Institut für Klinische Epidemiologie und Biometrie
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Sonstige beteiligte Institutionen
- Clinical Trial Center (CTC) / Zentrale für Klinische Studien Würzburg (ZKSW) (5)
- Klinische Studienzentrale (Universitätsklinikum) (2)
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany (1)
- Deutsches Zentrum für Herzinsuffizienz (1)
- Interdisziplinäre Zentrum für Klinische Forschung (IZKF) (1)
- Medizinische Klinik und Poliklinik 1, Abteilung Kardiologie (1)
- Medizinische Klinik und Poliklinik 1, Abteilung Nephrologie (1)
- Servicezentrum Medizin-Informatik (1)
- Servicezentrum Medizin-Informatik (Universitätsklinikum) (1)
- Universitätsklinikum Würzburg (UKW) (1)
Die chronische Niereninsuffizienz (CKD) ist ein weltweites Gesundheitsproblem. Insbesondere in den Industrienationen stellt es aufgrund des demographischen Wandels eine große gesundheitliche und finanzielle Herausforderung dar, da besonders ältere Menschen an einer eingeschränkten Nierenfunktion leiden. Hypertonie und Diabetes mellitus sind wichtige Risikofaktoren sowohl für die Entstehung der CKD, als auch für die koronare Herzerkrankung (KHK). Die Wahrnehmung der CKD in der Bevölkerung ist niedrig, wodurch eine frühzeitige Diagnose erschwert wird.
Die EUROASPIRE IV Studie hat es ermöglicht, die Prävalenz der CKD in einer Studienpopulation von KHK-Patienten im Raum Würzburg zu beschreiben. Nach den KDIGO-Leitlinien wurden die Patienten mit einer eGFRCKD-EPI<60ml/min als CKD-Patienten eingestuft. Zusätzlich wurde der Albumin/Kreatinin-Quotient (ACR) bestimmt. Zusammenhänge zwischen der Nierenfunktion und möglichen Determinanten wurden untersucht. Mit Hilfe eines Fragebogens wurde die Patienten-Awareness beschrieben. Retrospektiv erfolgte die Recherche, ob die Diagnose der CKD bei Aufnahme und/oder Entlassung des Indexaufenthalts im Arztbrief vermerkt wurde, dies wurde als Awareness der CKD seitens des behandelnden Arztes im Krankenhaus gewertet.
25% der 536-Teilnehmer wiesen am Tag der Untersuchung eine CKD auf. Das mediane Alter betrug 69 Jahre und die mediane eGFR lag bei 74 ml/min. Der ACR war mit 8,3 mg/g in der CKD-Gruppe deutlich erhöht (p<0,01). Das mediane Alter (p<0,01) und auch der prozentuale Anteil an Diabetikern (<0,01) waren in der CKD-Gruppe signifikant höher. 42,7% der Patienten mit CKD wussten von ihrer Nierenfunktionseinschränkung Bescheid. Bei 34 der 79 Patienten, die zum Zeitpunkt der Entlassung eine eGFR <60ml/min aufwiesen, wurde eine CKD im Arztbrief erwähnt.
Die vorliegende Studie zeigt eine hohe Prävalenz von CKD und klassischen kardiovaskulären Risikofaktoren wie beispielsweise Diabetes Mellitus. Trotz dieses hohen CKD-Anteils war sich nur ein geringer Teil der Patienten ihrer Nierenfunktionseinschränkung bewusst und wurde nur in geringem Maße von Ärzten im Entlassungsbrief erwähnt. Insgesamt war sowohl eine vermehrte Wahrnehmung der CKD seitens der Patienten als auch eine häufigere Erwähnung von CKD im Arztbrief mit zunehmendem Schweregrad der CKD assoziiert.
Background: Regular exercise is beneficial for cardiovascular health but a recent meta-analysis indicated a relationship between extensive endurance sport and a higher risk of atrial fibrillation, an independent risk factor for stroke. However, data on the frequency of cardiac arrhythmias or (clinically silent) brain lesions during and after marathon running are missing.
Methods/Design: In the prospective observational "Berlin Beat of Running" study experienced endurance athletes underwent clinical examination (CE), 3 Tesla brain magnetic resonance imaging (MRI), carotid ultrasound imaging (CUI) and serial blood sampling (BS) within 2-3 days prior (CE, MRI, CUI, BS), directly after (CE, BS) and within 2 days after (CE, MRI, BS) the 38\(^{th}\) BMW BERLIN-MARATHON 2011. All participants wore a portable electrocardiogram (ECG)-recorder throughout the 4 to 5 days baseline study period. Participants with pathological MRI findings after the marathon, troponin elevations or detected cardiac arrhythmias will be asked to undergo cardiac MRI to rule out structural abnormalities. A follow-up is scheduled after one year.
