Individual Patient Risk Profile Research Articles

Off versus on pump myocardial revascularization in patients with severe asymptomatic carotid stenosis.

Coronary artery disease is a global cause of morbidity and mortality, often managed by coronary artery bypass grafting (CABG). This study addresses a critical decision-making dilemma in CABG procedures for patients with severe asymptomatic carotid stenosis, comparing off-pump and on-pump techniques. We conducted a retrospective single-center analysis, employing propensity scored matched-pair methodology to compare perioperative outcomes in patients with asymptomatic severe carotid stenosis undergoing off-pump or on-pump CABG. The primary endpoint was the occurrence of perioperative stroke. Secondary endpoints included postoperative delirium, intrahospital mortality, intensive care unit stay, length of hospitalization and long-term survival. The study involved 243 patients with asymptomatic severe carotid stenosis operated between July 2009 and October 2018, subsequently propensity score matched into two groups of 78 patients each (off-pump and on-pump). The incidence of perioperative stroke was significantly higher in the On-Pump group compared to the off-pump group (10.3% vs. 1.3%, P=0.03). However, secondary endpoints, such as intrahospital mortality and length of hospitalization, showed no significant differences between the two groups. Long-term survival rates were also comparable. Our findings indicate that off-pump CABG significantly reduces the risk of perioperative stroke in patients with severe asymptomatic carotid stenosis compared to on-pump CABG, without compromising long-term outcomes. These results support the preference for off-pump CABG in this high-risk patient population, highlighting the need for tailored surgical approaches based on individual patient risk profiles.

Duration-Dependent Risk of Hypoxemia in Colonoscopy Procedures.

Background and Aims: Colonoscopy is a critical diagnostic and therapeutic procedure in gastroenterology. However, it carries risks, including hypoxemia, which can impact patient safety. Understanding the factors that contribute to the incidence of severe hypoxemia, specifically the role of procedure duration, is essential for improving patient outcomes. This study aims to elucidate the relationship between the length of colonoscopy procedures and the occurrence of severe hypoxemia. Methods: We conducted a retrospective cohort study at Sheba Medical Center, Israel, including 21,524 adult patients who underwent colonoscopy from January 2020 to January 2024. The study focused on the incidence of severe hypoxemia, defined as a drop in oxygen saturation below 90%. Sedation protocols, involving a combination of Fentanyl, Midazolam, and Propofol were personalized based on the endoscopist's discretion. Data were collected from electronic health records, covering patient demographics, clinical scores, sedation and procedure details, and outcomes. Statistical analyses, including logistic regression, were used to examine the association between procedure duration and hypoxemia, adjusting for various patient and procedural factors. Results: We initially collected records of 26,569 patients who underwent colonoscopy, excluding 5045 due to incomplete data, resulting in a final cohort of 21,524 patients. Procedures under 20 min comprised 48.9% of the total, while those lasting 20-40 min made up 50.7%. Only 8.5% lasted 40-60 min, and 2.9% exceeded 60 min. Longer procedures correlated with higher hypoxemia risk: 17.3% for <20 min, 24.2% for 20-40 min, 32.4% for 40-60 min, and 36.1% for ≥60 min. Patients aged 60-80 and ≥80 had increased hypoxemia odds (aOR 1.1, 95% CI 1.0-1.2 and aOR 1.2, 95% CI 1.0-1.4, respectively). Procedure durations of 20-40 min, 40-60 min, and over 60 min had aORs of 1.5 (95% CI 1.4-1.6), 2.1 (95% CI 1.9-2.4), and 2.4 (95% CI 2.0-3.0), respectively. Conclusions: The duration of colonoscopy procedures significantly impacts the risk of severe hypoxemia, with longer durations associated with higher risks. This study underscores the importance of optimizing procedural efficiency and tailoring sedation protocols to individual patient risk profiles to enhance the safety of colonoscopy. Further research is needed to develop strategies that minimize procedure duration without compromising the quality of care, thereby reducing the risk of hypoxemia and improving patient safety.

