[Polypharmacy and medication review in the context of prehabilitation]

Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.

Phosphine interacting with argon: potential energy surface and line widths of PH3 perturbed by Ar

The phosphine-Ar (PH₃-Ar) van der Waals complex's three-dimensional potential energy surface (3D-PES) was mapped along the intermonomer coordinates using the explicitly correlated Coupled Clusters approach. An analytical expansion of this 3D-PES is deduced. The complex characteristics of the intermolecular interactions between PH₃ and Ar, which are at the origin of the pressure broadening of the PH₃ rovibrational lines, are accurately described by this 3D-PES. Afterwards, the broadening of the phosphine lines perturbed by Ar at room temperature is computed using this 3D-PES. To be able to incorporate this 3D-PES into our collisional broadening computation software, we first modified it with a new "fractional" function. Then, we used the semiclassical Modified Robert and Bonamy model improved by the so-called notion of exact trajectory. For various branches of the ν₂ and ν₄ PH₃ rovibrational bands, room temperature data are provided. Our data agree with the experimental measurements. The precise estimation of PH₃ and Ar abundances in planetary atmosphere spectra should benefit greatly from the data provided here.

Mastoid obliteration versus canal wall down or canal wall up mastoidectomy for cholesteatoma: Systematic review and meta-analysis

BACKGROUND

There is ongoing debate over the optimal surgical approach for cholesteatoma treatment^1-5. The aim of this review was to determine whether canal-wall down with mastoid obliteration is associated with favourable outcomes compared to either canal-wall down without obliteration or canal-wall up. The primary outcome was cholesteatoma reoccurrence with secondary outcomes including otorrhoea, reoperation and patient-reported outcome measures.

METHODS

Medline, Embase, Cochrane databases and clinicaltrials.gov were searched for studies reporting outcomes of patients undergoing primary CWD-MO for cholesteatoma and directly compared with CWD and CWU mastoidectomies. Data were collated and meta-analysis performed.

RESULTS

2379 patients were included from 12 studies that met the inclusion criteria. CWD-MO was found to be associated with significantly less risk of recurrence when compared to CWU (OR = 0.330 (95 % CI 0.191-0.570, p < 0.001). When compared to CWD, CWD-MO was associate with significantly lower incidence of persistent otorrhoea (OR 0.405 (95 % CI 0.232-0.706, p < 0.001) while the rates of recurrence were comparable (OR: 1.231 [95 % CI: 0.550-2.757] p = 0.613). Otorrhoea rates between CWD-MO and CWU were equivalent as was reoperation. Quality of life and hearing outcomes were variably reported.

CONCLUSIONS

This systematic review demonstrates that CWD-MO technique achieves lower recurrence rates comparable to CWD approaches and superior to CWU, while offering improved long-term control of otorrhoea. The final procedural choice should be decided based on surgeon experience, skill set and individual patient factors. To address the risk of selection bias, a randomised controlled trial is needed to answer this important research question.

[Comparison of catheter-associated quality of life in external urinary diversion: nephrostomy vs. suprapubic catheter]

Einleitung

Die katheterbezogene Lebensqualität (LQ) bei Nephrostomieträgern wurde bisher noch nie systematisch untersucht. Dies sollte nun erstmalig vergleichend mit einer ebenfalls externen Urinableitung, dem suprapubischen Katheter, geschehen.

Methodik

Das die katheterbezogene LQ untersuchende Assessment nach Mary Wilde wurde bei Patienten mit perkutaner Nephrostomie (PCN) in lebenslanger Intention und minimaler Liegedauer von 3 Monaten vorgelegt.

Ergebnisse

Es zeigte sich insgesamt bei 66 Patienten (davon 42 mit unilateraler PCN) mit einem Punktwert von median 4,0 auf einer Skala von 0–5 eine nur moderat eingeschränkte katheterbezogene LQ. Diese wurde insgesamt und in allen Domänen schlechter als bei Patienten mit suprapubischem Katheter (SPK) bewertet, bei denen sich ein Score von 4,3 im Median fand. Signifikant waren die Unterschiede in den Einzelitems „Gefühl der Erniedrigung“, „Konflikte mit ärztlichem oder pflegerischem Personal“, „Angst vor schmerzhaften Katheterwechseln“, „Gefühl als kranke Person“, „Behinderungen in Aktivitäten des täglichen Lebens“ und „Besorgnis, nicht alles tun zu können, was ich mag“. Ebenso ergaben sich bei PCN-Trägern signifikant häufiger Angst vor Katheterlecks und Uringeruch. Die Anzahl der einliegenden PCN und die Grunderkrankung spielten für die Beurteilung der LQ keine Rolle.

Schlussfolgerung

Erstmals wurde die katheterassoziierte LQ, die sich bei PCN-Trägern nur moderat eingeschränkt fand, mit einem validierten Assessment quantitativ eingeordnet. Die Angabe der Betroffenen, sich als „krank“ und in der Ausübung von Aktivitäten des täglichen Lebens „behindert“ zu fühlen und die Angst vor Urinleckagen und schmerzhaften Wechseln sollten Ansporn für eine sorgfältige Indikationsstellung und technisch korrekte Katheterwechsel sein.

