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Biomedical subjects

W Schramm

Publications and source records attributed to W Schramm.

At least 73 records · Page 4Linked to original sources
PubMed1998

Lack of protection from HIV infection by the mutant HIV coreceptor CCR5 in intravenously HIV infected hemophilia patients.

The CCR5 chemokine receptor is an important coreceptor for macrophage-tropic HIV strains. Homozygous carriers of the mutated CCR5 receptor with a 32 bp deletion (delta 32-CCR5) are highly protected against HIV infection. A protective effect has also been described for heterozygous individuals carrying both mutated and wildtype CCR5 receptors. We compared the frequency of the mutated delta 32-CCR5 HIV coreceptor in HIV positive patients infected by sexual contact (N = 160) with intravenously HIV infected hemophilic patients (N = 84) and HIV negative individuals (N = 421). We found no protective effect of delta 32-CCR5 HIV coreceptor in hemophilic patients (p = 0.0134). If proteins of plasma concentrates would be responsible for facilitating the entry of HIV macrophages by upregulation of the CCR5 wildtype receptor it would be of therapeutical interest to identify the responsible plasma proteins.

Female↗
PubMed1998

State-of-the-art principles and practices of medical economics.

In an era of increasing constraints in health care expenditure, it has become necessary for the practising physician to utilise resources economically. Due to expenditure ceilings in many countries, the rational allocation of health care resources has become a central goal in health policy. Medical economics is the discipline which covers the issues of economic evaluation, policy and decision analysis and outcomes research. This paper discusses the fundamentals of this new type of research, highlighting the importance of such results in formulating health policy. Undoubtedly, medical economics will play a similar role as evidence-based medicine and clinical epidemiology in the continuous education within the medical community. This holds specially true for costly indications such as haemophilia and other coagulation disorders.

Economics, Medical↗
PubMed1998

Resource utilisation in haemophiliacs treated in Europe: results from the European Study on Socioeconomic Aspects of Haemophilia Care. The European Socioeconomic Study Group.

The objectives of our study was to answer the following questions: (1) What are the socioeconomic costs and benefits of different haemophilia treatment strategies? (2) Which savings can be achieved through a comprehensive care program? (3) How are haemophiliacs integrated into their social life? (4) What are the annual costs of treating haemophilia from a third party payer perspective? In this cross-sectional study, 840 consecutive haemophiliacs attending 16 haemophiliac treatment centres in 10 European countries at were entered in the study. The following six parameters were analysed: sociodemographic patient data, the type of substitution (on demand or prophylaxis), transfusion-transmitted diseases, the functional joint status, quality of life as well as the total costs of therapy. Three kinds of substitution modalities were distinguished: on demand therapy, pure and modified prophylaxis. The average number of medical visits, the average length of hospital stay, regular drug therapy and the average number of days off work per bleeding joint were recorded from the medical charts as a basis for the subsequent assessment of the costs of therapy. The total study sample comprised of 566 patients. Interestingly, statistically more significant (P = 0.0005) patients were unemployed in the on-demand group (14%) than in the prophylaxis group (3.4%). There was a higher ratio of white collar workers in the on-demand group as compared to the prophylaxis group and vice versa for blue collar workers. The distribution of blue collar workers, clerk, self-employed persons, students and housemen were quite comparable between the patients of the on-demand and prophylactic therapeutic regimen. The labor force participation rate was 55.2% in the patients in the on demand and 59.3% in the patients in the modified prophylactic group. The labor force participation rate across all patients was 56%. Patients on demand therapy used on average 38.3 (median: 12.5) units/kg/week as compared to 68.6 (median: 6) units/kg/week in the prophylaxis group. The mean usage across all patients was 46.1 (median 19.7) units/kg/week. There were an average of 7.4 (median: 3) joint bleeds per patient across all patients during the 6-month observation period. In the on-demand group 8.8 (median: 5) joint bleeds were recorded versus 3.1 joint bleeds (median: 0) in the prophylactic group. This difference was statistically different (95% CI of difference: 4.33-7.07). Our data suggest that patients receiving prophylactic clotting factor therapy require less additional health care resources, mainly due to the reduction in the number of joint bleeds.

Adolescent↗
PubMed1998

Resistance to activated protein C in women using oral contraceptives.

