Bruno Neuner

Participation preferences of patients with acute and chronic conditions

Background  There is little knowledge as to whether the chronicity of a disease affects patients’ desire for participation.

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

OBJECTIVE The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

Low Ankle-Brachial Index Predicts Cardiovascular Risk After Acute Ischemic Stroke or Transient Ischemic Attack

Background and Purpose— A low ankle-brachial blood pressure index (ABI) is an established risk marker for cardiovascular disease and mortality in the general population, but little is known about its prognostic value in individuals with acute ischemic stroke or transient ischemic attack (TIA). Methods— An inception cohort of 204 patients with acute ischemic stroke or TIA was followed up for a mean of 2.3 years. At baseline, patients underwent ABI measurement and were assessed for risk factors, cardiovascular comorbidities, and cervical or intracranial artery stenosis. The association between low ABI (≤0.9) and the risk of the composite outcome of stroke, myocardial infarction, or death was examined by Kaplan–Meier and Cox regression analyses. Results— A low ABI was found in 63 patients (31%) and was associated with older age, current smoking, hypertension, peripheral arterial disease, and cervical or intracranial stenosis. During a total of 453.0 person-years of follow-up, 37 patients experienced outcome events (8.2% per person-year), with a higher outcome rate per person-year in patients with low ABI (12.8% vs 6.3%, P=0.03). In survival analysis adjusted for age and stroke etiology, patients with a low ABI had a 2 times higher risk of stroke, myocardial infarction, or death than those with a normal ABI (hazard ratio=2.2; 95% CI, 1.1 to 4.5). Additional adjustment for risk factors and cardiovascular comorbidities did not attenuate the association. Conclusions— A low ABI independently predicted subsequent cardiovascular risk and mortality in patients with acute stroke or TIA. ABI measurement may help to identify high-risk patients for targeted secondary stroke prevention.

Value of ethyl glucuronide in plasma as a biomarker for recent alcohol consumption in the emergency room.

AIM This emergency department (ED) study compared the value of plasma ethyl glucuronide (EtG) testing with the information about alcohol consumption obtained using the standard alcohol biomarkers gamma-glutamyltransferase (GGT) and carbohydrate-deficient transferring (CDT) and the AUDIT questionnaire. METHODS Minimally injured and clinically non-intoxicated male patients (n = 81) admitted to an ED were screened regarding their alcohol consumption, using the computerized AUDIT questionnaire and a paper-and-pencil assessment including the type, amount and time of alcohol intake. Blood samples were collected for determination of ethanol, EtG (LC-MS) and GGT in plasma and %CDT in serum (Axis-Shield %CDT immunoassay). RESULTS Out of the 81 patients, 23 (28%) were positive (>/=8 points) on the AUDIT questionnaire. Only 3 (4%) showed a detectable ethanol concentration (range 0.01-0.07 g/L) but 31 (38%) showed a detectable EtG (0.16-39.5 mg/L). In four patients, EtG was detectable in plasma for >48 h after estimated completed elimination of ethanol. EtG was not correlated with the long-term biomarkers %CDT or GGT, or the AUDIT results, but with the time since estimated completed ethanol elimination. CONCLUSION EtG testing in blood was found useful in the ED as a way to detect recent drinking, even in cases of a negative ethanol test, and to confirm abstinence from alcohol. This sensitive and specific short-term biomarker provides valuable additional information about individual drinking habits and might also be helpful to identify an alcohol hangover.

Health-related quality of life in children and adolescents with stroke, self-reports, and parent/proxies reports: cross-sectional investigation.

Limited data are available on health‐related quality of life (HR‐QoL) in pediatric stroke survivors. The aim of the present study was to assess HR‐QoL by self‐assessment and parent/proxy‐assessment in children and adolescents who survived a first stroke episode.

European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium.

The purpose of this guideline is to present evidence-based and consensus-based recommendations for the prevention and treatment of postoperative delirium. The cornerstones of the guideline are the preoperative identification and handling of patients at risk, adequate intraoperative care, postoperative detection of delirium and management of delirious patients. The scope of this guideline is not to cover ICU delirium. Considering that many medical disciplines are involved in the treatment of surgical patients, a team-based approach should be implemented into daily practice. This guideline is aimed to promote knowledge and education in the preoperative, intraoperative and postoperative setting not only among anaesthesiologists but also among all other healthcare professionals involved in the care of surgical patients.

Smoking history and the incidence of age-related macular degeneration - results from the Muenster Aging and Retina Study (MARS) cohort and systematic review and meta-analysis of observational longitudinal studies.

To compare the association of smoking with age-related macular degeneration (AMD) in the Muenster Aging and Retina Study (MARS) cohort with current evidence. Adjusted risk ratios for incident AMD in MARS were compared with findings of a systematic review and meta-analysis of observational prospective studies. 9.6% of MARS participants progressed to AMD over a median of 30.9 months. In MARS the adjusted risk ratio in current versus never smokers was 3.25 (95% confidence interval [1.50-7.06]), and 1.28 [0.70-2.33] in former smokers versus never smokers. The meta-analysis of previous studies showed a pooled adjusted risk ratio of 2.51 [1.09-5.76] in current versus never smokers. Inclusion of the MARS findings removed between-study heterogeneity and accentuated the pooled adjusted risk ratio for current smokers to 2.75 [1.52-4.98]. Specific analyses in MARS revealed a protective effect for time since smoking cessation in former smokers with an adjusted risk ratio=0.50 [0.29-0.89] per log(year). Current smoking nearly triples AMD incidence, while smoking cessation lowers AMD incidence in a non-linear fashion even in the elderly.

