Frühdiagnostik von chronischen Nierenerkrankungen

Zusammenfassung Chronische Nierenerkrankungen laufen in der Regel über einen Zeitraum von mehreren Jahren ab, bevor der glomeruläre Filtrationsapparat und das Nierenparenchym soweit destruiert sind, dass eine Nierenersatztherapie erforderlich wird. Häufig dauern die Krankheitsverläufe länger als 10 Jahre. Um den Funktionsverlust der Nieren zu vermeiden, muss angestrebt werden, chronische Nierenerkrankungen möglichst frühzeitig zu erkennen, damit therapeutische Maßnahmen rechtzeitig eingeleitet werden können und die Medikamente zur Progressionsverlangsamung (z. B. ACE-Hemmer, AT₁-Blocker) ihre Wirkung in optimaler Weise entfalten können. Leider wird ein signifikanter Anteil der chronisch nierenkranken Patienten nach wie vor zu spät diagnostiziert, sodass therapeutische Maßnahmen häufig zu spät einsetzen und Chancen zum Erhalt einer ausreichenden Nierenfunktion ausgelassen werden.     

Frühdiagnostik kolorektaler Tumorleiden

Zusammenfassung Das kolorektale Karzinom (KRK) zählt in den westlichen Industrieländern zu den häufigsten malignen Tumoren und ist mit einer hohen Mortalität assoziiert. Das mittlere Lebenszeitrisiko für ein KRK beträgt in Deutschland etwa 6%. Menschen über 50 Jahre, Verwandte von Patienten mit Adenomen oder kolorektalem Karzinom, Patienten mit entzündlichen Darmerkrankungen sowie Menschen, bei denen der Verdacht auf ein erbliches kolorektales Karzinom besteht, weisen ein erhöhtes Erkrankungsrisiko auf. Der Nutzen einer systematischen Vorsorge für das KRK ist belegt, da durch die rechtzeitige Entfernung von präkanzerösen Läsionen ein invasiver Tumor verhindert werden kann. Untersuchungsmethode der Wahl ist bislang die komplette Rektokoloskopie, die virtuelle Kolonographie könnte in Zukunft eine sinnvolle Ergänzung darstellen. Symptomlose Personen mit durchschnittlichem Erkrankungsrisiko wird eine erste Vorsorgekoloskopie ab dem 50. Lebensjahr und bei unauffälligem Befund eine Verlaufsuntersuchung nach 10 Jahren empfohlen. Sind in einer Familie früh kolorektale Adenome oder Karzinome aufgetreten, ist eine Koloskopie 10 Jahre vor der frühest aufgetretenen Neoplasie, aber spätestens ab dem 40. Lebensjahr sinnvoll. Familien mit hereditärem KRK benötigen einen speziellen Vorsorgeplan.     

Frühdiagnostik der Lyme-Arthritis

Lyme-Arthritis is one of the most frequent manifestations of Lyme disease. Transient arthritides may already develop in the early disease stage. However, typical Lyme arthritis manifests weeks to months after the infection as intermittent mon- or oligoarthritis predominantly affecting the knees. Massive knee effusions may lead to popliteal cysts that often rupture. Chronic arthritides are rare.The diagnosis of Lyme arthritis mainly is based on clinical grounds and confirmed by laboratory tests. Direct detection of the causing agent by culture is difficult and not suitable for clinical use. With polymerase chain reaction based assays in up to 80% of untreated patients with Lyme arthritis B. burgdorferi DNA can be detected in joint fluid or synovial membrane specimens. While this method is not widely available yet it will become a routine diagnostic tool in Lyme arthritis in the near future.Borrelia serology is still the most important laboratory test. A negative serology almost certainly rules out Lyme arthritis. A positive serology alone, however, does not proof Lyme disease and must be critically interpreted in context with clinical symptoms.     

Stellenwert des Gewebe-Dopplers in der Frühdiagnostik von Kardiomyopathien

Tissue Doppler and its derived parameters strain and strain rate show characteristic changes in patients with cardiomyopathy. Longitudinal systolic (S) and early diastolic (E') peak tissue velocities are reduced in the basal segments of the left ventricle in patients with dilated, hypertrophic, and restrictive cardiomyopathies, and in the right ventricular free wall in patients with arrhythmogenic dysplasia of the right ventricle. Similarly, strain and strain rate are lower than in normals. These changes are detectable in asymptomatic, genetically affected patients and in early stages of cardiomyopathy, where conventional echo signs such as impaired left ventricular ejection fraction or increased wall thickness are not yet present. Thus, tissue Doppler analysis may contribute to better identifying carriers of disease and subclinical early stages of cardiomyopathy. However, lack of measurement standardization and small numbers of cardiomyopathy patients examined by Doppler, together with difficulty in defining reliable normalcy ranges, still hamper widespread clinical use of this new tool.     

