Die „Baxströmaffäre“

Zusammenfassung Bis zum Jahre 1966 verlegte die Gefängnisverwaltung New York, gestützt auf die einschlägigen Rechtsverordnungen, Häftlinge, die im Strafvollzug psychische Störungen aufwiesen, in die anstaltseigene Dannemora-Klinik, die Behandlung erfolgte dort durch angestellte Ärzte für Allgemeinmedizin, die streng weisungsgebunden waren. Einer der Betroffenen, J. K. Baxström, strengte gegen dieses Vorgehen einen Rechtsstreit an, in dem er letztlich vor dem Supreme Court der USA obsiegte: die Notwendigkeit eingehender medizinischer Sachaufklärung, richterlicher Anhörung und Billigung der Verlegung wurden auch für psychisch kranke Rechtsbrecher bestätigt. Die Soziologen Steatman und Cocozza nahmen daraufhin (1966–1974) bei 967 entlassenen früheren Patienten der Dannemora-Klinik Erhebungen vor; Fazit: Psychiater hätten in diesen Fällen ein willkürliches und menschenverachtendes Verhalten gezeigt, Diagnostik, Therapie und Prognosenstellung seien bei dieser Randgruppe unzureichend und fehlerhaft gewesen. Nachforschungen belegen jedoch, daß Psychiater an den Verlegungen in die Dannemora-Klinik weder planend, beratend noch ausführend beteiligt waren. Die Vorwürfe entbehren insoweit also jeder sachlichen Grundlage. Die in den Medien immer wieder aufgegriffene Baxströmaffäre erweist sich als ein Beispiel ideologisch determinierter Psychiatriekritik mit bedenklichen Mitteln.Herrn Prof. Dr. Dr. P. Bresser, Köln, zum 60. Geburtstag gewidmet     

Die interventionelle/endovaskuläre Therapie des infrarenalen abdominellen Aortenaneurysmas

The catheter-based interventional therapy (endovascular aortic repair EVAR) of abdominal aortic aneurysms (AAA) has gained an established place in the spectrum of therapeutic options. The procedure is characterized by low peri-interventional morbidity and mortality. Multislice computed tomography (CT) has a dominant role in defining the correct indications and in selecting an appropriate stent graft prior to the intervention. The rate of acute conversions could be reduced from 2.9 % to 0?% in our own elective patient population since 2010. In our vascular centre the proportion of patients treated by EVAR was 39.5?% (102 out of 258). The procedure is used routinely in patients who have an increased risk for general anesthesia or open surgery due to concomitant diseases. It is also used in patients with a reduced local operability due to prior surgery, abdominal diseases or radiation therapy. Arterial closure devices allow a completely percutaneous approach in a certain group of patients. However, after EVAR a life-long surveillance is mandatory because delayed therapy failure has been described. In younger patients who do not have a higher risk open surgery is still an option. The paper describes techniques, results und complications of EVAR.     

Die Verhandlungsfähigkeit des alten (multimorbiden) Patienten

Zusammenfassung Die Anforderungen an die Verhandlungsfähigkeit entsprechen im Wesentlichen dem Kompetenzmodell in der neuropsychiatrischen Literatur: Eine Person muss einen Sachverhalt verstehen, in einen Zusammenhang einordnen, die Konsequenzen bedenken sowie eine Entscheidung fällen und ausdrücken können. Gesundheitliche Störungen, die die Verhandlungsfähigkeit beeinflussen, sind im Alter vorwiegend bei Demenzen, Depressionen und/oder Delirien zu erwarten. Relevante Fakten zu diesen Syndromen werden dargestellt. Um die Interraterreliabilität und die Validität von Kompetenzbeurteilungen zu optimieren, erscheint es sinnvoll, strukturierte assessments unter Einbeziehung auch psychometrischer Tests heranzuziehen, statt sich allein auf ein klinisches Global- oder Gesamturteil zu verlassen. Bestuntersucht ist bis heute der Mini-Mental Status Test (MMSE). Bei Werten von weniger als 16 Punkten ist danach sicher von einer Kompetenzstörung auszugehen, bei solchen über 26 allenfalls fraglich. Skalen und Instrumente, die Depressivität oder andere psychopathologische Funktionen quantifizieren, wurden hierzu bisher nicht untersucht. Mit diesem Thema befasste Juristen sollten eine Basiskompetenz im Umgang mit diesen orientierenden Instrumenten erwerben.Nach einem Vortrag bei der Herbsttagung der Arbeitsgemeinschaft Forensische Psychopathologie und Ethik der Deutschen Gesellschaft für Rechtsmedizin am 26.10.2002 in Göttingen.     

Die zirkuläre Abreißung der Cervix uteri sub partu

Ohne ZusammenfassungMit 1 Textabbildung.     

