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Biomedical subjects

P Kalmár

Publications and source records attributed to P Kalmár.

At least 19 recordsLinked to original sources
PubMed2006

[Clinical pathways: experiences, expectations, and perspectives].

Due to economic necessities, existing reserves in clinical practice have to be used efficiently. The presentation of medical activity and systematic illustration of medical decisions in the form of clinical pathways constitute important tools to ensure the quality of patient care under fiscal pressure caused by the DRG system. To successfully establish clinical pathways, the architecture of the standard operating procedures developed specifically for a hospital must adequately reflect medical concerns and patient-related needs. The concept of necessity for the good of the patient applies in this instance rather than the principle of the complete depiction of all medical processes. Organizing the implementation into clinical practice should be assured and monitored. The standard operating procedures should be regularly adapted to suit medical developments. Success with the procedure should be reported and deviations from predetermined targets should be documented. A clinical pathway does not represent an administrative end in itself but rather a part of a higher control system that helps to improve the utilisation of the hospital's resources in terms of reliability and quality of patient care.

Communication↗
PubMed2001

Which factors render cost-covering lump-sum charging difficult for the treatment of patients with acute leukemias?

BACKGROUND: Growing budget limitations and the planned charging subject to Diagnosis-Related Groups (DRG) points raise the question as to what costs are incurred by the induction therapy and early consolidation treatment of patients with acute myeloid leukemias (AML) and whether these can be compensated in a cost-covering manner by a system based on DRG points. PATIENTS AND METHODS: For 100 patients recruited within the framework of the "Kooperative AML-Studie 96" of the Süddeutsche Hämoblastosegruppe a process cost analysis was made between 1996 and 1999. All manpower and material costs incurred in the department itself and in the secondary services departments as well as the basic cost shares were recorded taking into due account the length of stay. The cost breakdown was effected based on a double induction therapy and one early consolidation treatment. RESULTS: It turns out that substantial differences exist between lower und upper limits of the length of stay and costs. For all three therapy blocks for patients up to 60 years the cost spread varies between 63 and 204 kDM with a median of 105 kDM, and for older patients between 55.6 and 146.6 kDM with a median of 87.6 kDM. On average, the costs subject to length of stay were roughly 70%. CONCLUSIONS: As the costs per case are subject to a spread and, for this relatively small group of patients, are extremely high, the fixing of a case-related lump sum is problematic, the more so as age of patient, comorbidity, type of therapy, ist outcome, and therapy-induced complications represent decisive influencing factors.

Adult↗
PubMed2000

[Aortic valve replacement with homografts. An overview].

The implantation of fresh or cryopreserved human heart valves (homografts) in aortic position is a tool in cardiac surgery since 30 years. Homografts are attractive alternatives to the implantation of mechanical or xenobiological prostheses, because anticoagulation can be avoided and a near normal anatomy can be restored. Physicians should know about the several kinds of grafts and operative techniques to adequately take care of the patients in follow-up. This overview on the literature covers methods of harvesting, preparation and conservation of homografts according to standard protocols of the European Homograft Bank in Brussels. Their use in the therapy of human valvular disease is discussed with special emphasis to operative techniques (subcoronary, root) and the Ross procedure and in pediatric surgery. Complications and aspects of postoperative care are discussed including immunologic phenomena. Homografts are useful tools for aortic valve replacement, especially in juveniles, in the presence of contraindications for anticoagulation and in endocarditis. Whereas aortic homografts have excellent long-term results, pulmonic homografts show a significant rate of malfunction. Further studies should be performed to clarify the role of the Ross operation or stentless xenografts compared to homografts in aortic position. In pediatric cardiac surgery homografts are of value especially for the reconstruction of the right ventricular outflow tract. Homografts in mitral position show disappointing results up to now. The major limitation in the use of homografts is the mismatch of availability and request, therefore homografts can only be used for the above mentioned special indications.

Animals↗
PubMed1998

Expression of CTLA-4 (CD152) on human medullary CD4+ thymocytes.

CTLA-4 (CD152) is a T cell surface receptor with sequence homology to the co-stimulatory molecule CD28. The molecule, which is essential for the inhibitory regulation of the immune response, becomes transiently expressed on mature T cells after stimulation in vitro. In situ, CTLA-4+ T cells are enriched in the light zones of the germinal centers in human peripheral lymphoid organs. In this study we have studied expression of CTLA-4 in human thymus in situ. CTLA-4 was expressed on about one third of CD4+/CD8-/CD1- medullary thymocytes. CTLA-4 was acquired by a subset of immature (CD1+) thymocytes and lost from the mature (CD1-) subpopulation within 48 h of cell culture, suggesting that the expression on medullary thymocytes is transient. The demonstration of CTLA-4 on a substantial subpopulation of mature CD4+ thymocytes adds a new dimension to the understanding of this important molecule. When contemplating application of anti-CTLA-4 for therapy its potential influence on T cell maturation has to be taken into account.