Frühdiagnostik chronisch entzündlicher Systemerkrankungen

Zusammenfassung Funktionell relevante Spätschäden oder Organdysfunktionen idiopathischer chronisch entzündlicher Systemerkrankungen können durch eine frühzeitig eingeleitete Therapie in ihrer Schwere deutlich reduziert und teilweise verhindert werden. Voraussetzung hierfür ist die möglichst frühe und präzise Diagnosestellung, was aufgrund der zu Beginn oft uncharakteristischen Klinik eine erhebliche diagnostische Herausforderung darstellt. Der vorliegende Beitrag zeigt am Beispiel der rheumatoiden Arthritis, der Kollagenosen und Vaskulitiden die aktuellen Möglichkeiten und Grenzen in der Frühdiagnostik entzündlicher Systemerkrankungen. Auf die Fortschritte in der Autoantikörperdiagnostik und auch bei den bildgebenden Verfahren im Rahmen der Früherkennung chronisch entzündlicher Systemerkrankungen wird eingegangen.     

Frühdiagnostik bei Typ-1-Diabetes

Type 1 diabetes is an organ-specific autoimmune disease that is caused by selective destruction of the insulin-producing beta-cells. Depending on the individual stage of the pathogenesis, there are various diagnostic tools available for early diagnosis of (pre-) type 1 diabetes. Children with an increased diabetes risk can be identified prior to the appearance of islet autoimmunity by family history for type 1 diabetes and genetic screening. In non-diabetic individuals who have already developed islet autoimmunity, progression to diabetes onset can be assessed by measuring islet autoantibodies. Metabolic stimulation tests can provide additional information on the timing of the impending disease in autoantibody-positive subjects. In newly diagnosed diabetic patients, the detection of islet autoantibodies is an important criterion for differential diagnosis that allows distinction between autoimmune (type 1) and non-autoimmune diabetes.     

Frühdiagnostik der funktionell relevanten koronaren Herzerkrankung

Zusammenfassung Die koronare Herzkrankheit (KHK) ist nach angiographischen Kriterien definiert als das Vorliegen von Lumeneinengungen der Koronarien >50%. Die mit einer solchen Lumenreduktion einhergehenden hämodynamischen Veränderungen stellen heute die Grenze für die Nachweisbarkeit der KHK mit den sensitivsten funktionellen Untersuchungsverfahren der Ischämiediagnostik dar. Bei Verdacht auf das Vorliegen einer KHK oder atypischer Beschwerdesymptomatik wird die Indikationsstellung zur Herzkatheterdiagnostik durch eine Ischämiediagnostik abgesichert. Diese kann entweder durch ergometrische Belastungstests oder durch bildgebende Verfahren in Kombination mit ergometrischer oder pharmakologischer Belastung erfolgen. Etabliert sind die Myokardszintigraphie und die Stressechokardiographie sowie in zunehmenden Maße auch die Stressmagnetresonanztomographie. Neben dem sensitiven Ischämienachweis hat der technische Fortschritt in der Computertomographie (CT) und der Magnetresonanztomographie (MRT) die Möglichkeit einer nichtinvasiven Darstellung der Koronargefäße und der Gefäßwandmorphologie eröffnet. Während die CT-Koronarangiographie mit ihrer hohen räumlichen Auflösung an der Schwelle zur klinischen Anwendung bei selektierten Patienten steht, hat die MRT das Potenzial, von der Wandbewegungsanalyse über die Perfusion und Koronarflussmessung bis hin zur Plaquecharakterisierung zukünftig eine kardiovaskuläre Rundumuntersuchung zu gewährleisten.     