Recent Data about the Use of Corticosteroids in Sepsis-Review of Recent Literature.

Sepsis, characterized by life-threatening organ dysfunction due to a maladaptive host response to infection, and its more severe form, septic shock, pose significant global health challenges. The incidence of these conditions is increasing, highlighting the need for effective treatment strategies. This review explores the complex pathophysiology of sepsis, emphasizing the role of the endothelium and the therapeutic potential of corticosteroids. The endothelial glycocalyx, critical in maintaining vascular integrity, is compromised in sepsis, leading to increased vascular permeability and organ dysfunction. Corticosteroids have been used for over fifty years to treat severe infections, despite ongoing debate about their efficacy. Their immunosuppressive effects and the risk of exacerbating infections are significant concerns. The rationale for corticosteroid use in sepsis is based on their ability to modulate the immune response, promote cardiovascular stability, and potentially facilitate organ restoration. However, the evidence is mixed, with some studies suggesting benefits in terms of microcirculation and shock reversal, while others report no significant impact on mortality or organ dysfunction. The Surviving Sepsis Campaign provides cautious recommendations for their use. Emerging research highlights the importance of genomic and transcriptomic analyses in identifying patient subgroups that may benefit from corticosteroid therapy, suggesting a move toward personalized medicine in sepsis management. Despite potential benefits, the use of corticosteroids in sepsis requires careful consideration of individual patient risk profiles, and further research is needed to optimize their use and integrate genomic insights into clinical practice. This review underscores the complexity of sepsis treatment and the ongoing need for evidence-based approaches to improve patient outcomes.

Individual lifetime benefit from low-dose colchicine in patients with chronic coronary artery disease.

Low-dose colchicine reduces cardiovascular risk in patients with coronary artery disease (CAD), but absolute benefits may vary between individuals. This study aimed to assess the range of individual absolute benefits from low-dose colchicine according to patient risk profile. The European Society of Cardiology (ESC) guideline-recommended SMART-REACH model was combined with the relative treatment effect of low-dose colchicine and applied to patients with CAD from the Low-Dose Colchicine 2 (LoDoCo2) trial and the Utrecht Cardiovascular Cohort-Second Manifestations of ARTerial disease (UCC-SMART) study (n = 10 830). Individual treatment benefits were expressed as 10-year absolute risk reductions (ARRs) for myocardial infarction, stroke, or cardiovascular death (MACE), and MACE-free life-years gained. Predictions were also performed for MACE plus coronary revascularization (MACE+), using a new lifetime model derived in the REduction of Atherothrombosis for Continued Health (REACH) registry. Colchicine was compared with other ESC guideline-recommended intensified (Step 2) prevention strategies, i.e. LDL cholesterol (LDL-c) reduction to 1.4 mmol/L and systolic blood pressure (SBP) reduction to 130 mmHg. The generalizability to other populations was assessed in patients with CAD from REACH North America and Western Europe (n = 25 812). The median 10-year ARR from low-dose colchicine was 4.6% [interquartile range (IQR) 3.6-6.0%] for MACE and 8.6% (IQR 7.6-9.8%) for MACE+. Lifetime benefit was 2.0 (IQR 1.6-2.5) MACE-free years, and 3.4 (IQR 2.6-4.2) MACE+-free life-years gained. For LDL-c and SBP reduction, respectively, the median 10-year ARR for MACE was 3.0% (IQR 1.5-5.1%) and 1.7% (IQR 0.0-5.7%), and the lifetime benefit was 1.2 (IQR 0.6-2.1) and 0.7 (IQR 0.0-2.3) MACE-free life-years gained. Similar results were obtained for MACE+ and in American and European patients from REACH. The absolute benefits of low-dose colchicine vary between individual patients with chronic CAD. They may be expected to be of at least similar magnitude to those of intensified LDL-c and SBP reduction in a majority of patients already on conventional lipid-lowering and blood pressure-lowering therapy.

