Postpartum cryptococcosis in an HIV-negative patient

PURPOSE AND METHODS

We present an unusual case of an HIV-negative patient with postpartum pulmonary cryptococcosis and cryptococcemia.

RESULTS

The diagnostic methods and treatment of cryptococcosis in a postpartum patient are presented in this case report. Due to anaphylaxis to liposomal amphotericin B, desensitisation to the drug was performed.

CONCLUSION

We would like to raise awareness about rare infections such as cryptococcosis in pregnancy and the postpartum period. In addition, we were able to document a successful desensitisation to liposomal amphotericin B.

Whole-genome sequencing reveals two prolonged simultaneous outbreaks involving Pseudomonas aeruginosa high-risk strains ST111 and ST235 with resistance to quaternary ammonium compounds

OBJECTIVE

Water-bearing systems are known as frequent Pseudomonas aeruginosa (PA) outbreak sources. However, many older buildings continue to have sanitary facilities in high-risk departments such as the ICU. We present two simultaneous prolonged multi-drug-resistant (MDR) PA outbreaks detected at the ICU of a pulmonology hospital, which were resolved by whole-genome sequencing (WGS).

METHODS

Outbreak management and investigations were initiated in August 2019 after detecting two patients with nosocomial VIM-2-positive MDR PA. The investigations involved weekly patient screenings for four months and extensive environmental sampling for 15 months. All patient and environmental isolates were collected and analysed by WGS.

RESULTS

From April to September 2019, we identified 10 patients with nosocomial MDR PA, including five VIM-2-positive strains. VIM-2-positive strains were also detected in nine sink drains, two toilets, and a cleaning bucket. WGS revealed that of 16 VIM-2-positive isolates, 14 were ST111 that carried qacE, or qacEΔ1 genes, whereas 13 isolates clustered (difference of ≤11 alleles by cgMLST). OXA-2 (two toilets), and OXA-2, OXA-74, PER-1 (two patients, three toilets) qacEΔ1-positive ST235 isolates dominated among VIM-2-negative isolates. The remaining seven PA strains were ST17, ST233, ST273, ST309 and ST446. Outbreak containment was achieved by replacing U-bends, and cleaning buckets, and switching from quaternary ammonium compounds (QUATs) to oxygen-releasing disinfectant products.

CONCLUSION

Comprehension and management of two simultaneous MDR PA outbreaks involving the high-risk strains ST111 and ST235 were facilitated by precise control due to identification of different outbreak sources per strain, and by the in-silico detection of high-level QUATs resistance in all isolates.

[Rare cause of necrotizing pneumonia : A case report]

A 29-year-old Indian patient was admitted to the authors' pulmonary clinic with cough and fever. Community-acquired pneumonia was initially suspected. Various antibiotic therapies were administered, which did not lead to any clinical improvement. Despite detailed diagnostics, no pathogen was found. Computed tomography showed rapidly progressive pneumonia in the left upper lobe. Since the infection could not be managed conservatively, upper lobe resection was performed. Histologically, an amoebic abscess was found to be the cause of the infection. Since cerebral and hepatic abscesses were also found, hematogenous dissemination may be assumed.

Head-to-Head Comparison of Dual-Source and Split-Beam Filter Multi-Energy CT versus SPECT/CT for Assessing Lobar Lung Perfusion in Emphysema

Purpose

To evaluate dual-source and split-beam filter multi-energy chest CT in assessing pulmonary perfusion on a lobar level in patients with lung emphysema, using perfusion SPECT as the reference standard.

Materials and Methods

Patients with emphysema evaluated for lung volume reduction therapy between May 2016 and February 2021 were retrospectively included. All patients underwent SPECT and either dual-source or split-beam filter (SBF) multi-energy CT. To calculate the fractional lobar lung perfusion (FLLP), SPECT acquisitions were co-registered with chest CT scans (hereafter, SPECT/CT) and semi-manually segmented. For multi-energy CT scans, lung lobes were automatically segmented using a U-Net model. Segmentations were manually verified. The FLLP was derived from iodine maps computed from the multi-energy data. Statistical analysis included Pearson and intraclass correlation coefficients and Bland-Altman analysis.

