Optimierung der Pharmakotherapie schizophrener Patienten durch objektive Symptomerfassung und Therapeutisches Drug Monitoring

Der Erfolg einer Schizophrenie-Behandlung ist zum größten Teil abhängig vom Ansprechen des Patienten auf seine antipsychotische Medikation. Welches Medikament und welche Dosis bei einem individuellen Patienten wirksam sind, kann derzeit erst nach mehrwöchiger Behandlung beurteilt werden. Ein Grund für variierendes Therapieansprechen sind variable Plasmakonzentrationen der Antipsychotika. Ziel dieser Arbeit war es, zu untersuchen, in wieweit der Therapieerfolg zu einem frühen Zeitpunkt der Behandlung durch objektive Symptomerfassung vorhersagbar ist und welche Faktoren die hohe Variabilität der Antipsychotikaspiegel im Blut beeinflussen. rnEine 18-monatige naturalistische klinische Studie an schizophrenen Patienten wurde durchgeführt, um folgende Fragen zu beantworten: Kann man das Therapieansprechen prädizieren und welche Instrumente sind dafür geeignet? Die Psychopathologie wurde anhand zweier Messskalen (Brief Psychiatric Rating Scale, BPRS und Clinical Global Impressions, CGI) wöchentlich ermittelt, um die Besserung der Krankheitssymptome im Verlauf von 8 Wochen zu bewerten. Therapiebegleitend wurden noch die Serum-Konzentrationen der Antipsychotika gemessen. Objektive Symptomerfassung durch BPRS oder CGI waren als Messinstrumente geeignet, Therapieansprechen vorherzusagen. Bezogen auf den Behandlungsbeginn war eine Verminderung der Symptome hoch prädiktiv für späteres Therapieversagen oder -ansprechen. Eine Verminderung um mehr als 36,5% auf der BPRS Skala in Woche 2 wurde als signifikanter Schwellenwert für Nichtansprechen ermittelt. Patienten, deren Symptombesserung unterhalb des Schwellenwertes lag, hatten eine 11,2-fach höhere Wahrscheinlichkeit, am Ende der Studie nicht auf ihre medikamentöse Therapie anzusprechen als die Patienten, die sich um mindestens 36,5% verbesserten. Andere Faktoren, wie Alter, Geschlecht, Dauer der Erkrankung oder Anzahl der stationären Aufenthalte hatten keinen Einfluss auf die Prädiktion des Therapieansprechens. Therapeutische Antipsychotika-Spiegel übten einen positiven Einfluss auf die Ansprechrate aus. Bei Patienten mit therapeutischen Spiegeln war das Ansprechen rascher und die Ansprechrate größer als unter denjenigen deren Spiegel außerhalb der therapeutisch üblichen Bereiche lag. rnEine wichtige Voraussetzung für den Einsatz von TDM ist das Vorhandensein einer präzisen, reproduzierbaren, zeit- und kostensparenden analytischen Methode zur quantitativen Bestimmung der untersuchten Substanzen. Die Entwicklung und Validierung einer solchen geeigneten Methode wurde für den Nachweis von Haloperidol vorgenommen. Eine HPLC-Methode mit Säulenschaltung erwies sich für TDM geeignet. rnBasierend auf den Ergebnissen der eigenen klinischen Studie zur Response Prädiktion wurde untersucht, welche Faktoren die Variabilität der Pharmakokinetik von Antipsychotika beeinflussen. Die Variabilität der Pharmakokinetik ist ein Grund für fehlendes oder unzureichendes Ansprechen. Es wurde zum einen der Einfluss der galenischen Formulierung auf die Freisetzung und zum anderen der Einfluss von entzündlichen Prozessen auf die Metabolisierung eines Antipsychotikums untersucht. Dazu wurden Patientendaten retrospektiv ausgewertet.rnDie Analyse von 247 Serumspiegeln von Patienten, die mit Paliperidon in OROS®Formulierung, einer neu eingeführten Retardform, behandelt wurden, zeigte, dass die intraindividuelle Variabilität der Talspiegel (Vk) von Paliperidon 35% betrug. Er war damit vergleichbar wie für nicht retardiertes Risperidon 32% (p=n.s.). Die Retardierung hatte demnach keinen Varianz mindernden Effekt auf die Talspiegel des Antipsychotikums. Der Wirkstoff-Konzentrations-Bereich lag bei 21-55 ng/ml und entsprach ebenfalls nahezu dem therapeutischen Bereich von Risperidon (20-60 ng/ml). rnEntzündliche Prozesse können die Metabolisierung von Medikamenten verändern. Dies wurde bisher für Medikamente nachgewiesen, die über CYP1A2 abgebaut werden. Durch die eigene Analyse von 84 Patienten-Serumspiegeln konnte festgestellt werden, dass die Metabolisierung von Quetiapin während eines entzündlichen Prozesses beeinträchtigt war, wahrscheinlich durch Hemmung von CYP3A4. Dies sprach dafür, dass auch Wirkstoffe, die über CYP3A4 abgebaut werden, während eines entzündlichen Prozesses im Körper in ihrer Pharmakokinetik beeinträchtigt sein können. Aus diesem Grund sollte während einer Infektion unter der Therapie mit Quetiapin besonders auf die Nebenwirkungen geachtet werden und der Serumspiegel sollte in dieser Zeit überwacht werden, um den Patienten vor eventuellen Nebenwirkungen oder sogar Intoxikationen zu schützen. rnDie Befunde dieser Arbeit zeigen, dass bei einer Behandlung schizophrener Patienten mit Antipsychotika die Messung der Psychopathologie zur Vorhersage des Therapieansprechens und die Messung der Blutspiegel zur Identifizierung von Faktoren, die die pharmakokinetische Variabilität bedingen, geeignet sind. Objektive Symptomerfassung und Therapeutisches Drug Monitoring sind demnach Instrumente, die für die Steuerung der antipsychotischen Pharmakotherapie genutzt werden sollten.rn

