Felix Kork

Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients

Background:Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes. Methods:The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012. Results:The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)—by definition of the Kidney Disease: Improving Global Outcome group—was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (&Dgr;creatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery. Conclusions:Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.

[The Intensive Care Delirium Screening Checklist (ICDSC)--translation and validation of intensive care delirium checklist in accordance with guidelines].

BACKGROUND Although Delirium is the most common psychiatric disease in ICU settings, it is recognized late or not at all in up to 84 % of all cases. METHODS Translation of the ICDSC, in accordance with ISPOR guidelines and validation by conducting a screening of 68 ICU patients. RESULTS The translation process was authorized by the original author. The final German translation of the ICDSC showed a sensitivity and specificity of 89 % and 57 % respectively. CONCLUSION The ICDSC is suitable for delirium screening by nurses even on ventilated patients. Besides a high sensitivity another advantage is the possibility to screen for a subsyndromal delirium.

Die Nursing Delirium Screening Scale (Nu–DESC) – Richtlinienkonforme Übersetzung für den deutschsprachigen Raum

BACKGROUND Both in the recovery room as well as in the intensive care unit post-operative delirium is the most common psychiatric disease. The post-operative delirium is stated in literature to occur in 15 % to 50 % of patients, whereby up to 80 % of patients requiring intensive care with artificial respiration develop a delirium. The delirium correlates with the length of hospital stay and leads to a tripple rate of the six-month-mortality. Nu-DESC, developed by Gaudreau et al. is a measuring instrument for the clinical diagnostics of deliriums which is quickly operable, care-based and which can thus be easily integrated in everyday routine. The aim of this study was the translation of Nu-DESC from English as basis for the use in clinical research and routine. MATERIALS AND METHODS The translation process was conducted in accordance with the internationally acknowledged guidelines of Translation and Cultural Adaptation of Patient Reported Outcomes Measures - Principles of Good Practice (PGP). An interim German version was developed from 3 independently devised translations, a back-translation of which was then conducted by a registered state-approved translator. The back-translation was then presented to the author of the original for evaluation. RESULTS The back-translation of the German translation was authorised by the author of the original. On the basis of the cognitive debriefing results which were consistently very good to good, the translation process could be finalised and the final German version of Nu-DESC could be passed by the expert team. An evaluation of the German Nu-DESC regarding its practicability showed significant differences between doctors and nursing staff. CONCLUSION The German version of Nu-DESC provides an instrument for evaluating the delirium in the area of clinical routine and research.

A Possible New Diagnostic Biomarker in Early Diagnosis of Alzheimers Disease

Early diagnosis in patients with Alzheimers disease (AD) is of great importance since only a sufficient treatment in early stages of this disease helps to keep patients in an autonomous state for as long as possible. Until now, there is no single diagnostic biomarker for AD derived from material routinely obtained. In this study, proton nuclear magnetic resonance (1H-NMR) spectra of the cerebrospinal fluid (CSF) of AD patients were compared with 1H-NMR spectra of the CSF of healthy control subjects using a metabonomic approach. The 1H-NMR spectra of CSF of AD patients showed specific multiplets at 2.15 ppm and 2.45 ppm, which could not be detected in the majority (59.3% and 70.4%, respectively) of healthy control subjects (positive likelihood ratio (+LR) 2.33, 95% CI [1.46, 3.72], p<0.01; +LR 3.22, 95% CI [1.78, 5.78], p<0.01). Moreover, CSF 1H-NMR spectra of AD patients showed specific resonances at 7.03 ppm (+LR 3.38, 95% CI [1.60, 7.14], p<0.05), 7.19 ppm (+LR 2.89, 95% CI [1.46, 5.74], p<0.05), 7.43 ppm (+LR 3.15, 95% CI [1.47, 6.75], p<0.05), and at 7.91 ppm (+LR 3.38, 95% CI [1.60, 7.14], p<0.01). CSF 1H-NMR spectroscopy is obviously a capable method for detection and quantification of substances in the CSF of AD patients even without the knowledge of molecular structures. These substances can be used as a biomarker in the early diagnosis of AD. We assume that this biomarker will simplify the diagnosis of AD, especially in early stages of the disease.

Incidence and Risk Factors for Cognitive Dysfunction in Patients with Severe Systemic Disease

OBJECTIVE: To determine the relevance of surgery and other causative factors to the incidence of postoperative cognitive dysfunction (POCD) in patients with severe systemic disease. METHODS: This observational study included 107 noncardiac surgical patients and 26 nonsurgical control subjects, all of whom had an American Society of Anesthesiologists physical classification status of 3. Cognitive assessment was performed preoperatively and 7 days postoperatively, or with a 7-day interval for the control group. POCD was calculated as a combined Z-score. Mini Mental State Examination (MMSE) was used to exclude patients with pre-existing cognitive deficit (MMSE score ≥ 23). Surgical and other factors including duration of surgery/anaesthesia and length of stay in the intensive care unit (ICU) were recorded. RESULTS: After 7 days, POCD was found in 40/107 (37.4%) surgical patients compared with 4/26 (15.4%) nonsurgical controls. Preoperative MMSE score, duration of surgery/anaesthesia, and length of stay in the ICU and hospital were associated with POCD. Logistic regression analysis revealed that preoperative MMSE score was an independent predictor of POCD. CONCLUSION: Lower baseline MMSE score was the only independent predictor for POCD in patients with severe systemic disease.

