Typology and implications of verified attacks on health care in Ukraine in the first 18 months of war

Attacks on health care are part of the spectrum of threats that health care endures during conflict. Protecting health care services against attacks depends on understanding the nature and types of attacks that occur during conflict. The World Health Organisation has implemented the Surveillance System for Attacks on Health Care (SSA) in Ukraine since 2020, and the system has continued to monitor and report on attacks on health care during the war in Ukraine. This study aims to analyse the data reported through the SSA for the first 18 months of the war. This paper involves a retrospective, descriptive study based on the analysis of publicly available SSA data of all incidents of attacks on health care in Ukraine reported through the SSA between February 24th 2022 and August 24th 2023. Out of the 1503 verified attacks, 37% occurred in the initial six weeks of the war. Attacks involving violence with heavy weapons were among the most common incidents reported (83%). The reported attacks were associated with a total of 113 deaths and 211 injuries among health care workers and patients: 32 (2%) attacks were associated with a death of a health care worker or patient, and 63 (4%) were associated with an injury. Health transports facing attacks had a higher probability of experiencing casualties than other health resources (p<0.0001, RR 3.1, 95%CI 1.9-4.9). In conclusion, the burden of attacks on health care in Ukraine was high and sustained over the course of the first 18 months of the war. Reported casualties were not homogenously distributed among attack incidents, but occurred in a set of high-casualty incidents. Health transports were found to be particularly vulnerable. In addition to continued calls for a cessation of hostilities, prevention, protection, mitigation, and reconstruction strategies are urgently required.

Prevalence of noncommunicable diseases risk factors in the Kyrgyz Republic

AIM

To investigate the prevalence of noncommunicable diseases (NCD) risk factors in the Kyrgyz Republic.

MATERIALS AND METHODS

By using WHO STEPS approach survey findings were estimated from 2623 Kyrgyz residents aged 25-64 years. It was determined the prevalence of behavioral risk factors for NCDs, the prevalence of hypercholesterolemia and hyperglycemia. STEPS survey has covered all regions of the Kyrgyz Republic.

RESULTS

NCD-related death rates are the leading causes (76,8%) of mortality among the population of the Kyrgyz Republic. STEPS approach survey showed high prevalence of NCDs main risk factors among 2623 Kyrgyz residents aged 25-64 years.

CONCLUSION

High prevalence of NCDs main risk factors shows that there is necessity to develop effective policy to raise public awareness of healthy life style, health promotion, collaboration with all sectors of civil society.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data

Background

Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system.

Methods

Using routinely collected health billing records for 2005–2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply–side variables, and PHC use.

Findings

Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow–up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services.

Interpretation

Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments

BACKGROUND

Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of health care costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out-of-pocket (OOP) payments for medicines or services, and the likelihood of forgoing health care when unwell.

METHODS

Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, health care utilization, health insurance coverage, and costs incurred by individuals for the years 2006-2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for health care, and forgoing health care when ill, controlling for socio-economic and demographic covariates.

FINDINGS

Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments-especially for medicines. Healthcare utilization is in line with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25-49 years, the self-employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Over time, the likelihood of OOP for medicines increased (odds ratio OR = 1.422 in 2012 compared to 2006), but fell for health care services (OR = 0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing health care when sick, but we found the likelihood of forgoing health care to be increasing over time (OR = 1.295 in 2012 compared to 2009).

CONCLUSIONS

Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for health care costs incurred by patients and patients forgoing health care. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from health care costs.

Progress in increasing affordability of medicines for non-communicable diseases since the introduction of mandatory health insurance in the Republic of Moldova

BACKGROUND

To assess progress in improving affordability of medicines since the introduction of mandatory health insurance in the Republic of Moldova.

METHOD

Using data from national health insurance, we estimate affordability of partially reimbursed medicines for the treatment of non-communicable diseases, and analyse which factors contributed to changes in affordability.

RESULTS

Affordability of subsidized medicines improved over time. In 2013, it took a median of 0.84 days of income for the lowest income quintile (ranging from 0 to 3.32 days) to purchase 1 month of treatment for cardiovascular conditions in comparison to 1.85 days in 2006. This improvement however was mainly driven by higher incomes rather than deeper coverage through the reimbursement list.

CONCLUSION

If mandatory health insurance is to improve affordability of medicines for the Moldovan population, more funds need to be (re-)allocated to enable higher percentage coverage of essential medicines and efficiencies need to be generated within the health system. These should include a budget reallocation between secondary and primary care, strengthening primary care to manage chronic conditions and raise population awareness, implementation of evidence-based selection and quality use of medicines in both outpatient and inpatient settings, improving monitoring and regulation of prices and the supply chain; and alignment of national treatment guidelines and clinical practice with international best practices and evidence-based medicine.

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments

BACKGROUND

Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.

METHODS

The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.

RESULTS

OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.

