Leistungsmessgrössen in der Grundversorgung von Patienten mit COPD – eine Analyse Zusammenfassung. Hintergrund: Das Befolgen der Empfehlungen für ein gutes Management der chronisch-obstruktiven Lungenkrankheit (COPD) verbessert wichtige Endpunkte. Leistungsmessgrössen (LM) reflektieren die Qualität der Betreuung, dennoch existieren über die Dokumentation dieser Messgrössen bei COPD für die Grundversorgung kaum Daten. Ziel: Überprüfen der Dokumentation von COPD spezifischen Messgrössen in Grundversorgerpraxen des Kanton Zürich. Methode: Retrospektive Auswertung der Krankengeschichten von Patienten mit ärztlich diagnostizierter COPD, über einen Zeitraum von zwölf Monaten. Die Dokumentation der LM wurde durch Berechnen des Prozentsatzes der dokumentierten Parameter bewertet. Zusätzlich erfolgte ein Vergleich der LM Dokumentation mit einer Praxis, die ein strukturiertes COPD-Programm implementiert hatte. Resultate: Es wurden Daten von 115 Patienten aus 14 Praxen, davon 57% männlich, mit einem Durchschnittsalter von 68 (44–93) Jahren, analysiert. 46% waren aktive Raucher mit 56 (22–150 py) Packyears. Komorbiditäten waren in 73% der Fälle dokumentiert, der Schweregrad mit GOLD-Klassifizierung in 70% (GOLD I 11%, GOLD II 64%, GOLD III 21%, GOLD IV 4%).Gemäss Dokumentation hatten die Patienten durchschnittlich 1,4 Exazerbationen pro Jahr. Die Dokumentation der LM lag zwischen 16% (schriftlicher Aktionsplan im Falle von Exazerbationen) und 95% (Raucherstatus). Eine Dokumentation für eine Rauchstopp-Empfehlung fand sich in 74% der Fälle, für die Grippeimpfung in 49%. Eine adäquate medikamentöse Therapie und Instruktion der Inhalation war für 65 bzw. 57%, für pulmonale Rehabilitation in 27% der Patienten dokumentiert. Angaben zu einer kollaborativen und proaktiven Betreuung fanden sich bei 60 resp. 51%. Die Praxis mit dem laufenden COPD-Programm zeigte eine signifikant bessere Dokumentation (p<0,01) für alle LM ausser für die Grippeimpfung. Schlussfolgerung: In der Schweizer Grundversorgung bestehen Lücken in der Dokumentation hinsichtlich der Empfehlungen für eine nutzbringende COPD-Versorgung. Die Identifikation und Überbrückung dieser Lücken ist zentral für mehr Qualität in der Gesundheitsversorgung.

Metastatic melanoma is a highly aggressive disease. Recent progress in immunotherapy (IT) and targeted therapy (TT) has led to significant improvements in response and survival rates in metastatic melanoma patients. The current project aims to determine the benefit of the introduction of these new therapies in advanced melanoma across several regions of Switzerland. This is a retrospective multicenter analysis of 395 advanced melanoma patients treated with standard chemotherapy, checkpoint inhibitors, and kinase inhibitors from January 2008 until December 2014. The 1-year survival was 69% (n=121) in patients treated with checkpoint inhibitors (IT), 50% in patients treated with TTs (n=113), 85% in the IT+TT group (n=66), and 38% in patients treated with standard chemotherapy (n=95). The median overall survival (mOS) from first systemic treatment in the entire study cohort was 16.9 months. mOS of patients treated either with checkpoint or kinase inhibitors (n=300, 14.6 months) between 2008 and 2014 was significantly improved (P<0.0001) compared with patients treated with standard chemotherapy in 2008–2009 (n=95, 7.4 months). mOS of 61 patients with brain metastases at stage IV was 8.1 versus 12.5 months for patients without at stage IV (n=334), therefore being significantly different (P=0.00065). Furthermore, a significant reduction in hospitalization duration compared with chemotherapy was noted. Treatment with checkpoint and kinase inhibitors beyond clinical trials significantly improves the mOS in real life and the results are consistent with published prospective trial data.

