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M H Kramer

Publications and source records attributed to M H Kramer.

At least 19 recordsLinked to original sources
PubMed2006

[Surveillance of infectious foodborne diseases after enactment of the German Protection against Infection Act in 2001. Potentials and requirements].

The epidemiology of infectious foodborne diseases has changed. Outbreaks more frequently occur geographically dispersed or protractedly over longer periods of time, and they often appear as a scatter of seemingly sporadic cases. This hampers and delays the identification of their epidemiological link. The surveillance of infectious foodborne diseases has to be refined accordingly to be able to detect these diffuse outbreaks. The German Protection against Infection Act, enacted in 2001, offers the potential of increased sensitivity due to timely electronic reporting of individual cases and detailed data accompanying each report. In addition to a timely and comprehensive reporting system, subtyping of pathogens has become an invaluable tool in identifying epidemiologically linked cases, i.e. outbreaks. Still, the sensitivity of foodborne disease surveillance still hinges on the willingness of physicians to order stool testing for enteric pathogens (and to report suspected outbreaks to local health departments). Without the active participation of physicians, the chance of detecting outbreaks and successfully investigating them is markedly reduced. Consequently, the general preventive strategy would be jeopardised, namely to understand the (often new) mechanisms by which contamination and disease transmission occur well enough to interrupt them.

Communicable Disease Control↗
PubMed2006

Influence of prolonged use of intravenous administration sets in paediatric cancer patients on CVAD-related bloodstream infection rates and hospital resources.

BACKGROUND: To assess the effects of extending the routine intravenous administration set (IVAS) change-interval from 72 h (group 1) to 7 days (group 2) on the incidence density for central venous access device (CVAD)-related bloodstream infections (BSIs) and on resource expenditures in a singlecentre pilot study. PROCEDURE: Prospective pre-/post-intervention comparison of two consecutive 12-month surveillance periods (2001-2003) in a 17-bed paediatric oncology tertiary care unit. IVAS changes and nosocomial infections (NIs) were prospectively analysed using a standardized unit-based surveillance system (Oncopaed NI). RESULTS: All 175 eligible patients were enrolled, 96 in group 1 and 79 in group 2. Both groups had similar distributions of primary diagnoses and risk factors. The proportion of IVAS changes performed after 3 days increased from 5.6% to 22.5%, but only 8% of IVASs in group 2 were changed after 7 days. Most IVAS changes (64.8% in group 1 and 92.9% in group 2) were done because of therapeutic interventions (blood products, parenteral nutrition [TNP]) before the scheduled endpoint. Overall, the rates and incidence densities of NIs were significantly lower during the second period. The corresponding results for CVAD-related BSIs did not show significant differences. No death attributable to a NI occurred. The '7-day' strategy resulted in cost savings for devices (3,300 dollars/year) and of nursing time (23 working days/year). CONCLUSIONS: Extending the routine IVAS change-interval from 3 days to 7 days appears to be safe and cost-effective in a paediatric oncology unit with high infection control standards and continuous surveillance for NIs. These results do not prove that 7-day intervals prevent infections, but they do suggest that this policy probably is not harmful and that a prospectively randomized study with sufficient power is needed.

Adolescent↗
PubMed2005

Prospective surveillance for healthcare-associated infections in German nursing home residents.

We undertook a prospective surveillance study in order to determine the incidence of healthcare-associated infections (HCAIs) in German nursing home residents. All people residing for more than one day in a 103-bed nursing home for the elderly in Bonn, Germany between December 1998 and November 1999 were included. Active surveillance was based on previously published consensus definitions. Rates for HCAIs and urinary tract infections (UTIs) were calculated based on resident-days and device-utilization days, respectively. The overall incidence of HCAIs was 6.0 per 1000 resident-days, with respiratory tract infections, gastroenteritis, skin/soft tissue infections and UTIs representing 94% of all HCAIs (2.2, 1.2, 1.2 and 1.0 infections per 1000 resident-days, respectively). Residents with pneumonia were more likely to die than residents with other HCAIs (RR=5.09; 95%CI 1.87-13.89; P=0.011). We conclude that HCAIs are a serious health problem in German nursing home residents. Standardized surveillance in nursing homes is important to assess the effectiveness of infection control standards, and should be based on consensus definitions in order to allow for meaningful interfacility comparisons. In Germany, the implementation of a hospital reimbursement system based on diagnosis-related groups is likely further to increase the proportion of vulnerable populations in long-term-care facilities.