Abatacept↗
PubMed1998

Long-term hemodynamic benefit of atrial synchronization with A2A2D or A2A2T pacing in sinus node syndrome after orthotopic heart transplantation.

BACKGROUND: Exercise capacity after heart transplantation (HTx) may be limited by sinus node disease of the donor heart and atrioatrial dissociation. The role of pacemaker therapy in this setting is not well defined. The purpose of this study was to compare clinical and hemodynamic data of heart transplant recipients with acquired sinus node disease treated with atrial synchronized pacing and patients with other pacing modes or without pacemakers 1 year after operation. METHODS: Our cohort comprises a total of 112 HTx recipients from the years 1984 to 1996. Atrial synchronized pacing was performed in 21 patients with donor sinus node disease and recipient sinus rhythm. There was no associated morbidity or death for the pacemaker implantation. Fourteen patients received a dual-chamber pacemaker programmed with a short atrioventricular-Delay in A2A2D mode (donor atrial pacing triggered by recipient atrial sensing or both atria stimulated on demand); in the last 6 consecutive patients a single-chamber pacemaker was implanted with two unipolar leads to the atria connected with a Y adapter programmed in A2A2T mode (both atria were sensed and stimulated by triggering each other). RESULTS: Signals and thresholds remain stable over time. When clinical and hemodynamic data of 12 A2A2D/T patients with complete 1 year follow-up were compared to age- and sex-matched control HTx recipients with other pacing modes or without pacemakers, a significant benefit of atrial synchronization could be shown regarding rise in heart rate response to exercise (+38% vs 30% vs 16% at 50 watt), New York Heart Association classification (1.6 vs 1.8 vs 2.2), Roskamm staging (1.3 vs 2.5 vs 1.5), cardiac index at rest (3.2 vs 2.78 vs 3.1 L/min x m2), cardiac index at 50 watt (5.5 vs 4.5 vs 5.2 L/min x m2), stroke work at rest (51 vs 38 vs 42 pondmeter [PM]), stroke work at 50 watt (66 vs 48 vs 51 PM), pulmonary wedge pressure at rest (7 vs 13 vs 8 mm Hg) and pulmonary wedge pressure at 50 watt (14 vs 24 vs 18 mm Hg). CONCLUSION: It is concluded that electromechanical synchronization of the atria was of long-term benefit in heart transplant recipients with recipient sinus rhythm and donor sinus node disease.

Arrhythmia, Sinus↗
PubMed1997

Smoking after heart transplantation: an underestimated hazard?

OBJECTIVE: Risk factors for the development of vasculopathy and malignancies as the most important causes of morbidity and mortality after heart transplantation are not well defined. METHODS: Univariate and multivariate Cox regression analysis of the data derived from our 84 survivors of more than 3 months after orthotopic heart transplantation between 1984 and 1996. Measurement of carbonmonoxide-hemoglobin blood levels with an ABL 520 analyzer. RESULTS: Recipient or donor age, the mode of immunosuppression, total-, LDL- and HDL-cholesterol, the HDL/LDL-ratio, triglycerides, hypertension, diabetes mellitus, CMV status and rejection episodes had no independent influence on total mortality or the occurrence of graft vasculopathy or cancer. By means of an intensive questionnaire (in case of deceased patients, by their relatives) and measurement of CO-Hb blood levels we detected a high rate of patients who smoked after transplantation (22/84 = 26%). Four patients confessed smoking after undergoing the blood test. Non-smokers were defined as denying it in the questionnaire and having CO-Mb levels < 2.5% in repeated measurements. All but one were smokers before heart transplantation. Mean consumption was 11 cigarettes per day. Five and 10 years survival was significantly reduced in smokers vs. non-smokers (37 vs. 80% and 10 vs. 74%, respectively, P < 0.0001). Survival curves diverged dramatically after 4 years of observation. Smokers had a higher prevalence of transplant vasculopathy as revealed by coronary angiography and/or autopsy (10/22 smokers vs. 2/62 non-smokers, P < 0.00001) and a higher rate of malignancies (7/22 smokers developed cancer, as compared to 4 cancers in 62 non-smokers, P = 0.0001). The primary site of cancer was the lung in 5/6 smoking and lymphoma in all non-smoking cancer patients. CONCLUSIONS: Our data show that the prevalence of smoking after heart transplantation may be relatively high, especially in former smokers. Repeated measurements of CO-Hb could be helpful in its detection. Despite a relatively low cigarette count, smoking is a major risk factor of morbidity and mortality after heart transplantation (HTx). Approximately 4 years of exposure time is needed to uncover its negative influence. These findings should lead to aggressive smoking screening and weaning programs in every HTx center.

Carboxyhemoglobin↗
PubMed1996

Positive inotropic effects of the calcium sensitizer CGP 48506 in failing human myocardium.