Pharmakovigilanz bei Patienten mit Phenprocoumon-Therapie : Untersuchungen zu potentiellen Interaktionen und Betreuungsqualität

Zur Verbesserung der Sicherheit und Effektivität der Phenprocoumon-Therapie wurden drei unterschiedliche Untersuchungen durchgeführt.rnZunächst wurde auf Grundlage bekannter Datenbanken und Informationsquellen zu Arznei-mittelinteraktionen (Drugdex, Abda Datenbank, Marcumar® Fachinformation, Coumarin-Interaktionsliste der Federatie van Nederlandse Trombosediensten, Review zu Warfarin-Interaktionen) eine handlungsorientierte Interaktionsdatenbank für Phenprocoumon erstellt. Dazu wurden in einer Übersichtstabelle relevante Informationen zu potentiellen Interaktionen für insgesamt 375 Arzneimittel zusammengestellt. Diese Tabelle wurde durch ein dreiköpfiges Expertenteam begutachtet und die potentiellen Interaktionspartner fünf verschiedenen Schweregraden und Stufen klinischer Relevanz zugeordnet. Für fast 50% der potentiellen Interaktionspartner wurden Handlungen als nicht erforderlich erachtet. Für die restlichen potentiellen Interaktionspartner wurden Handlungen zum klinischen Management der Interaktion in Abhängigkeit vom zeitlichen Zusammenhang mit der Phenprocoumon-Einnahme festgelegt. rnAnschließend wurde in einer Anwendungsbeobachtung der Zusammenhang zwischen der zusätzlichen Einnahme potentiell interagierender Arzneimittel (in der entwickelten Datenbank eingestuft mit dem Schweregrad „hoch“ und „sehr hoch“) und der Häufigkeit von Änderungen der Phenprocoumon-Wochendosis an 116 Patienten untersucht. Das relative Risiko für eine Dosisanpassung war bei Patienten in der Interaktions-Gruppe (n=23) signifikant erhöht (RR=1,9; p<0,001). Als weitere potentielle Einflussfaktoren stellten sich zunehmendes Alter (Alter 80-85 Jahre: RR=2; p<0,05), vielfache Komorbiditäten (4 Komorbiditäten: RR=2,1; p<0,05) und eingeschränkte Nieren- (RR=1,47; p>0,05) und Leberfunktion (RR=1,3; p>0,05) heraus.rnZur Untersuchung der Betreuungsqualität von VKA-Patienten im Thrombosedienst Mainz wurden retrospektiv die Daten von 118 Patienten ausgewertet. Als Qualitätsparameter wurden die prozentuale Häufigkeit von INR-Werten im Zielbereich, die TTR (Time in Therapeutic Range), die Dauer der NMH-Therapie, die Zeit bis zum Erreichen des Zielbereichs und der durchschnittliche Abstand zwischen zwei Kontrollterminen ermittelt. Im Median lag jeder Patient mit 73% der gemessenen INR-Werte und im individuellen Zielbereich. Die TTR betrug im Median 80%. Die Patienten benötigten 7 Tage zum Erreichen des Zielbereiches. Die NMH-Therapie wurde über 8 Tage durchgeführt. Die Patienten kamen im Median alle 11 Tage zu einem Kontrolltermin. Im Benchmark zu international publizierten Qualitätskenn-zahlen zur VKA-Therapie ist die Betreuungsqualität im Thrombosedienst Mainz als sehr gut einzustufen.rn

