Klinikum Lüdenscheid

Increasing evidence suggests that RT and ICI have synergistic effects on anti-tumor immune response, and abscopal responses (AR) have been described more frequently with this combination. Here, we analyzed the frequency and factors associated with AR in NSCLC patients receiving ICI and RT. In ARTIC (ARO 2022-10, DRKS00032390), a multicenter, retrospective study, patients treated with RT for progressive disease during or after receiving ICI were analyzed for abscopal benefit (AB) and overall survival (OS). Patients were grouped by non-irradiated lesion response; logistic and Cox regression were used to analyze factors linked to AR, AB, and OS. Fifty-six patients from 13 centers with 137 non-irradiated lesions were analyzed. Most received hypofractionated or stereotactic RT. The most common RT sites were lung, bone, and brain. Thirty-three patients showed AB, with 15 patients developing an AR in at least one non-irradiated lesion. In the logistic regression analysis, older age was associated with a higher rate of AP (odds ratio (OR): 1.07, 95%-CI: 1.00-1.14; p=0.05). Male sex showed a trend towards higher risk of AP (OR=3.13; 95%- CI: 0.93-11.86; p=0.075). In the multivariable Cox analysis, ECOG performance score at the start of RT (hazard ratio (HR): 0.29, 95%-CI: 0.12-0.69; p<0.01) and oligometastatic disease (HR: 0.34, 95%-CI: 0.12-0.94; p=0.039) were significantly associated with improved OS. RT was able to induce AR in some NSCLC patients who were progressive under ICI, possibly delaying a switch in systemic treatment. AB was less frequent in older patients and in men.

Up to one third of patients with an implantable cardioverter defibrillator (ICD) experience shock discharges in the last 24 h before death, which no longer have any therapeutic benefit. Even in patients who have aliving will (do not resuscitate, DNR, directive), the shock function of the ICD is activated in over 50% of those affected 24 h before death. Asignificant subgroup of ICD wearers must therefore experience painful, significantly stressful and unnecessary ICD shocks at the hour of their death. All available position papers on this topic call for patients to be informed about this issue in good time; however, in reality such aconversation almost never takes place. This paper outlines the legal basis that helps doctors to deactivate the ICD in the final stage of life and the specific conditions that must be met. This paper advocates repeatedly addressing the issue during the course of the illness and to involve relatives. The actual conversation about deactivation at the end of life should be proactively initiated by the responsible attending physician and should take the form of astructured, patient-centered dialogue in the spirit of good dialogue.

BackgroundSeasonal Influenza is a major cause of morbidity and mortality worldwide. Despite the well-established preventive role of the influenza vaccine particularly for patients at high risk, influenza vaccine uptake remains suboptimal. In Jordan, data on the influenza vaccine uptake among adults with chronic diseases at high risk of influenza complications is still lacking.MethodsA cross-sectional study was conducted to assess influenza vaccine knowledge, attitudes, uptake, and barriers among adults with selected chronic disease in Jordan. Data was collected via a structured questionnaire based on the health belief model (HBM). The face-to-face interviews were conducted between February and June 2023 at multiple healthcare centers and hospitals are representative sites of Jordan.ResultsA total of 786 participants completed the study questionnaire with a mean age of 50.04 ± 15.9 years. There was a low uptake rate of influenza vaccine (10.4%) during the 2022/2023 season, while around one third of participants (32.7%) reported history of been ever vaccinated against influenza. This study identified different predictors of influenza vaccine uptake such as advice from the healthcare professional, history of complications from influenza, availability of free influenza vaccine and awareness about the vaccine availability. Worry about the vaccine safety was one of the important detected barriers.ConclusionSimilar to the global trend, particularly in developing countries, the influenza vaccine uptake rate is low among adults with different high-risk illnesses in Jordan. Results of the study provided baseline data for future interventions to improve the uptake rates of influenza vaccines in Jordan.