Influence of staple line reinforcement on the occurrence of bleeding complications following laparoscopic sleeve gastrectomy: a retrospective analysis.

Laparoscopic sleeve gastrectomy (LSG) has gained prominence as a therapeutic option for obesity and metabolic diseases. The choice of staple line reinforcement technique in LSG remains a subject of debate, particularly concerning postoperative bleeding complications. The aim of this retrospective analysis is to assess the influence of different staple line reinforcement techniques on the occurrence of bleeding complications LSG. We conducted a retrospective analysis of patients undergoing LSG between September 2021 and April 2023 at our institution. Patients were stratified into two groups based on the staple line reinforcement method: continuous suturing (n = 53) and clipping (n = 28). Surgical outcomes, including operative time, length of hospital stay, and bleeding complications, were assessed. Complications were classified using the Clavien-Dindo classification. Continuous suturing was associated with a significantly longer operative time (88.15 min vs. 74.64 min, p < 0.05) but a similar length of hospital stay. Notably, no bleeding complications occurred in the continuous suturing group, while the clipping group experienced postoperative bleeding in 7.14% of cases (p < 0.05). Continuous suturing exhibited a slightly higher incidence of minor complications classified as Class I in the Clavien-Dindo classification (7.55% vs. 0%). This retrospective analysis suggests that continuous suturing may provide enhanced hemostasis along the staple line, reducing the risk of postoperative bleeding compared to clipping. Despite the longer operative time and a slightly higher rate of minor complications, the clinical significance of these findings should be considered within the context of individual patient risk profiles.

30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic

Aims Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. Methods This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. Results Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade &gt; 3 and/or age &gt; 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. Conclusion Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus. Cite this article: Bone Joint Open 2020;1-7:392–397.

30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic: a multicentre regional analysis of 484 patients.

AimsNow that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.MethodsThis multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019.ResultsOverall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period.ConclusionOverall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus.Cite this article: Bone Joint Open 2020;1-7:392–397.

Perioperative blood pressure management : What is the optimal pressure?

Measurement of blood pressure is part of standard monitoring procedures in anesthesia, in addition to the other vital parameters of heart frequency and peripheral oxygen saturation. In recent years the relevance of the duration and extent of perioperative episodes of hypotension for the occurrence of postoperative complications or even increased mortality have become the focus of scientific investigations. The aim of this review is to briefly recapitulate the physiological aspects of blood pressure and to describe the pathophysiology and risk factors of perioperative hypotension. It describes which potential organ damage can be caused by hypotension and discusses which perioperative blood pressure values are acceptable without harming the patient. Review and analysis of the currently available literature. Perioperative hypotension is defined by either absolute systolic arterial pressure (SAP) or mean arterial pressure (MAP) thresholds and by relative blood pressure declines from an individual preoperative baseline value. For the definition of absolute and relative thresholds it needs to be considered that the ultimate target is an adequate perfusion pressure (and not the MAP) and that the preinduction blood pressure is a poor reflection of the patients' normal blood pressure profile. Risk factors for an intraoperative drop in blood pressure are advanced age, higher American Society of Anesthesiologists (ASA) status, low blood pressure prior to induction of anesthesia, the premedication, e.g. angiotensin-converting enzyme (ACE) inhibitors, the anesthesia technique (combination of general and epidural anesthesia) and emergency surgery. The lowest tolerable intraoperative blood pressure should be defined according to the individual patient's preoperative blood pressure and risk profile. Individual thresholds should be determined for the severity and duration of intraoperative hypotension. Empirically, MAP values <65 mm Hg and relative pressure declines of >20-30% are often recommended as thresholds. Below critical blood pressure values the risk of postoperative organ damage (myocardium, kidneys and central nervous system) and mortality increases with longer duration of hypotension. Older people and high-risk patients (e.g. patients in vascular surgery) have a poorer and shorter tolerance of low blood pressure. Postoperative organ complications can be minimized by maintenance of an adequate intraoperative blood pressure CONCLUSION: Anesthesiologists should avoid extensive and prolonged hypotension by timely interventions in order to improve the postoperative outcome of patients.