Cambiamenti epidemiologici dell'epatocarcinoma agli inizi del xxi secolo: Dal ruolo emergente delle malattie dismetaboliche quali fattori eziopatogemetici alla necessita' di revisione del sistema di stadiaziome

Introduzione e scopo: la rapida diffusione delle malattie dismetaboliche sta modificando l’epidemiologia dell’epatocarcinoma (HCC). Scopo della tesi è, attraverso quattro studi, analizzare l’impatto di questi cambiamenti nella gestione clinica del paziente affetto da HCC. Materiali e metodi: quattro studi di coorte, condotti con analisi retrospettiva del database ITA.LI.CA. Studio 1:3658 pazienti arruolati tra il 01-01-2001 ed il 31-12-2012 suddivisi in base alla data di diagnosi:2001-2004 (954 pazienti), 2005-2008 (1122 pazienti), 2009-2012 (1582 pazienti). Studio 2:analisi comparativa tra 756 pazienti con HCC-NAFLD e 611 pazienti con HCC-HCV. Studio 3:proposta di quattro modelli alternativi al BCLC originale con validazione di una proposta di sottostadiazione dell’intermedio, considerando 2606 pazienti arruolati tra il 01-01-2000 e il 31-12-2012 e riallocati secondo gradi diversi di perfomance status (PS). Studio 4:analisi di 696 pazienti con HCC in stadio intermedio diagnosticato dopo il 1999 stratificati per trattamento. Risultati: studio 1:progressivo aumento dell’età alla diagnosi e delle eziologie dismetaboliche; più frequente esordio dell’HCC in stadio precoce e con funzione epatica più conservata; aumento della sopravvivenza dopo il 2008. Studio 2:i pazienti con HCC-NAFLD mostrano più frequentemente un tumore infiltrativo diagnosticato fuori dai programmi di sorveglianza, con prognosi peggiore rispetto ai pazienti HCC-HCV. Questa differenza di sopravvivenza si elimina rimuovendo i fattori di confondimento attraverso propensity analysis. Studio 3:il PS1 non è un predittore indipendente di sopravvivenza. Il modello 4 (considerando PS1=PS0 e con la sottostadiazione proposta), ha la migliore capacità discriminativa. Studio 4:i trattamenti curativi riducono la mortalità più della TACE, anche dopo propensity analysis. Conclusioni: l’aumento delle patologie dismetaboliche comporterà diagnosi di malattia ad uno stadio più avanzato, quando sintomatica, rendendo necessario stabilire un programma di sorveglianza. Inoltre per una migliore stratificazione e gestione dei pazienti, bisogna riconsiderare il ruolo del PS ed offrire un ventaglio di opzioni terapeutiche anche per il pazienti in stadio intermedio.