Interdisziplinäre Schockraumversorgung: Die Aufgaben der Radiologie aus unfallchirurgischer Sicht

Efficient resuscitation of major trauma requests an interdisciplinary communication between trauma surgeons, anaesthesiologists and radiologists. Trauma outcome is significantly influenced by horizontal trauma team organisation and coherence to clinical algorithms, which allow fast diagnosis and intervention. A radiologist present on patients arrival in the trauma room provides a major impact on trauma care. Nevertheless optimal integration in the trauma team implies profound knowledge of the priorities of advanced trauma life support and trauma algorithms. His or her involvement is not limited to patient care only, also active participation in trauma room design, interdisciplinary algorithm development and trauma research are essential tasks for radiologists devoted to emergency radiology. Based on the pathophysiology of polytrauma and the structure of German trauma system, current concepts and proven clinical algorithms with special regard to the radiologist and his duties and tasks will are presented.     

Prostatakarzinom (PC) – eine organspezifische Neoplasie aus der Sicht der Pathologie

The organ- and tumour-related specific characteristics of prostate carcinoma (PC) are presented in an overview under various aspects. It is the key for understanding pathological changes, including PC, to consider the subdivision of the prostate into anatomically and functionally distinguishable zones, especially the transitional zone (TZ) and the peripheral zone (PZ). The pseudoneoplastic hyperplasia of the TZ, combined with inflammatory consequences and age-related changes, forms a differential diagnostic challenge to both clinico-radiological diagnosis and macroscopic and microscopic examination. High-degree prostatic intra-epithelial neoplasia (PIN III) and atypical adenomatous hyperplasia (AAH) are presented as precursor lesions of PC with varying significance and assessment. Moreover, there are discussed the following characteristic features of PC: localisation types, focality, volume, progression, double-graduation according to Gleason, tumour stage, and prognosis. The most important prognosis factors of PC (category I) include the categories of the TNM system, such as stage, surgical marginal situation, degree and also the preoperative PSA level as a (poor) substitute for the tumour volume. Potential prognosis parameters (category II) show the tumour volume and the DNS ploidy, while there continues to exist a large number of non-established parameters (category III). The prognostic validity of the pathological examinations depends, on the one hand, on the tissue extent (needle biopsy, transurethral resection (TURP), so-called simple prostatectomy, radical prostatectomy (RPE)) and the prostate zones covered. On the other hand, the prognostic certainty also depends on the tumour-adequate macroscopic and microscopic assessment of an RPE that can only be a partial or complete handling in transversal large-area sections.     

Interdisziplinäre Gesichtsrekonstruktion einer Moorleiche

In 2000 a severely fragmented bog body was uncovered in the “Großes Uchter Moor” (District of Nienburg, Lower Saxony). An interdisciplinary team of forensic scientists, anthropologists, palaeopathologists and archaeologists initiated the reconstruction of the skull and face of this female bog body, named “Moora”. With a newly developed computerized animation based on computed tomographic (CT) findings of individual bones and fragments, the skull was reconstructed digitally and subsequently by using the rapid-prototyping technique.On the basis of this skull model five scientists formed different faces of the bog body using different facial reconstruction techniques. The results are presented two dimensionally.     

Interdisziplinäre Zusammenarbeit im Schockraummanagement

Accidents do not only cause human harm but also tremendous costs. Prevention of injuries and improvement of management has reduced the mortality in trauma during recent years. Because time is an important factor in treatment of severely injured patients, the initial clinical treatment is the key in the management of these patients. Appropriate equipment and personnel are necessary to provide an efficient management of trauma patients. A strategy focused on life-threatening injuries and simultaneous diagnostic and therapeutic procedures are critical in the "golden hour of shock".     

Intramuskuläre Applikation von Depotmedikamenten

Drug-loaded microparticles (microspheres) based on poly(lactic-co-glycolic) acid (PLGA) are used for long-term drug release mainly after intramuscular injection. The particles are rarely seen in histological sections from autopsy specimens. The case of a 65-year-old woman who died following a generalized infection and erysipelas is presented where the origin of histologically detected microparticles could only be identified with great difficulty.     

Vaskuläre Rekanalisationstechniken: Nierenarterienstenosen

Decisive for the evaluation for radiological interventional therapy of renal artery stenosis, are the morphologic diagnostic by Duplex sonography, non-invasive cross-sectional angiography and digital subtraction angiography in addition to the anamnesis and clinical constellation. A standardized diagnostic algorithm and an evidence-based indication status contribute just as importantly to improvement of outcome as the implementation of uniform peri-interventional measures and a structured procedure for angiography, percutaneous transluminal renoangioplasty and follow-up. The aim of this article is to provide a practical introduction for the current radiological management of renal artery stenosis.     

Endovaskuläre Interventionen beim Polytrauma

Clinical issue

In recent years interventional radiology has significantly changed the management of injured patients with multiple trauma. Currently nearly all vessels can be reached within a reasonably short time with the help of specially preshaped catheters and guide wires to achieve bleeding control of arterial und venous bleeding.