CONCLUSIONS

Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

An in-depth analysis of pharmaceutical regulation in the Republic of Moldova

OBJECTIVE

Regulation of the pharmaceutical system is a crucial, yet often neglected, component in ensuring access to safe and effective medicines. The aim of this study was to provide an in-depth analysis of the existing pharmaceutical regulation, including recent changes, in the Republic of Moldova.

METHODS

Data from field work conducted by the World Health Organization (WHO) together with a review of policy documents and quantitative secondary data analysis was used to achieve this aim.

RESULTS

This analysis identified several ways in which pharmaceutical regulation affects availability of quality medicines in the Republic of Moldova. These include lack of full implementation bioequivalence requirements for generics registration, incomplete implementation of good manufacturing practices and no implementation of good distribution practices, use of quality control instead of quality assurance as a method to ensure quality of medicines, frequent change of power within the Medicines and Medical Devices Agency (MMDA) leading to lack of long-term strategy and plans, conflict of interest between the different functions of the MMDA, the lack of sufficient funding for the MMDA to conduct its activities and to invest in continuous training of its staff (particularly inspectors) and very weak post-marketing control. Notably, several improvements have been recently introduced, including a roadmap for change for the MMDA, the introduction of good manufacturing practices and the drafting of a quality manual for the Agency.

CONCLUSION

Based on these findings the authors propose a set of priority actions to address existing gaps and draw lessons learned from other countries.

Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia

BACKGROUND

In an era when an increasing amount of clinical information is available to health care professionals, the effective implementation of clinical practice guidelines requires the development of strategies to facilitate the use of these guidelines. The objective of this study was to assess attitudes towards clinical practice guidelines, as well as the barriers and facilitators to their use, among Estonian physicians. The study was conducted to inform the revision of the clinical practice guideline development process and can provide inspiration to other countries considering the increasing use of evidence-based medicine.

METHODS

We conducted an online survey of physicians to assess resource, system, and attitudinal barriers. We also asked a set of questions related to improving the use of clinical practice guidelines and collected free-text comments. We hypothesized that attitudes concerning guidelines may differ by gender, years of experience and practice setting. The study population consisted of physicians from the database of the Department of Continuing Medical Education of the University of Tartu. Differences between groups were analyzed using the Kruskal-Wallis non-parametric test.

RESULTS

41% (497/1212) of physicians in the database completed the questionnaire, comprising more than 10% of physicians in the country. Most respondents (79%) used treatment guidelines in their daily clinical practice. Lack of time was the barrier identified by the most physicians (42%), followed by lack of medical resources for implementation (32%). The majority of physicians disagreed with the statement that guidelines were not accessible (73%) or too complicated (70%). Physicians practicing in outpatient settings or for more than 25 years were the most likely to experience difficulties in guideline use. 95% of respondents agreed that an easy-to-find online database of guidelines would facilitate use.

CONCLUSIONS

Use of updated evidence-based guidelines is a prerequisite for the high-quality management of diseases, and recognizing the factors that affect guideline compliance makes it possible to work towards improving guideline adherence in clinical practice. In our study, physicians with long-term clinical experience and doctors in outpatient settings perceived more barriers, which should be taken into account when planning strategies in improving the use of guidelines. Informed by the results of the survey, leading health authorities are making an effort to develop specially designed interventions to implement clinical practice guidelines, including an easily accessible online database.

Social inequalities in the use of health care services after 8 years of health care reforms - a comparative study of the Baltic countries

OBJECTIVE

In nineties, Estonia, Latvia and Lithuania have implemented a wide range of changes to health systems. The objective of this paper was to assess social inequalities in utilisation of, and access to, health care services in the late nineties.

METHODS

The comparative NORBALT Survey conducted in 1999 is used. Direct standardization and logistic regression was applied to analyse primary, out-patient and hospital care utilisation, and self reported financial barriers, by socio-demographic and geographical variables.

RESULTS

In all three countries social inequalities in utilization were large for out-patient specialist care, smaller or absent with regards to primary care or to hospitalisations. Inequalities were large and consistent in relationship to household income, less so in relationship to educational level. Inequalities in utilization of care were larger in Latvia as well in the self reported barriers to health care in absolute and relative terms were larger.

CONCLUSIONS

After 8 years of reforms, important pro-rich inequalities in the use of health services existed. In Latvia, these inequalities were largest, possibly due to higher ratio of cost sharing as compared to Estonia and Lithuania.

Costs, health effects and cost-effectiveness of alcohol and tobacco control strategies in Estonia

OBJECTIVE

To assess the population-level costs, effects and cost-effectiveness of different alcohol and tobacco control strategies in Estonia.

DESIGN

A WHO cost-effectiveness modelling framework was used to estimate the total costs and effects of interventions. Costs were assessed in Estonian Kroon (EEK) for the year 2000, while effects were expressed in disability-adjusted life years (DALYs) averted. Regional cost-effectiveness estimates for Eastern Europe, were used as baseline and were contextualised by including country-specific input data.