Results: Here we report the baseline data of the enrolled 110 athletes aged 36-61 years. Their mean age was 48.8 \(\pm\) 6.0 years, 24.5% were female, 8.2% had hypertension and 2.7% had hyperlipidaemia. Participants have attended a mean of 7.5 \(\pm\) 6.6 marathon races within the last 5 years and a mean of 16 \(\pm\) 36 marathon races in total. Their weekly running distance prior to the 38\(^{th}\) BMW BERLIN-MARATHON was 65 \(\pm\) 17 km. Finally, 108 (98.2%) Berlin Beat-Study participants successfully completed the 38\(^{th}\) BMW BERLIN-MARATHON 2011.
Discussion: Findings from the "Berlin Beats of Running" study will help to balance the benefits and risks of extensive endurance sport. ECG-recording during the marathon might contribute to identify athletes at risk for cardiovascular events. MRI results will give new insights into the link between physical stress and brain damage.
Background: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines.
Methods: A total of 6187 patients (18-80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012-2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. Results: A total of 2846 (46 %) patients had no diabetes, 1158 (19 %) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60 %, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54 % and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28 %. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0 % (53 mmol/mol) in 95 and 53 % and 11 % of those with previously known diabetes had an HbA1c >9.0 % (>75 mmol/mol). Of the patients with diabetes 69 % reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (approximate to 40 %) and only 27 % of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets.
Conclusions: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.
Das Ziel der vorliegenden Arbeit ist es, den Stellenwert von Trost im Umgang mit Patienten und Angehörigen aufzuzeigen und mittels einer empirischen Untersuchung zur Sterbebegleitung festzustellen, wie dies in der Realität im Klinikalltag umgesetzt wird. Hierfür wurde die Sterbebegleitung auf zwei unterschiedlichen Stationen innerhalb eines Krankenhauses qualitativ ausgewertet.
Der theoretische Teil der vorliegenden Arbeit zeigt anhand wissenschaftlicher Daten, welche unterschiedlichen Bedürfnisse schwerstkranke und sterbende Patienten und ihre Angehörigen an den Arzt im Hinblick auf Trost haben und wie diesen angemessen begegnet werden kann.
Mittels teilstrukturiertem Leitfadeninterview wurden Ärzte und Pflegekräfte als Experten dazu befragt, wie die Begleitung sterbender Patienten und ihrer Angehörigen aussieht und wie sie den Betroffenen Trost spenden. Die Aspekte Zeit, Raum, Personal und Ausbildung und ihr Einfluss auf die Begleitung wurden thematisiert. Zuletzt wurden die Experten nach ihrer Vorstellung von einem würdevollen Sterben im Krankenhaus und Ansätzen zur Verbesserung des Umgangs mit sterbenden Patienten und ihren Angehörigen gefragt.
Nach dem Prinzip des Theoretical Sampling der Grounded Theory nach Glaser und Strauss wurde die Sterbebegleitung auf einer Normal- und einer Palliativstation gegenübergestellt. Insgesamt wurden vier Ärzte und acht Pflegekräfte interviewt. Das Sampling pro Gruppe wurde beendet, nachdem die theoretische Sättigung erreicht war.
Die Auswertung der Interviews erfolgte nach dem Prinzip von Meuser und Nagel. Es wurde untersucht, wie Trost in der Begleitung sterbender Patienten und ihrer Angehörigen gestaltet wird. Unterschiede zwischen den beiden Stationen wurden herausgearbeitet und analysiert, worauf diese zurückzuführen sind. Lösungsansätze für eine Verbesserung der Situation im Krankenhaus wurden konzipiert.
Das Ergebnis der Untersuchung zeigt, dass sich alle befragten Ärzte und Pflegekräfte der existentiellen Ausnahmesituation von Sterbenden und Angehörigen bewusst sind und ein hohes Maß an Bereitschaft vorhanden ist, eine adäquate Begleitung zu gewährleisten.
Die Möglichkeiten der Sterbebegleitung auf der Palliativstation werden insgesamt als gut bewertet. Im Mittelpunkt steht die individuelle Begleitung des sterbenden Patienten und seiner Angehörigen. Bemängelt werden ein teilweise zu hoher Patientendurchlauf und eine zu geringe pflegerische Besetzung im Nachtdienst.
Im Gegensatz dazu wird die Arbeit der Begleiter auf der Normalstation durch den niedrigeren Personalschlüssel und die gegebenen Räumlichkeiten limitiert. Problematisch ist vor allem die mangelnde Ausbildung im Umgang mit Sterbenden und Angehörigen.
