陈旧性肱骨外髁骨折的手术治疗观察

目的探讨陈旧性肱骨外髁骨折的手术方法和治疗效果。方法2003年6月～2006年6月,收治儿童陈旧性肱骨外髁骨折13例,男8例,女5例;年龄4～17岁,平均10岁。其中畸形愈合8例,均有肘关节活动受限,平均活动范围20～100°;骨不连伴肘外翻畸形5例,外翻畸形角度28～55°,平均44.2°,术前肘关节活动基本正常。受伤至手术治疗时间1个月～10年。8例畸形愈合者行切开复位内固定;5例骨不连并肘外翻畸形者行在内侧柱髁上楔形短缩截骨和外侧柱重建术。结果13例术后随访8个月～2年4个月,平均16个月,均获骨折愈合,平均愈合时间6周。8例畸形愈合者肘关节活动度改善了30～60°,平均36°。5例骨不连并肘外翻畸形者肘外翻畸形平均改善40.2°。根据Jupiter等评分系统评价肘关节功能,优9例,良2例,可2例。1例术后出现桡神经牵拉损伤表现,3个月后完全恢复,无其他并发症。结论对于儿童陈旧性肱骨外髁骨折,积极的手术治疗能有效恢复肘关节外观和功能。     

髁上截骨治疗儿童肱骨外髁陈旧骨折并肘外翻畸形疗效观察

目的：探讨儿童肱骨外髁陈旧骨折并肘外翻手术治疗方法。方法：收治陈旧肱骨外髁骨折骨不连并肘外翻11例,其中3例伴有迟发性尺神经炎,全部采用肱骨髁上截骨矫正肘外翻畸形,骨不连未作处理。结果：10例平均术后随访28个月,按HSS评分系统进行肘关节功能评定。优良率达到90％。结论：肱骨髁上截骨治疗肱骨外髁陈旧骨折合并肘外翻畸形是一种可行方法。     

儿童陈旧性肱骨外髁骨折的治疗

目的探讨儿童肱骨外髁骨折治疗的注意事项及对陈旧性肱骨外髁骨折治疗的经验。方法1997年1月～2002年2月，收治儿童陈旧性肱骨外髁骨折13例。其中男11例，女2例；年龄4～11岁，平均7．2岁。3例有明显肘外翻畸形。初期诊断Ⅰ度骨折4例，Ⅱ度骨折5例，诊断不明确或漏诊4例。伸肘障碍13例，受限30～70°，屈肘〉90°；疼痛2例；肘外翻1例；X线片示骨折不愈合10例，畸形愈合3例。12例患儿损伤至手术时间为32～81d，平均56d，行切开复位加钢针内固定术；另1例患儿为受伤后6个月就诊，行切开复位加钢针内固定和植骨术。结果13例均获随访3～8年，平均5．4年。无肘内翻或外翻畸形，5例有外髁部轻度突起畸形。肘部屈伸活动度改善40～70°，平均56°（包括术前屈肘受限），前臂旋转活动好。X线片示术后6-8周骨折愈合，基本恢复关节平面；无骨不连或骨延迟愈合，无无菌性坏死发生。结论肱骨外髁骨折治疗重点在于早诊断、早治疗，避免发生陈旧性骨折。对于陈旧性骨折，尽早手术能有效修复重建肘关节外观和功能。     

