Hans Jürgen Heppner

Heart failure epidemiology 2000–2013: insights from the German Federal Health Monitoring System

Considerable differences in the long‐term trends of heart failure (HF) exist between different countries. To extend the existing knowledge on HF epidemiology in Germany, we analysed trends of HF‐related hospitalizations, hospital days and in‐hospital deaths during a 14‐year period (2000–2013).

C-reactive protein, severity of pneumonia and mortality in elderly, hospitalised patients with community-acquired pneumonia

BACKGROUND increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients. OBJECTIVE to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP. METHODS the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality. RESULTS in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU). CONCLUSION in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.

Patients With Syncope in a German Emergency Department: Description of Patients and Processes

BACKGROUND We studied the characteristics and resource utilization of patients with syncope in a German emergency department (ED). METHODS We carried out a single-center retrospective analysis of patients with syncope who presented to the ED of the Klinikum Nürnberg (a municipal hospital in Nuremberg, Germany). RESULTS Among the 28 477 patients who presented to the ED from 15 May 2009 to 30 September 2009, 440 (1.5%) presented with syncope. Their mean age was 62 years (standard deviation, 20 years); 50.4% were women, 43.4% were over age 70, 11.8% had cardiogenic and 4.8% neurological syncope, and 18.2% had more than two comorbid conditions. 20.7% were discharged after evaluation in the ED, 14.1% were brielfly hospitalized in the EDs clinical observation unit, and 56.6% were admitted to one of the hospitals specialty wards. 8.6% left the ED against medical advice. All of the syncope patients were evaluated by history-taking, physical examination, and 12-lead electrocardiogragraphy (ECG); ECG revealed abnormal findings in 36.4% of patients. Nearly all patients also underwent laboratory testing, which revealed hyponatremia (a serum sodium concentration under 130 mmol/L) in 5.9% and a serum creatinine level above 2 mg/dL in 5.3%. Many underwent technology-intensive tests such as cranial computed tomography (129 patients), but these tests only rarely yielded abnormal findings (3.1%). 27% of the syncope patients underwent Doppler ultrasonography of the vessels supplying the brain, with abnormal findings in 6.7% of cases. (Orthostatic testing was performed in 14.5% of the patients and was positive in 26.6%.) CONCLUSION Many patients presenting with syncope to a German ED are elderly, and multiple comorbidities are common. Technology-intensive testing in patients with syncope has a low diagnostic yield and consumes resources. The introduction of standards for the evaluation of syncope in the ED would be helpful.

A 3-Hour Diagnostic Algorithm for Non-ST-Elevation Myocardial Infarction Using High-Sensitivity Cardiac Troponin T in Unselected Older Patients Presenting to the Emergency Department

OBJECTIVES To determine if an algorithm implementing a serial high-sensitive cardiac troponin T (hs-cTnT) measurement at presentation (0 h) and at 3 hours after presentation (3h) is helpful for early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) in older patients. DESIGN Prospective observational cohort study. SETTING An emergency department (ED) of a city hospital covering a population of approximately 1 million in Germany. PARTICIPANTS A total of 332 consecutive unselected patients were recruited, of whom 25 had one or more of the prespecified exclusion criteria and 1 had a missing hs-cTnT at 3h, resulting in a final population of 306 patients. MEASUREMENTS In addition to clinical examination, hs-cTnT was measured at 0 h and 3 h. The final diagnosis of NSTEMI was adjudicated by two independent consultants and an algorithm for rule-in and rule-out of NSTEMI was developed using classification and regression tree analysis. All patients were followed-up for cardiovascular outcome within 12 months. RESULTS Among 306 patients (mean age 81 ± 6 years), 38 (12%) patients had NSTEMI. Accuracy to diagnose NSTEMI was significantly higher for hs-cTnT measurements at 3 h versus 0 h (area under the receiver operating characteristic curve [AUC] 0.88 vs. 0.82, P = .0038) and for absolute versus relative hs-cTnT delta changes (AUC 0.89 versus 0.69, P < .001). A diagnostic algorithm using hs-cTnT values at presentation and absolute delta changes values ruled-in NSTEMI in 23% and ruled-out NSTEMI in 35% of patients. For patients neither fulfilling the rule-in nor the rule-out criteria, an observational zone was established. Cumulative 1-year survival was 79.4%, 88.5%, and 99.1% in patients classified as rule-in, observational zone, and rule-out, respectively. CONCLUSION In older patients, serial hs-cTnT measurements and absolute delta-changes at 3h were valuable for early diagnosis of NSTEMI. An algorithm ruled-in NSTEMI in one quarter of patients with high risk and ruled-out NSTEMI in one-third with low risk.