Aged↗
PubMed2004

[Survival of patients with aggressive non-hodgkin's lymphoma: no difference between first line treatment in a prospective randomised phase III clinical trial and first line treatment according to routine clinical practice].

OBJECTIVE: To compare survival of patients with disseminated aggressive non-Hodgkin's lymphoma (NHL) who were treated either as part of a clinical trial or in routine clinical practice. DESIGN: Retrospective. METHOD: The survival was studied of patients with disseminated NHL of an intermediate or high degree of malignancy who were treated in the Meander Medical Centre, Amersfoort, the Netherlands, in the years 1994-2001 with chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). This took place either in routine clinical practice (RCP) or as part of a clinical trial where patients < or = 60 years of age received intensified CHOP and patients > 60 years received CHOP with growth factors. Treatment data, the response to therapy, survival and prognostic factors according to the International Prognostic Index for aggressive NHL were collected by a review of the patient records. RESULTS: Fifty-nine patients were eligible for this analysis: 32 men and 27 women with a median age of 63 years (range 30-83). Of these, 35 were treated within a clinical trial and 24 were treated in RCP. The patient characteristics in the two groups were comparable. There was no difference in median survival between the trial and RCP groups, this being 27 months for all patients, 34 months for the younger patients, 20 months for the elderly patients, and 42 months for patients who achieved complete remission following chemotherapy. CONCLUSION: No difference in overall survival was found between patients with disseminated aggressive NHL who underwent treatment according to either RCP or as part of a clinical trial. It demonstrates that both patients in clinical trials and patients treated according to RCP received equally effective therapy. Recent developments in NHL treatments are promising, and therefore participation in clinical trials should be encouraged.

Adult↗
PubMed2004

[Survey among local health departments concerning the implementation of the new infectious disease reporting system].

The Infectious Disease Control Act enacted in Germany in January 2001 led to the establishment of a new reporting system for infectious disease. The implementation of this system was evaluated to identify opportunities for further improvement. In a survey of all German local health departments the following criteria were analyzed: resources (staff and technical equipment), information needs (satisfaction with current offers/further training requirements), data analysis (extent of local data analysis/feedback of national data), and acceptability (case definitions/electronic reporting). In local health departments, 11% of the staff were assigned to the infectious disease reporting system. Data were processed mainly by nonmedical staff (78.4%). A computer work-station is available for most staff members. One-third of the local health departments uses the RKI software "SurvNet@rki" for data transmission. All others use commercial software. Experience with the electronic reporting system was rated as very good/good by 47.1% of local health departments, as satisfactory by 44.5%, and as problematic by 8.4%. Most of the local health departments were satisfied with the offers of information provided by RKI (96.4%) and state health departments (83.7%), respectively. However, 49.1% of the local health departments saw a need for further education and training. The implementation of case definitions was supported by 95% of the local health departments, but transmission criteria were criticized. In summary, the new infectious disease reporting system in Germany was successfully implemented. However, the system could be improved through reduction of software problems concerning electronic data processing and transmission, expansion of current offers of in-formation and provision of special staff training programs, and revision of the case definitions concerning clearness and simpler handling.

Communicable Disease Control↗
PubMed2003

Strong association between shiga toxin-producing Escherichia coli O157 and virulence genes stx2 and eae as possible explanation for predominance of serogroup O157 in patients with haemolytic uraemic syndrome.