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Aims Despite their low individual metastatic potential, thin melanomas (≤1 mm Breslow thickness) contribute significantly to melanoma mortality overall. Therefore, identification of prognostic biomarkers is particularly important in this subgroup of melanoma. Prompted by preclinical results, we investigated cyclin D1 protein and Ki‐67 expression in in‐situ, metastatic and non‐metastatic thin melanomas. Methods and results Immunohistochemistry was performed on 112 melanoma specimens, comprising 22 in situ, 48 non‐metastatic and 42 metastatic thin melanomas. Overall, epidermal and dermal cyclin D1 and Ki‐67 expression were semiquantitatively evaluated by three independent investigators and compared between groups. Epidermal Ki‐67 expression did not differ statistically in in‐situ and invasive melanoma (P = 0.7). Epidermal cyclin D1 expression was significantly higher in thin invasive than in in‐situ melanoma (P = 0.003). No difference was found in cyclin D1 expression between metastatic and non‐metastatic invasive tumours. Metastatic and non‐metastatic thin melanomas did not show significant differences in epidermal expression of Ki‐67 and cyclin D1 (P = 0.148 and P = 0.611, respectively). In contrast, strong dermal expression of Ki‐67 was more frequent in metastatic than non‐metastatic samples (28.6 versus 8.3%, respectively, P = 0.001). The prognostic value of dermal Ki‐67 expression was confirmed by multivariate analysis (P = 0.047). Conclusion We found an increased expression of cyclin D1 in invasive thin melanomas compared to in‐situ melanomas, which supports a potential role of this protein in early invasion in melanoma, as suggested by preclinical findings. Moreover, our results confirm that high dermal Ki‐67 expression is associated with an increased risk of development of metastasis in thin melanoma and could possibly serve as a prognostic biomarker in clinical practice, especially if combined with additional methods.

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Vascular auscultation is known to be of great use in routine clinical practice in recognising arterial abnormalities. Diagnosis of PAD is based on various diagnostic tools (pulse palpation, ABI measurement) and auscultation can localise relevant stenosis. However, auscultation alone is of limited sensitivity and specificity in grading stenosis in femoropopliteal arteries. Where PAD is clinically suspected further diagnostic tools, especially colour-coded duplex ultrasound, should be employed to quantify the underlying lesion.

Introduction:We looked at the reasons why fluorescent cholangiography (FC) should be used routinely in laparoscopic cholecystectomy (LC). Method: A single dose of 0.05 mg/kg of Indocyanin Green (ICG) was administered intravenously one hour prior to the surgery to perform fluorescent cholangiograhy. Results: FC could be performed in all 45 (100%) patients whereas intra-operative cholangiography (IOC) could be performed in 42 out of 45 (93%) patients (p < 0.078). Individual median cost of performing FC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 US dollars per patient, p = 0.0001). The mean operative time was 64.95 ± 17.43 minutes. FC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by FC in 44 out of 45 patients (97.77 %). The residents were able to identify the extrahepatic structures in all 45 cases (100%) with FC. No complications were detected related to surgery and the use of FC. Learning curve was not necessary to identify structures using FC. X-ray leads were only used for IOC. FC could be performed by all residents at different level of training in 100% of the cases. Smooth dissection, transection and resection could be safely performed in 45 cases (100%). Conclusion: Fluorescent cholangiography seems to be feasible, cheap, expeditious, useful, an effective teaching tool, safe, no learning curve is necessary, does not require x-ray and easy to perform. It can be used for real time surgery to delineate the extrahepatic biliary structures.Background: Objective of this study is to compare rates of pancreatic fistulas and complications following the Whipple operation between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG).Methods: 98 patients undergoing Whipple resection were randomized to either PG (48) or PJ (50) reconstruction. T-test and Chi-square tests were used for intention to treat data analysis. Logistic regression was used to measure the influence of surgical technique, preoperative ASA score and soft pancreatic gland on overall complications, severe post operative complications and overall fistula rates. Results: The rate of pancreatic fistula formation was 18% (Grade A = 6%, B = 10%, C = 2%) in the PJ arm and 25% (Grade A = 8%, B = 13%, C = 4%) in the PG arm, p = 0.399. The rate of postoperative complications was 48% (Clavien 1 = 14%, 2 = 36%, 3 = 10%, 4 = 0%, 5 = 2%) in the PJ and 58% (Clavien 1 = 21%, 2 = 38%, 3 = 25%, 4 = 6%, 5 = 4%) in the PG arm, p = 0.306. There was a significant difference in severe complications (Clavien 3-5) with 12% in the PJ and 31% in the PG arm, p = 0.02. In the multivariate analysis randomization (together with ASA) was only predictive of severe complications (OR 0.10, p < 0.005 for randomization to PJ reconstruction; OR 11.58, p < 0.05 for ASA 2 and OR 30.89, p < 0.05 for ASA 3 compared to ASA 1). Conclusion: Results of the study suggest that while there are no overall differences in rates of pancreatic leak/fistula and overall complications between PG and PJ arms, pancreaticogastrostomy is associ...