Der implantierbare Kardioverter-Defibrillator

Zusammenfassung Die ad?quate Versorgung von Patienten, die bereits einmal einen Herz-Kreislaufstillstand durch tachykarde Arrhythmien überlebt haben, war lange Zeit auf eine Behandlung mit Antiarrhythmika beschr?nkt, wenn der Rhythmusst?rung keine behebbare orga-nische Ursache zugrunde lag. Trotz optimierter Pharmakotherapie sterben 30% dieser Patienten innerhalb von drei Jahren durch eine erneute maligne Arrhythmie. Deshalb wurde in den letzten Jahren die Implanta-tion von automatischen, implantierbaren Kardioverter-Defibrillatoren (ICD) der Standard bei der Versorgung dieser Patienten. Zunehmend werden ICDs auch bei Patienten mit stark erh?htem Risiko für einen pl?tzlichen Herztod ohne überlebten Kreislaufstillstand implantiert, ins-besondere bei Patienten mit Kardio-myopathie oder angeborenen ar-rhythmogenen Anomalien des Herzens. In neuen klinischen Studien konnte bei selektierten Patienten ein deutlicher überlebensvorteil gegen-über der Behandlung mit Anti-arrhythmika gezeigt werden [7]. Die Implantation von ICDs wird bei den neuen transven?sen Systemen ohne Thorakotomie durchgeführt, wodurch das Operationsrisiko wesentlich verringert wurde. Moderne ICDs werden unter den linken M. pectoralis major implantiert, eine mehrpolige Elektrode im rechten Ventrikel dient der Wahrnehmung, der Stimulation und der Schockab-gabe. Die Ger?te sind in weiten Bereichen patientenspezifisch programmierbar und erlauben so eine differenzierte Erkennung und mehrstufige Therapie von ventrikul?ren Tachykardien und Kammerflimmern. Neben der Defibrillation und der synchronisierten Kardioversion stellt die antitachykarde Stimulation eine hocheffektive und für die Patienten angenehme Methode zur Beendigung von langsamen ventrikul?ren Tachykardien dar. Der interne Speicher moderner ICDs dokumentiert nicht nur die Anzahl der Arrhythmien und die abgegebene Therapie, auch intrakardiale EKGs vor und nach den Episoden k?nnen ausgelesen werden. Diese Eigenschaften erlauben heute eine sehr spezifische und individuelle Anpassung der Therapie an die zugrundeliegende Arrhythmie. Eingegangen: 3. September 1997 Akzeptiert: 4. Oktober 1997     

Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt

BACKGROUND: In patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), prognostic scores may identify those with a poor prognosis or even those with a clear survival benefit. The Child-Pugh score (CPS) is well established but several drawbacks have led to development of the model of end stage liver disease (MELD). AIM: The aim of the study was to compare the predictive power of CPS and MELD, to validate the original MELD formula, and to assess the predictive value of the determinants used in the two prognostic scores outside of a study setting. PATIENTS: A total of 501 patients underwent elective TIPS placement and 475 patients fulfilled the inclusion criteria. METHODS: Data of all patients undergoing elective TIPS in one university hospital and four community hospitals in Vienna, Austria, between 1991 and 2001, were analysed retrospectively. The main statistical tests were Cox proportional hazards regression model, the log rank test, Kaplan-Meier analysis, and concordance c statistics. RESULTS: Median follow up was 5.2 years and median survival was 4.6 years. During follow up, 230 patients died, 75 within three months after TIPS placement. In stepwise proportional hazards analyses, independent predictors of death were creatinine level, bilirubin level, age, and refractory ascites. MELD was better in predicting survival in a stepwise Cox model but both scores were equally predictive in c statistics for one month, three month, and one year survival. Renal function was the strongest independent predictor of survival. CONCLUSIONS: Although MELD was the primary predictor of overall survival in multivariate analysis, c statistics showed that both scores can be used for patients undergoing TIPS with equal accuracy. For assessing prognosis in patients undergoing TIPS implantation, there seems little reason to replace the well established Child-Pugh score.     