Um die Situation in Krankenhäusern, insbesondere auf den Normalstationen zu verbessern, sollte ein gesellschaftliches Umdenken stattfinden. Voraussetzung hierfür ist das Bewusstsein und die Akzeptanz, dass Sterben unabdingbar zum Leben gehört und somit auf jeder Station eines Krankenhauses stattfindet. Auf politischen Ebenen können entsprechende Maßnahmen in die Wege geleitet und die notwendigen Mittel bereitgestellt werden, damit nicht nur auf Palliativ- sondern auch auf Normalstationen geschultes Personal und geeignete Räumlichkeiten zur Verfügung stehen, um allen sterbenden Patienten und ihren Angehörigen eine bestmögliche Begleitung zuteilwerden zu lassen.
Eczema often precedes the development of asthma in a disease course called the 'atopic march'. To unravel the genes underlying this characteristic pattern of allergic disease, we conduct a multi-stage genome-wide association study on infantile eczema followed by childhood asthma in 12 populations including 2,428 cases and 17,034 controls. Here we report two novel loci specific for the combined eczema plus asthma phenotype, which are associated with allergic disease for the first time; rs9357733 located in EFHC1 on chromosome 6p12.3 (OR 1.27; P = 2.1 x 10(-8)) and rs993226 between TMTC2 and SLC6A15 on chromosome 12q21.3 (OR 1.58; P = 5.3 x 10(-9)). Additional susceptibility loci identified at genome-wide significance are FLG (1q21.3), IL4/KIF3A (5q31.1), AP5B1/OVOL1 (11q13.1), C11orf30/LRRC32 (11q13.5) and IKZF3 (17q21). We show that predominantly eczema loci increase the risk for the atopic march. Our findings suggest that eczema may play an important role in the development of asthma after eczema.
Background: Sudden cardiac death is common and accounts largely for the excess mortality of patients on maintenance dialysis. It is unknown whether aldosterone and cortisol increase the incidence of sudden cardiac death in dialysis patients.
Methods and results: We analysed data from 1255 diabetic haemodialysis patients participating in the German Diabetes and Dialysis Study (4D Study). Categories of aldosterone and cortisol were determined at baseline and patients were followed for a median of 4 years. By Cox regression analyses, hazard ratios (HRs) were determined for the effect of aldosterone, cortisol, and their combination on sudden death and other adjudicated cardiovascular outcomes. The mean age of the patients was 66 ± 8 years (54% male). Median aldosterone was <15 pg/mL (detection limit) and cortisol 16.8 µg/dL. Patients with aldosterone levels >200 pg/mL had a significantly higher risk of sudden death (HR: 1.69; 95% CI: 1.06–2.69) compared with those with an aldosterone <15 pg/mL. The combined presence of high aldosterone (>200 pg/mL) and high cortisol (>21.1 µg/dL) levels increased the risk of sudden death in striking contrast to patients with low aldosterone (<15 pg/mL) and low cortisol (<13.2 µg/dL) levels (HR: 2.86, 95% CI: 1.32–6.21). Furthermore, all-cause mortality was significantly increased in the patients with high levels of both hormones (HR: 1.62, 95% CI: 1.01–2.62).
Conclusions: The joint presence of high aldosterone and high cortisol levels is strongly associated with sudden cardiac death as well as all-cause mortality in haemodialysed type 2 diabetic patients. Whether a blockade of the mineralocorticoid receptor decreases the risk of sudden death in these patients must be examined in future trials.
Patients with Fabry disease frequently develop left ventricular (LV) hypertrophy and renal fibrosis. Due to heat intolerance and an inability to sweat, patients tend to avoid exposure to sunlight. We hypothesized that subsequent vitamin D deficiency may contribute to Fabry cardiomyopathy. This study investigated the vitamin D status and its association with LV mass and adverse clinical symptoms in patients with Fabry disease. 25-hydroxyvitamin D (25[OH]D) was measured in 111 patients who were genetically proven to have Fabry disease. LV mass and cardiomyopathy were assessed by magnetic resonance imaging and echocardiography. In cross-sectional analyses, associations with adverse clinical outcomes were determined by linear and binary logistic regression analyses, respectively, and were adjusted for age, sex, BMI and season. Patients had a mean age of 40 ± 13 years (42 % males), and a mean 25(OH)D of 23.5 ± 11.4 ng/ml. Those with overt vitamin D deficiency (25[OH]D ≤ 15 ng/ml) had an adjusted six fold higher risk of cardiomyopathy, compared to those with sufficient 25(OH)D levels >30 ng/ml (p = 0.04). The mean LV mass was distinctively different with 170 ± 75 g in deficient, 154 ± 60 g in moderately deficient and 128 ± 58 g in vitamin D sufficient patients (p = 0.01). With increasing severity of vitamin D deficiency, the median levels of proteinuria increased, as well as the prevalences of depression, edema, cornea verticillata and the need for medical pain therapy. In conclusion, vitamin D deficiency was strongly associated with cardiomyopathy and adverse clinical symptoms in patients with Fabry disease. Whether vitamin D supplementation improves complications of Fabry disease, requires a randomized controlled trial.
