as the SAPS (Simplified Acute Physiology Score) (at day 2) showed higher score points in case of low pre-interventional zinc levels. No significant correlation between patient comorbidities and zinc level before intervention, except for peripheral arterial disease (PAD), which was significantly correlated to reduced baseline zinc levels, was observed. Septic shock, pneumonia and urinary tract infections were not associated to reduced zinc levels preoperatively as well as during therapy. Patients with adverse outcome after TAAA repair showed reduced pre-interventional zinc levels. We speculate that decreased zinc levels before intervention may be related to a poorer outcome because of poorer physical status as well as negatively altered perioperative inflammatory response.
Collapse
Affiliation(s)
- Benjamin Rolles
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany.,Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Inga Wessels
- Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Lothar Rink
- Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Margherita Vieri
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany
| | - Michael Jacobs
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
| |
Collapse
|
29
|
Steuder R, Pott H, Maxheim M, Schmeck B. Pneumonie und COVID-19 bei COPD-Patienten. PNEUMO NEWS 2021; 13:30-35. [PMID: 34691274 PMCID: PMC8526095 DOI: 10.1007/s15033-021-2749-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Regina Steuder
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Hendrik Pott
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Michael Maxheim
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Bernd Schmeck
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| |
Collapse
|
30
|
Dettmer S, Vogel-Claussen J. [Imaging in respiratory infections]. DER PNEUMOLOGE 2021; 18:256-267. [PMID: 34248454 PMCID: PMC8254451 DOI: 10.1007/s10405-021-00401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/04/2022]
Abstract
The conventional X‑ray image is the method of choice for suspected pneumonia. Computed tomography (CT) is indicated for treatment refractory or recurrent infiltrates, difficult differential diagnostics, suspected complications and in immunocompromised patients. Thoracic sonography can be used as an alternative method for initial diagnostics and in the intensive care unit to monitor progress. In addition to the detection of infiltrates the radiological classification can help to limit the pathogen spectrum. Radiologically, three forms of pneumonia can principally be differentiated: lobar pneumonia, bronchopneumonia and interstitial pneumonia. Furthermore, there are special forms of pneumonia with certain pathogens, such as aspergilloma, invasive mycosis, postprimary tuberculosis and nontuberculous mycobacteriosis or in a specific clinical context, such as aspiration pneumonia, postinfarction pneumonia, retention pneumonia and septic emboli. The most frequent complications of pneumonia are lung abscesses and pleural empyema. Both can sometimes but not always be seen in the X‑ray image. If clinically suspected the indications for CT should be generously applied. Certain pre-existing diseases, such as immunodeficiency or structural alterations of the lungs can predispose to pulmonary infections, frequently with unusual pathogens or manifestation forms and must be taken into account in the diagnostics.
Collapse
Affiliation(s)
- Sabine Dettmer
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30629 Hannover, Deutschland
| | - Jens Vogel-Claussen
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30629 Hannover, Deutschland
| |
Collapse
|