成人陈旧肱骨外髁骨折的手术治疗

肱骨外髁骨折是儿童常见的骨折,常发生于2~14岁的儿童,其中6~10岁最常见,分为Milch I型和Milch II型两种类型。儿童肱骨外髁骨折大多经石膏固定或复位后穿针固定而愈合,且功能良好,少数患者因漏诊或处理不当造成不愈合,部分合并明显肘外翻、尺神经炎、疼痛、肘关节不稳定等。儿童陈旧性肱骨外髁骨折,多以肘关节畸形就诊,部分有尺神经炎症状,多主张明确诊断后积极手术治疗。成人陈旧性肱骨外髁骨折,多因承重或提物时疼痛、承重或对抗恐惧感、部分尺神经炎症状或外翻不稳定等问题就诊,较儿童患者易造成骨折不愈合、肘关节活动范围损失和外髁缺血坏死等问题,是否手术治疗存在争论,髁上截骨与骨折固定是否同时进行有争议。2011年5月至2013年10月,我科收治成人陈旧肱骨外髁骨折11例,Milch I型3例、Milch II型8例,术后随访平均时间20.6个月（8~36个月）。对于Milch I型髁上骨折,采用髁上截骨并植骨手术方式;对于Milch II型髁上骨折患者,采用陈旧骨折固定并植骨的手术方式,并处理尺神经炎情况,术中穿针评估手术对活动度影响。1例患者肘外翻明显,行骨折内固定并植骨手术骨折愈合后,二次手术髁上截骨矫正外翻畸形。所有病例最终都获得愈合,疼痛明显减轻或消失,关节稳定,尺神经炎症状消除或明显减轻,肘关节屈伸活动范围平均减少11.4°,前臂旋转减少不明显。整体来说,成人陈旧肱骨外髁骨折可通过手术消除或减轻肘关节承重疼痛和关节不稳症状;术后会减少肘关节活动范围,但大都功能良好;术中需临时固定陈旧骨块检查关节活动,确保术后肘关节活动所受影响不大。     

肱骨外髁陈旧骨折肘外翻尺神经炎的手术治疗

目的探讨成人肱骨外髁陈旧骨折并肘外翻、尺神经炎的手术治疗方法。方法收治成人肱骨外髁陈旧骨折并肘外翻、尺神经炎16例,均伴有肱骨外髁骨不连,全部采用肱骨髁上截骨、尺神经前移手术治疗,骨不连未作处理。结果16例平均术后随访28个月,尺神经炎按Amadio疗效评定标准,优良率87．5％;按HSS评分系统进行肘关节功能评定．优良率92％。结论肱骨髁上截骨、尺神经前移是治疗成人肱骨外髁陈旧骨折合并肘外翻畸形、尺神经炎一种可行方法。     

空心螺钉及克氏针治疗儿童肱骨外髁骨折

目的探讨空心加压螺钉及克氏针治疗儿童肱骨外髁骨折的临床效果。方法 2010年1月至2014年12月共收治315例儿童肱骨外髁有移位骨折患者,应用空心加压螺钉及克氏针进行复位固定,其中男233例,女82例;年龄1岁9个月~12岁,平均5.7岁。左侧171例,右侧144例。术后短期外固定,约术后1周可进行肘关节主动活动功能锻炼。结果 315例患者术后经平均10个月(6~24个月)随访。骨折愈合时间平均为2.6个月(2~5个月)。无延迟愈合及骨不连,无肘内翻、肘外翻肘关节畸形,无神经并发症,无肱骨小头骨骺缺血性坏死,无骨化性肌炎。按HHS肘关节功能评分标准,本组优247例,良58例,一般10例,优良率96.8%。结论采用空心加压螺钉结合克氏针治疗儿童肱骨外髁有移位骨折,具有固定牢固、可早期功能锻炼等优点,无骨折不愈合、骺早闭、骨骺缺血坏死、肘外翻等并发症,可取得满意效果。     

克氏针治疗小儿肱骨外髁骨折疗效分析

目的：探讨克氏针治疗儿童肱骨外髁骨折疗效。方法：Ⅱ型骨折41例、Ⅲ型和Ⅳ型骨折23例、陈旧性骨折8例,本组72例全部采用手术治疗。结果：2例Ⅱ型骨折病例出现肘内翻,1例轻度肱骨外髁隆凸,1例轻度肘关节功能受限,1例肱骨小头及滑车坏死,1例内固定感染骨髓炎,8例手术治疗的陈旧性病例,5例效果满意,2例肘关节功能受限,1例骨不连。结论：手术治疗儿童肱骨外髁骨折正确合理应用克氏针均能取得满意疗效。     