Results

Fifty-nine patients (30 male, 29 female; 31 underwent dual-source CT, 28 underwent SBF CT; mean age for all patients, 67 years ± 8 [SD]) were included. Both multi-energy methods significantly correlated with the SPECT/CT acquisitions for all individual lobes (P < .001). Pearson correlation concerning all lobes combined was significantly better for dual-source (r = 0.88) than for SBF multi-energy CT (r = 0.78; P = .006). On the level of single lobes, Pearson correlation coefficient differed for the right upper lobe only (dual-source CT, r = 0.88; SBF CT, r = 0.58; P = .008).

Conclusion

Dual-source and SBF multi-energy CT accurately assessed lung perfusion on a lobar level in patients with emphysema compared with SPECT/CT. The overall correlation was higher for dual-source multi-energy CT.Keywords: Chronic Obstructive Pulmonary Disease, Comparative Studies, Computer Applications, CT Spectral Imaging, Image Postprocessing, Lung, Pulmonary Perfusion© RSNA, 2023.

Pirfenidone in patients with progressive fibrotic interstitial lung diseases other than idiopathic pulmonary fibrosis (RELIEF): a double-blind, randomised, placebo-controlled, phase 2b trial

BACKGROUND

Pirfenidone has been shown to slow disease progression in patients with idiopathic pulmonary fibrosis (IPF). However, there are few treatment options for progressive fibrotic interstitial lung diseases (ILDs)) other than IPF. In view of the pathomechanistic and clinical similarities between IPF and other progressive fibrotic ILDs, we aimed to assess the efficacy and safety of pirfenidone in patients with four non-IPF progressive fibrotic ILDs.

METHODS

We did a multicentre, double-blind, randomised, placebo-controlled, parallel phase 2b trial (RELIEF) in 17 centres with expertise in ILD in Germany. Eligible participants were patients aged 18-80 years with progressive fibrotic ILD due to four diagnoses: collagen or vascular diseases (ie, connective tissue disease-associated ILDs), fibrotic non-specific interstitial pneumonia, chronic hypersensitivity pneumonitis, or asbestos-induced lung fibrosis. Other eligibility criteria included a forced vital capacity (FVC) of 40-90% predicted, a diffusing capacity of the lung for carbon monoxide of 10-90% predicted, and an annual decline of FVC of at least 5% predicted despite conventional therapy, based on at least three measurements within 6-24 months before enrolment. Patients who had received any previous antifibrotic therapy were excluded. We randomly assigned patients (1:1) to either oral pirfenidone (267 mg three times per day in week 1, 534 mg three times per day in week 2, and 801 mg three times per day thereafter) or matched placebo, added to their ongoing medication. Randomisation was done centrally using permuted block randomisation with varying block sizes stratified by the four diagnostic groups. Patients, investigators, statisticians, monitors, and the study coordinator were masked to treatment assignment until database closure. The placebo-controlled study period was 48 weeks (including up-titration). The primary endpoint was absolute change in percentage of predicted FVC (FVC % predicted) from baseline to week 48 in the intention-to-treat population, with imputation of missing data by the smallest sum of squared differences and attribution of deceased patients to the lowest rank in a rank ANCOVA model. Additionally, we did linear mixed-model repeated measures slope analyses of FVC % predicted longitudinal data over the course of the study as a prespecified sensitivity analysis and post-hoc sensitivity analyses of the primary endpoint in the intention-to-treat population using imputation methods of last observation carried forward [LOCF] and a regression-based multiple imputation procedure. Safety was assessed in all patients who received at least one dose of study medication. This trial is registered with EudraCT 2014-000861-32; DRKS00009822 and is no longer recruiting.