Standard treatment/treatment innovations

Whereas bleeding control formerly required extensive open surgery, current interventional methods allow temporary vessel occlusion (occlusion balloons), permanent embolization and stenting.

Diagnostic work-up

In injured patients with multiple trauma preinterventional procedural planning is performed with the help of multidetector computed tomography whenever possible.

Performance

Interventional radiology not only allows minimization of therapeutic trauma but also a considerably shorter treatment time.

Achievements

Interventional bleeding control has developed into a standard method in the management of vascular trauma of the chest and abdomen as well as in vascular injuries of the upper and lower extremities when open surgical access is associated with increased risk. Additionally, pelvic trauma, vascular trauma of the superior thoracic aperture and parenchymal arterial lacerations of organs that can be at least partially preserved are primarily managed by interventional methods.

Practical recommendations

In an interdisciplinary setting interventional radiology provides a safe and efficient means of rapid bleeding control in nearly all vascular territories in addition to open surgical access.     

Zelluläre Mechanismen der Tumorresponse

Diseases caused by cancer have become more common due to an increase in life-expectation, but the probability of reaching an old age with or without a tumor disease is still increasing. According to the statistics of the German Cancer register, at present more than half of cancer patients survive for at least 5 years after cancer has been diagnosed. Many tumors can be cured using innovative neoadjuvant and adjuvant therapy regimes, but the options for palliative therapy have also been improved. This leads to an increasing importance of the evaluation of the tumor response using imaging techniques. Classically, tumor response is measured by imaging using the RECIST (response evaluation criteria in solid tumors) criteria, which define the changes in size of the tumor during therapy. However, there is increasingly more evidence that RECIST as the only measure of tumor response, does not document tumor response for all tumor entities and especially not for many medications known as targeted therapy. This article gives a review of the principles and mode of effect of various therapy regimes as well as the clinical demands on imaging techniques.     

Primäre Strahlentherapie des Larynxkarzinoms

Purpose

In the treatment of laryngeal carcinoma definitive radiotherapy results in a similar outcome as surgical treatment in the early stages with a lower morbidity rate and good functional results. In fact no randomized studies exist, so far, and the optimal treatment concept for the different stages is not well defined. The following study analyses retrospectively the treatment results and the recurrence data in patients with a squamous cell carcinoma of the larynx treated with definitive radiotherapy.

Patients and Method

Two hundreds and eighty-three patients with carcinoma of the larynx were treated with radiation therapy in the department of radiology of the LMU München between September 1971 and June 1986. Twenty-six patients (9.2%) were female and 257 (73.1%) male. The median age was 68.5 years, respectively 70 years. All patients had a histologically confirmed squamous cell carcinoma of the larynx. No true subglottic cases were observed. Forty-one (14.5%) tumors were localized supraglottically, 207 (73.1%) glottically. Thirty-five patients had a T4 tumor with glottic and supraglottic involvement. In 147 patients the histopathological grading was evaluable: 32 tumors were classified as G1, 95 as G2, 15 as G3 and 5 as G4. According to the UICC classification of 1979 25 patients had a carcinoma in situ (Tis), 93 patients had a stage T1, 90 stage T2, 40 stage T3 and 35 stage T4. Two hundreds and thirty-three of 283 (82.3%) had no lymph node involvement. In 50 patients clinically a lymph node involvement was observed. 22 patients had a stage N1, 5 patients stage N2 and 23 patients stage N3. An external beam radiation mostly with cobalt-60 was performed with a mean dose of 61.9 Gy.

Results

The 5-years relapse free survival for the whole group was 61.7%. The probability for “no evidence of disease” (NED) depended on tumor stage and-localisation (glottic tumors: Tis/T1 90.5%; T2 59.4%; T3 39.6%; [5-year NED]; supraglottic tumors: T1 64.2%; T2/3 28.6%; T4/N3 24.7% [3-year NED]). Other signifikant prognostic factors besides T-stage were N-stage (N0 vs. N1–3: 3-year recurrence-free survival 68% vs. 37.2%, p<0.001) and histopathologic grading (G1 vs. G3/4: 3-year recurrence-free survival 74% vs. 37.1%, p<0.01). One hundred and twenty-two (43.1%) patients had a recurrence, which occurred in 75.4% local, in 12.3% locoregional, in 8.2% with distant metastases and 4.1% combined. In 50 patients with a recurrent disease a salvage-therapy was carried out. Thereby 17 patients achieved a complete response.

Conclusion

Even for the here described negatively selected patient group with a high median age and multimorbidity, good local controlrates could be achieved escpecially in early stages with definitive radiation therapy. In more advanced stages even in elderly patients a combined surgical-radiotherapeutic treatment should be performed.     

Die kriminalistischen Universitätsinstitute

Ohne Zusammenfassung