RESULTS

Increased excise taxes are the most cost-effective intervention to reduce both hazardous alcohol consumption and smoking: 759 EEK (euro 49) and 218 EEK (euro 14) per DALY averted, respectively. Imposing additional advertising bans would cost 1331 EEK (euro 85) per DALY averted to reduce hazardous alcohol consumption and 304 EEK (euro 19) to reduce smoking. Compared to WHO-CHOICE regional estimates, interventions were less costly and thereby more cost-effective in Estonia.

CONCLUSIONS

Interventions in alcohol and tobacco control are cost-effective, and broad implementation of these interventions to upgrade current situation is warranted from the economic point of view. First priority is an increase in taxation, followed by advertising bans and other interventions. The differences between WHO-CHOICE regional cost-effectiveness estimates and contextualised results underline the importance of the country level analysis.

Quality improvement in the Estonian health system--assessment of progress using an international tool

OBJECTIVE

To assess the quality of the Estonian health system with the assessment tool provided by the World Health Organization (WHO).

DESIGN

Situation analysis of health care quality using the self-assessment questionnaire proposed by the Council of Europe and WHO Regional Office for Europe as a framework for evaluating national quality activities.

SETTING

Estonia.

MAIN OUTCOME MEASURES

Four domains for evaluating the national quality activities: policy, organization, methods, and resources.

RESULTS

The quality policy of Estonian health care developed in the late 1990s defines the scope of quality and reflects the different viewpoints of stakeholders. Nevertheless, it is not comprehensive enough, activities planned for the involvement of consumers in defining and assessing quality are lacking, and key roles of institutions in quality improvement and incentives for quality are not clearly defined. At present, the responsibilities for quality assurance are distributed among the different stakeholders, but there is no single coordinating structure or mechanism for facilitating or assessing the implementation of the quality activities. Many regulations are established to assure the quality of health services and to protect patients' rights, but the implementation of voluntary mechanisms for quality assurance should be promoted. Access to the sources of information is good, but there is a shortage of unified quality and performance indicators at the national level.

CONCLUSION

The results of this study indicated the strengths and shortages of the present organization of quality activities in Estonia and the ways for improvement. Strengthening coordination with explicit quality monitoring was found as a key factor for improvement.

Prognostic factors affecting long-term outcomes in patients with resected stage IIIA pN2 non-small-cell lung cancer: 5-year follow-up of a phase II study

The aim was to investigate the efficacy of neoadjuvant docetaxel-cisplatin and identify prognostic factors for outcome in locally advanced stage IIIA (pN2 by mediastinoscopy) non-small-cell lung cancer (NSCLC) patients. In all, 75 patients (from 90 enrolled) underwent tumour resection after three 3-week cycles of docetaxel 85 mg m-2 (day 1) plus cisplatin 40 or 50 mg m-2 (days 1 and 2). Therapy was well tolerated (overall grade 3 toxicity occurred in 48% patients; no grade 4 nonhaematological toxicity was reported), with no observed late toxicities. Median overall survival (OS) and event-free survival (EFS) times were 35 and 15 months, respectively, in the 75 patients who underwent surgery; corresponding figures for all 90 patients enrolled were 28 and 12 months. At 3 years after initiating trial therapy, 27 out of 75 patients (36%) were alive and tumour free. At 5-year follow-up, 60 and 65% of patients had local relapse and distant metastases, respectively. The most common sites of distant metastases were the lung (24%) and brain (17%). Factors associated with OS, EFS and risk of local relapse and distant metastases were complete tumour resection and chemotherapy activity (clinical response, pathologic response, mediastinal downstaging). Neoadjuvant docetaxel-cisplatin was effective and tolerable in stage IIIA pN2 NSCLC, with chemotherapy contributing significantly to outcomes.

Detecting changes in financial protection: creating evidence for policy in Estonia

Ninety-four per cent of the Estonian population is covered by public health insurance, but private expenditure has been increasing quickly both in real terms and as a percentage of total health expenditure. To date, little attention has been given to the impact this could have on the population's financial protection. Out-of-pocket payments, which account for the bulk of the private expenditure in many low- and middle-income countries, can push people into poverty and more generally represent too high a burden for some households. It is therefore very important that governments monitor the impact of out-of-pocket payments on health. Using an example from Estonia, this paper aims to illustrate that, if household budget survey data are available, monitoring a population's financial protection is not a complex undertaking. Further, by combining simple statistical analyses of these data with a good knowledge of a country's health system, it is possible to give a fairly detailed diagnostic of the nature of the population's coverage limitation. This allows for the presentation of easily interpretable results that can raise awareness among policy-makers and help to target adequate policy responses. Using Estonian household budget surveys from 1995, 2001 and 2002, we show that the proportion of households who spend more than 20% of their capacity to pay on health increased from 3.4% in 1995 to 7.4% in 2002 and that in 2002, 1.3% of the population fell into poverty because of health payments. Logistic regression helps in identifying the population most at risk: elderly patients who belong to poor households and spend high amounts on medicines. This study, which can be replicated, did raise awareness among policy-makers about the changes in financial protection over the years in Estonia.