Screening trauma patients with the alcohol use disorders identification test and biomarkers of alcohol use.

BACKGROUND Alcohol screening and brief interventions have been shown to reduce alcohol-related morbidity in injured patients. Use of self-report questionnaires such as the Alcohol Use Disorder Identification Test (AUDIT) is recommended as the optimum screening method. We hypothesized that the accuracy of screening is enhanced by combined use of the AUDIT and biomarkers of alcohol use in injured patients. METHODS The study was conducted in the emergency department of a large, urban, university hospital. Patients were evaluated with the AUDIT, and blood sampled to determine carbohydrate-deficient transferrin, gamma-glutamyl-transferase, and mean corpuscular volume. Alcohol problems were defined as presence of ICD-10 criteria for dependence or harmful use, or high-risk drinking according to World Health Organization criteria (weekly intake >420 g in males, >280 g in females). Screening accuracy was determined using Receiver Operating Characteristic curves. RESULTS There were 787 males and 446 females in the study. Median age was 33 years. The accuracy of the AUDIT was good to excellent, whereas all biomarkers performed only fairly to poorly in males, and even worse in females. At a specificity >0.80, sensitivity for all biomarkers was <0.43, whereas sensitivity for the AUDIT was 0.76 for males and 0.81 for females. The addition of biomarkers added little additional discriminatory information compared to use of the AUDIT alone. CONCLUSIONS Screening properties of the AUDIT are superior to %CDT, MCV, and GGT for detection of alcohol problems in injured patients and are not clinically significantly enhanced by the use of biomarkers.

Sense of Coherence as a Predictor of Quality of Life in Adolescents With Congenital Heart Defects: A Register-Based 1-Year Follow-Up Study

Objective: Sense of coherence (SOC) is a resource for health and quality of life (QoL) in adults. The aim of this investigation was to prospectively evaluate the association between SOC and QoL in adolescents with congenital heart defects (CHDs). Methods: This is an observational study among 770 adolescents aged 14 to 17 years from a national CHD register. SOC was measured at baseline with the SOC-L9 questionnaire. QoL was measured at baseline and at a follow-up 12 months later. For this, we used the KINDL-R (revidierter KINDer Lebensqualitätsfragebogen) questionnaire to evaluate overall well-being and 6 subscales (physical well-being, psychological well-being, self-esteem, family-related well-being, friend-related well-being, and school-related well-being). The association between SOC and QoL both in terms of overall well-being and the KINDL-R subscales was evaluated in multilevel linear models. Fully adjusted models accounted for age, gender, behavioral factors, and medical and socioeconomic status. Results: Overall well-being, self-esteem, and school-related well-being were significantly higher at follow-up than at baseline. SOC (median: 50 [range: 16–63] points) was positively associated with overall well-being and all KINDL-R subscales at baseline. In overall well-being and the KINDL-R subscales (except in psychological well-being), significant negative interaction terms were observed for SOC at baseline and time to follow-up. However, the associations between SOC at baseline and overall well-being and all KINDL-R subscales at follow-up remained significant even in fully adjusted models. Conclusion: SOC is an independent predictor of QoL in adolescents with CHD. In psychological well-being, this prediction remains stable, whereas in total well-being and all other QoL subdimensions, its strength as such wanes over the course of a year but does not entirely dissipate. Further studies should evaluate whether interventions designed to increase SOC in children with CHD would also improve their QoL.

Emergency department-initiated tobacco control: a randomised controlled trial in an inner city university hospital

Objectives: Emergency department (ED) patients show high smoking rates. The effects of ED-initiated tobacco control (ETC) on 7-day abstinence at 12 months were investigated. Methods: A randomised controlled intention-to-treat trial (trials registry no.: ISRCTN41527831) was conducted with 1044 patients in an urban ED. ETC consisted of on-site counselling plus up to four telephone booster sessions. Controls received usual care. Analysis was by logistic regression. Results: In all, 630 (60.7%) participants were males, the median age was 30 years (range 18–81) and the median smoking intensity was 15 (range 1–60) cigarettes per day. Overall, 580 study participants (55.6%) were unmotivated, 331 (31.7%) were ambivalent and 133 (12.7%) were motivated smokers. ETC (median time 30 (range 1–99) min) was administered to 472 (91.7% out of 515) randomised study participants. At follow-up, 685 study participants (65.6% of 1044) could be contacted. In the ETC group, 73 out of 515 (14.2%) in the ETC group were abstinent, whereas 60 out of 529 (11.3%) controls were abstinent (OR adjusted for age and gender = 1.31 (95% CI 0.91 to 1.89, p = 0.15). Stratified for motivation to change behaviour, the adjusted ORs for ETC versus usual care were OR = 1.00 (95% CI 0.57 to 1.76) in unmotivated smokers, respectively OR = 1.37 (95% CI 0.73 to 2.58) in ambivalent smokers and OR = 2.19 (95% CI 0.98 to 4.89) in motivated smokers, p for trend = 0.29. Conclusions: ETC, in the form of on-site counselling with up to four telephone booster sessions, showed no overall effect on tobacco abstinence after 12 months. A non-significant trend for a better performance of ETC in more motivated smokers was observed.