Association of Comorbidities With Postoperative In-hospital Mortality: A Retrospective Cohort Study

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A biomarker for severity of Alzheimer's disease: 1H-NMR resonances in cerebrospinal fluid correlate with performance in mini-mental-state-exam.

Context: There is no valid biomarker for severity of Alzheimer’s disease (AD) available until now. Objective: Therefore, we investigated 1H-NMR spectroscopy for specific resonances as biomarkers for severity of AD. Materials and methods: Cerebrospinal fluid (CSF) of patients with diagnosed AD and healthy control subjects was analysed by one-dimensional water-suppressed 1H-NMR spectroscopy. The resonances were correlated with the cognitive performance of the patients and controls. Results: Specific 1H-NMR resonances showed higher intensities in AD patients than in control subjects. Mini-mental-state-exam scores correlated with 1H-NMR resonances in AD patients. Discussion and conclusion: 1H-NMR resonances of CSF are obviously valid biomarker for severity of AD, despite the lack of knowledge of the underlying molecular structure. Successful isolation and identification of these substances will most likely provide details to the pathophysiology of AD.

Proteomic-Biostatistic Integrated Approach for Finding the Underlying Molecular Determinants of Hypertension in Human Plasma

Despite advancements in lowering blood pressure, the best approach to lower it remains controversial because of the lack of information on the molecular basis of hypertension. We, therefore, performed plasma proteomics of plasma from patients with hypertension to identify molecular determinants detectable in these subjects but not in controls and vice versa. Plasma samples from hypertensive subjects (cases; n=118) and controls (n=85) from the InGenious HyperCare cohort were used for this study and performed mass spectrometric analysis. Using biostatistical methods, plasma peptides specific for hypertension were identified, and a model was developed using least absolute shrinkage and selection operator logistic regression. The underlying peptides were identified and sequenced off-line using matrix-assisted laser desorption ionization orbitrap mass spectrometry. By comparison of the molecular composition of the plasma samples, 27 molecular determinants were identified differently expressed in cases from controls. Seventy percent of the molecular determinants selected were found to occur less likely in hypertensive patients. In cross-validation, the overall R2 was 0.434, and the area under the curve was 0.891 with 95% confidence interval 0.8482 to 0.9349, P<0.0001. The mean values of the cross-validated proteomic score of normotensive and hypertensive patients were found to be −2.007±0.3568 and 3.383±0.2643, respectively, P<0.0001. The molecular determinants were successfully identified, and the proteomic model developed shows an excellent discriminatory ability between hypertensives and normotensives. The identified molecular determinants may be the starting point for further studies to clarify the molecular causes of hypertension.

Oral fluid testing for illicit substance use in preanaesthetic care.

OBJECTIVE: Due to specific risks associated with illicit drug use, the preanaesthetic detection of illicit substances is essential. This prospective observational study evaluated oral fluid testing and self reporting of illicit drug use compared with confirmatory blood testing. METHODS: Consecutively enrolled preanaesthetic and emergency room patients (n = 939) completed a paper-based lifestyle questionnaire. An oral fluid sample was obtained and analysed for illicit substance use by a point-of-care testing device (Dräger Drugtest® 5000). Patients who tested positive by self reporting or oral fluid testing underwent confirmatory blood testing (n = 117). RESULTS: Self reporting revealed more overall illicit substance use and more users of cannabinoids, amphetamines, opioids, cocaine and benzodiazepines than oral fluid testing. Self reporting was more sensitive than blood testing for the detection of overall illicit substance use, and for use of cannabinoids and benzodiazepines. CONCLUSIONS: Self reporting revealed higher rates of illicit substance use than oral fluid testing in preanaesthetic patients, and may lead to more interventions and more appropriately tailored treatment and anaesthesia compared with oral fluid testing.

Back-calculating baseline creatinine overestimates prevalence of acute kidney injury with poor sensitivity.

Acute kidney injury (AKI) is diagnosed by a 50% increase in creatinine. For patients without a baseline creatinine measurement, guidelines suggest estimating baseline creatinine by back‐calculation. The aim of this study was to evaluate different glomerular filtration rate (GFR) equations and different GFR assumptions for back‐calculating baseline creatinine as well as the effect on the diagnosis of AKI.