The Brockenbrough – Braunwald – Morrow Sign

Hypertrophic cardiomyopathy is a relatively common genetic disorder and usually asymptomatic. However, approximately 25% of patients develop left ventricular outflow obstruction and can develop angina, syncope, or congestive heart failure. Initiation and titration of beta-blockade usually results in symptomatic improvement. Patients with medically refractory symptoms can see further symptomatic improvement and relief of obstruction with either surgical myectomy or alcohol septal ablation (ASA). Although surgical myectomy has been the gold standard, ASA has been shown in nonrandomized studies and a meta-analysis to be comparable. In patients undergoing ASA without a rest obstruction, the Brokenbrough-Braunwald-Morrow sign can be used to accurately determine the degree of left ventricular outflow tract (LVOT) obstruction prior to, during, and after ASA.     

Corticoide in der Rheumatherapie gestern – heute – morgen

The discovery of the suprarenal glands and their function is discussed. The complicated history of cortisone from the synthesis until its use as an antirheumatic is told. Pharmacotherapy with this physiologic hormone also caused serious side effects. Changing the molecular structure did not essentially solve this problem. Only after finding novel ways of application could these risks be reduced. The indications for therapy were further effectively reduced after understanding the mechanisms of action. Modern standards for corticoid therapy of rheumatoid arthritis are discussed. The important problem of corticoid osteoporosis and the myth of cortisone ulcers are also explained. The problems of coping with patient fears to cortisone are considered. Concurring drugs of cortisone and their special benefits are compared.     

Sterbehilfe – Sterbebegleitung

Zum Thema Auf einem Gebiet, das nicht frei von Emotionen ist, ist eine Begriffserkl?rung unbedingt notwendig, um einen angemessenen Diskussionsstil zu finden. Die Begriffe der aktiven, passiven und indirekten Sterbehilfe werden unter rechtlichen, standesrechtlichen und ethischen Gesichtspunkten besprochen. Sehr ausführlich wird zu den niederl?ndischen Erfahrungen auf dem schwierigen Gebiet der aktiven Sterbehilfe Stellung genommen. Bei uns unter Strafe verboten, ist sie in den Niederlanden unter strengen Auflagen erlaubt. Der Begriff Euthanasie wird in Anlehnung an die internationale Literatur mit aktiver Sterbehilfe gleichgesetzt. Da die aktive Sterbehilfe den Wunsch der Patienten unbedingt voraussetzt, sei daran erinnert, da? somit ein fundamentaler Gegensatz zu jener Euthanasie des Dritten Reichs vorliegt, die in Deutschland damals gegen den Willen der Betroffenen aus sogenannten eugenischen, rassischen oder anderen Gründen durchgeführt wurde. Schwerpunkt und richtungsweisende Perspektive dieser Arbeit ist die Erl?uterung palliativmedizinischer Ma?nahmen und kompetenter Sterbebegleitung, gleichsam als ?rztlich und ethisch begründete Antwort auf die Forderung nach aktiver Sterbehilfe, für die bei einer Umfrage neuesten Datums 42% niedergelassener ?rzte in Deutschland aussprachen. Die kollegiale überzeugung dürfte hier wirksamer als die Androhung strafrechtlicher Verfolgung sein.     

Stomakomplikationen – Korrekturverfahren

Background: Despite the progress of surgical technique, cumulative rates of complications after stoma construction up to 70% have been reported. It is therefore apparent that correcting procedures are a focus of surgeons interest. A well functioning stoma will preserve independence and complete socialisation of the patient. Preoperatively, the patient should be informed in details by an especially trained stomatherapist. The stoma should be positioned in distance to the umbilicus, iliac spine, costal arch, or operation wounds.The stoma site brings out the bowel through the rectus muscle without any tension, while the diameter amounts to two fingers.Constitutional faults or stoma construction at itself as a locus minoris resistentiae may further stoma complications. Besides stomal prolapse, stenosis and retraction, the peristomal herniation is the most common complication after stoma construction. Surgical repair contains local procedures, which leave the stoma where it is, stoma relocation and augmentation of the abdominal wall by alloplastic meshes.Own Data: From 1997 to 2002 631 stomata were created, while 23 stomata had to be corrected.There are satisfactory results with low complication rate.Conclusion: There are different procedures to correct stoma complications, while the risk of complications increases with each new intervention. Great care should be taken when a stoma is created in order to guarantee a high functionality combined with a minimized rate of complication.     

