Arthropathien bei endokrinen Störungen

Diseases of different endocrine organs may cause symptoms at the locomotor system leading the patient to the rheumatologist. A correct interpretation of symptoms and findings the right may allow diagnosis and a causal treatment may be introduced. In this review the manifestations of disorders of the hypophysis, the thyroid, the parathyroid, the cortex and of diabetes mellitus at peripheral joints, the vertebral column, muscles, bones, and, as far as important for the rheumatologist, the peripheral nerve system are summarized. Carcinoid arthropathy is also mentioned.     

Störungen der Hirndurchblutung bei arteriovenösen Angiomen des Gehirns

Zusammenfassung Bei einer Gesamtzahl von 150 intrazerebralen arteriovenösen Angiomen standen 30 prä- und postoperative Serienangiogramme zur Verfügung. Es werden die Veränderungen der Hirnzirkulation sowie die morphologischen Veränderungen der Hirngefäße bei den einzelnen Operationsmethoden (Totalexstirpation, Teilexstirpation und Verschluß zuführender Gefäße) besprochen. Einzelne Fälle werden ausführlich dargestellt. Die Möglichkeit der Ausbildung von Kollateralen wird durch die Totalexstirpation am besten ausgenützt. Die gestörte Hirndurchblutung wird ebenfalls durch die Totalexstirpation am günstigsten beeinflußt, bzw. normalisiert. Die klinischen Ergebnisse sind entsprechend besser.Mit 21 Abbildungen in 29 Einzeldarstellungen und 2 Tabellen     

Herzrhythmusstörungen bei der Schwangeren und beim Fetus

For the acute treatment of supraventricular (SVT) and ventricular tachycardias (VT) in pregnant women, electrical cardioversion with 50-100 J is indicated in all unstable patients. In stable SVT the initial therapy includes vagal maneuvers or intravenous adenosine. For long-term therapy, beta-blocking agents with beta(1)-selectivity are first-line drugs or specific anti-arrhythmic drugs. An implantable cardioverter-defibrillator is another approach. In patients with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of pregnancy. Evaluation of fetal arrhythmias in clinical practice is based on assessment of the chronological relationship between atrial and ventricular contraction (M-mode and Doppler ultrasound or magnetocardiography). Most forms of SVT can be treated with transplacental administration of anti-arrhythmic drugs. Atrioventricular (AV) block in fetuses with structural heart disease is frequently associated with hydrops fetalis and intrauterine death. Administration of corticoids and beta-mimetic drugs is used to treat antibody-mediated AV block and cardiomyopathy.     

Menschliche Immunsysteme und ihre Störungen

Ohne Zusammenfassung     

Diagnostik und Bedeutung psychischer Störungen bei körperlich kranken geriatrischen Patienten

Psychic disorders were studied with a naturalistic design in 125 consecutive patients of a medical-geriatric department in a general hospital. Based on the clinical examination and the values of the Mini-Mental-State-Examination (2), 51 patients were classified as unable for diagnostic procedures concerning psychic state. The other 74 patients underwent these diagnostic procedures including clinical investigation and three screening-scales (Geriatric Depression Scale (11); Hospital Anxiety and Depression-Scale (4)). If these examinations led to the suspicion that a patient suffered from a psychic disorder, an interview was performed by a psychotherapist with experience in gerontopsychosomatic treatment and information was collected from the medical and nursing staff. Dementia was detected or excluded by neuropsychological tests. Psychic disorders were found in 41 patients, mostly adaptation disorders and depressions. In more than half of the patients, the disorder was estimated to be relevant for the whole hospital therapy. The screening instruments turned out to be reliable, so they can be recommended for further use. Difficult to answer remains the question, how the treatment of the psychic disorders--in our sample necessary for each 5th to 6th patient--can be implemented in a medical-geriatric department.     

Störungen des Mineralstoffwechsels bei chronischer Nierenerkrankung

Background

Mineral and bone disorder (MBD) in chronic kidney disease (CKD) is associated with increased cardiovascular calcification and mortality. Pharmacological interventions for MBD in CKD are characterized by inconsistent data and a wide spectrum of (sometimes costly) treatment options. The objective of this article is a guideline-oriented overview of the differential indications for pharmacotherapy considering cost-effectiveness.

Current data

The serum phosphate concentration in patients with CKD stages 3–5 with a glomerular filtration rate (GFR) of <?45 ml/min should be kept within the normal range. Currently, under consideration of cost-effectiveness, calcium-containing phosphate binders and combinations of calcium acetate with magnesium carbonate are the preferred treatment options. Phosphate binders free of calcium are indicated in patients with high normal or elevated serum calcium levels. Low vitamin D concentrations in CKD stages 3–5 should be treated under consideration of serum calcium and parathyroid hormone (PTH) with calcidiol (25-cholecalciferol) and in dialysis patients (CKD 5D) with calcitriol (1,25 dihydroxycholecalciferol, activated vitamin D). In CKD the PTH levels should be kept in the range of 2–9-times the upper limit of normal levels. This is achieved by administration of phosphate binding drugs, activated vitamin D, calcimimetic compounds and parathyroidectomy. In CKD stages 3–5 patients metabolic acidosis with <?22 mmol/l serum bicarbonate should be treated with oral sodium bicarbonate.