Impact of joined-up HIV harm reduction and multidrug resistant tuberculosis control programmes in Estonia: System dynamics simulation model

In Eastern Europe and Central Asia (ECA) the control of tuberculosis, multidrug resistant tuberculosis (MDRTB) and human immunodeficiency virus (HIV) poses important public health challenges. We used system dynamics simulation to determine impact on cumulative HIV/AIDS, tuberculosis and HIV-associated-tuberculosis deaths, over 20 years, of harm-reduction programmes to reduce needle-sharing and injection-frequency amongst injecting drug users (IDUs) and multidrug resistant tuberculosis (MDRTB) control in a population with an explosive HIV epidemic in IDUs and high MDRTB prevalence. We estimate that the number of HIV-associated-deaths will decline by 30% with effective harm-reduction programmes but double if these are ineffective. In our model, effective MDRTB and HIV control reduces cumulative tuberculosis deaths by 54%, cumulative MDRTB deaths 15-fold and cumulative HIV-associated-tuberculosis-deaths 2-fold. Effective MDRTB control, without effective harm-reduction programmes, only reduce tuberculosis deaths by 22%. However, effective harm-reduction programme with a poor MDRTB control reduce cumulative tuberculosis deaths by 34%, MDRTB by 14% and HIV-associated-tuberculosis by 56%. Even with good control programmes for drug sensitive TB, neglecting harm reduction and MDRTB control will result in 50% more tuberculosis-related deaths than if both are effectively addressed. Effective harm-reduction programmes reduces cumulative deaths from tuberculosis more substantively than effective MDRTB control. Our finding have important policy implications for communicable disease policies in post-Soviet countries, which need to substantially change if they are to effectively address the emerging HIV and MDRTB epidemics.

Introducing a complex health innovation--primary health care reforms in Estonia (multimethods evaluation)

All post-Soviet countries are trying to reform their primary health care (PHC) systems. The success to date has been uneven. We evaluated PHC reforms in Estonia, using multimethods evaluation: comprising retrospective analysis of routine health service data from Estonian Health Insurance Fund and health-related surveys; documentary analysis of policy reports, laws and regulations; key informant interviews. We analysed changes in organisational structure, regulations, financing and service provision in Estonian PHC system as well as key informant perceptions on factors influencing introduction of reforms. Estonia has successfully implemented and scaled-up multifaceted PHC reforms, including new organisational structures, user choice of family physicians (FPs), new payment methods, specialist training for family medicine, service contracts for FPs, broadened scope of services and evidence-based guidelines. These changes have been institutionalised. PHC effectiveness has been enhanced, as evidenced by improved management of key chronic conditions by FPs in PHC setting and reduced hospital admissions for these conditions. Introduction of PHC reforms - a complex innovation - was enhanced by strong leadership, good co-ordination between policy and operational level, practical approach to implementation emphasizing simplicity of interventions to be easily understood by potential adopters, an encircling strategy to roll-out which avoided direct confrontations with narrow specialists and opposing stakeholders in capital Tallinn, careful change-management strategy to avoid health reforms being politicized too early in the process, and early investment in training to establish a critical mass of health professionals to enable rapid operationalisation of policies. Most importantly, a multifaceted and coordinated approach to reform - with changes in laws; organisational restructuring; modifications to financing and provider payment systems; creation of incentives to enhance service innovations; investment in human resource development - was critical to the reform success.

Social inequalities in health care services utilisation after eight years of health care reforms: a cross-sectional study of Estonia, 1999

Fundamental health care reforms in Estonia started in 1991 with the introduction of a social health insurance system. While increasing the efficiency of the health care system was one of the targets of the health care reforms, equity issues have received relatively less attention. The objective of this study is to provide an overview of social inequalities in health care utilisation in Estonia in 1999, after 8 years of large-scale reforms. Data were obtained from a nationally representative household interview survey including 3990 respondents aged 25-74 years. Health care utilisation was measured by the telephone consultations, visits to the general practitioner, visits to the specialist, visits to the dentist, and hospitalisation. These utilisation measures were related to variables on ethnicity, place of residence, education, income and employment, by means of direct standardisation and logistic regression models. Three different regression models were applied in order to (a) describe social differences in health care utilisation, (b) to assess whether these differences can be explained by differences in health needs, and (c) to assess the independent effect of each social variable net of all other social variables. Substantial inequalities were observed for all types of health care services and according to most social dimensions. Residents of rural areas were more likely to visit a general practitioner or to use telephone consultation, but less often used outpatient specialist care or dentist care. Ethnic differences were generally smaller, with no consistently higher use by either Russians or ethnic Estonians. Large differences were observed in relation to socio-economic status (education, income, or employment), with a more favourable socio-economic status being associated with higher probability to use health care services, especially after controlling for health needs. In case of hospitalisation, however, no notable social inequalities were found. These findings suggest that important geographic, financial and information barriers to health care utilisation exist after almost one decade of health care reforms in Estonia. Further health care reforms should aim to lessen or even remove these barriers.