Phase of Care Mortality Analysis According to Individual Patient Risk Profile

Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk (<4%), intermediate (4% to 8%), and high risk (>8%). A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

Total Hip and Knee Arthroplasty Perioperative Pain Management: What Should Be in the Cocktail.

* There are multiple available agents and modalities for controlling pain perioperatively during total joint arthroplasty to improve the patient experience, and their unique mechanisms and applications should be considered for use preoperatively, intraoperatively, and postoperatively, keeping in mind that each has differing efficacy and side-effect profiles.* Preoperative pain control or preemptive analgesia using anti-inflammatory drugs and opioid analgesics appears to be effective in reducing postoperative pain, although the recommended timing and type of agents are unclear.* With regard to intraoperative anesthetic choice and pain control, spinal anesthesia appears to have fewer systemic risks than general anesthesia, and periarticular injections of local anesthetic agents, regardless of technique, and with or without the addition of sympathetic modulators, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, have been shown to improve pain scores postoperatively and to overall carry a low risk profile.* When considering postoperative pain control, there are several modalities including cryotherapy, peripheral nerve blockade, and parenteral and enteral medication options including acetaminophen, cyclooxygenase inhibitors, neuromodulators, tramadol, ketamine, and opioid patches, but there is no clearly preferred medication regimen and individual patient risk profiles must be considered when choosing appropriate pain management agents.* Multimodal pain management can decrease opioid usage, improve pain scores, increase patient satisfaction, and enhance early recovery. The ideal preoperative, intraoperative, and postoperative pain medication regimen remains unclear, and an individualized approach to perioperative pain management is recommended. Despite this, good results are demonstrated with the existing variations in pain management protocols in the literature.* Treatment of severe postoperative pain in a multimodal fashion carries the risk for serious side effects, including respiratory depression, mental status changes influencing safe gait mechanics, hypotension, renal and hepatic dysfunction, hematologic variations, gastrointestinal considerations including gastric ulcers, constipation or ileus, nausea or vomiting, infection at injection sites, and peripheral nerve injury with peripheral blockade.

Dual therapy in a patient with atrial fibrillation at high risk of bleeding

In patients with atrial fibrillation (AF) undergoing coronary angioplasty (PCI) the guidelines recommend the use of triple therapy (oral anticoagulant therapy in addition to dual antiplatelet therapy) for varying periods depending on the individual patient's risk profile, limiting the possibility of starting immediately with dual antithrombotic therapy to patients with relevant haemorrhagic risk. Triple therapy is associated with a high frequency of major bleeding; in recent years there have been several studies investigating new therapeutic strategies attempting to reduce the risk of bleeding without increasing the thrombotic risk. We report the case of an elderly patient suffering from hypertension, a previous acute coronary syndrome with anterior descending stenting and permanent AF treated with dabigatran 110 mg bid for 2 years. The patient is admitted to hospital for syncope with facio-brachio-crural hemiparesis associated with myocardial infarction; she is treated with idarucizumab and coronary angiography shows trivessel disease with acute occlusion of the right proximal coronary arteru. This case is an example of how in a patient with AF, in which the risk of bleeding increases 4-fold, the adoption of the dual therapy rather than the triple therapy immediately after the acute event (according to data from the RE-DUAL PCI) or after 1 month (according to the guidelines), can prove effective over the long term, ensuring adequate protection both from hemorrhagic events and from the risk of stent thrombosis (Cardiology).

Neoadjuvant Chemotherapy, Concurrent Chemoradiation, and Adjuvant Chemotherapy for High-Risk Extremity Soft Tissue Sarcoma.