Frühdiagnostik der funktionell relevanten koronaren Herzerkrankung

Die koronare Herzkrankheit (KHK) ist nach angiographischen Kriterien definiert als das Vorliegen von Lumeneinengungen der Koronarien >50%. Die mit einer solchen Lumenreduktion einhergehenden hämodynamischen Veränderungen stellen heute die Grenze für die Nachweisbarkeit der KHK mit den sensitivsten funktionellen Untersuchungsverfahren der Ischämiediagnostik dar. Bei Verdacht auf das Vorliegen einer KHK oder atypischer Beschwerdesymptomatik wird die Indikationsstellung zur Herzkatheterdiagnostik durch eine Ischämiediagnostik abgesichert. Diese kann entweder durch ergometrische Belastungstests oder durch bildgebende Verfahren in Kombination mit ergometrischer oder pharmakologischer Belastung erfolgen. Etabliert sind die Myokardszintigraphie und die Stressechokardiographie sowie in zunehmenden Maße auch die Stressmagnetresonanztomographie. Neben dem sensitiven Ischämienachweis hat der technische Fortschritt in der Computertomographie (CT) und der Magnetresonanztomographie (MRT) die Möglichkeit einer nichtinvasiven Darstellung der Koronargefäße und der Gefäßwandmorphologie eröffnet. Während die CT-Koronarangiographie mit ihrer hohen räumlichen Auflösung an der Schwelle zur klinischen Anwendung bei selektierten Patienten steht, hat die MRT das Potenzial, von der Wandbewegungsanalyse über die Perfusion und Koronarflussmessung bis hin zur Plaquecharakterisierung zukünftig eine kardiovaskuläre Rundumuntersuchung zu gewährleisten.     

Frühdiagnose von Vaskulitiden

The often unspecific symptoms like myalgias, fever and weight loss at the onset of vasculitides are a frequent cause for a delay in diagnosis. Organ-specific symptoms like hemoptysis, dyspnoea, epistaxis, edema and organ infarcts a present when organ dysfunction occurs as a result of vasculitis. Targeted serologic testing including antineutrophil cytoplasm antibodies (ANCA) and cryoglobulins allows early diagnosis of certain vasculitides. Modern imaging techniques like magnetic resonance imaging, computed tomography, positron-emission tomography and ultrasound are cornerstones for an early diagnosis as they allow the detection of subclinical disease and are helpful in the identification of a site for biopsy. Bioptic proof of vasculitis is still the gold standard for diagnosis. Functionally relevant damage caused by systemic inflammatory disorders can by reduced or sometimes avoided by early initiation of treatment. This requires a correct diagnosis is made as early as possible.     

Elektrische und pharmakologische Frühkardioversion von Vorhofflimmern

Cardioversion of atrial fibrillation as an element of rhythm control strategy is indicated in patients with first episode of atrial fibrillation, hemodynamic instability, recurrent atrial fibrillation with low probability of spontaneous conversion, or severe symptoms. Early cardioversion is performed within 48 h of onset of atrial fibrillation. The best point in time is still unknown. It can be performed by pharmacological, or, preferentially, by electrical cardioversion. The advantages of electrical cardioversion are higher efficacy and no proarrhythmic risk, however, short time general anaesthesia is needed. Electrical cardioversion is most effective when biphasic shocks are delivered. For pharmacological cardioversion, several antiarrhythmic drugs are available which have to be considered individually. Thromboembolic risk does not differ between the two methods. Early cardioversion and maintenance of sinus rhythm is most effective in atrial fibrillation of short duration, normal left atrial size and no or only mild structural heart disease.     

Bildgebende Verfahren in der Frühdiagnostik rheumatischer Veränderungen der Hände

Purpose

Besides the use of conventional x-rays in the diagnostic work-up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of ultrasound of the hands with proven methods such as conventional x-rays, low-field MRI and 3P-Sz.

Methods

A total of 30 patients were studied using a 1 day protocol with ultrasound, 3P-Sz, MRI and x-ray of the hands. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA typical and non-RA typical changes. All methods were compared to the summarized findings interpreted by a rheumatologist after 2 years.

Results

Of the 30 patients, 19 presented with clinical symptoms of initial changes due to rheumatoid arthritis. Ultrasound revealed 14/19 patients with the correct diagnosis. Conventional x-rays indicated 11/19 patients, while 3P-Sz (100%) and low-field MRI (95%) showed high sensitivity. It was possible to differentiate between inflammation and inconspicuous findings.

Conclusions

An experienced examiner can use ultrasound effectively for the initial diagnosis of RA. Based on its low cost, ultrasound is a valid alternative to conventional x-rays.     

Frühe Spondyloarthritiden

The spondyloarthritides (SpA) are often included in the differential diagnosis of early arthritis with or without low back pain. This is namely true for reactive arthritis which occurs as acute or subacute arthritis in association with urogenital or gastrointestinal bacterial infection. Reactive arthritis can result in chronic or relapsing disease. The SpA group also includes ankylosing spondylitis (axial form or with peripheral arthritis), psoriatic arthritis and SpA in association with inflammatory bowel disease. (Early) undifferentiated SpA has now come into the focus of many researchers since more effective and specific therapy has become available for the SpA. Diagnostic algorithms have been developed and evaluated.     