Short- and Long-term Outcome after Lung Resection for Invasive Pulmonary Aspergillosis

BACKGROUND

Lung resection for invasive pulmonary aspergillosis (IPA) is controversial. Neutropenia, thrombopenia and poor general condition may increase perioperative morbidity and mortality, and the redeeming benefit is questionable. Therefore we analyzed short- and long-term outcome after lung resection for IPA.

METHODS

41 patients with hematological disease underwent lung resection for suspected IPA: lobectomy (23 patients), wedge-resection (16) and enucleation (2).

RESULTS

4 (10%) patients developed major complications: pleural aspergillosis, bronchial stump insufficiency, severe bleeding, ARDS. 11 (27%) patients showed minor complications: pleural effusion (6), pneumothorax (2), seroma (2) and hematothorax (1). 30-day mortality was 10 % (4 of 41 patients): two died of bacterial septicemia, two of disseminated aspergillosis. One (2%) death was possibly surgery-related. IPA was cleared in 87% of patients, fungal relapse occurred in 4 (10%) patients. Overall survival was 65%, 58% and 40% at 6 months, 12 months and 5 years.

CONCLUSION

Lung resection for IPA even in profound cytopenia is feasible with acceptable morbidity and mortality. Fungal infection can be cured in more than 80 % of patients. Long-term outcome can be achieved if the hematological disease is under control.

Aneurysmal and partially thrombosed orifice of a coronary artery fistula into the right atrium combined with patent foramen ovale

We report a case of a right atrial sessile tumor combined with a patent foramen ovale and the characteristics of fat containing tumor in magnetic resonance imaging. Histologic study revealed this to be an aneurysmal and partially thrombosed formation of a coronary artery fistula.

[The indications for and results of video thoracoscopic sympathectomy]

BACKGROUND AND OBJECTIVES

Thoracoscopic sympathectomy, for years an effective way to treat mainly palmar and axilla hyperhidrosis, experienced a revival since the application of the principles of minimally invasive surgery. We report the personal experiences of three surgeons with this technique, as well as patients' view of the outcome.

PATIENTS AND METHODS

Between January 1990 and November 1997, 73 procedures were performed in 43 patients (23 males, 20 females, mean age 38.1 years, range 15-82 years), and the outcome was prospectively studied. Palmar hyperhidrosis without axilla symptoms was the indication for the operation in 27 patients (54 sympathectomies), Raynaud's syndrome in 15 (18 sympathectomies), and causalgia in one. Thoracic ganglia 2-4 were always completely resected. Perioperative morbidity as well as patient satisfaction in the long-term course (standardized interview) 25.8 (1-77) months postoperatively were assessed.

RESULTS

The complication rate in all 73 sympathectomies was 8.2%. Only two severe incidents were observed: in one patient intermittent Horner's syndrome (1.4%) occurred, and in another severe bleeding required conversion to open surgery (1.4%). Both complications occurred in the early study phase. The initial success rate in all 27 patients with hyperhidrosis was 100%. In 30% of these cases a mild partial relapse was observed, which did not interfere with their daily activities. 53% of the patients reported compensatory and 23% gustatory sweating. 9% would have refused the operation, had they known these side effects. In all patients with Raynaud's disease the ulcerations healed completely. At the time of the interview, two patients (13%) complained of painless relapses. They too stated that they had refused the operation, if they had known about the relapses.

CONCLUSIONS

Even in the longer-term course, thoracoscopic sympathectomy is rated subjectively successful by 93% of patients after treatment of hyperhidrosis of the upper extremities, and by 87% of patients after treatment of Raynaud's disease, despite some untoward effects and partial relapses.

Prospective evaluation of 3 risk stratification scores in cardiac surgery

BACKGROUND

The aim of the study was to evaluate 3 different risk stratification scores in cardiac surgery, based on the hospital results of 1,299 patients.

METHODS

From June 1995 to December 1997, all patients (n = 1,299) undergoing coronary artery bypass grafting (CABG) and/or heart valve surgery were prospectively enrolled. The postoperative in-hospital outcome (mortality, morbidity and length of hospital stay) was analysed in relation to three different risk stratification scores (Parsonnet, Higgins and French score).

RESULTS

The results of 1,299 patients (mean age 62.8 +/- 10.2 years) were analysed. 10 patients died, accounting for a total mortality of 0.8%. 13 patients (1%) underwent cardiopulmonary resuscitation. In 25 patients (1.9%), perioperative myocardial infarction occurred. Performance of the 3 systems was assessed by evaluating discrimination with receiver operating characteristic (ROC) curves. The area under the ROC curve was 0.761 for Parsonnet, 0.786 for Higgins and 0.798 for French score. The French and the Higgins score showed an increase of in-hospital mortality, morbidity and length of stay in relation to increasing risk classes.

CONCLUSION

For objective evaluation of the outcome in cardiac surgery, case-mix severity needs to be considered, which is reflected by preoperative risk stratification scores. In our study, all the 3 scores showed a high discrimination and are appropriate tools to assess mortality in cardiac surgery. Especially the French and the Higgins score (restricted to 5 groups), due to their simplicity, were useful to predict postoperative outcome in clinical routine.