Osteoimmunologie – IMMUNOBONE – Das Wechselspiel zwischen Knochen und Immunsystem verstehen

The special program ?Osteoimmunology?? under the leadership of the Universities of Erlangen, Jena, Gie?en and Münster, is investigating in 27 projects clarification approaches on the causes of inflammatory rheumatic diseases, such as rheumatoid arthritis and ankylosing spondylitis with the aim of developing new forms of treatment. The molecular mechanisms involved in bone damage and the interaction between the immune system and bone and cartilage are topics of research.     

Tremor – neue Therapieoptionen

Zum Thema In den letzten Jahren sind mehrere neue Therapiem?glichkeiten des Tremors entwickelt worden. Neben medikament?sen Therapiekonzepten und der Injektion von Botulinumtoxin besteht auch die Alternative der tiefen Hirnstimulation. Aufgrund der unterschiedlichen Tremorformen und -?tiologien müssen diese neuen Therapieoptionen differenziell eingesetzt werden. Im vorliegenden Beitrag wird daher eine klare Tremorklassifikation als Grundlage für die daraus folgende Therapieentscheidung aufgezeigt.     

Palliativmedizin – psychologische Therapie

Zum Thema Im Falle einer fortschreitenden Krebserkrankung haben Patienten und deren Angeh?rige eine Reihe von Krisen zu bestehen, die sich über die verschiedenen Krankheitsetappen bis zur palliativen Behandlungssituation in ihrer existentiellen Bedrohlichkeit steigern, bis die Auseinandersetzung mit dem Lebensende schlie?lich real und unabweisbar wird. Dadurch kommt es zu einer Ausnahmesituation von hoher emotionaler Intensit?t, die sich in vielf?ltiger und sehr individueller Weise, offen oder verborgen, direkt oder indirekt ausdrückt. In dieser Lage stehen die behandelnden ?rzte und die Pflegenden vor dem Problem, sich nicht von der Todesn?he l?hmen, aber auch nicht zu überaktivit?t verleiten zu lassen und den Patienten als kompetente und wahrhaftige Gespr?chspartner zur Verfügung zu stehen. Die Notwendigkeit zugleich einen hohen onkologisch-medizinischen Standard aufrecht zu erhalten und den komplexen psychosozialen Erfordernissen gerecht zu werden, macht die Arbeit im palliativen Bereich zu einer pers?nlichen Herausforderung, die es zurecht verdient, “Ganzheitsmedizin” [34] genannt zu werden.     

Heart Transplantation – Surgical Results

Heart transplantation has become a widely used therapeutic option for the treatment of end-stage heart failure. Since the first human orthotopic heart transplant in the late 1960s, the surgical technique has undergone several revisions. These revisions have addressed certain anatomic and geometric distortions that occurred with the original biatrial technique of Lower and Shumway. Early revisions have included the use of a bicaval technique for implanting the right atrium. Subsequently, the additional use of a direct pulmonary venous anastomosis has lead to the surgical concept of the total orthotopic heart transplant. These revisions of the original bi-atrial technique have led to a decrease in atrial size and distortion, conduction abnormalities and tricuspid and mitral valve regurgitation. This has also resulted in less atrial thromboembolic events, less need for permanent postoperative pacemaker placement, and in an overall increase in right and left heart performance in the early postoperative period. Overall, this has contributed to better clinical results with patients returning sooner to their normal exercise capacity. Ninety percent of heart transplant patients lead a relatively normal lifestyle having no limitations in their activity and 40 % return to work. We believe that the technique of total orthotopic heart transplantation has improved surgical results and clinical outcomes.     

Peripartum cardiomyopathy – case series

Objectives

To study the pattern of presentation, course of disease and outcome of pregnancy in Peripartum Cardiomyopathy.