BackgroundThe number of CIEDs implantations has steadily increased over the past decade and is one of the most common procedures in cardiology. There are approximately 230 actively implanting hospitals in the German federal state North Rhine-Westphalia (NRW) with 17.9 million inhabitants. A large variation in implantation numbers exists between hospitals, from < 10 to 1,234 cases per year. Peri-/post-operative complications (C) such as pneumothorax, hemothorax, pericardial effusion, pocket hematoma, wound infection and lead problems (dislocation and dysfunction) are not uncommon after pacemaker (PM) and defibrillator (ICD) implantation. We analyzed whether the C rate depends on the number of implantations in the hospital which has not been clarified statistically for such a wide variability of implantation procedures.MethodsThe analysis is based on the data of all first implantation of CIEDs (including CRT systems) performed between January 1st, 2010 and December 31st, 2020 in any hospital in NRW. All peri-/post-operative C documented as part of the mandatory quality assurance were recorded. A potential association between implantation volume and quality (VOR) was evaluated using the statistical software R, based on the report on "Data evaluation on minimum quantities" (IQTIG 2020). The method includes risk adjustment and takes into account the high statistical uncertainty with small case numbers.ResultsA total of 249,615 cases were examined (PM 73.4%, ICD 26.6%, male 61.3%). ICD patients (pts) were younger (66 y) than PM pts (76 y, p < 0.001). The total number of C was 2.4% (PM 2.6%, ICD 1.6, p<0.001). The most C was lead related at 1.5% (PM 1.7%, ICD 0.7%, p<0.001). Pts with C were older (median 78 y vs 76 y, p<0.001). The forest plot analysis of the general risk factors resulted in an odds ratio (OR) in PM/ICD pts for the ASA class 3 of 1.7/2.1 and the class 4 of 4.2/6.1 (reference ASA class 1). ORs for the type of PM-system were 1.5/2.2 for DDD and 1.0/2.1 for CRT (reference VVI). The VOR revealed a statistically significant relationship between the number of implantations and the occurrence of C, especially for PM patients (p<0.001, AUC 0.7) (see figure). Further evaluation showed that, for example, with a cut-off of 50 annual implantations ~59 of 377 (~16%) C could be avoided and ~2,500 of 16,073 (~16%) pts would have to be redirected to other hospitals. In case of cut-off of 25 annual implantations ~30 of 377 (~8%) C could be avoided and ~850 of 16,073 (~5%) pts. would have to be redirected to other hospitals.ConclusionIn addition to the risk factors that have been analyzed in the literature, such as age, high ASA class or type of system, the VOR demonstrated a significant influence of the implantation volume. With a relevant number of possibly avoidable C, minimum quantities can be justified and consequences can be estimated.VOR for PM implantations in 2010-2020

Background/Objective: Previous studies have indicated a higher incidence of complications associated with dual-lead devices compared to single-lead devices. This retrospective study aimed to investigate the effect of lead count and other factors on peri/postoperative complications for new pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantations in a representative German cohort. Methods: In accordance with quality assurance (QS) requirements, all hospitals in Germany collect patient-specific data on cardiac device implantation. We utilized the QS database from North Rhine-Westphalia to analyze data from 169,547 patients who underwent PM (n = 137,208) or ICD (n = 32,339) implantation between 2010 and 2014. The primary endpoint was the incidence of perioperative complications in the PM and ICD groups, analyzed separately for single- and dual-lead systems. Regression analysis was performed to identify specific risk factors and the effect of lead number on complications. Results: In the PM group, patients with dual-lead devices experienced significantly more complications than those with single-lead devices (3.27% vs. 2.85%, p < 0.001), largely driven by lead dislocations. In the ICD group, no significant difference in complication rates was observed between single-lead and dual-lead devices (1.39% vs. 1.46%, p = 0.635). The risk of complications was over twice as high for PM implantation compared to ICD implantation (3.17% vs. 1.42%). Patients with intrahospital complications faced a significantly higher risk of mortality than those without complications (PM: 4.5% vs. 1.6%; ICD: 3.9% vs. 0.5%). Independent risk factors for complications and mortality were identified in both groups, with a notable increase in the risk of intrahospital mortality associated with complications. Conclusions: Complications of dual-lead PM implantations are higher than single-lead procedures, mostly due to lead dislocations. Such a difference, though, was not observed in ICD implantations. Our findings may help optimize procedural strategies to improve patient safety, especially in PM implantations.