Standard treatment of large intermediate- and high-grade extremity soft tissue sarcoma (ESTS) typically includes wide excision and radiation therapy. Many patients do well with this approach, but for those with unfavorable features, risk for distant recurrence and, ultimately, mortality can exceed 50%. Unfortunately, universally accepted data elucidating effective treatments to prevent recurrences and improve survival for such high-risk patients are lacking. Accordingly, opinions about the appropriate role of systemic therapy for patients with high-risk localized ESTS vary. This article reviews the current literature pertaining to neoadjuvant chemotherapy, concurrent chemoradiation, and adjuvant chemotherapy for high-risk ESTS. All of these approaches are feasible and reasonable to consider. Ultimately, the decision to incorporate chemotherapy into the treatment regimen is best reached by discussion among an experienced multidisciplinary sarcoma team and should be tailored to the individual patient risk profile.

PDB43 - COST EFFECTIVENESS OF DAPAGLIFLOZIN/METFORMIN VERSUS GLIBENCLAMIDE/METFORMIN FOR THE TREATMENT OF TYPE 2 DIABETES IN CHILE

To assess the cost-effectiveness of dapagliflozin in combination with metformin versus glibenclamide in combination with metformin for the treatment of patients with type 2 diabetes, from the perspective of the Chilean public healthcare system A discrete event simulation model was built to estimate the lifetime expected costs and health benefits measured as quality adjusted life years (QALYs). Individual patient risk profile based on the Chile 2010 national health survey were used. Time to event for disease complications and death was estimated using the published equations from the UKPDS Outcomes Model 2 study. Efficacy was obtained from a network meta-analyses and costs were estimated from local sources. Utilities were obtained from the literature. A time horizon of 50 years and a 3% discount rate was considered for costs and outcomes. Probabilistic sensitivity analyses was performed The ICER of dapagliflozin/metformin compared to glibenclamide/metformin was US$ 20.811/QALY at a price of US$38 per month (pm); US$13.887/QALY at a price of US$29 pm and US$6.963/QALY at a price of US$19 pm. The probability of cost effectiveness of dapagliflozin/metformin at a pm price of US$38 was 42% and increases to 95% when the pm price is reduced to US$19 dapagliflozin/metformin can be considered cost-effective at a particular price range. These results provide decision makers useful information about the value of incorporating these drugs into the public Chilean healthcare system

Anticipation of complications after laparoscopic cholecystectomy: prediction of individual outcome

Complication rates after a laparoscopic cholecystectomy are still up to 10%. Knowledge of individual patient risk profiles could help to reduce morbidity. The aim of this study is to create risk profiles for specific complications to anticipate on individual outcome. Individual patient outcome for a specific post-operative complication was assessed from a retrospective database of two major teaching hospitals, using uni- and multivariable analyses. A total of 4359 patients were included of which 346 developed one or more complications (8%). Five risk profiles were found to predict specific complications: older patients (>65year) are at risk for pneumonia (OR 7.0, 95% CI 3.3-15.0, p<0.001) and bleeding (OR 2.2, 95% CI 1.2-3.9, p=0.014), patients with acute cholecystitis are at risk for intra-abdominal abscess (OR 5.9, 95% CI 3.4-10.1, p<0.001), bile leakage (OR 3.6, 95% CI 2.0-6.6, p<0.001) and pneumonia (OR 3.5, 95% CI 1.6-7.6, p<0.002), previous history of cholecystitis is predictive for wound infection (OR 5.1, 95% CI, (2.7-9.7), p<0.001), intra-abdominal abscess (OR 6.1, 95% CI 2.8-13.8, p<0.001), post-operative bleeding (OR 4.8, 95% CI 2.1-11.1, p<0.001), bile leakage (OR 7.2, 95% CI 3.4-15.4, p<0.001) and pneumonia (OR 3.9, 95% CI 1.3-11.9, p=0.018), pre-operative ERCP is predictive for intra-abdominal abscess (OR 3.3, 95% CI 2.0-5.7, p<0.001), post-operative bleeding (OR 2.1, 95% CI 1.2-3.9, p=0.058) and pneumonia (OR 3.8, 95% CI 1.9-7.8, p=0.001), and converted patients are at risk for wound infection (OR 4.0, 95% CI 2.1-7.7, p<0.001) and intra-abdominal abscess (OR 3.5, 95% CI 1.6-7.7, p=0.002). Individual risk prediction of outcome after laparoscopic cholecystectomy is feasible. This facilitates individual pre-operative doctor-patient communication and may tailor surgical strategies.