Frühe Repolarisation

Early repolarization, involving infero-lateral ST segment elevation and prominent J waves at the QRS-ST junction has been considered a normal ECG variant for more than 80 years. More recent studies suggest that this phenomenon is not as benign as earlier believed and may represent a risk for subsequent ventricular fibrillation in patients with and without structural heart disease. However, based on current data it seems unjustified to consider these often accidental ECG findings a marker for high risk of sudden cardiac death. The concept of a reduced repolarization reserve developed for the Long QT syndrome can be transformed to early repolarization syndrome. In general a “fibrillation reserve” is relatively high but if triggers such as a genetic background, age, gender, influences of the autonomous nervous system, changes in body temperature, or an acute coronary syndrome act together ventricular fibrillation may occur. A combination of an “early repolarization ECG” with syncope and/or a positive family history of sudden cardiac death may justify defibrillator therapy just on an individual basis. This review intends to summarize actual aspects of early repolarizations syndrome and focuses on the dilemma of risk stratification.     

Frühe Spondyloarthritiden

The diagnosis of axial spondyloarthritis (SpA) or ankylosing spondylitis (AS) is often delayed by 5?C10?years after the first symptoms have appeared. In order to improve the early diagnosis of SpA an evidenced-based algorithm including clinical, laboratory and imaging parameters was developed. Moreover, the recently published ASAS criteria for axial and peripheral SpA should give rheumatologists more confidence in making the diagnosis of SpA and provide further support for the SpA concept. Furthermore, an easy strategy for the recognition of patients with a high probability of AS/SpA on the primary care level has been developed and recently validated.     

Geriatrische Frührehabilitation

Background

Physicians in Germany who are not specialized in geriatric medicine often have to make decisions regarding referral of patients for early geriatric rehabilitation. The risk of inadequate patient allocation is due to lack of knowledge or underestimation of the potential benefit of early rehabilitation in reducing a patient’s need of care. Particularly the oldest old are affected by those inadequate decisions.

Materials and methods

Based on the nationwide database Gemidas Pro, the data sets of ≥?90-year-old patients were analysed regarding diagnoses, multimorbidity, gender, length of stay, procedures, outcome parameters as nursing personnel regulation (PPR), Barthel index and the Timed Up and Go (TUG) test compared to younger age groups. Data from 85 acute inpatient geriatric institutions during the period from January 2006 to December 2009 were included.

Results

Neither the analysis of the diagnosis nor multimorbidity showed relevant differences compared to younger patients. Despite poorer functional status at admission, the ≥?90 year olds experienced a 25?% increase in the activities of daily living (ADL) measured by PPR, 30?% increase in mobility classification based on the TUG and 59?% increase in ADL measured with the Barthel index. These changes were significantly different. In addition, the length of stay was 18.96 days on average in the group of ≥?90-year-old patients, which was but not significantly shorter than the length of stay in the group of 70- to 79-year-old (19.7 days) and 80- to 89-year-old patients (19.65 days).

Conclusion

The analyses show that the oldest old suffer from more severe deficits in functional status on admission in acute geriatric wards compared to younger patient groups. However, on discharge the oldest old show a significant and relevant increase in mobility and ADL without increase in length of stay.     

Frühdiagnose von Spondyloarthritiden mit besonderer Betonung auf die axialen Formen

The axial spondyloarthritis (SpA) is the most important disease out of the whole group of SpA. If a sacroiliits is clearly detectable by x-rays a diagnosis of ankylosing spondylitis can be made. However, there is still a delay of 5-10 years from the first symptoms until a final diagnosis is made. An important reason for this is the fact that radiological changes are often only detectable after several years of disease, despite the presence of inflammation as detected by MRI and the presence of clinical manifestations such as pain and stiffness. An early diagnosis becomes more and more important because effective therapies have become available which are probably even more effective if given early. New strategies how to make an early diagnosis and how primary care physicians can screen for these patients are discussed.     

Frühe palliative Führung

Despite advances in chemotherapy treatment, the prognosis for patients with advanced lung cancer still remains serious accompanied by devastating effects on physical well-being, psychological health and psychosocial care. Although chemotherapy is accepted as an effective treatment, the high prevalence of disease-specific symptoms, depressed mood and aggressive end-of-life care highlight the need for palliative care to minimise symptom distress and promote quality of life. In this context, a randomised palliative intervention trial performed by Temel et al. in Boston, USA (N Engl J Med 2010) was remarkable comparing standard oncological chemotherapy alone with an early palliative concept integrated into standard chemotherapy in patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC). The results show that those patients receiving additional palliative care had a better quality of life and less depressive symptoms than did patients assigned to the standard therapy alone. In addition, median survival of patients in the palliative care group was significantly prolonged for 2.7?months compared to standard therapy alone. Data support the incorporation of early palliative care into the therapeutic concept for metastatic NSCLC.