FINDINGS

Between April 5, 2016, and Oct 4, 2018, we randomly assigned 127 patients to treatment: 64 to pirfenidone, 63 to placebo. After 127 patients had been randomised, the study was prematurely terminated on the basis of an interim analysis for futility triggered by slow recruitment. After 48 weeks and in the overall population of 127 patients, rank ANCOVA with diagnostic group included as a factor showed a significantly lower decline in FVC % predicted in the pirfenidone group compared with placebo (p=0·043); the result was similar when the model was stratified by diagnostic group (p=0·042). A significant treatment effect was also observed when applying the LOCF and multiple imputation methods to analyses of the primary endpoint. The median difference (Hodges-Lehmann estimate) between pirfenidone and placebo groups for the primary endpoint was 1·69 FVC % predicted (95% CI -0·65 to 4·03). In the linear mixed-model repeated measures slope analysis of FVC % predicted, the estimated difference between treatment and placebo groups from baseline to week 48 was 3·53 FVC % predicted (95% CI 0·21 to 6·86) with imputation of deaths as prespecified, or 2·79 FVC % predicted (95% CI 0·03 to 5·54) without imputation. One death (non-respiratory) occurred in the pirfenidone group (2%) and five deaths (three of which were respiratory) occurred in the placebo group (8%). The most frequent serious adverse events in both groups were infections and infestations (five [8%] in the pirfenidone group, ten [16%] in the placebo group); general disorders including disease worsening (two [3%] in the pirfenidone group, seven [11%] in the placebo group); and cardiac disorders (one ([2%] in the pirfenidone group, 5 [8%] in the placebo group). Adverse events (grade 3-4) of nausea (two patients on pirfenidone, two on placebo), dyspnoea (one patient on pirfenidone, one on placebo), and diarrhoea (one patient on pirfenidone) were also observed.

INTERPRETATION

In view of the premature study termination, results should be interpreted with care. Nevertheless, our data suggest that in patients with fibrotic ILDs other than IPF who deteriorate despite conventional therapy, adding pirfenidone to existing treatment might attenuate disease progression as measured by decline in FVC.

FUNDING

German Center for Lung Research, Roche Pharma.

Cardiopulmonary exercise pattern in patients with persistent dyspnoea after recovery from COVID-19

Cause and mechanisms of persistent dyspnoea after recovery from COVID-19 are not well described. The objective is to describe causal factors for persistent dyspnoea in patients after COVID-19. We examined patients reporting dyspnoea after recovery from COVID-19 by cardiopulmonary exercise testing. After exclusion of patients with pre-existing lung diseases, ten patients (mean age 50±13.1 years) were retrospectively analysed between May 14^th and September 15^th, 2020. On chest computed tomography, five patients showed residual ground glass opacities, and one patient showed streaky residua. A slight reduction of the mean diffusion capacity of the lung for carbon monoxide was noted in the cohort. Mean peak oxygen uptake was reduced with 1512±232 ml/min (72.7% predicted), while mean peak work rate was preserved with 131±29 W (92.4% predicted). Mean alveolar-arterial oxygen gradient (AaDO₂) at peak exercise was 25.6±11.8 mmHg. Mean value of lactate post exercise was 5.6±1.8 mmol/l. A gap between peak work rate in (92.4% predicted) to peak oxygen uptake (72.3% pred.) was detected in our study cohort. Mean value of lactate post exercise was high in our study population and even higher (n.s.) compared to the subgroup of patients with reduced peak oxygen uptake and other obvious reason for limitation. Both observations support the hypothesis of anaerobic metabolism. The main reason for dyspnoea may therefore be muscular.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Incidence of patients with non-cystic fibrosis bronchiectasis in Germany - A healthcare insurance claims data analysis

BACKGROUND

Incidence and prevalence of patients with non-cystic fibrosis bronchiectasis (NCFB) appear to be increasing worldwide but supporting epidemiological data are scarce. This study assesses the incidence of NCFB patients in Germany in 2013 and analyzes comorbidities and basic patterns of resource use.