Background: Early medical complications are potentially modifiable factors influencing in-hospital outcome. We investigated the influence of acute complications on mortality and poor outcome 3 months after ischemic stroke.
Methods: Data were obtained from patients admitted to one of 13 stroke units of the Berlin Stroke Registry (BSR) who participated in a 3-months-follow up between June 2010 and September 2012. We examined the influence of the cumulative number of early in-hospital complications on mortality and poor outcome (death, disability or institutionalization) 3 months after stroke using multivariable logistic regression analyses and calculated attributable fractions to determine the impact of early complications on mortality and poor outcome.
Results: A total of 2349 ischemic stroke patients alive at discharge from acute care were included in the analysis. Older age, stroke severity, pre-stroke dependency and early complications were independent predictors of mortality 3 months after stroke. Poor outcome was independently associated with older age, stroke severity, pre-stroke dependency, previous stroke and early complications. More than 60% of deaths and poor outcomes were attributed to age, pre-stroke dependency and stroke severity and in-hospital complications contributed to 12.3% of deaths and 9.1% of poor outcomes 3 months after stroke.
Conclusion: The majority of deaths and poor outcomes after stroke were attributed to non-modifiable factors. However, early in-hospital complications significantly affect outcome in patients who survived the acute phase after stroke, underlining the need to improve prevention and treatment of complications in hospital.
Purpose: To determine the effects of progressive resistance training on mobility, muscle strength, and quality of life in nursing-home residents with impaired mobility.
Methods: Nursing-home residents aged 77 years and older with impaired mobility were recruited in Berlin, Germany. The eight-week exercise program consisted of progressive resistance training twice a week. Mobility (primary outcome) was assessed with the Elderly Mobility Scale (zero = worst, 20 = best) at baseline and after 8 weeks. Muscle strength (secondary outcome) was determined by the eight-repetition maximum. The Short Form-36 Health Survey was used to assess quality of life.
Results: Of the 15 participants (mean age 84 years, range 77-97 years), ten completed the 8-week program. Mobility (Elderly Mobility Scale mean +/- standard deviation pre 14.1 +/- 3.2 and post 17.5 +/- 3.6; P = 0.005) as well as muscle strength of upper and lower limbs improved (from 62% at chest press up to 108% at leg extension machine), whereas most quality of life subscales did not show considerable change.
Conclusion: Resistance training twice a week over 2 months seemed to considerably improve mobility and muscle strength in persons aged 77-97 years with impaired mobility.
Background: It remains unclear to what extent asthma in adults is linked to allergic rhinitis (AR), gastroesophageal reflux disease (GERD), and acetylsalicylic acid exacerbated respiratory disease (AERD), and how these comorbidities may affect asthma outcomes in the general population. We therefore aimed to assess the prevalence of these major comorbidities among adults with asthma and examine their impact on asthma exacerbations requiring hospital care.
Methods: A total of 22,050 adults 18 years and older were surveyed in the German National Health Telephone Interview Survey (GEDA) 2010 using a highly standardized computer-assisted interview technique. The study population comprised participants with self-reported physician-diagnosed asthma, among which the current (last 12 months) prevalence of AR and GERD-like symptoms (GERS), and life-time prevalence of AERD was estimated. Weighted bivariate analyses and logistic regression models were applied to assess the association of each comorbid condition with the asthma outcome (any self-reported asthma-related hospitalization and/or emergency department (ED) admission in the past year).
Results: Out of 1,136 adults with asthma, 49.6% had GERS and 42.3% had AR within the past 12 months; 14.0% met the criteria of AERD, and 75.7% had at least one out of the three conditions. Overall, the prevalence of at least one exacerbation requiring emergency room or hospital admission within the past year was 9.0%. Exacerbation prevalence was higher among participants with comorbidities than among those without (9.8% vs. 8.2% for GERS; 11.2% vs. 7.6% for AR, and 22.2% vs. 7.0% for AERD), but only differences in association with AERD were statistically significant. A strong association between asthma exacerbation and AERD persisted in multivariable logistic regression analyses adjusting for sex, age group, level of body mass index, smoking status, educational attainment, and duration of asthma: odds ratio (OR) = 4.5, 95% confidence interval (CI) = 2.5-8.2.
Conclusions: Data from this large nation-wide study provide evidence that GERS, AR and AERD are all common comorbidities among adults with asthma. Our data underline the public health and clinical impact of asthma with complicating AERD, contributing considerably to disease-specific hospitalization and/or ED admission in a defined asthma population, and emphasize the importance of its recognition in asthma care.