The aim of this study was to investigate the association between Shiga toxin-producing Escherichia coli (STEC) O157 and the simultaneous presence of the virulence genes stx2 and eae in STEC from patients with gastroenteritis. In Germany, the proportion of serogroup O157 is substantially higher among STEC isolates from patients with haemolytic uraemic syndrome (HUS) than among STEC isolates from patients with gastroenteritis. The reason for this is unknown. Independent of serogroup, the virulence genes stx2 and eae have been associated with severe disease. Data collected in 2000-2001 from a Germany-wide laboratory-based surveillance system for STEC-associated gastroenteritis in patients <15 years were analysed. Overall, 18% of the STEC isolates belonged to serogroup O157. Compared with non-O157 strains, 0157 isolates were strongly associated with the simultaneous presence of both an stx2 gene and the eae gene (OR, 76; 95%CI, 27-230). Within the subset of STEC isolates that carried both virulence genes, 60% belonged to serogroup O157, a proportion similar to that found in STEC isolates from pediatric patients with HUS in Germany and Austria (67%, P=0.35). These data suggest that the more frequent carriage of both virulence genes, i.e. stx2 and eae, forms the basis of why STEC O157 predominates in patients with HUS.

Adhesins, Bacterial↗
PubMed2003

[Drug treatment of chronic myeloid leukemia: a cost effectiveness analysis of first- and second-line treatment ].

OBJECTIVE: To determine the average cost-effectiveness ratio of treatment of patients with chronic myeloid leukaemia (CML): with first-line interferon alpha-2a (IFN) or with second-line imatinib following IFN failure. DESIGN: Cost-effectiveness analysis. METHOD: A general cost-effectiveness analysis was performed using a model. This model consists of two phases: an induction phase of eight months, in which newly-diagnosed patients are treated with either IFN or imatinib, and a chronic treatment phase wherein patients are treated according the result of the induction phase. The model calculated the costs and effects of the treatment. Input for this model was derived from literature and expert opinion. Costs were based on real cost prices and tariffs. RESULTS: Treatment with imatinib resulted in 6.67 quality-adjusted life years (QALYs) and treatment with IFN resulted in 4.98 QALYs. Average costs of treatment with 5 million IU/day of IFN were [symbol: see text] 76,969 and [symbol: see text] 53,257 with 3 million IU/day. For imatinib at 400 mg/day the costs were [symbol: see text] 140,765 per patient. Costs per QALY were [symbol: see text] 15,445, [symbol: see text] 10,687 and [symbol: see text] 21,082, respectively. CONCLUSION: The addition of imatinib to the treatment options in CML resulted in increased quality-adjusted survival, but also higher costs of treatment.

Antineoplastic Agents↗
PubMed2001

[Immunologic phenomena as the first sign of myelodysplastic syndrome].

Two patients, men aged 77 and 66 years, presented with a vasculitis. Due to an abnormal blood smear they were referred to the internist, who subsequently diagnosed a myelodysplastic syndrome (MDS). They were initially treated with a high dose of corticosteroids and this dosage later became a maintenance dose. Immunological phenomena occur in 10-14% of MDS patients and seem to have a poor prognosis. Most patients respond well to treatment with corticosteroids. Occasionally, favourable haematological responses to corticosteroid therapy are seen, although this was not the case in the two patients described. When patients present with an immunological disorder, such as a vasculitis or an autoimmune disease, it is important to be aware of the possibility of an underlying MDS.

Aged↗
PubMed2001

Antimalarial chemoprophylaxis in infants and children.

The evolving patterns of drug resistance in malaria parasites and changes in recommendations for malaria prevention present a challenge to physicians who advise travellers on chemoprophylaxis. Because compliance with personal protection measures is usually low, children should receive appropriate chemoprophylaxis, including breast-fed infants who are not protected through maternal chemoprophylaxis. For travel to areas where chloroquine resistance has not yet been reported (i.e. parts of Central America, the Caribbean and parts of the Middle East), chloroquine alone is sufficient for antimalarial prophylaxis. Mefloquine is the drug of choice for chemoprophylaxis in areas with chloroquine-resistant Plasmodium falciparum, and can be given to infants and young children. The combination of chloroquine and proguanil is well tolerated in children but is much less effective against drug-resistant malaria. Further research is needed to determine the best dosage regimen for antimalarial drugs used for chemoprophylaxis in children.