METHODS

A representative sample of 3.988.648 anonymized persons covered by German public statutory health insurances was used to identify incident patients with NCFB in 2013.

RESULTS

After extrapolation to the general population of the 728 patients found in the reference insurance database, we estimate that a total of 17,095 NCFB patients were newly diagnosed across the country in 2013 as having NCFB. This corresponds to an incidence of 21.23 per 100.000 inhabitants. The majority of NCFB patients (98.4%) was at least 18 years old, and 52.7% of the NCFB patients were male. Trend analysis shows a rise of NCFB incidence in Germany from 2011 through 2013. COPD (41.4%), asthma (32.8%) and gastroesophageal reflux (18.3%) were the most frequent predisposing conditions. Coronary heart disease was observed in more than one quarter of NCFB patients (28.2%). 58.4% of the NCFB outpatients received antiobstructive inhalative medication. Of the adult NCFB patients, 51.6% were prescribed antibiotics to treat NCFB by settled doctors (outpatient treatment); 51.5% of those patients were males. The peak of antibiotic treatment was observed in the 75-79 age group for males and 70-74 and 75-79 years for females. The majority of diagnosed patients (54.1%) received at least two prescriptions during 2013. Bacterial pathogens were coded for a total of 10.7% of NCFB patients, while Pseudomonas aeruginosa was only documented in 2.3%. Among those diagnosed in 2013, 8.0% of the adult NCFB patients who received antibiotic treatment had to be hospitalized.

CONCLUSIONS

Although hospital admissions due to exacerbation in the first year of diagnosing NCFB are not rare, outpatient burden and costs must also be considered a major part of care. Given the increasing recognition of NCFB, a better understanding of the economic burden of the disease is required, with a view towards improving patient management. For this, more detailed, prospective studies are needed.

[Pneumocystis jirovecii pneumonia in patients with autoimmune diseases]

Pneumocystis jirovecii pneumonia plays an increasing role in patients with autoimmune disorders, due to more intensive immunosuppressive therapy. Humans seem to be the most important pathogen reservoir. Diseases are probably caused by airborne new infections. Cough, subfebrile temperature and dyspnea on exertion are the leading symptoms. In addition to imaging, in particular high-resolution computed tomography, pathogen detection by staining methods or molecular genetic methods plays the decisive role. Trimethoprim and sulfamethoxazole (TMP-SMX) is the most important medication for treatment. Adjuvant corticosteroid treatment is sometimes recommended, but evidence for benefits in patients with rheumatological disorders is not well documented. For patients on high-dose systemic corticosteroid treatment or intensive combined immunosuppression, primary prophylaxis is recommended by many experts. TMP-SMX remains the first-choice preventive treatment in these patients.

[Tuberculosis]

Epidemiologie Bedingt durch die Zunahme der Migration ist es 2015 in Deutschland zu einem deutlichen Anstieg von Tuberkulosefällen gekommen. Die resistente Tuberkulose nimmt weltweit zu.

Neue Leitlinie Die Leitlinie zur Behandlung der Tuberkulose bei Erwachsenen wurde im Sommer 2017 aktualisiert. Für Kinder wird eine eigene Leitlinie für 2017 erwartet.

Fremdsprachige Patienteninformationen finden sich z. B. unter http://www.explaintb.org.

Resistente Tuberkulose Zur Behandlung der multiresistenten Tuberkulose (MDR-TB) gibt es neue WHO-Empfehlungen. Darin wird unter bestimmten Voraussetzungen ein verkürztes Therapieregime vorgeschlagen. Dieses wird für Deutschland aufgrund der hierzulande zu erwartenden Resistenzen nicht empfohlen.

Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial

Background

The lung volume reduction (LVR) coil is a minimally invasive bronchoscopic nitinol device designed to reduce hyperinflation and improve elastic recoil in severe emphysema. We investigated the feasibility, safety and efficacy of LVR coil treatment in a prospective multicentre cohort trial in patients with severe emphysema.