Aesthetic outcome and oncological safety of nipple-areola complex replantation after mastectomy and immediate breast reconstruction

Immediate breast reconstruction (IBR) has become an established procedure for women necessitating mastectomy. Traditionally, the nipple-areola complex (NAC) is resected during this procedure. The NAC, in turn, is a principal factor determining aesthetic outcome after breast reconstruction, and due to its particular texture and shape, a natural-looking NAC can barely be reconstructed with other tissues. The aim of this study was to assess the oncological safety as well as morbidity and aesthetic outcome after replantation of the NAC some days after IBR. Retrospective analysis of 85 patients receiving 88 mastectomies and IBR between 1998 and 2007 was conducted. NAC (n=29) or the nipple alone (n=23) were replanted 7 days (median, range 2-10 days) after IBR in 49 patients, provided the subareolar tissue was histologically negative for tumour infiltration. Local recurrence rate was assessed after 49 months (median, range 6-120 months). Aesthetic outcome was evaluated by clinical assessment during routine follow-up at least 12 months after the last intervention. Malignant involvement of the subareolar tissue was found in eight cases (9.1%). Patients qualifying for NAC replantation were in stage 0 in 29%, stage I in 15%, stage IIa in 31%, stage IIb in 17% and stage III in 8%. Total or partial necrosis occurred in 69% and 26% if the entire NAC or only the nipple were replanted, respectively (P<0.01). Depigmentation was seen in 52% and corrective surgery was done in 11 out of 52 NAC or nipple replantations. Local recurrence and isolated regional lymph node metastasis were observed in one single case each. Another 5.8% of the patients showed distant metastases. We conclude that the replantation of the NAC in IBR is oncologically safe, provided the subareolar tissue is free of tumour. However, the long-term aesthetic outcome of NAC replantation is not satisfying, which advocates replanting the nipple alone.

Renal insufficiency is independently associated with a distal distribution pattern of symptomatic lower-limb atherosclerosis

Objectives The purpose of this study was to assess the impact of renal insufficiency (RI) on the distribution pattern of peripheral arterial disease (PAD). We hypothesised that RI is associated with a distally accentuated involvement of the peripheral arterial tree. Design This is a retrospective analysis. Materials and Methods Analysis was based on a consecutive series of 2709 patients with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower-extremity arteries. Atherosclerotic pattern was grouped into femoropopliteal (n = 2085) and infragenicular (n = 892) disease according to target lesions treated while using iliac disease (n = 1133) as reference. Univariable and multivariable multinomial regression analyses were performed to assess relation with RI. Results are shown as relative risk ratio (RRRs) with 95% confidence intervals (95% CIs). A p < 0.05 was considered statistically significant. RI was defined as glomerular filtration rate (GFR) < 60 ml min−1 1.73 m−2. Results Presence of RI was an independent risk factor for a centrifugal lesion pattern (RRR 1.48, 95% CI: 1.17–1.86, p = 0.001). Moreover, a decrease in GFR by 10 ml min−1 1.73 m−2 was associated with an RRR of 1.08 for below-the-knee arterial disease (95% CI: 1.03–1.13, p = 0.003). Conclusion Presence and severity of RI are independent predictors of a distal obstructive pattern in patients with symptomatic PAD.

Endovascular treatment of popliteal artery aneurysms: a single-center experience

PURPOSE: To evaluate the use of covered stent-grafts in the endovascular treatment (ET) of popliteal artery aneurysms (PAAs). MATERIALS AND METHODS: A retrospective analysis was conducted over a period of 52 months in 18 consecutive patients (17 men; mean age +/- SD, 70 years +/- 11) undergoing ET of PAAs with the Viabahn endograft in a single center. Patient symptoms, aneurysm characteristics, technical outcomes, complications, and follow-up were assessed. RESULTS: Aneurysm diameters ranged from 12 to 51 mm with a mean of 30 mm (+/-11). Thirteen aneurysms (72.2%) were partially thrombosed and 12 patients (66.6%) had symptoms of lower limb ischemia at presentation (11 chronic and one acute). The technical success rate was 94%. Intraprocedural emboli and endoleak occurred in one and two patients, respectively. Fourteen patients were available for follow-up after successful treatment, with a mean follow-up time of 15 months (range, 7-37 months). All stent-grafts were patent after 1 month, with no mortality or limb loss. The primary patency rate with complete exclusion of the aneurysm at 6 months was 86%. Pre- and postprocedural noninvasive arterial studies were available in 10 patients, demonstrating improvement of the ankle-brachial index from 0.96 +/- 0.41 to 1.17 +/- 0.18, respectively (P = .06). CONCLUSIONS: Endovascular stent-graft repair of PAAs is a feasible treatment option. However, further follow-up studies regarding the durability of results are required.