Diagnostic yield of bronchoscopy in histologically proven invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) is a life-threatening infectious complication in neutropenic patients after high-dose chemotherapy or hematopoietic stem cell transplantation. Its diagnosis is mainly based on clinical symptoms, and radiological signs on thoracic CT scan. The value of bronchoscopy is controversial. We analyzed the diagnostic yield of bronchoscopy in 23 consecutive patients with histologically proven invasive pulmonary aspergillosis. In seven patients (30%) bronchoscopically obtained specimens were diagnostic for pulmonary fungal infection. Typical hyphae were detected by cytology in six patients and fungal cultures were positive in four cases. Patients with a positive bronchoscopic result presented more often with multiple changes on thoracic CT scan (71%; 5/7), but had received a lower median cumulative dose of amphotericine B (300 mg; 168-3010 mg) compared to patients with non-diagnostic bronchoscopy (25% multiple lesions (4/16); amphotericine dose 1100 mg, 260-2860 mg). The diagnostic yield of bronchoscopy was not associated with clinical symptoms or duration of neutropenia. Bronchoscopy allows the diagnosis of IPA in about one third of patients. Fungal cultures and cytological examination of intrabronchial specimens obtained during bronchoscopy have a high specificity, but its sensitivity is low. It is advisable to perform diagnostic bronchoscopy before starting antifungal therapy. Better diagnostic tools are urgently needed.

[Video-assisted thoracosopic sympathectomy: spectrum of indications and our own results (1995-1997)]

INTRODUCTION

Video-assisted thoracoscopic (VATS) sympathectomy is the most frequently used technique for surgical sympathectomy of the upper limbs. It has proven to be particularly effective in hyperhidrosis of the hands. The aim of this study is to review and discuss possible indications and analyse our own results from 1995 to 1997, including technical details on the use of a new 2-mm thoracoscope and instrumentation.

PATIENTS AND METHODS

Data of all 14 consecutive patients were prospectively assessed (8 females, 6 males, mean age 44 years; range 22-74 years). A total of 26 thoracoscopic sympathectomies were performed. Indications included: 7 cases of hyperhidrosis, 4 of inoperable and medically intractable angina pectoris, 3 of vascular diseases of the upper extremity. All patients were reexamined 3 months postoperatively and late follow-up was obtained in all patients, with a mean follow-up of 20 months postoperatively (4-36 months) by questionnaire.

RESULTS

22 Th2-Th5 and 4 Th2-Th4 resections of the sympathetic chain were performed. There was no conversion to open surgery. The mean operating time was 67 minutes (range 50-90 min.). One (3.8%) unilateral Horner syndrome occurred with complete recovery during follow up. Compensatory sweating occurred in 7 (50%). The mean hospitalisation was 4.7 days for all patients and 2.8 days for those with hyperhidrosis. In 10 patients (71.5%), symptoms of the underlying disease had completely ceased on the day of discharge, and in 4 (28.5%) the symptoms had improved. Two months postoperatively a unilateral relapse occurred in one patient with Raynaud's disease. After a mean of 20 months, the quality of life was improved in 12 (85%) and was unchanged as compared to preoperatively in 2 (15%).

CONCLUSIONS

Primary hyperhidrosis showed the best results after thoracoscopic sympathectomy. Although experience with angina pectoris is still limited, thoracoscopic sympathectomy seems to be a valuable alternative in otherwise inoperable cases. In upper-extremity vascular diseases the operation can be performed as a last therapeutic option, but relapse often occurs in these patients. 2-mm instrumentation decreases trauma and postoperative pain and improves cosmetic results, which obviously may play a role in younger patients with hyperhidrosis. Patients should be warned about compensatory sweating before thoracic sympathectomy.

Prospective evaluation of an algorithm for the functional assessment of lung resection candidates

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV1, diffusing capacity of the lungs for carbon monoxide (DLCO), and maximal oxygen uptake (VO2max), as well as their respective ppo values (FEV1-ppo, DLCO-ppo, and VO2max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 (+/- 1.8) d, and the mean hospital stay was 14.6 (+/- 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results.