Multiresistente Erreger – Infektionsmanagement 2015

The global spread of multi-drug resistant organisms (MDRO) is a major threat to public health. Fighting MDRO spread requires a multi-faceted approach as summarized in the German Antibiotic Resistance Strategy (DART). In the hospital, this includes antibiotic stewardship concepts and strict infection control measures. Treatment of MDRO is sophisticated. Within the last years, several antibiotics with activity against MRSA were launched and facilitate an individual therapy according to site of infection and co-morbidities. In contrast, novel antibiotics against carbapenemase producing Gram-negatives are still lacking. Current studies have shown, that a colistin-based combination treatment can improve the prognosis in these patients. The following article reviews MDRO definitions, burden of disease, treatment options and general strategies against MDRO.

Instruments to identify elderly patients in the emergency department in need of geriatric care

AbstractThe number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further.ZusammenfassungDie Anzahl an Patienten mit funktionellen Einschränkungen, kognitiver Einschränkung oder Behinderung, die ungeplant in Kontakt mit der Notaufnahme eines Krankenhauses kommen und akutmedizinischer Versorgung bedürfen, nimmt zu. Damit stellt sich zunehmend das Problem, wie ältere Patienten mit Bedarf einer akut-geriatrischen Behandlung identifiziert werden können. Die Durchführung eines umfassenden geriatrischen Assessments bei Erstkontakt könnte eine Lösung sein. Allerdings gilt das umfassende geriatrische Assessment als zu aufwendig und komplex, um sinnvoll in der Notaufnahme umsetzbar zu sein. Deshalb wurden verschiedene Screening-Instrumente entwickelt und vorgeschlagen. Das in verschiedenen Versorgungszusammenhängen und unterschiedlichen Ländern am besten untersuchte Instrument ist derzeit das ‚Identification of Seniors At Risk‘ (ISAR) Screening Instrument. Es besteht aus sechs einfachen Fragen, die rasch angewendet und auch in dringlichen Situationen erhoben werden können. In den letzten Jahren wurde die Validität des ISAR-Instruments in verschiedenen europäischen Ländern getestet. Die meisten Studien, eine Studie aus Deutschland und eine aktuelle systematische Übersicht eingeschlossen, bestätigen die Validität. Die Ergebnisse sind aber nicht widerspruchsfrei. Einige Studien haben nur einen schwachen oder gar keinen Zusammenhang zwischen ISAR und negativen Gesundheitsfolgen gefunden. Andere Instrumente wurden deutlich weniger gut untersucht und scheinen keinen offensichtlichen Vorteil zu bieten. Trotz der zunehmenden Evidenz zum Thema bleiben etliche Unsicherheiten bestehen. Weitere Studien werden benötigt, um bestehende Inkonsistenzen aufzulösen und zu klären, wie im Screening positive Patienten am besten weiter behandelt werden können.

Recognizing the Importance of Dysphagia: Stumbling Blocks and Stepping Stones in the Twenty-First Century.

The oropharyngeal swallow involves a rapid, highly coordinated set of neuromuscular actions beginning with lip closure and terminating with opening of the upper esophageal sphincter. The central coordination of this complex sensorimotor task uses a widespread network of cortical, subcortical, and brainstem structures. Many diseases and disorders affecting the central swallowing network or downstream peripheral nerves, muscles, and structures may result in an impaired oropharyngeal swallow. In addition, aging is also associated with multifactorial changes of swallowing physiology for which the term presbyphagia has been coined. Oropharyngeal dysphagia broadly affects respiratory safety due to the increased risk of aspiration, and swallowing efficacy leading to the impeding danger of insufficient nutrition and hydration.

