ZusammenfassungDie in Bild 9-1 zusammengefassten Megatrends der Gesellschaft bestimmen auch die Zukunftsaspekte des Fahrwerks. Diese sind die Treiber für die Anforderungen der Kunden an die Automobilhersteller. Die stark wachsende Bedeutung von Elektronik im Automobilbau wird einerseits durch die Nachhaltigkeitsdiskussion und den Trend zur Elektrifizierung des Antriebsstranges bestimmt. Andererseits wird die Weiterentwicklung von Komponenten, z. B. für das Fahrwerk maßgeblich von der Elektronik geprägt (Bild 9-2). Für die fahrwerkrelevanten Anforderungen stehen neben dem Umweltschutz die Themen Komfort, Sicherheit, Elektrifizierung und Fahrerassistenzsysteme im Vordergrund.
Neuroprognostication after cardiac arrest (CA) is critical for guiding treatment decisions. However, concerns about self-fulfilling prophecy related to withdrawal of life-sustaining therapy (WLST) complicate outcome prediction. This study evaluated the accuracy of guideline-recommended prognostic markers within 14 days after CA for predicting poor 12-month outcomes in patients without WLST during the first four weeks after CA. This prospective multicenter observational study enrolled adults who remained comatose 72 h after CA across eight German hospitals between 2014 and 2017. Patients with WLST during the first four weeks, stroke, pre-existing disorders of consciousness, or terminal malignancy were excluded, leaving 101 patients for analysis. Prognostic markers assessed included pupillary light and corneal reflexes (PLR + CR), EEG, somatosensory evoked potentials (SEP), neuron-specific enolase (NSE) concentration, and the best Coma Recovery Scale–Revised (CRS-R) score. Poor outcome was defined as a modified Rankin Scale score of 4–6 at 12 months. Poor outcomes occurred in 67.3
INTRODUCTION:Heart failure with reduced ejection fraction (HFrEF) accompanied by moderate or severe ventricular tricuspid-valve leaflet regurgitation (vTR2/3) is prognostically unfavourable; however, the underlying pathophysiology has not yet been sufficiently clarified. The hypothesis of a causative role of left ventricular (LV) dysfunction +/- secondary mitral regurgitation (sMR) on the extent and severity of secondary vTR was investigated. METHODS:We integrated right ventricular (RV) pressure-volume loop and Swan-Ganz catheter data with RV/LV imaging findings in a retrospective analysis of 134 HFrEF patients. RESULTS:Parameters independently associated with the presence of vTR2/3 were (i) presence of sMR (adjusted odds-ratio [aOR] = 1.67, P = .045), (ii) increased pulmonary vascular pulsatile RV loads (lower pulmonary artery [PA] compliance, aOR = 0.43, P = .021; area under the curve [AUC] = 0.82, cut-off <2.24 ml/mmHg, P < .001), mainly due to concomitant moderate/severe sMR (sMR2/3) (aOR = 4.56, P = .012), and (iii) progressive uncoupling of RV elastance/contractility (Ees) to an increasing total afterload (pulmonary elastance, Ea) (Ees/Ea ratio: aOR = 0.024, P = .005; AUC = 0.84, cut-off <0.6, P < .001). In addition, the RV-PA uncoupling was not only determined by the higher afterload in vTR2/3, but was also observed across the entire total afterload range (Ea tertile). This resulted in a larger and more dysfunctional RV in vTR2/3 compared with vTR0/1, independent of the afterload. RV-PA uncoupling and reduced PA compliance were independently associated with all-cause mortality. CONCLUSION:The vTR2/3 in context of HFrEF was independently associated with the presence of sMR, increased pulsatile loads, and a pronounced RV-PA uncoupling over almost the entire afterload range. Future studies will need to determine under which haemodynamic conditions a mechanical tricuspid regurgitation reduction in HFrEF patients is advisable.
Die uroonkologische Versorgung geriatrischer Patienten gewinnt durch die steigende Lebenserwartung und zunehmende Inzidenz uroonkologischer Erkrankungen zunehmend an Bedeutung. Therapeutische Entscheidungen orientieren sich jedoch häufig primär am chronologischen Alter oder an Leitlinien, während die funktionelle Reserve älterer Patienten unzureichend berücksichtigt wird. Geriatrische Patienten weisen spezifische physiologische Veränderungen wie Einschränkungen der Niere- und Leberfunktion, Sarkopenie, Multimorbidität, Polypharmazie, Malnutrition und kognitive Einschränkungen auf, die das Risiko für postoperative Komplikationen, funktionellen Abbau, Delirien, Stürze und Pflegebedürftigkeit erhöhen. Standardtherapien können daher trotz onkologischen Nutzens zu relevanten funktionellen Einschränkungen führen. Ziel moderner uroonkologischer Therapie ist neben der Lebensverlängerung insbesondere der Erhalt von Autonomie, Mobilität und Lebensqualität. Zur individualisierten Therapieplanung empfehlen aktuelle Leitlinien ein stufenbasiertes geriatrisches Assessment. Hierbei erfolgen zunächst Screeningverfahren mittels G8 und Mini-Cog©, gefolgt von einem vereinfachten geriatrischen Assessment beziehungsweise einem umfassenden geriatrischen Assessment (CGA) bei auffälligen Befunden. Die Einteilung in fitte, vulnerable und gebrechliche Patienten ermöglicht eine risikoadaptierte Therapieentscheidung sowie gezielte geriatrische Interventionen. Dadurch können funktionelle Reserven verbessert, Komplikationen reduziert und langfristige Pflegebedürftigkeit potenziell vermieden werden.
The management of geriatric patients with urological cancers is becoming increasingly important due to rising life expectancy and the growing incidence of such diseases. However, treatment decisions are often based primarily on chronological age or clinical guidelines, whilst insufficient consideration is given to the functional reserve of older patients. Geriatric patients exhibit specific physiological changes such as impaired renal or liver function, sarcopenia, multimorbidity, polypharmacy, malnutrition and cognitive impairments, which increase the risk of postoperative complications, functional decline, delirium, falls and the need for care. Standard therapies can therefore lead to significant functional limitations despite their oncological benefits. The aim of modern uro-oncological treatment is not only to prolong life but, in particular, to preserve autonomy, mobility and quality of life. For the purpose of individualised treatment planning, current guidelines recommend a stepwise geriatric assessment. This begins with screening using the G8 and mini-COG©, followed by a simplified geriatric assessment or a comprehensive geriatric assessment (CGA) if any abnormalities are detected. Classifying patients as fit, vulnerable or frail enables risk-adapted treatment decisions and targeted geriatric interventions. This can improve functional reserves, reduce complications and potentially avoid the need for long-term care.