In trabeculae carneae from failing human myocardium, CGP 48506 increased the force of contraction, which reached 310 +/- 41% of predrug values at 100 mumol/l. Its stereoisomer CGP 48508 did not affect the force of contraction (100 mumol/l). The positive inotropic effect of CGP 48506 was not sensitive to 10 mumol/l carbachol. The positive inotropic effect of CGP 48506 was accompanied by increases in time to peak tension and time of relaxation amounting to 175 +/- 4% and 205 +/- 15% of control, respectively, at 100 mumol/l. CGP 48506 but not CGP 48508 sensitized skinned trabeculae from failing human myocardium to calcium with an EC50 value of 10 mumol/l. However, CGP 48506 and CGP 48508 (up to 300 mumol/l) did not affect the activity of PDE isoenzymes I to IV from failing human myocardium. CGP 48506 is the first inotropic agent with calcium-sensitizing properties in the human heart that has been found to be devoid of inhibitory activity on human cardiac PDE isoenzymes.

1-Methyl-3-isobutylxanthine↗
PubMed1996

[Delayed surgical therapy of acute aortic rupture].

Immediate surgical treatment of traumatic aneurysms of the aorta is in our point of view in most cases problematic, also because of the combination with life threatening injuries of other organ systems. In our own patient-collection seven patients out of 44 with traumatic transsection were immediately operated. Six patients died in tabula, three of them due to uncontrollable hemorrhage. An analysis of over 5,000 post mortem findings from the department of forensic medicine in Hamburg revealed that injuries of the aorta lead in 98.3% to death in the first two hours after the accident. This shows that only a small number of injured victims survive. The danger of a two stage rupture is judged differently. We did not observe this problem in the patients with aortic lesion following blunt chest trauma and stable conditions who had first undergone treatment for other injuries and therefore operated in the interval period after two to ten weeks. With this strategy the lethality involving surgical management of aortic injuries in our unit decreased to 13%.

Adolescent↗
PubMed1996

[Quality assurance in heart surgery in Germany. Development, current status and outlook].

In a multicenter pilot study and with the support of the German Federal Ministry of Research and Technology, a commission of the German Association for Thoracic, Cardiac and Vascular Surgery developed a procedure for cardiosurgical quality assurance. After concluding the pilot phase, the data were reduced for general practicability to the essential characteristics and now comprise 205 items. After a cooperation contract between funding agents, the German Hospital Association, The German Federal Hospital Association and the German Association for Thoracic, Cardiac and Vascular Surgery, The Federal Working Group on Cardiosurgical Quality Assurance was founded. Under supervision of a federal board, the practical work is performed in a project office, which works closely together with a board of cardio-surgeons. The quality assurance comprises almost all cardiac surgery performed on adults. The data collected in the hospitals are drawn by the office into comparative statistics that allow judgement of the quality.

Adult↗
PubMed1995

[Successful operation of a symptomatic aneurysm of the superior mesenteric artery in a child with Ehlers-Danlos syndrome].

Bleeding of an aneurysm--especially of a great vessel--represents a complication of Ehlers-Danlos syndrome that is often lethal. A successful operation of a symptomatic aneurysm of the superior mesenteric artery in a 12-year old girl with an Ehlers-Danlos syndrome type VI is reported. The aneurysm was resected and replaced by a venous graft. Four years postoperatively the artery is perfectly patent; a new aneurysm did not develop.

Aneurysm↗
PubMed1993

Changes in cardiac beta-adrenoceptors in human heart diseases: relationship to the degree of heart failure and further evidence for etiology-related regulation of beta 1 and beta 2 subtypes.

Radioligand binding studies were performed to investigate total beta-adrenoceptor density (Bmax) and beta 1 and beta 2 subtype distribution in left ventricular biopsies obtained from 8 prospective transplant donors serving as controls and from 143 patients with different degrees of heart failure (NYHA class II to IV) undergoing aortic or mitral valve surgery due to aortic or mitral stenosis, aortic or mitral regurgitation, as well as combined aortic or mitral valve lesions (stenosis and regurgitation). In 13 other patients, heart failure was due to hypertrophic obstructive cardiomyopathy (N = 6, NYHA III), tetralogy of Fallot (N = 4, NYHA III), or Becker's muscular dystrophy (N = 3, NYHA IV). Bmax was assessed by (-)-(125I)-iodocyanopindolol used as radioligand. Competition experiments with the highly selective beta 1-adrenoceptor antagonist CGP 20712A were performed for determination of beta 1- and beta 2-adrenoceptor subtypes. In biopsies taken from transplant donors, the Bmax was found to be 70.1 +/- 5.8 fmol/mg protein. In all groups investigated the extent of total beta-adrenoceptor downregulation was related to the degree of heart failure. The decrease in Bmax was found to be about 20% (NYHA II), 45% (NYHA III), and 60% (NYHA IV) when compared with controls. There was no significant difference in the reduction of total beta-adrenoceptor density between isolated aortic or mitral valve diseases and combined valve lesions. Independent of the degree of heart failure, selective downregulation of the beta 1 subtype was found in patients with isolated or combined aortic valve diseases, hypertrophic obstructive cardiomyopathy, and Becker's muscular dystrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