Methods

Patients were treated in 11 centres. Safety was evaluated by recording all adverse events, efficacy by the St George's Respiratory Questionnaire (SGRQ) as primary endpoint, and pulmonary function testing, modified Medical Research Council dyspnoea score (mMRC) and 6-min walk distance (6MWD) up to 12 months after the final treatment.

Results

Sixty patients (60.9 ± 7.5 years, forced expiratory volume in 1 s (FEV₁) 30.2 ± 6.3% pred) were bronchoscopically treated with coils (55 bilateral, 5 unilateral), with a median of 10 (range 5–15) coils per lobe. Within 30 days post-treatment, seven chronic obstructive pulmonary disease exacerbations (6.1%), six pneumonias (5.2%), four pneumothoraces (3.5%) and one haemoptysis (0.9%) occurred as serious adverse events. At 6 and 12 months, respectively, ΔSGRQ was −12.1±12.9 and −11.1±13.3 points, Δ6MWD was +29.7±74.1 m and +51.4±76 m, ΔFEV₁ was +0.11±0.20 L and +0.11±0.30 L, and ΔRV (residual volume) was −0.65±0.90 L and −0.71±0.81 L (all p<0.01). Post hoc analyses showed significant responses for SGRQ, 6MWD and RV in patients with both heterogeneous and homogeneous emphysema.

Conclusions

LVR coil treatment results in significant clinical improvements in patients with severe emphysema, with a good safety profile and sustained results for up to 1 year.

Trial registration number:

NCT01328899.

Perceived risks of adverse effects and influenza vaccination: a survey of hospital employees

BACKGROUND

Many hospital employees shun influenza immunization because they want to avoid adverse reactions. We surveyed hospital employees to elucidate whether the conception of the adverse effects of vaccination stems from correct or misperceived incidence rates of vaccine adverse effects. 

METHODS

We used an anonymous self-administered paper questionnaire at a tertiary-care university hospital in Germany, in 2006. Multiple-choice questions probed respondents' knowledge about influenza, influenza vaccine and about rates of 12 possible vaccine adverse effects. We correlated overestimation of each adverse effect with failure to obtain vaccination in 2005-06, stratified by professional group. 

RESULTS

The overall response rate was 34% (652/1898). Of the 304 respondents unvaccinated in 2005-06, 127 (42%) attributed their vaccination status mainly to concerns about adverse effects. Among physicians, failure to obtain influenza vaccination was associated with the overestimation of both non-severe and severe adverse effects. Non-vaccinated nurses were significantly more likely than the vaccinated nurses to overestimate the rates of five of six non-severe adverse effects, but differed significantly in rates of overestimation of merely one of the six severe adverse effects. Overestimation of vaccine-caused absenteeism from work was negatively associated with vaccination rates among all professionals. 

CONCLUSIONS

Overestimation of the actual low rates of influenza vaccine adverse effects was associated with non-receipt of the vaccine among hospital employees. Due to our finding of different misconceptions about adverse effects, educational and promotional programmes should be targeted differentially for nurses and physicians.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes

BACKGROUND

The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment.

METHOD

We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years).

RESULTS

We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR).

CONCLUSIONS

DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

Self-injurious behavior in adolescent girls. Association with psychopathology and neuropsychological functions

BACKGROUND

Self-injurious behavior (SIB) is increasingly popular in psychically ill adolescents, especially in girls with posttraumatic stress (PTSD) and personality disorders. Adolescents with SIB frequently exhibit neurofunctional and psychopathological deficits. We speculated that specific neuropsychological deficits and temperamental factors could predispose patients to SIB and prospectively explored adolescent psychiatric patients with and without SIB in order to find out differences in psychopathology, and neuropsychological or temperamental factors.