Serum 25-Hydroxyvitamin D Levels: Variability, Knowledge Gaps, and the Concept of a Desirable Range.

Hypovitaminosis D is prevalent worldwide but proportions vary widely between regions, depending on genetic and lifestyle factors, the threshold to define deficiency, and accuracy of 25-hydroxyvitamin D (25OHD) assays used. Latitude, pollution, concealing clothing, sun exposure, gender, dietary habits, and lack of government regulation account for up to 50% in variations in serum 25OHD levels, whereas genetic polymorphisms in the vitamin D pathway account for less than 5%. Organizations/societies have developed guidelines for recommended desirable 25OHD levels and vitamin D doses to reach them, but their applicability across age groups and populations are still debated. This article and the accompanying online Supporting Information highlight sources of variations in circulating 25OHD levels, uncertainties and knowledge gaps, and analytical problems facing 25OHD assays, while keeping efficacy and safety data as the dominant factors when defining a desirable range for 25OHD levels. We propose a desirable range of 20 to 40 ng/mL (50 to 100 nmol/L), provided precise and accurate assays are used. Although slightly lower levels, 15 to 20 ng/mL, may be sufficient for some infants and adults, higher levels, 40 to 60 ng/mL, may still be safe. This desirable range allows physicians to tailor treatment while taking season, lifestyle, vitamin D intake, and other sources of variation into account. We reserve 25OHD measurements for at-risk patients, defined by disease or lifestyle, and the use of 25OHD assays calibrated against the recommended international standards. Most target groups reach desirable target levels by a daily intake of 400 to 600 IU for children and 800 IU for adults. A total daily allowance of vitamin D of up to 1000 IU in the pediatric age groups, and up to 2000 IU in adults, tailored to an individual patient risk profile, is probably safe over long durations. Additional data are needed to validate the proposed range and vitamin D doses, especially in children, pregnant women, and non-white populations.

Monitoring von Tumortherapien

BackgroundUp to 30 years ago tumor metastases were considered to be fatal for most tumor entities. Since then the development of novel forms of systemic treatment, interventional methods and surgical techniques has led to a significant advance in oncological treatment methods.ObjectiveThis article summarizes the current evidence regarding indications, surgical techniques and survival after resection of hepatic and pulmonary metastases.Material and methodsA selective literature search and summary of the latest data on hepatic and pulmonary metastatic resection were performed.ResultsThe current goal of treatment of metastatic disease is to convert a limited systemic tumor burden into a potentially curable disease. In 20–40 % of cases hepatic or pulmonary metastases can be resected or treated by interventional methods. Depending on the primary tumor and the individual patient risk profile, 5-year survival rates of up to 50 % can be achieved after R0 resection.ConclusionIn the last 30 years significant advances have been achieved in the field of resection of hepatic and pulmonary metastases. Together with new systemic and interventional therapies, further promising developments are expected in the future.

Novel risk factors for acute kidney injury.