Methods

A prospective study of sixteen cases of PPCM was conducted at Apple Saraswati Multispecialty Hospital and Dr. D.Y. Patil Medical College and Hospital, Kolhapur, Maharashtra, India from January 2006 to December 2012. Data included age distribution, parity, gestational age, symptoms and risk factors. Medical management and pregnancy outcome were documented. Serial echocardiography data was compiled for a period of one year.

Results

In our study 9/16 (56%) were primigravidae, 4/16 (25%) had pre-eclamsia and 6/16 (35%) had co-existing hypertension. The difference in Echocardiography parameters observed between recovered and non-recovered patients was significant: Left Ventricular End diastolic dimension (5.6 cm vs 6.06 cm), Left Ventricular Ejection Fraction (28.7% vs 22.4%) and Left Ventricular fractional shortening (17.5% vs 13.4%). Thirteen out of sixteen patients were followed up for a period of one year out of which 61% (8/13) patients recovered completely. There was one mortality.

Conclusion

PPCM is a diagnosis of exclusion. Majority were young primigravidae presenting postnatally. Pre-eclampsia and hypertension were risk factors. ECHO parameters were reliable predictors of recovery. Future pregnancies are better avoided.     

Reizdarmsyndrom – Diagnostik und Therapie

Up to 25?% of gastroenterology outpatients complain of symptoms attributable to irritable bowel syndrome (IBS). A well founded diagnosis of IBS is the key to subsequent successful treatment. To safely establish a diagnosis of IBS a panel of basic investigations to carefully exclude alternative diagnoses is warranted. Once the diagnosis of IBS is established repetition of examinations, especially repeat endoscopy should be avoided in the absence of new clinical information. Medical treatment should be tailored to individual symptoms. Non-medical forms of treatment including dietary changes, exercise and alternative forms of treatment, such as hypnotherapy can be effective supportive measures in IBS.     

COPD – eine Kinderkrankheit?

Several decades ago it was hypothesized that chronic obstructive pulmonary disease (COPD) starts in childhood. Reduced lung function may be present shortly after birth and persist into adulthood. This reduction might not only predispose to wheezy bronchitis but could also be the first sign of future COPD. Several risk factors have been identified including prenatal and passive and active postnatal smoke exposure, pollutants, lower respiratory tract infections, intrauterine growth retardation and prematurity. It has recently been shown that lung function and respiratory morbidity during the first years of life are associated with known COPD genes. Whether prevention and early treatment will influence subsequent development of COPD is still unknown.     

WeanNet – Kompetenznetzwerk pneumologischer Weaningzentren

In the past two decades an increasing number of chest hospitals and departments of pulmonary medicine have specialized in difficult weaning from mechanical ventilation. Recently the task force “WeanNet”, a network of weaning units, was founded under the patronage of the German Society for Pneumology and Ventilation Medicine. The main aim of WeanNet is to improve cooperation of the weaning centres and the quality of patient management. Important instruments for this are the register of patients being weaned and the accreditation of the weaning centres. To develop the register an intensive cooperation between the task force and the Institute for Lung Research (ILF) was necessary. The completed register is now logistically run by the ILF. In less than 1 year after the official start approximately 60 weaning units have already been registered. Furthermore, the task force developed a specification sheet for accreditation with the main focus on quality of the weaning process. After finishing the currently performed pilot phase to confirm feasibility, the procedure will be open for all weaning units in spring 2010.     

Panvascular risk factor – Diabetes

Diabetes mellitus is the metabolic bed rock on which macrovascular and microvascular complications develop, hence diabetes is often regarded as a panvascular risk factor. Diabetes, a major risk factor of coronary artery disease (CAD), is also a maker for systemic atherosclerosis. Macrovascular complications include CAD, cerebrovascular disease and peripheral arterial disease (PAD), while microvascular complications include retinopathy, nephropathy and neuropathy. The underlying pathophysiological mechanism of diabetic vasculopathy is complex and multi-factorial, which requires an active research for potential therapeutic targets. The Achilles heel of diabetes related morbidity and mortality is diabetic vasculopathy and its related complications. Hence the management of diabetes per se is often translated into managing its vascular complications. A comprehensive understanding of diabetes as a panvascular risk factor is important. This review has briefly addressed the pathophysiology of diabetic vasculopathy and its complications.