Combined meropenem and linezolid as a systemic treatment for postoperative endophthalmitis

PURPOSE The aim of this study was to evaluate the antibiotic treatment of postoperative endophthalmitis with combined systemic meropenem and linezolid. METHODS A retrospective analysis of endophthalmitis treated with systemic meropenem and linezolid compared to conventional systemic antibiotics by evaluation of outcome and adverse effects was carried out. RESULTS 26 patients with unilateral postoperative endophthalmitis with a systemic combination regimen of meropenem (2 g TID, mean duration of treatment 5.5 days) and linezolid (600 mg BID, mean duration of treatment 8.9 days) (group 1, mean follow-up time 140 days) were included in this study and compared to 45 postoperative endophthalmitis patients treated with conventional systemic antibiotics (group 2; mean follow-up time 320 days). In group 1, 69.2 % of eyes additionally received intravitreal amikacin and vancomycin (vs. 24.4 % in group 2; p < 0.001), in 92.3 % pars plana vitrectomy was performed (vs. 68.9 % in group 2, p = 0.047). Mean best corrected visual acuity improved from a baseline of 1.76 logMar for group 1 and 1.83 logMar for group 2 to 0.91 logMar (p = 0.0001) and 0.90 logMar (p < 0.0001), respectively, at the end of the follow-up, revealing no significant differences between the two groups at any time point (p > 0.05). Ocular complications were observed in 34.6 % of eyes in group 1 (vs. 37.8 % in group 2; p > 0.05). Adverse drug effects occurred significantly more frequently in group 1 (26.9 % vs. 4.4 % p = 0.02). CONCLUSION In spite of the reported better penetration through the blood-ocular barrier and the broader antibacterial spectrum of meropenem and linezolid, no benefit in outcome was found in the present study. In contrast, adverse effects and costs of the combination regimen were significantly higher.

The association between early hemodynamic variables and outcome in normothermic comatose patients following cardiac arrest

Currently, few data exist on the association between post-cardiac arrest hemodynamic function and outcome. In this explorative, retrospective analysis, the association between hemodynamic variables during the first 24 h after intensive care unit admission and functional outcome at day 28 was evaluated in 153 normothermic comatose patients following a cardiac arrest.

Proximal row carpectomy in emergency

Proximal row carpectomy (PRC) is a well-accepted procedure for the treatment of early post-traumatic degenerative disease of the wrist. Much less frequently, PRC has been advocated as an emergency procedure for irreparable fracture-dislocation of the wrist. Our objective was to compare the results of PRC in patients having undergone this procedure in the two contexts. We conducted a retrospective analysis of the clinical and radiographic results of six patients treated by emergency PRC as compared to six patients who underwent elective PRC. The mean follow-up was 36 months. Both the patient's satisfaction and the grasp of the wrist joint were significantly better in patients who underwent PRC emergency as compared to those having undergone elective PRC. Quick DASH score, radiographic results, and return to work were also more favourable in these patients, but the difference between the two groups was not significant. This study confirms that PRC is a valuable salvage technique indicated in early posttraumatic wrist collapse. Moreover, when performed in emergency, the procedure shows even better subjective and objective results, allowing a majority of patients to return to their previous job.

Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different

The purpose of this study was to analyse hysteroscopic results in patients with recurrent miscarriages and to compare the frequency of uterine anomalies in women with a history of exactly two and with more than two consecutive miscarriages. A retrospective analysis of 206 patients undergoing hysteroscopy for repeated early pregnancy losses was performed at two university centres. Late miscarriages were excluded, terminations of pregnancy were not counted. Eighty-seven patients had suffered from exactly two early miscarriages and 119 from more than two. Both groups were comparable with respect to age at admission (32.95+/-4.46 versus 34.06+/-5.02 years) and at first miscarriage (30.43+/-4.24 versus 29.08+/-5.38 years). The prevalence of acquired (adhesions, polyps, fibroids) and congenital uterine anomalies (septate or bicornuate uterus, etc.) did not differ significantly (acquired: 28.7 versus 27.7%; congenital: 9.2 versus 16.8%). The rates of uterine anomalies did not differ significantly overall (36.8 versus 42.9%). In conclusion, uterine anomalies are frequently found in patients with two and with more than two early miscarriages. Due to the high rate of anomalies, their risk for adverse pregnancy outcome and a possible therapeutic approach, hysteroscopy might be a diagnostic option even after two early miscarriages.

Prevalence and densitometric characteristics of incomplete distal renal tubular acidosis in men with recurrent calcium nephrolithiasis

The aim of this study was to assess the prevalence of incomplete distal renal tubular acidosis (idRTA) in men with recurrent calcium nephrolithiasis and its potential impact on bone mineral density. We conducted a retrospective analysis of 150 consecutive, male idiopathic recurrent calcium stone formers (RCSFs), which had originally been referred to the tertiary care stone center of the University Hospital of Berne for further metabolic evaluation. All RCSFs had been maintained on a free-choice diet while collecting two 24-h urine samples and delivered second morning urine samples after 12 h fasting. Among 12 RCSFs with a fasting urine pH >5.8, a modified 3-day ammonium chloride loading test identified idRTA in 10 patients (urine pH >5.32, idRTA group). We matched to each idRTA subject 5 control subjects from the 150 RCSFs, primary by BMI and then by age, i.e., 50 patients, without any acidification defect (non-RTA group) for comparative biochemistry and dual energy X-ray absorptiometry (DEXA) analyses. The prevalence of primary idRTA among RCSFs was 6.7% (10/150). Patients with idRTA had significantly higher 2-h fasting and 24-h urine pH (2-h urine pH: 6.6 ± 0.4 vs. 5.2 ± 0.1, p = 0.001; 24-h urine pH: 6.1 ± 0.2 vs. 5.3 ± 0.3, p = 0.001), 24-h urinary calcium excretion (7.70 ± 1.75 vs. 5.69 ± 1.73 mmol/d, p = 0.02), but significantly lower 24-h urinary urea excretion (323 ± 53 vs. 399 ± 114 mmol/d, p = 0.01), urinary citrate levels (2.32 ± 0.82 vs. 3.01 ± 0.72 mmol/d, p = 0.04) and renal phosphate threshold normalized for the glomerular filtration rate (TmPO(4)/GFR: 0.66 ± 0.17 vs. 0.82 ± 0.21, p = 0.03) compared to non-RTA patients. No significant difference in bone mineral density (BMD) was found between idRTA and non-RTA patients for the lumbar spine (LS BMD (g/cm(2)): 1.046 ± 0.245 SD vs. 1.005 ± 0.119 SD, p = 0.42) or femoral neck (FN BMD (g/cm(2)): 0.830 ± 0.135 SD vs. 0.852 ± 0.127 SD). Thus, idRTA occurs in 1 in 15 male RCSFs and should be sought in all recurrent calcium nephrolithiasis patients. Bone mineral density, however, does not appear to be significantly affected by idRTA.

How obliteration of petrosal air cells by vestibular schwannoma influences the risk of postoperative CSF fistula

For postoperative CSF-fistula prevention a better understanding of its origins and risk factors is necessary. To identify the role of the tumor growth for the risk to develop CSF-fistula we performed a retrospective analysis.