Arzneimittelformen und Arzneimittelverabreichung in der Geriatrie

Die Entwicklungen des Alterns stellen veranderte Herausforderungen an die medizinische Versorgung und das Management von geriatrischen Patienten. Der betagte Patient mit seinen altersbedingten Funktionseinschrankungen und der Multimorbiditat ist durch alternsphysiologische Veranderungen sowie durch unreflektierte Pharmakotherapie gefahrdet und auf die hausarztliche Hilfestellung angewiesen. Beim geriatrischen Patienten ist die Verordnung der geeigneten Arzneiform und der praktikablen Applikationsform der Schlussel zum Therapieerfolg. Altersgerechte Einnahmeverordnungen, wiederholte Aufklarung und Einnahmeschulung sind unersetzliche Versorgungsleistungen in der hausarztlichen Praxis und dem klinischen Alltag, die zunehmend an Bedeutung gewinnen.

Ambulant erworbene Pneumonie in der Notfallmedizin – Sind Diagnostik- und Behandlungsstandards in der Notaufnahme hilfreich?

Community acquired pneumonia (CAP) is associated with high in-hospital mortality. The initial correct diagnosis, risk assessment and initiation of treatment are responsibilities of the emergency department (ED). In Germany, emergency medicine is not well established nationwide and organized in a very heterogeneous manner. Therefore, systematic approaches to improve quality of care are scarce and standardisations of processes are required. Standardized care bundles for CAP identify patients at increased risk for an adverse outcome. Early detection of CAP in the emergency department is essential for initiating timely and appropriate treatment. As part of the nationwide CAP quality improvement program we use CRB-65 for initial risk stratification in the ED. In own investigations we demonstrated that implementation of systematic guideline based care bundles for pneumonia significantly improves quality of care in the ED subsequently leading to decreased mortality during hospitalization. Early standardized care bundles in the ED reduce length-of-stay in the hospital and the intensive care unit. Furthermore, those strategies are accompanied with an improvement of economic characteristics.

Short-term mortality of adult inpatients with community-acquired pneumonia: external validation of a modified CURB-65 score

Objective The management of community-acquired pneumonia (CAP) continues to be a challenge, especially in older people. To enable better risk stratification, a variation of the severity scores CRB-65 and CURB-65, called CURB-age, has been suggested. We compared the association between risk groups as defined by the scores and 30-day mortality for a cohort of mainly older inpatients with CAP. Methods We retrospectively analysed data from the CAP database from the years 2005 to 2009 of a single centre in Herne, Germany. Patient characteristics, criteria values within the severity scores CURB-65, CRB-65 and CURB-age, and 30-day mortality were assessed. We compared the association between score points and score-defined risk groups and mortality. Sensitivity and specificity with corresponding 95% CIs were calculated, and receiver operating characteristic (ROC) curve analysis was performed. Results Data from 559 patients were analysed (mean age 74.1 years, 55.3% male). Mortality at day 30 was 10.9%. CURB-age included more patients in the low-risk category than CRB-65 (195 vs 89), and the patient group had a lower mortality (2.6% vs 3.4%). When compared with CURB-65, CURB-age included slightly fewer patients (195 vs 214) with lower mortality (2.6% vs 4.2%). CURB-age sorted the most patients who died within 30 days into the high-risk CAP group (CURB-age, 32; CURB-65, 28; CRB-65, 9), which had the highest mortality (CURB-age, 26.4%; CURB-65, 19.4%; CRB-65, 21.4%). Advantages of CURB-age categories were depicted through ROC curve analysis (area under the curve 0.73 (95% CI 0.67 to 0.79) for CURB-age categories, 0.67 (95% CI 0.60 to 0.74) for CURB-65 categories, and 0.59 (95% CI 0.52 to 0.66) for CRB-65 categories). Conclusions In comparison with CRB-65 and CURB-65, risk stratification as defined by CURB-age showed the closest association with 30-day mortality in our sample. Further prospective studies are needed to assess the potential of CURB-age for better risk prediction, especially in older patients with CAP.