Antimalarials↗
PubMed2000

Surveillance for nosocomial and central line-related infections among pediatric hematology-oncology patients.

OBJECTIVE: To determine the incidence of all nosocomial infections (NIs) in pediatric hematology-oncology patients, as well as central venous access device (CVAD)-associated infections acquired during home care. DESIGN: Prospective surveillance study. SETTING: The Pediatric Hematology and Oncology Department at the University Hospital Bonn. PATIENTS: All patients admitted from January through October 1998 (surveillance period). METHODS: Standardized surveillance system based on the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System. RESULTS: A total of 143 patients were hospitalized for 3,701 days (776 admissions) during the surveillance period. Of the 40 NIs detected, 26 were CVAD-related, with 21 bloodstream infections (BSIs) and 5 local infections. Four were Clostridium difficile-associated diarrheal illnesses, 3 were pneumonias, and 7 were other infections. The incidence of NIs was 10.8 per 1,000 patient-days (5.2 NIs/100 admissions). The overall CVAD-related BSI rate was 7.4 per 1,000 utilization days, without a significant difference between implanted infusion ports and tunneled catheters. In addition, 7 CVAD-related infections occurred during home care. All 8 BSIs associated with tunneled catheters and 13 (76%) of the 17 BSIs associated with ports were acquired nosocomially. For inpatients and outpatients combined, the exit sites of tunneled catheters were more likely to become locally infected than were the needle entry sites of ports (relative risk, 8.0; P=.007). In 30 (75%) of the 40 NIs, the affected patients had severe neutropenia (<500/mm3) at the time of infection. CONCLUSIONS: Most NIs in the pediatric hematology-oncology patients were associated with CVAD devices. Although many infections in this high-risk population may not be preventable through infection control measures, the careful evaluation of specific infection rates permits the identification of risk factors that may be targeted by infection control programs. Prospective surveillance for NIs on pediatric oncology units is an indispensable tool for this internal quality control.

Adolescent↗
PubMed1999

Acute abdominal pain and eosinophilia, two cases of eosinophilic gastroenteritis.

Two patients are presented who were admitted with acute abdominal pain for which they underwent laparotomy. No clear-cut diagnosis could be established during operation. Eventually, eosinophilic gastroenteritis was diagnosed and treated with corticosteroids. The heterogeneous presentation of eosinophilic gastroenteritis is discussed, ranging from mild non-specific gastrointestinal symptoms to an acute abdominal emergency prompting surgical intervention. The pathogenesis and treatment of eosinophilic gastroenteritis are discussed.

Abdomen, Acute↗
PubMed1999

CD44 expression predicts disease outcome in localized large B cell lymphoma.

Diffuse large B cell non-Hodgkin's lymphomas (DLCL) form a heterogeneous group of tumors with diverse morphology, clinical features, treatment response and prognosis. The biological variables underlying this heterogeneity are unknown. In the present study, we explored the value of the lymphocyte homing receptor CD44, a putative determinant of lymphoma dissemination, in predicting prognosis in DLCL. Expression of the standard form of CD44 (CD44s) and of CD44 isoforms containing exon v6 (CD44v6) on tumor cells was assessed by immunohistochemistry in a cohort of 276 DLCL patients from a population based lymphoma registry. We observed that CD44s as well as CD44v6 expression correlated with tumor dissemination in patients with primary nodal DLCL. Importantly, in patients with localized nodal disease, CD44s was a strong prognosticator predicting tumor related death independent of the other parameters of the International Prognostic Index (IPI). Incorporation of CD44s in the IPI parameter 'stage', increased the prognostic value of this parameter in nodal DLCL. Our data identify CD44 as a biological prognosticator, which can be used to 'fine-tune' the IPI for nodal DLCL.