Conclusion

In MBD of CKD patients an individualized pharmacotherapy which is closely guideline-oriented is required in order to achieve cost-effectiveness.     

Volumen- und Elektrolytstörungen bei Ausdauersport

Long-lasting endurance exercise is associated with significant losses of fluid and sodium chloride, mainly due to sweat loss. To maintain endurance capacity and to avoid negative health consequences, endurance athletes should, therefore, drink fluids containing electrolytes during and after training or competition. In long-lasting endurance exercise it is recommended that athletes drink about 600-800 ml/h of fluid including adequate substitution of sodium. The excessive ingestion of fluid, however, brings about a danger of hyponatremia, which can be avoided by suitable measures. Body weight control is one of the parameters that should be carefully monitored before and after intensive endurance exercise.     

Neurobiologie posttraumatischer und somatoformer Störungen im Alter

Background

Clinically relevant posttraumatic stress disorders are almost always associated with physical symptoms, which are, on the one hand, classified as somatoform and, on the other hand, may also present as somatic comorbidities. The psychological, neurobiological, endocrinological and immunological correlations are only now beginning to be understood. Thereby, integration into a meaningful biopsychosocial model is still pending.

Purpose

The following article gives a concise summary of the knowledge concerning the relationship between body and psyche in posttraumatic stress spectrum disorders and provides the neuroscientific foundation which could establish a biological link between the phenomenologies of the disorder.

Results

Neurobiological data on posttraumatic disorders and somatoform disorders are diverse and not uniform. This is even more true when it comes to those disorders that are within the intersection of these two entities and, above all, their special features in the elderly. Psychophysiological, neuroanatomical, endocrine–immunological, genetic, and epigenetic factors play an important role here. With regard to posttraumatic stress disorder, for example, higher autonomic reactivity was observed, which indicates an acquired general sensitization of the nervous system.     

Akute Herzrhythmusstörungen bei Schrittmacher- und Defibrillatorpatienten

Zusammenfassung W?hrend Herzschrittmacher (SM) zur Behandlung bradykarder Herzrhythmusst?rungen erfolgreich eingesetzt werden, ist der implantierbare Defibrillator (ICD) ein geeignetes Therapie-Verfahren zur Behandlung ventrikul?rer Tachyarrhythmien. Trotz eindeutiger Erfolge in der Therapie und Pr?vention lebensbedrohlicher Herzrhythmusst?rungen sind diese Verfahren nicht ohne Risiken und Komplikationen. Notfallsituationen k?nnen durch „echte” Komplikationen von SM/ICD-Generator und/oder Elektrodensystem hervorgerufen werden oder durch Situationen bedingt sein, die durch die Grunderkrankung des Patienten verursacht sind. Infektionen sind sicher am schwerwiegendsten und werden in einer H?ufigkeit von 2–7% beobachtet. Sie gehen mit einer erh?hten Morbidit?t und Mortalit?t einher und erfordern die Explantation des gesamten ICD-Systems. H?matome im Bereich der Generatortasche und/oder einer subkutan implantierten Fl?chenelektrode kommen in einer H?ufigkeit von 2–5% vor und k?nnen durch lokale Kompressionsma?nahmen behandelt werden oder erfordern in Einzelf?llen die operative Revision. Komplikationen des Elektrodensystems werden in etwa 5–10% nachgewiesen. Es handelt sich vor allem um Dislokationen (Inzidenz 3–10%), Elektrodenbrüche (Inzidenz 1–5%) oder Isolationsdefekte. Hinweise auf St?rungen des Elektrodensystems ergeben sich aufgrund ineffektiver Stimulationen oder Wahrnehmungen von extrakardialen Signalen mit der Folge von Inhibierung der Schrittmacherstimulation oder inad?quater ICD-Entladungen. Für die Differentialdiagnostik von tachykarden und bradykarden Herzrhythmusst?rungen bei Schrittmacherpatienten ist eine genaue Zuordnung der Schrittmacherstimulationsspikes zu den P-Wellen und R-Zacken im EKG erforderlich. W?hrend bei einem Oversensing die Schrittmacherstimulation inhibiert wird, kommt es bei einem Undersensing zu einer starrfrequenten Stimulation, die in Konkurrenz mit dem Eigenrhythmus treten kann. Schrittmacherinduzierte Tachykardien (PMT) kommen durch ein Reentry-Kreis zwischen retrograder AV-überleitung und AV sequentieller Stimulation zustande. Eine Magnetauflage führt bei den meisten Schrittmacheraggregaten zu einem starrfrequenten Stimulationsmodus, wodurch Dysfunktionen durch Oversensing und PMT tempor?r terminiert werden k?nnen.    Bei ICD-Patienten k?nnen auch Notfallsituationen durch inad?quate ICD-Entladungen bei supraventrikul?ren Tachyarrhythmien oder durch h?ufige ad?quate ICD-Therapien verursacht werden. Die h?ufigste Ursache inad?quater ICD-Entladungen ist tachykardes Vorhofflimmern (Inzidenz 20–40%), das relativ einfach durch medikament?se Beeinflussung der atrioventrikul?ren überleitung behandelt werden kann. Ad?quate h?ufige ICD-Entladungen (Inzidenz≈1%), oft Zeichen einer h?modynamischen Verschlechterung, sind wesentlich schwieriger zu behandeln und hier sollte in erster Linie eine aggressive Therapie der Herzinsuffizienz durchgeführt werden. Alternative Verfahren wie Katheterablation oder antiarrhythmische Behandlung sollten zurückhaltend erfolgen. Die Betreuung von Notf?llen nach SM/ICD-Implantation erfordert vor allem ein rasches gezieltes diagnostisches und therapeutisches Vorgehen, um weitere Entladungen und eine m?gliche Gef?hrdung eines Patienten zu vermeiden. Eingegangen: 21. Oktober 2000 Akzeptiert: 20. November 2000     