Lung resection for invasive pulmonary aspergillosis in neutropenic patients with hematologic diseases

Invasive pulmonary aspergillosis (IPA) is associated with a high mortality. In 27 consecutive neutropenic patients who underwent lung resection for suspected IPA, we analyzed preoperative diagnostic evaluation, operative procedure, perioperative management, histological findings, outcome concerning recurrence of aspergillosis, and survival to evaluate the morbidity and mortality of a surgical treatment of IPA. Seventeen patients with hematologic diseases had previously undergone high-dose chemotherapy and four stem cell transplantation. Six patients with aplastic anemia were treated with antilymphocyte globulin. IPA was suspected if localized infiltrates developed on thoracic CT scan, and fever persisted under antibiotic therapy in neutropenic patients. In only one case a diagnosis of IPA could be made preoperatively. Twenty patients underwent lobectomy and seven wedge resection. At day of surgery the neutrophil count was below 500 x 10(9)/L in 78% of patients, and the platelet count below in 50 x 10(9)/L in 58% of patients. Invasive fungal infection was confirmed histologically in 22 of 27 patients (81.5%); in five patients no fungal infection was documented. The median duration of surgery was 120 min. Postoperatively, patients stayed one night in the intensive care unit, and chest tubes were removed after 2 d. Within 7 d a median of four erythrocyte packs and two platelet packs per patient were replaced. Major surgical complications occurred in two patients (bronchial dehiscence; pleural aspergillosis). Minor surgical complications included prolonged chest tube drainage (recurrent pneumothorax, n = 2; air leakage, n = 1; hematothorax, n = 1), pleural effusion (n = 4), and seroma (n = 2). Postoperatively, two patients suffered from histologically proven disseminated aspergillosis (pleural aspergillosis, renal aspergilloma) and another patient from suspected orbital aspergillosis. At 30 d postoperative mortality was 11% and 3-mo survival was 77%. After lung resection, seven patients underwent stem cell transplantation without recurrence of IPA. In conclusion, we suggest lung resection is a therapeutic option for invasive pulmonary aspergillosis in neutropenic patients with hematologic diseases and is associated with a low surgery-related morbidity and mortality.

Microdialytic monitoring during a cardiovascular operation

In an aorta-coronary bypass operation, the heart is excluded from the circulation for many minutes, leading to ischemia. During this time the heart is cooled in order to mitigate damage. Microdialysis has been shown to be very suitable for detecting ischaemic changes e.g. in brain. We therefore used this method to study the time courses of several neurochemical parameters which have been shown to indicate ischaemia in animal models (ascorbic acid, glutathione, cysteine, uric acid, glucose, lactate and pH), during such a bypass operation. Three patients were investigated, the microdialysis probe being inserted into the interventricular septum of the heart. Our results show that microdialysis is technically feasible in the human heart in a clinical setting, although the operation becomes more demanding for the surgeon. All the above-mentioned parameters could be detected in the heart muscle. Some of them showed changes characteristic of ischaemia, and the effects of cooling on the metabolism could also be noted. Long term measurements are planned to enable delayed damage to be disclosed.

Decision making in the surgical treatment of massive pulmonary embolism

Pulmonary embolectomy in the treatment of acute massive pulmonary embolism (PE) is the subject of considerable controversy with regard to indication, technique of embolectomy and perioperative management. Since 1968 50 patients have undergone surgery for massive PE in our unit. Inflow occlusion technique and cardiopulmonary bypass were used in 33 and 17 patients, respectively. The overall operative mortality was 46%. Univariate analysis disclosed age (< 60 vs > 60), preoperative hemodynamics (cardiogenic shock vs cardiac arrest), location of emboli (peripheral vs central), duration of symptoms (hours vs days vs weeks) and number of episodes (first episode vs recurrent pulmonary emboli) as predictive factors of the post-operative outcome. The results of the retrospective analysis show that pulmonary embolectomy remains an acceptable procedure in patients with acute massive pulmonary emboli who are in refractory cardiogenic shock or who need intermittent resuscitation.

Selection of independent plasmids determining phenol degradation in Pseudomonas putida and the cloning and expression of genes encoding phenol monooxygenase and catechol 1,2-dioxygenase

Long-term cultivation of the Pseudomonas putida multiplasmid strain EST1020 on phenol resulted in the formation of individual PHE plasmids determining phenol degradation. Four types of PHE plasmids, pEST1024, pEST1026, pEST1028, and pEST1029, are characterized. They all contain a transferrable replicon similar to pWWO-8 with a partly duplicated DNA sequence of the 17-kb transposable element of this plasmid and include various amounts of DNA that carry genes encoding phenol degradation (phe genes). We cloned the genes determining phenol monooxygenase and catechol 1,2-dioxygenase from the Pseudomonas sp. parent strain plasmid DNA into the broad host range vector pAYC32 and studied the expression of the cloned DNA. The formation of a new hybrid metabolic plasmid, pEST1354, was demonstrated in P. putida PaW85 as the result of transposition of the 17-kb genetic element from the chromosome of PaW85 into the plasmid carrying cloned phe genes. The target site for the 17-kb transposon was localized in the vector DNA, just near the cloning site. In subcloning experiments we found two regions in the 17-kb DNA stretch that are involved in the expression of the cloned phe genes.