Resistance to activated protein C (APC resistance) is an important and common risk factor for deep vein thrombosis. The majority of patients with APC resistance carry a mutation on the factor V gene at nucleotide position 1691 (G/A), called factor V Leiden mutation. Besides the factor V Leiden mutation several acquired risk factors like lupus anticoagulant, elevated levels of acute phase proteins (increased plasma levels of factor VIII and fibrinogen), pregnancy, or the use of oral contraceptives are known to induce APC resistance in plasma. We studied the effect of oral contraceptives (OC) on hemostasis variables known to be risk factors for venous thromboembolism, especially looking for acquired APC resistance and the plasmatic factors of the protein C system. We studied 821 women, who were randomly selected and enrolled in the BATER- cohort study (Bavarian Thromboembolic Risk Study), which was carried out in Bavaria (Germany) from 1996 to 1997. Current use of any OC type compared with noncurrent use showed a significantly impaired response to APC. There was no difference in APC response among women currently using OCs of different generations. Coagulation factor VIII was the only factor of the protein C pathway that was not altered under OC use. All other plasmatic factors of the protein C system changed in the expected range as described before. On the other hand, coagulation factor VIII was the only factor of the protein C system which negatively correlated with the APC response in the assays applied. Thus, APC resistance is significantly lower in OC users than in nonusers but cannot be attributed to increased factor VIII levels. Whether a decreased response to APC in OC users is of clinical relevance has to be proven in further studies.

Activated Protein C Resistance↗
PubMed1998

Patients with increased intracranial pressure cannot be monitored using near infrared spectroscopy.

The hypothesis of this study was that with near infrared spectroscopy a decrease of the regional cerebral saturation would be detectable in patients with increased intracranial pressure. For this purpose, two study groups were compared: (A) eight healthy volunteers and (B) eight heart beating organ donors with brain stem herniation. The regional cerebral saturation was measured according to the developer's suggestions. Mean arterial pressure and peripheral pulse oximetry were recorded. The statistical comparison, using the unpaired t-test, revealed no significant differences for the regional cerebral saturation (p = 0.97) or for the mean arterial pressure or peripheral pulse oximetry between the groups. In both of the studied situations, no differences in the regional cerebral situation were detectable, even though the patient situations were completely antagonistic. Therefore, it is reasonable to discourage the use of the INVOS 3100 Cerebral Oxymeter to monitor patients with increased intracranial pressure indirectly.

Adult↗
PubMed1998

A simple whole-blood test for detecting antibodies to human immunodeficiency virus.

We developed an immunochromatographic whole-blood test (WBT) which detects antibodies to human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2) from fingerstick blood. The sensitivity and specificity of the WBT were 99.41% (1,018 confirmed positive patients) and 99.89% (941 uninfected patients), respectively (enzyme immunoassay [EIA] on serum or plasma as a reference). WBT performance was comparable to those of licensed EIAs and Western blotting, using 18 HIV-2 sera, 23 HIV-1 seroconversion panels, and a low-titer performance panel (in lieu of whole blood).

HIV Infections↗
PubMed1998

Hyaline membrane disease is underreported in a linked birth-infant death certificate database.

OBJECTIVE: This study compared the Missouri State Department of Health linked birth-infant death certificate database and medical records with respect to recording hyaline membrane disease in very low-birth-weight infants. METHODS: We reviewed the records for all 976 infants weighing 500 to 1500 g who were born to St. Louis, Mo, residents in 1989, 1991, and 1992. RESULTS: Eighteen percent of the birth certificates and 54% of the medical records documented hyaline membrane disease, resulting in 34% sensitivity and 99% specificity. CONCLUSIONS: The Missouri State Department of Health birth-infant death certificate database underestimates the incidence of hyaline membrane disease, which suggest that national statistics for the disease are also underestimated.

Birth Certificates↗
PubMed1997

Consumer reports in health care. Do they make a difference in patient care?