Experimentelle Untersuchungen zum Problem Cytostatica und Wundheilungsstörungen

Zusammenfassung Oberschenkelfrakturen bei Meerschweinchen werden nach massiver Medikation von E 39 solubile (Dosierung über die Dosis tolerata maxima hinaus bis nahe an die Dosis letalis 50) untersucht. Eine Hemmung der Callusdifferenzierung und somit der Wundheilung entsprechend den Eigenschaften der Cytostatica als Proliferationshemmer wird nachgewiesen. Die im Versuch verwendete Dosierung kommt im klinischen Gebrauch praktisch nicht in Frage; es ist demnach in der menschlichen Tumorchemotherapie nur mit einer geringfügigen, beherrschbaren Wundheilungsverzögerung zu rechnen. Wundheilungsstörungen stellen somit keine Kontraindikation gegen eine zu fordernde intensive Tumorcheomotherapie dar.

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Summary Fractures of the femurs of guinea pigs were studied after massive medication with soluble E 39 (administered above the maximal tolerated dose and approaching the lethal dose 50). A suppression of the differentiation of the callus and thus the healing of the wound were demonstrated, revealing thereby the characteristics of the cytostatica as an inhibitor of proliferation. The dose used in the experiments would be out of question clinically. Accordingly, in the chemotherapy of human tumors one would expect only a slight delay in wound healing.

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Mit 2 Textabbildungen     

Antikoagulation und Gerinnungsstörungen in der Schwangerschaft

A review of coagulation disturbances during pregnancy and the current management of the anticoagulated patient with heart valve prostheses, atrial fibrillation, and thromboembolic events is presented. All patients with mechanical heart valve prostheses require life-long oral anticoagulation with coumarin or one of its derivatives. Recommendations for the treatment and prevention of thromboembolic events are discussed. The advantages and disadvantages of three different treatment approaches to anticoagulation during pregnancy are discussed and recommendations for the management in different situations are outlined with delineation of specific risks for the mother and the fetus.     

Sexuelle Funktionsstörungen bei Herzkranken und die Folgen

Purpose

Due to the high prevalence of sexual disorders in men and women with cardiovascular disease, the associations between sexual dysfunction, depression, anxiety, quality of life and partnership were investigated. Studies examining impairments to certain aspects of psychological health and interpersonal life in cardiac patients are still lacking. The SPARK (Sexuality of Patients in Rehabilitation of Cardiovascular Diseases) investigation is the first study which explores these relevant associations in German rehabilitation patients.

Methods

Five rehabilitation centers for cardiovascular diseases took part in our cross-sectional study. Associations between sexual dysfunction and depression, anxiety, quality of life and partnership were tested using z-tests (resulting parameter prevalence rate ratio, PRR) and via multiple binary logistic regressions controlling for age and severity of cardiovascular disease as possible confounders (resulting parameter odds ratio, OR).

Results

Sexual function could be assessed in 261 men and 75 women (sexual activity during the previous month; for detailed flow chart see Fig. 1). In total, 43.1% of female patients reported a sexual dysfunction, while 20.2% of male patients stated to have at least moderate erectile dysfunction (ED). The proportion of self-assessed sexual problems is shown in Fig. 2. Women with a sexual dysfunction were impaired to a significantly higher extent compared to women without sexual dysfunction with regard to their quality of partnership (PRR 13.0; p=0.019; OR 25.42, confidence interval, CI, 2.5–254.9), anxiety (PRR 3.2; p=0.053; OR 4.43, CI 1.2–16.4) and psychological quality of life (PRR 2.4; p=0.115; OR 6.08, CI 1.6–22.9). Men with ED reported significantly stronger depression (PRR 3.6; p=0.003; OR 3.63, CI 1.5–8.8) and anxiety (PRR 2.4; p=0.008; OR 2.88, CI 1.4–5.9) compared to men without ED. For detailed information see Tables 1 and 2.

Conclusion

Due to the high proportion of men and women with cardiovascular disease reporting sexual disorders, depression and anxiety, screening for these disorders should be an integral part of comprehensive rehabilitation programs. In particular, the diagnosis and treatment of psychiatric comorbidity seem to be necessary from a tertiary preventive perspective.