SAMPLING AND METHODS

Ninety-nine psychically ill adolescent girls with SIB, aged 12-19 years and treated at our clinic, were prospectively recruited during a period of 5.5 years (1999-2005). The clinical (ICD-10) diagnoses were mainly substance abuse, eating disorders, depression, PTSD and personality disorders. The control group was also prospectively recruited during the same period and consisted of 77 girls with similar diagnoses and ages but no SIB. All patients were subjected to the same selection of clinical and neuropsychological tests, mainly self-rating questionnaires and tests evaluating executive functions.

RESULTS

Adolescent girls with psychiatric disease and SIB were more severely traumatized and depressed. They reported severe emotional and behavioral problems and deficits of self-regulation. In addition, their parents more frequently had psychiatric problems. Temperament, intelligence, investigated executive functions and presence of dissociative symptoms were not different in patients with and without SIB.

CONCLUSIONS

We could not verify our primary hypothesis that SIB is related to specific neuropsychological deficits or temperamental factors. SIB was associated with traumatic experience, depression, problems of self-regulation and parental psychiatric disease. The prevention of SIB should therefore focus on improving affect regulation, the management of emotional distress and problem-solving strategies.

[Epidemiology of severe sepsis at a German university hospital]

BACKGROUND AND PURPOSE

Sepsis still represents a major medical challenge despite several advances in therapy. Most published data on sepsis have been derived from clinical trials evaluating new drugs and from international cohort studies. The aim of this study was to analyze risk factors, mortality and causative pathogens in a cohort of unselected patients with severe sepsis at a German university hospital and to compare the data with international cohorts and recently published therapeutic trials.

PATIENTS AND METHODS

Between May 1999 and December 2002, all patients of the surgical and internal medicine intensive care units of a university medical center with newly manifested severe sepsis and at least one organ failure were recruited into the prospective observational study "Unicenter Sepsis Survey Regensburg" (USSR).

RESULTS

182 patients were included. The median age of the patients studied was 58 years, the median SAPS II amounted to 42, mortality at day 14 and day 30 was 25% and 34%, respectively. 48% of the patients developed sepsis due to an internal disease, 33% after surgical emergency interventions, and 19% after planned surgical interventions. Patients with surgical emergencies had higher SAPS II values and a worse outcome. 35% of all patients developed acute renal failure. 85% of the patients were treated with vasopressors, and 90% had to be ventilated mechanically. 58% of the patients had a probable and 38% a confirmed focal infection; in the final retrospective analysis, an infectious genesis proved to be unlikely in 4% of the patients.

CONCLUSION

The characteristics of unselected patients with severe sepsis at the authors' institution are comparable to data from recently published sepsis studies with respect to mortality, severity of disease, and range of causative pathogens.

Effekte des ärztlichen Controllings auf die DRG-gerechte Diagnosenverschlüsselung

OBJECTIVE

In a prospective study we analysed the quality of ICD-coding in clinical everyday life of a department for internal medicine.

METHODS

A skilled intern--the so-called DRG assistant--was temporarily released from clinical work. Over nine weeks he had to control all diagnoses contemporaneously that were ICD-coded by his colleagues on admission and discharge of their patients. The DRG-assistant had to ask for missing or correct implausible diagnoses, or inappropriate ICD-coding and with it also train his colleagues in appropriate coding. The effects of the DRG-assistant's correction of coding, on DRG-consistent grouping and on the potential financial loss or benefit generated by his work were recorded. After stoppage of this control in a subsequent phase of the study the effect of the absence of the DRG-assistant, the absence of reminders and coding control and the changes of the clinic's revenue were determined.

RESULTS

Corrections of ICD-coding by the DRG-assistant alone caused a remarkable increase in case-mix-index (CMI). CMI's mean value increased from 1.76 to 1.84 and the clinic's revenue increased by 180 Euro per patient (a total of about 80,000 Euro in nine weeks). After the end of the control, the case-mix-index dropped within three weeks down to 1.14, corresponding with a potential loss of 1200 Euro per patient (assuming that patients' morbidity was the same over the time of the study). Coding corrections could not improve CMI in this situation.

CONCLUSION

Contemporaneous control of ICD-coding by physicians seems to be essential in DRG based accounting.