CONTEXT: Consumer reports in health care are a relatively recent phenomenon. Primarily designed to assist consumers in making more informed decisions about their personal health care, they appear to have an important by-product-they led to positive changes in the behavior of clinicians and health care delivery organizations. While there has been much speculation on their impact on health care consumer behavior, consumer reports offer an effective strategy in improving the quality of patient care. OBJECTIVE: To examine the impact of an obstetrics consumer report developed and issued by the Missouri Department of Health on hospital behavior. DESIGN AND SETTING: A retrospective study of hospital behavior using both primary survey and secondary clinical data. PARTICIPANTS: Consumer reports were issued in 1993 to all Missouri hospitals providing obstetrical services (n=90). A survey was conducted a year later, and the results were analyzed with other available data to determine the effect of the report. Two hospitals discontinued obstetrical services by the time of the survey; of the remaining 88 hospitals, 82 (93%) responded to the survey. MAIN OUTCOME MEASURES: The following outcomes were examined: (1) number and percentage of hospitals that previously did not have services at the time report was issued, but had, or planned to have, services after a guide was published; (2) the percentage of obstetrical policies that were changed, planned to change, or are under discussion for change (car seat program, obstetrical follow-up services, formal transfer agreement, nurse educator for breast-feeding, and availability of tubal ligations); and (3) clinical outcomes, including satisfaction, appropriateness of charges, and the rates of cesarean delivery, high-risk infant transfer, ultrasound, vaginal birth after cesarean, very low birth weight, and newborn death. RESULTS: Within 1 year of the report, approximately 50% of hospitals that did not have car seat programs, formal transfer agreements, or nurse educators for breast-feeding prior to the report either instituted or planned to institute these services. Hospitals in competitive markets that did not offer one of these services at the time of the report were more likely to institute a service and/or were about twice as likely to consider improving several indicators. Clinical outcome indicators all improved in the expected direction. CONCLUSION: Public release of consumer reports may be useful not only in assisting consumers to make informed health care choices, but also in facilitating improvement in the quality of hospital services offered and care provided. Changes occur especially in competitive markets.

Cesarean Section↗
PubMed1997

[Neostigmine and edrophonium. Antagonism of profound and shallow mivacurium blockade].

UNLABELLED: Mivacurium has a short duration of action because it is rapidly hydrolysed by plasma cholinesterase. There is ongoing controversy concerning the antagonism of mivacurium-induced neuromuscular block, firstly because of its short spontaneous recovery time, and secondly because the metabolism of mivacurium may be inhibited by anticholinesterases. We therefore compared neostigmine and edrophonium reversal of deep and moderate mivacurium-induced blocks. METHODS: After approval by the local ethics committee, 48 ASA class I and II adult patients were investigated during nitrous oxide-fentanyl-thiopental anaesthesia using train-of-four (TOF) stimulation and monitoring of the isometric force of adduction of a thumb. The patients received 0.2 mg/kg mivacurium i.v. Neuromuscular transmission was allowed to recover spontaneously in 10 patients (group SP). In 2 other groups the neuromuscular block was antagonised by administration of 0.04 mg/kg neostigmine (group N5; n = 9) or 1.0 mg/kg edrophonium (group E5; n = 10) when T1 had recovered spontaneously to 5% of control. In two other groups the neuromuscular block was antagonised with the same doses of neostigmine or edrophonium in 10 patients (group N25) and 9 patients (group E25), respectively, when T1 had recovered spontaneously to 25% of control. RESULTS: Neostigmine or edrophonium administered when T1 had recovered spontaneously to 25% of control shortened the recovery time (time from administration of ant-agonist to a T4/T1-ratio of 0.7) significantly from 10.7 +/- 2.2 min (mean +/- SD) in the SP group to 5.1 +/- 2.0 and 5.3 +/- 1.5 min in the N25 and E25 groups, respectively (P < 0.05). The corresponding recovery times in the SP, N5, and E5 groups were 15.9 +/- 2.9, 10.0 +/- 1.9, and 7.7 +/- 2.2 min, respectively. The difference between the SP and E5 groups was significant (P < 0.05). The recovery indices (time from 25% to 75% recovery of T1) of 3.0 +/- 1.3 and 1.7 +/- 0.9 min for the E5 and E25 groups, respectively, were shorter than those of the SP group at 6.1 +/- 2.0 min (P < 0.05). CONCLUSIONS: Two theoretical reasons, the very rapid onset time and the fact that it does not inhibit plasma cholinesterase, suggest edrophonium to be the preferred antagonist of a mivacurium-induced blockade. These two characteristics are reflected in our results: only edrophonium was able to shorten the recovery index significantly and, administered at a profound level of mivacurium-induced neuromuscular block, only edrophonium was successful in shortening recovery time significantly. Therefore, edrophonium should be the anticholinesterase of choice to antagonise a mivacurium-induced neuromuscular block.