Whole-abdomen radiation in patients with advanced ovarian carcinoma after surgery,chemotherapy and second-look laparotomy

Summary Forthy-three patients with ovarian carcinoma were treated with whole-abdomen radiation (moving strip±pelvic radiation), 15 patients had not received prior chemotherapy, and 28 patients were irradiated following chemotherapy and second-look laparotomy. Ten of these had been treated with a variety of chemotherapy regimens (L-PAM, CHAD, Hexa-CAF). Eighteen patients were treated in an ongoing prospective trial with combination chemotherapy consisting of melphalan, cis-platinum, and hexamethylmelamin (HexaPAMP). Thrombocytopenia was the limiting toxicity. A temporary pause in the radiation schedule allowing platelets to recover made it possible to complete treatment in 80% of the patients. The acute toxic effects, which included the expected side effects of radiation therapy on intestine, liver and lung, were not more frequent or more severe in the patients who had received prior chemotherapy than in those who had radiation therapy alone. Thirty-four of 43 patients (stage I, seven patients; stage II, seven patients; stage III, 27 patients; stage IV, two patients) are alive and without evidence of disease 26+ months (range 7 to 64 months) after entering the postsurgical treatment program.Paper presented at the Annual Meeting of the Swiss Society for Oncology, Basel, March 1983     

Compliance with antihypertensive therapy.

Poor compliance with antihypertensive therapy is a major cause of unsatisfactory blood pressure control. The doctor has a key role in all steps that lead the patient to adopt a treatment and to take it as prescribed lifelong. Compliance with therapy is a parameter which is difficult to assess. There is often an important mismatch between the subjective views of physicians and patients regarding long-term drug taking. Electronic monitoring of compliance represents a valuable method to evaluate the "real time" compliance of the patient. Discussing a compliance recording with a patient may help to identify and solve problems linked with everyday adherence to antihypertensive treatment. Improving compliance is an important task not only for the doctors, but also for all healthcare providers.     

A Post‐Hoc Comparison of the Utility of Sanger Sequencing and Exome Sequencing for the Diagnosis of Heterogeneous Diseases

The advent of massive parallel sequencing is rapidly changing the strategies employed for the genetic diagnosis and research of rare diseases that involve a large number of genes. So far it is not clear whether these approaches perform significantly better than conventional single gene testing as requested by clinicians. The current yield of this traditional diagnostic approach depends on a complex of factors that include gene‐specific phenotype traits, and the relative frequency of the involvement of specific genes. To gauge the impact of the paradigm shift that is occurring in molecular diagnostics, we assessed traditional Sanger‐based sequencing (in 2011) and exome sequencing followed by targeted bioinformatics analysis (in 2012) for five different conditions that are highly heterogeneous, and for which our center provides molecular diagnosis. We find that exome sequencing has a much higher diagnostic yield than Sanger sequencing for deafness, blindness, mitochondrial disease, and movement disorders. For microsatellite‐stable colorectal cancer, this was low under both strategies. Even if all genes that could have been ordered by physicians had been tested, the larger number of genes captured by the exome would still have led to a clearly superior diagnostic yield at a fraction of the cost.     

Radiotherapy for SMAD4-negative musculoskeletal lesions from pancreatic cancer

Background

Pancreatic cancer (PC) predominantly metastasizes to liver, lung, and peritoneum. Metastatic disease correlates with SMAD4 status. Musculoskeletal metastases (MSM) are rare in pancreatic cancer. The role of radiation therapy (RT) in patients with musculoskeletal metastases is not clear.

Methods

We present a case of a woman with musculoskeletal metastases of PC evolving 4 years after Whipple’s procedure and adjuvant therapy. She was treated with RT for 7 MSM. Radiation dose was 15–45 Gy, delivered in doses of 2.5–5 Gy per fraction. SMAD4 status was examined by immunohistochemistry. Furthermore we undertook a review of the literature to examine the value of RT in musculoskeletal metastasis of PC.

Results

In the presented patient we treated 7 MSM of SMAD4-mutant PC with RT. RT achieved local control in 4 of the 7 MSM. At the resection margin of one MSM recurrent tumor was observed after RT. The status of one MSM was unknown and one MSM showed local progression. Follow-up revealed progression of pain in 1 of the 7 MSM. Except of hyperpigmentation no side effects occurred. There was no dose–correlation effect on tumor control observed. A review of the literature showed that a musculoskeletotrophic phenotype of metastases is rare in PC. MSM of PC are rapidly increasing soft tissue masses causing pain and loss of anatomical function. RT as a treatment option for musculoskeletal metastasis is described in the current literature in only 2 cases. Radiotherapy aims to achieve local control, pain relief, and to maintain anatomical function.

Conclusion

Radiotherapy is an effective and well-tolerated approach for multiple musculoskeletal metastases of PC.