Introduction: We used CBCT application as one-stop-shop nodule orientated approach in regards to increase DY, reduce complication rate, reduce time on-table and economical costs with classical peripheral instruments including mini-cryoprobe (ERBE 1,1mm), rEBUS (Olympus) and standard RUFBs (Olympus Company) with at least 2mm working channel and 4,2mm outer diameter for the diagnosis of peripheral targets (iSPNs) in a prospective all-comers registry after detailed analysis of pre-interventional CT for vessel- and bronchus sign classes. Materials and Methods: From Jun 2017 until Nov 2019 in 90 all-comers patients between 16 and 95 years fit for bronchoscopy with 101 peripheral lesions in a daily routine scheme after informed consent about this prospective registry were included. For histological proven benign disease in any lesion patients had to adhere FU according radiological guidelines and further on by re-visits for at least 2 years after biopsy resulting into last visit in Feb 2022 without any drop-out. Present HRCT was mandatory to achieve one day before intervention. It had to be decided by the examiner mainly after analysis of the preset HRCT which of the 3 CBCT driven modalities were used for diagnostical approach: A) Pure endobronchial approach (CBCT, rEBUS, TBB), B) Pure transthoracical approach with a 21G core-biopsy needle (BIOPINCE needle) with CBCT only, or C) Combined approach as described below (CBCT, rEBUS, TTNA). As instruments were available common forceps and needles, EWC, curette and various RUFB (Olympus Company) mentioned in the materials section. A second CBCT was only allowed in the combined approach group to plan the 3D transthoracic approach in expiration whereas even a CBCT for tool-in-lesion control (TIL CBCT) was never allowed in all 3 groups. Results: In 100 lesions predefined modalities pure endobiopsy, pure TTNA and combined approaches were performed in 77, 9 and 14 lesions respectively without any pneumothorax or bleeding. In these 3 modalities we found confirmed (mostly specific) benign and malignant cases 47 and 30, 4 and 5, 2 and 12 respectively. Lesion sizes in the 3 different groups were (median, mean) 14 and 17,7mm (of those 41 invisible of 77 under XR (53%) in the pure endobiopsy group), 27 and 31mm (11% invisible under XR in the pure TTNA group), 18,5 and 23mm (35% invisible under XR in the combined group) respectively. In the 3 groups for the malignant cases 25 of 30, 5 of 5 and 12 of 12 were diagnosed correctly rendering a diagnostical yield of 42 in 47 malignant cases for the whole algorithm (89,4%) with sizes (mean, median) for the whole algorithm of 16 and 19,7mm respectively which is comparable to published data for robotic-assisted bronchoscopy yield. In regards to vessel sign analysis it has to be clearly stated that the significance level for outcome prediction is inferior to bronchus sign analysis. In multivariate analysis there was a clear tendency towards higher outcome prediction especially if a pulmonary artery branch leads into such target even when a bronchus sign is missing. For NY when comparing univariate analysis and partition model analysis at a set diameter of >11mm with significance (p=0,0052) the additional advantage of analysing a given vessel sign (especially pulmonary artery branches) seems to add on 19% of valuable outcome prediction. Conclusion: A nodule orientated approach in a manual CBCT-AF environment including typical instruments renders in experienced hands comparable results to robotic assisted bronchoscopy even without UTN bronchoscopes or other specialized, therefore expensive tools. In multivariate analysis only bronchus sign analysis revealed significant (p = 0,05) prediction of navigational yield outcome prediction whereas vessel sign analysis increases highly the odds ratio in favor of positive outcome prediction but without significance at the given level. In a partition model to erase outliers at a set iSPN diameter >11mm vessel sign analysis (especially pulmonary artery branches) renders a significant and ameliorated prediction of NY.

Spreading depolarizations (SD) contribute to lesion progression after experimental focal cerebral ischemia while such correlation has never been shown in stroke patients. In this prospective, diagnostic study, we investigate the association of SDs and secondary infarct progression after malignant hemispheric stroke. SDs were continuously monitored for 3–9 days with electrocorticography after decompressive hemicraniectomy for malignant hemispheric stroke. To ensure valid detection and analysis of SDs, a threshold based on the electrocorticographic baseline activity was calculated to identify valid electrocorticographic recordings. Subsequently SD characteristics were analyzed in association to infarct progression based on serial MRI. Overall, 62 patients with a mean stroke volume of 289.6 ± 68 cm3 were included. Valid electrocorticographic recordings were found in 44/62 patients with a mean recording duration of 139.6 ± 26.5 hours and 52.5 ± 39.5 SDs per patient. Infarct progression of more than 5% was found in 21/44 patients. While the number of SDs was similar between patients with and without infarct progression, the SD-induced depression duration per day was significantly longer in patients with infarct progression (593.8 vs. 314.1 minutes; *p = 0.046). Therefore, infarct progression is associated with a prolonged SD-induced depression duration. Real-time analysis of electrocorticographic recordings may identify secondary stroke progression and help implementing targeted management strategies.