Adolescent↗
PubMed1997

[Recurrent thrombophlebitis and ulcera crurum as manifestations of hereditary blood coagulation disorders and Klinefelter syndrome. Discussion based on 4 case examples].

Recurrent phlebothromboses in young patients with subsequent severe postthrombotic syndrome and chronic venous leg ulcers may be caused by underlying hereditary disorders of hemostasis or may occur as part of other congenital syndromes. The most common hereditary disorders of hemostasis in this respect appear to be deficiencies of antithrombin III, protein C, and protein S, and activated protein C resistance (mutations of factor V). Less frequently, dysfibrinogenemia, increased plasminogen activator inhibitor levels, or deficiencies of tissue plasminogen activator or heparin cofactor II may be found. Klinefelter's syndrome and homocystinuria are prime examples of those rare congenital disorders indirectly associated with an elevated risk of thrombosis in young individuals. Early diagnosis of these disorders will allow timely treatment, preventive care and counselling of patients as well as family members.

Adult↗
PubMed1997

Frequencies of GB virus C/hepatitis G virus genomes and of specific antibodies in German risk and non-risk populations.

The prevalence of the new flavivirus GB virus C/hepatitis virus G (GBV-C/HGV) in different German populations was investigated by detection of viral genomes and anti-E2 antibodies. While blood donors had an overall prevalence of 10.4% there were increased rates for hemophiliacs (54.7%), hemodialysis patients (30.2%), male homosexuals (30.2%) and intravenous drug users (74.4). Most GBV-C/HGV positive samples were either viral genome positive or antibody positive, exclusively. Samples with the rare constellation "positive for both GBV-C/HGV genome and specific antibody" originated in almost all cases from patients who were additionally infected with HIV or HCV. Probable transmission of GBV-C/HGV by PCR-positive blood transfusions was observed in 5 of 6 cases approximately six months after transfusion.

Blood Donors↗
PubMed1996

[Health care economics evaluation of inpatient treatment of venous thrombosis with unfractionated heparin versus subcutaneous low molecular weight heparin at home].

BACKGROUND: An intravenous course of unfractionated heparin as initial treatment is the standard method to treat venous thromboembolism. Increasing scientific knowledge indicates that subcutaneous low-moleculare-weight heparin is just as effective and save as unfractionated heparin. A possible advantage of low-moleculare-weight heparin is the cost saving potential in minor hospitalisation days. Both therapies will be continued for at least three months with an oral anticoagulative. Because hospitalisation belongs to the cost-intensivest factors in the German health care system the question of a health economic difference between both initial treatments raises. METHOD: We transformed published empirical evidences to the German health care system, valued them in a cost analysis for a hypothetical cohort of 100 patients and compared the outcome intertherapeutically. RESULT AND CONCLUSION: From perspective of sickness insurance fund as cost unit we estimate that a partial in hospital initial treatment with subcutaneous low-moleculare-weight heparin is more cost-effective than a total in-hospital initial treatment with unfractionated heparin.

Cost-Benefit Analysis↗
PubMed1996

[Public health economic evaluation of screening for APC resistance (Leiden mutation) in new oral contraceptive users].

BACKGROUND: Thromboembolic events in users of oral contraceptives rank among the most important complications with potential economic consequences. It is well known that a large part of thromboembolic complications correlates with hereditary thrombophilias. The relative high prevalence of the newly described resistance of activated protein C and an easy test for it rise up the question if general screening of new users of oral contraceptives is sensible of health economic view. METHOD: We conducted a cost-effectiveness analysis using decision analytic techniques, analysing the costs and outcomes in a hypothetical cohort of 10,000 women. RESULT AND CONCLUSION: From a third party payer perspective we estimate that screening for APC resistance by new users of oral contraceptives is more cost-effective than many other primary preventive methods. The cost per life-year gained of testing for APC resistance were in the order of DM 1544,--including direct medical cost only. From perspective of sickness insurance fund as cost unit we estimate that screening for APC resistance by new users of oral contraceptives is more cost-effective than many other primary preventive methods.

Adolescent↗