髁上截骨和外侧柱重建术治疗肱骨外髁骨折不连伴肘外翻畸形

目的 总结青少年肱骨外髁骨折后骨不连伴肘外翻畸形的手术方法 和治疗效果. 方法 2004年6月-2006年lO月,收治肱骨外髁骨折后骨不连伴肘外翻畸形5例.其中男3例,女2例;年龄8～17岁.曾于外院行外固定2～3周3例,误诊为软组织损伤2例.外伤后4～12年发现骨折不连伴肘外翻畸形就诊.术前肘外翻角25～55°,平均44.8°;肘关节活动范围为屈135～140°,平均139°;伸0～20°,平均70°1例伴尺神经炎表现,确诊为尺神经不全损伤.入院至手术时间3～7 d.均行髁上内翻楔形短缩截骨和外侧柱重建内固定术治疗.术后定期随访,按Jupiter等肘关节评分系统评价肘关节功能. 结果 5例术后切口均Ⅰ期愈合;均获随访,随访时间14～28个月,平均20个月.X线片示5例骨折均达骨性愈合,其中髁上内翻楔形短缩截骨区愈合时间为术后5～8周,平均6周;外侧柱重建区为术后3～6个月.肘外翻畸形均矫正,末次随访时肘外翻角-5～10°,平均2°;肘关节屈曲100～135°,平均121.;伸直0～30°,平均13°.根据Jupiter等评分系统评价肘关节功能,优2例,良2例,可1例.1例术后出现桡神经牵拉损伤表现,3个月时自行恢复;1例原有尺神经炎表现者,术后6个月症状消失;无其他并发症. 结论 髁上内翻楔形短缩截骨和外侧柱重建内固定术治疗青少年肱骨外髁骨折后骨不连伴肘外翻畸形可获得满意效果.     

肱骨远端外柱重建治疗的手术疗效观察

[目的]评价肱骨远端外柱重建治疗肱骨外髁陈旧性骨折后遗肘外翻畸形及断端骨片不连接临床疗效。[方法]通过回顾性分析2001～2007年间收治38例肱骨外髁陈旧骨折且有肘外翻畸形及断端骨片不连接的病例,分别采用自体髂骨或异体骨移植重建肱骨外柱内固定治疗。解决肱骨远端外嵴滑动及桡骨小头移位状况。[结果]按随访1～6年疗效观察,所有病例均在术后10～24周达到骨性愈合连接,按肘部外形、活动功能和尚存并发症分级等进行分级评定,优18例,良16例,差4例,总优良率为89.5%。[结论]肱骨远端外柱重建手术既可消除骨缺损促进骨折愈合,更有支撑肱骨外髁,恢复外髁关节面平整,增强肘关节稳定性,还能保留肱骨长度及恢复力线,纠正改善肘外翻畸形。因此该术式是治疗肱骨外髁骨折后遗肘外翻畸形及外髁断片不连接的理想术式。     

儿童陈旧性肱骨外髁骨折的手术治疗

本文报告手术治疗儿童陈旧性肱骨外髁骨折４４例，其中行开放复位内固定术４２例，肱骨髁上截骨术２例。随访３～３４年，平均１０．６年，优良率为４３．２％。并发骨不愈合３例，肱骨外髁缺血性坏死５例，肘内翻４例，肘外翻１５例，尺神经炎１２例。骨折时间越长，功能恢复越差，并发症越多。主张尽早手术解剖复位以提高疗效。陈旧性肱骨外髁骨折块有明显移位，关节活动明显受限者应积极手术复位，改善功能。开放复位术中应尽可能保留伸肌腱的附丽，以免发生骨不连、骨缺血坏死、影响骨骺发育和关节软骨变性坏死。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.