Acute kidney injury (AKI) is a serious problem. Understanding an individual patient's risk profile may offer opportunities for prevention or early intervention. The aim of this review is to describe novel nontraditional risk factors. The risk of AKI is determined by patient factors and nephrotoxic exposures. Hyperuricaemia, obesity, hypoalbuminaemia and certain genetic polymorphism have been found to be associated with an increased susceptibility to AKI, especially in surgical patients. However, there is no convincing evidence that albumin replacement or uric acid lowering ameliorates the risk. Genetic predisposition contributes to AKI in general and also drug-nephrotoxicity. The exact relationship between obesity and AKI has not been fully understood.Patients exposed to starches, chloride-rich fluids or mechanical ventilation have an increased risk of AKI. Starches in particular should be avoided in high-risk patients. Although chloride-rich fluids are associated with AKI based on observational studies, direct proof of harm is lacking. Novel risk factors for AKI have been identified but more work is necessary to investigate the nature of the association. There is no evidence that correction of hyperuricaemia or hypoalbuminaemia is beneficial but high-risk exposures should be avoided in patients at risk of AKI.

Diagnosis and treatment of mantle cell lymphoma

Mantle cell lymphoma (MCL) is a relatively rare lymphoma entity accounting for an estimated 3%-6% of all non-Hodgkin's lymphoma cases. Characterised by both the incurability of indolent lymphomas and the rapid growth of aggressive lymphomas, MCL has a median overall survival of only 4-5 years. Although the disease often shows an encouraging response to first-line treatment, its clinical course is usually marked by recurrent relapses, resulting in a dismal long-term outcome. The choice of therapy for managing the disease is a complex problem that still requires evidence-based guidance. Owing to the rarity of MCL, the bulk of data comes from phase II trials in small numbers of patients. Nevertheless, therapeutic strategies for MCL have evolved in an effort to adapt treatment according to the individual patient's risk profile, and the overall survival has nearly doubled in the last 30 years. The use of effective immunochemotherapy regimens in first-line therapy, advances in stem cell transplantation, and the development of more active salvage therapy regimens have improved the outcome. This review will summarise the key factors that drive clinical practice with respect to the management of MCL.

2960 – Importance of physical health in the long-term management of bipolar I disorders

Bipolar I disorder is associated with a number of physical health concerns and a higher prevalence of eating, anxiety, and substance abuse disorders compared with the general population. In addition, patients are prone to exhibit risk factors for cardiovascular disease such as obesity, hypertension, hyperglycaemia, dyslipidaemia, and type 2 diabetes. 1 Moreover, pharmacotherapy has been linked to metabolic abnormalities that may exacerbate the physical health risk factors and comorbidities prevalent in patients with bipolar disorder. Choosing an initial treatment regimen that takes into account the significant physical health risks associated with bipolar disorder may minimise the subsequent common problem of polypharmacy and may reduce the side-effect burden associated with the disease. Regular monitoring of physical health in the months after initiating pharmacotherapy is essential in preventing and correctly managing comorbidities. Clinicians should gain a comprehensive insight into patient lifestyle choices and should, as part of preventative care, choose treatments according to individual patient risk profiles. If required, clinicians should make recommendations to specialists or facilities offering therapies to minimise key risk factors. 2 This presentation will review the physical health risks associated with bipolar disorder and with chronic exposure to pharmacotherapy. Because practice guidelines recommend regular physical health monitoring in patients with bipolar disorder, this presentation will discuss approaches to incorporate regular monitoring in routine clinical practice.

Medikamentöse Therapie des benignen Prostatasyndroms

Male lower urinary tract symptoms (LUTS) include storage and voiding disorders and should be carefully evaluated before the start of any treatment. Medical therapy is directed at improving symptoms and reducing the risk of progression in order to improve quality of life and prevent complications, such as acute urinary retention, or the need for surgical intervention. Careful assessment of the individual complaints helps to identify the best drug which should be adapted to each individual patient's risk profile. At present, α(1)-adrenoreceptor inhibitors and 5-alpha reductase inhibitors and their combination form the gold standard for pharmacological treatment. In addition, anticholinergic agents are increasingly being used as monotherapy or in combination with α1-adrenocepetor inhibitors for patients with predominant storage disorders while phosphodiesterase 5 (PDE5) inhibitors may be suitable for patients suffering from LUTS and concomitant erectile dysfunction.