Predictors of steroid-refractory immune checkpoint inhibitor associated myocarditis

Background/Introduction

Immune checkpoint inhibitor (ICI)-associated myocarditis has a high mortality rate of approximately 50%. Clinical decompensation often occurs despite first-line treatment with corticosteroids. Factors associated with steroid failure are currently unknown.

Purpose

To identify predictors of steroid failure in patients with ICI-associated myocarditis.

Methods

We developed a web-based registry to collect and study 157 cases with clinical manifestations of ICI-associated myocarditis across 16 countries. Steroid failure was defined as patients who were escalated to immunomodulators after ≥1mg/kg daily dose of prednisone or had in-hospital death due to myocarditis despite ≥1mg/kg daily dose of prednisone. Steroid response was defined as all other patients treated with steroids without escalation to immunomodulators and without death due to myocarditis. A multivariate logistic model accounting for age and sex was used to predict association with steroid failure.

Results

Compared to steroid responsive cases, steroid failure was more likely to result in fulminant myocarditis (56.7% vs 19.6%, OR=5.37 [2.62–10.98] p&lt;0.001) and all-cause in-hospital mortality (49.1% vs 12.9%, OR=6.50 [2.86–14.73] p&lt;0.001) with shorter time from presentation to death (27.5 vs 43.0 days HR: 2.56 [1.45–4.50] p=0.001). When adjusting for age and sex, cases were more likely to be steroid-refractory if they were female (46.7% vs 30.1%, OR=2.77 [1.31–5.85] p=0.007), higher body mass index (27.2 vs 22.0, OR=1.09 [1.01–1.18] p=0.012), had higher intake creatine kinase (2800.5 vs 528.0 U/L, OR=1.48 [1.14–1.90] p=0.003) had higher intake troponin T (1.40 vs 0.25 ng/mL OR=1.63 [1.00–2.64] p=0.049), or had one or more concomitant non-cardiac immune-related adverse event (90.0% vs 74.2%, OR=3.10 [1.14–8.25] p&lt;0.026). The only immune-related adverse events independently associated with steroid failure in myocarditis were myasthenia gravis-like syndrome (26.7% vs 8.2%, OR=3.84 [1.47–10.10] p=0.006) and myositis (45.0% vs 24.7%, OR=2.38 [1.16–4.92] p=0.018). Steroid failure was not significantly associated with cardiovascular or autoimmune history but was associated with a history of thymoma (12.0% vs 2.6%, OR=18.86 [0.10–356.7] p=0.05)

Conclusion(s)

Features such as female sex, high body mass index, and pre-existing thymoma as well as findings of elevated cardiac biomarkers and other non-cardiac immune-related adverse events – particularly myositis and myasthenia gravis-like syndrome – may represent a steroid-refractory phenotype of ICI-associated myocarditis. These results suggest that a multidisciplinary approach to diagnosing concomitant non-cardiac immune related adverse events is key to risk-stratifying ICI-associated myocarditis.

Forrest Plot

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): National Institutes of Health

[Interdisciplinary education in urology: innovations for better training]

The current version of the urology training program will concentrate on the mediation of competences and skills in various fields of action for outpatient urology instead of persisting on the minimum and reference numbers of surgical and diagnostic procedures. However, the following fields of action must be fulfilled: microbiology, andrology and systemic cancer therapy. There is justifiable concern that various institutions will lose their permission for a complete 5‑year residency program based on the above-mentioned demands since not all institutions have all subspecialties in urology. Those institutions need to define new ways of residency training such as interdisciplinary programs within their own institution between disciplines like pediatric surgery, gynecology and medical oncology. Other options are combined training programs between regional urology departments with different main focuses or training programs between institutions and urologists in private practice. There is an unmet need to improve residency training as well as board examinations by new structures and a reliable curriculum. Based on the changed main focuses of the new version of urology training, we need to discuss the future of residency programs. It might be helpful to discuss two different types of urology training with a common trunk for the first three years followed by a more outpatient-based residency training for the general urologist and a more specialized training for the inpatient urologist to be educated in complex treatment modalities. An open mind to broadening our own horizon, respectful discussion with other departments and the development of common, reliable and interdisciplinary contents represent indispensable prerequisites to realize such an innovative future training program.

[Work and training conditions of residents in urology in Germany : Results of a 2015 nationwide survey by the German Society of Residents in Urology]

BACKGROUND

High-quality urologic residency training programs are crucial to secure both the future of our specialty and patient care. However, little is known about the current training and working conditions among German urology residents.

OBJECTIVES

To comprehensively assess the training- and working conditions among urologic residents in Germany.

MATERIALS AND METHODS

The GeSRU invited all German urologic residents to complete an online survey on training- and work conditions. Furthermore, the model of effort-reward imbalance (ERI) was applied to measure psychosocial strain at work.

RESULTS

A total of 476 urologic residents participated in the survey. Workdays are characterized by high pace and workload and economic considerations. This comes at the cost of professional training, research and family time. Due to these circumstances, a relevant part of residents draws or at least considers consequences. Psychosocial strain among participants is high and conveys a risk for physicians' health and patients' quality of care.

CONCLUSION

Our findings call for an adjustment of urologic working and training conditions to preserve high-quality medical treatment and to ensure an attractive working environment.