A role of Ia-associated invariant chains in antigen processing and presentation

Most native antigens require processing in a cellular compartment for efficient presentation to T helper cells. The cellular elements that permit processing are not known. We investigated a possible role of the class II MHC-associated invariant chains in antigen processing. Fibroblast cells that were transfected with class II genes were compared with fibroblasts supertransfected with the invariant chain gene for their capacity to present the fifth component of complement (C5) to C5-specific class II restricted T cell clones or influenza virus protein to a virus-specific T cell clone. Only fibroblasts supertransfected with the invariant chain gene were able to present native antigen, even at very low antigen concentration, whereas both fibroblast types could present cyanogen bromide-fragmented C5 or the virus peptide. Presentation of intact antigen but not of fragmented antigen was totally abrogated by treatment of fibroblasts with chloroquine. The invariant chain gene encodes two polypeptides, li31 and li41. Expression of either li31 or li41 was sufficient to render class II-expressing fibroblasts capable of presenting intact antigen.

Primary structure of the gene for the murine Ia antigen-associated invariant chains (Ii). An alternatively spliced exon encodes a cysteine-rich domain highly homologous to a repetitive sequence of thyroglobulin

The gene for murine Ia-associated invariant (Ii) chains (Ii31 and Ii41) was characterized by sequence analysis. The gene extends over approximately 9 kb and is organized in nine exons. Exon 1 encodes the 5' untranslated region and the cytoplasmic segment, exon 2 the membrane spanning segment and adjacent amino acids and exons 3-8 the extracytoplasmic portion of Ii31. Putative promoter sequences were found upstream of the start of the coding sequence. Between exons 6 and 7 an additional, alternatively spliced exon 6b has been identified. This exon is spliced into the mRNA coding for the Ii-related Ii41 protein. Exon 6b encodes a cysteine-rich domain of 64 amino acids. It shows a remarkably high homology to the repetitive elements in thyroglobulin, a precursor for thyroid hormone. Based on this homology, it is suggested that this domain (TgR) in Tg and in Ii41 may play a role either in hormone formation or as a carrier in the transport of molecules (thyroid hormone or processed antigen respectively) between intracellular compartments.

Inhibition of prostaglandin E2 release by salicylates, benzoates and phenols: a quantitative structure-activity study

Concentrations inhibiting 50% of the prostaglandin E2 release from phorbol ester-stimulated mouse peritoneal macrophages in-vitro were determined for 59 monosubstituted congeners of salicylic acid, benzoic acid and phenol. Twenty-seven further compounds, mainly benzoic acids, were found to be inactive. An attempt was made to establish a quantitative structure-activity relationship (QSAR) form our experimental data using literature or calculated values for the logarithmic n-octanol/water partition coefficients of the compounds, molar refractivity and sigma values of substituents as well as structural indicator variables. The equations found have moderate predictive power and must be considered as a first step in the investigation of factors determining the biological activity of salicylates, benzoates and phenols.

Quantum chemical analysis of structure-activity relationships in nonsteroidal anti-inflammatory drugs

Ab initio, quantum chemical methods are being used to analyze and interpret structure-activity relationships in nonsteroidal anti-inflammatory drugs. The biological data for this study derive from full dose-response curves of the inhibitory potency of phenols, salicylates, and benzoates on prostaglandin production in mouse macrophages. To date, about 80 compounds have been assayed and from this group a sample of 30 has been selected for calculation. The results show a correlation between the potency of the active compounds and the orbital energy of the highest occupied molecular orbital (HOMO) with a correlation coefficient of r approximately 0.8. These results indicate that potency increases with decreasing binding strength of the pi-HOMO electrons, suggesting that charge transfer may be important for interaction with specific or nonspecific binding sites.

The isolation of the antibody moieties of immune complexes from serum by the pepsin digestion of conglutinin-anti-conglutinin complexes

A technique is described which allows the antibodies of circulating immune complexes to be isolated as their F(ab')2 fragments. The method is based on the precipitation of the complexes by the sequential addition of conglutinin and anti-conglutinin, and the subsequent digestion of these precipitates by pepsin. Using this technique it has been possible to show antibodies to Epstein-Barr (EB) virus antigens in the immune complexes of patients with Burkitt's lymphoma and to microbial antigens in two patients with nephritis. By substituting DNAase for pepsin it has also been possible to show antibodies to DNA-containing nuclear antigens in the serum of patients with systemic lupus erythematosus.

Intracerebral synthesis of antibodies to measles and distemper viruses in patients with subacute sclerosing panencephalitis and multiple sclerosis

Serum and cerebrospinal fluid (CSF) measles and distemper antibody levels were quantified in a series of twenty patients (four subacute sclerosing panencephalitis (SSPE); ten multiple sclerosis (MS); six non-MS neurological cases) using independent competitive inhibition radioimmunoassays. These results were used in a Tourtellotte calculation to measure the intracerebral IgG synthesis to each virus. The results confirmed that in SSPE there is a greatly enhanced intracerebral measles antibody synthesis (6.0 mg/day). However, it was found that in SSPE this represents only part of a general systemic measles hyperimmunization as the intracerebral measles antibody synthesis relative to the total body measles synthesis was not significantly different from other groups (8%); In MS patients there was increased intracerebral immunoglobulin synthesis but the measles antibody levels were neither significantly elevated nor different from the control group. No evidence was found to support the concept that canine distemper virus is implicated in either MS or SSPE.