Adult↗
PubMed1999

Primary non-Hodgkin's lymphoma of bone: a clinicopathological investigation of 60 cases.

A retrospective analysis of patients presenting with primary lymphoma of bone (PLB) was performed to determine clinical factors affecting prognosis in relation to histological subtype and treatment outcome. Data from 106 patients, presenting with a PLB between 1943 and 1996, were retrieved from the files of the Netherlands Committee on Bone Tumours and Leiden University Medical Centre. The lymphomas were reclassified according to the REAL and updated Kiel classification. The clinical presentation, survival and prognostic factors were investigated. Sixty patients had sufficient clinical information and adequate follow-up to be included in the study. All 33 PLB that could be immunophenotyped were of B cell origin. According to the REAL classification, most PLB were large (B) cell lymphomas (92%) and according to the Kiel classification 45% of the tumours were centroblastic multilobated. PLB presented most often in the long bones (48%), with Ann Arbor stage I (46%), II (16%), IV (16%) and unknown (20%). Stage IV disease was exclusively caused by the presence of multiple bone lesions. Notwithstanding the heterogeneous treatment, the 5-year overall survival was 61%; 46% of patients were progression free at 5 years. Patients at presentation older than 60 had a worse overall survival (76% vs 37%, P = 0.0002) and a worse progression-free period (58% vs 28%, P = 0.0073). Patients with the immunoblastic subtype had a worse survival than the centroblastic mono/polymorphic subtype or the centroblastic multilobated subtype (P = 0.015). Primary lymphoma of bone represents an uncommon bone tumour with a relatively homogeneous morphology and clinical behaviour. Compared to other aggressive lymphomas, PLB have a favourable prognosis.

Adolescent↗
PubMed1999

Extensive capillary malformation with a compensated coagulopathy.

A 79-year-old male patient had an extensive vascular malformation, a thrombocytopenia and a low survival half-time of the thrombocytes without a bleeding problem. Recognition of this compensated coagulopathy is important, as it may become exacerbated into a bleeding disorder during periods of stress.

Aged↗
PubMed1999

Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy.

OBJECTIVE: To identify risk factors that might explain a sudden increase in the rate of surgical-site complications following laminectomy. DESIGN: Retrospective cohort study. PATIENTS AND SETTING: Patients who underwent laminectomy at a 120-bed hospital from August 1 through October 15, 1996 (the epidemic period). A case-patient was defined as a patient with postoperative surgical-site complications (surgical-site drainage, edema, or swelling) requiring surgical debridement. RESULTS: Of the 148 patients who underwent a laminectomy during the epidemic period, 17 (11%) met our case definition. The rate of postoperative surgical debridement was 7.6-fold higher during the epidemic period than the preceding 19-month period (17/148 vs 15/995, P<.001). Development of surgical-site complications was associated with intraoperative receipt of morphine nerve paste (relative risk [RR], 11; P<.001), preoperative shaving by nurses rather than surgeons (RR, 6.6; P=.006), procedures done by a certain surgeon (RR, 3.1; P=.022), or receipt of iodine rather than povidone-iodine for preoperative skin antisepsis (RR, 5.1; P=.002). In multivariate analysis, only receipt of morphine nerve paste remained as a risk factor (RR, 18; P=.011). The paste was used to control postoperative pain and was applied directly to exposed dura and surrounding tissues. At the time of surgical debridement (median, 24 days postsurgery), the original surgical sites showed residual paste and a lack of healing. Ten of 16 cultures from surgical sites were positive; all but three grew skin commensals. Histological examination of surgical specimens showed a foreign-body reaction, but no marked acute inflammation. CONCLUSIONS: The intraoperative use of morphine nerve paste may delay wound healing and increase postoperative morbidity. When new products are introduced, standardized protocols should be developed for their use, and systematic surveillance should be done to monitor for potential adverse outcomes.

Administration, Cutaneous↗