Surveillance and simulation of bovine spongiform encephalopathy and scrapie in small ruminants in Switzerland

BACKGROUND: After bovine spongiform encephalopathy (BSE) emerged in European cattle livestock in 1986 a fundamental question was whether the agent established also in the small ruminants' population. In Switzerland transmissible spongiform encephalopathies (TSEs) in small ruminants have been monitored since 1990. While in the most recent TSE cases a BSE infection could be excluded, for historical cases techniques to discriminate scrapie from BSE had not been available at the time of diagnosis and thus their status remained unclear. We herein applied state-of-the-art techniques to retrospectively classify these animals and to re-analyze the affected flocks for secondary cases. These results were the basis for models, simulating the course of TSEs over a period of 70 years. The aim was to come to a statistically based overall assessment of the TSE situation in the domestic small ruminant population in Switzerland. RESULTS: In sum 16 TSE cases were identified in small ruminants in Switzerland since 1981, of which eight were atypical and six were classical scrapie. In two animals retrospective analysis did not allow any further classification due to the lack of appropriate tissue samples. We found no evidence for an infection with the BSE agent in the cases under investigation. In none of the affected flocks, secondary cases were identified. A Bayesian prevalence calculation resulted in most likely estimates of one case of BSE, five cases of classical scrapie and 21 cases of atypical scrapie per 100'000 small ruminants. According to our models none of the TSEs is considered to cause a broader epidemic in Switzerland. In a closed population, they are rather expected to fade out in the next decades or, in case of a sporadic origin, may remain at a very low level. CONCLUSIONS: In summary, these data indicate that despite a significant epidemic of BSE in cattle, there is no evidence that BSE established in the small ruminant population in Switzerland. Classical and atypical scrapie both occur at a very low level and are not expected to escalate into an epidemic. In this situation the extent of TSE surveillance in small ruminants requires reevaluation based on cost-benefit analysis.

Acute cardiac disorder or pneumonia and concomitant presence of pulmonary embolism

Purpose To determine the frequency of apparent acute pulmonary embolism (PE) and of concomitant disease in computed tomography pulmonary angiography (CTPA); to compare the frequency of PE in patients with pneumonia or acute cardiac disorder (acute coronary syndrome, tachyarrhythmia, acute left ventricular heart failure or cardiogenic shock), with the frequency of PE in patients with none of these alternative chest pathologies (comparison group). Methods Retrospective analysis of all patients who received a CTPA at the emergency department (ED) within a period of four years and 5 months. Results Of 1275 patients with CTPA, 28 (2.2%) had PE and concomitant radiologic evidence of another chest disease; 3 more (0.2%) had PE and an acute cardiac disorder without radiological evidence of heart failure. PE was found in 11 of 113 patients (10%) with pneumonia, in 5 of 154 patients (3.3%) with an acute cardiac disorder and in 186 of 1008 patients (18%) in the comparison group. After adjustment for risk factors for thromboembolism and for other relevant patient’s characteristics, the proportion of CTPAs with evidence of PE in patients with an acute cardiac disorder or pneumonia was significantly lower than in the comparison group (OR 0.13, 95% CI 0.05–0.33, p<0.001 for patients with an acute cardiac disorder, and OR 0.45, 95% CI 0.23–0.89, p = 0.021 for patients with pneumonia). Conclusion The frequency of PE and a concomitant disease that can mimic PE was low. The presence of an acute cardiac disorder or pneumonia was associated with decreased odds of PE.

Transvaginal ultrasound in fertile patients with suspected appendicitis: an experience report of current practice

Background. Transvaginal ultrasound (TVU) in female patients with acute right lower quadrant (RLQ) abdominal pain is time and infrastructure intensive and not always available. This study aims to evaluate the role of TVU in these patients. Methods. Retrospective analysis identified 224 female patients with RLQ pain and TVU. Results. TVU revealed an underlying pathology in 34 (15%) patients, necessitating a diagnostic laparoscopy in 12 patients. Six patients (2%) had a true gynaecological emergency. The remaining 23 patients did not require surgery. The other 190 patients with RLQ pain had a bland TVU; 127 (67%) were discharged, while 63 patients (33%) received a diagnostic laparoscopy. Conclusion. The incidence of true gynaecological emergencies requiring urgent surgical intervention is very low in our patient cohort. TVU is a helpful tool if performed by a physician who is well trained in TVU.