Therapie des akuten Myokardinfarkts in der Prähospitalphase

The time period from symptom onset to hospital admission is of outstanding importance for the prognosis of a patient with an acute myocardial infarction. He is threatened by sudden cardiac death triggered by ventricular fibrillation on the one hand and on the other hand this period offers the chance for a timely decision on the optimal reperfusion strategy. A broad spectrum of therapeutic opportunities regarding thrombolysis, antiplatelets and anticoagulation has been proven to be effective in large randomised trials and registries. These results should influence the individual decision on reperfusion treatment as well as the patient's conditions, time lines, logistics and local resources.     

Diagnostik des akuten Myokardinfarkts bei ?lteren Patienten

The early diagnosis of an acute myocardial infarction (MI) is improved by the introduction of novel high-sensitivity troponin assays. These assays can measure low level myocardial injury not detectable by standard troponin assays. Especially in older patients who appear to have a higher basal troponin level, the results must always be judged in the context of the medical history, physical examination, electrocardiogram (ECG) and any further findings. Even small increases in high-sensitivity troponin indicate increased risk for death or MI during follow-up. In the case of MI an invasive strategy results in better survival rates compared with conservative therapy but at the expense of an increased risk of bleeding in elderly patients. This article provides an overview on the diagnosis of MI in elderly patients.     

Interdisziplinäre Therapie des Rektumkarzinoms

Due to improved interdisciplinary staging, rectal cancer can be treated in a more individualized manner. Over the last decade, high-quality resection has reduced the incidence of local recurrence. In locally advanced situations, patients receive multimodal treatment, based on preoperative RTx/RCTx, which is completed with chemotherapy after the operation. Further studies concerning dose effects, changing chemotherapeutic agents, adding antibodies, and extending the total mesorectal excision (TME) technique to rectal cancer in the upper third to improve the efficiency of the multimodal therapy are in progress.     

Prim?re Lymphome des Gastrointestinaltrakts

Primary lymphomas of the gastrointestinal tract comprise different entities. Indolent marginal zone B-cell lymphoma of MALT (MALT lymphoma) and aggressive diffuse large cell B-cell lymphoma (DLBCL) represent the most common gastric lymphomas. In the small intestine, enteropathy associated T-cell lymphomas (EATCL) are of some importance. Diagnosis of gastrointestinal lymphoma is based on histological and immunohistochemical characteristics. Once the diagnosis of lymphoma is established various staging procedures are necessary to determine the stage of the lymphoma. Therapy of most gastrointestinal lymphomas has a curative intention. Surgery no longer plays a role in this context. Considering the pathogenetic importance of H.?pylori for gastric MALT lymphoma eradication of the bacteria is the treatment of first choice. For non-responders radiation and chemotherapy are good candidates. Immunochemotherapy with rituximab and CHOP offer a curative therapeutic attempt in DLBCL of the stomach and small intestine. There is no established therapy for EATCL which is characterized by a bad prognosis. Follicular lymphomas grade I/II of the duodenum and small intestine reveal an indolent course of disease and often do not require any oncological therapy.     

Primäre ziliäre Dyskinesie

Primary ciliary dyskinesia (PCD) is a rare autosomal recessive disorder with defective structure or function of normally motile cilia, leading to chronic upper and lower respiratory tract infections, fertility problems and organ site abnormalities. The PCD is a genetically heterogeneous condition entailing a broad range of different disease variants. Diagnosing these different PCD phenotypes requires a combined approach using complementary methods for detection of defects of ciliary function, ultrastructure and composition as well as low nasal nitric oxide values and biallelic genetic mutations. To date, mutations in 31 different genes have been linked to PCD permitting a genetic diagnosis in approximately 60?% of cases. Due to the lack of adequate trials evidence-based knowledge on the epidemiology, disease course and management of PCD is currently lacking. An international PCD registry has been developed to overcome these limitations (www.pcdregistry.eu) and is currently recruiting patients. Current treatment regimens have to rely on expert opinions and on experience gained from other respiratory diseases. The management of PCD includes surveillance of pulmonary function, culturing upper and lower airway secretions and diagnostic imaging. Daily airway clearance techniques as well as prompt antibiotic treatment of infections are the cornerstones of PCD treatment regimens.     

Primäre Hyperoxalurie

The three currently known forms of primary hyperoxaluria (PH) types I, II and III are autosomal recessive inherited defects of glyoxylate metabolism resulting in overproduction of endogenous oxalate and hence extremely elevated urinary oxalate excretion (>1 mmol/1.73 m² body surface area per day; normal <0.5). Primary clinical hallmarks of PH are recurrent urolithiasis and/or progressive nephrocalcinosis. These and chronic inflammatory processes often lead to early renal failure in most PH type I and in 20% of PH type II patients resulting in systemic deposition of calcium oxalate crystals, which makes PH an often fatal multisystemic disease. Diagnosis is often missed or delayed until end-stage renal disease (ESRD) or when isolated kidney transplantation has failed due to recurrent oxalosis. Treatment options are scarce, even in patients with an early diagnosis. High fluid intake and medication to increase urine solubility of oxalate, e.g. alkaline citrate, are the therapy of choice. Pyridoxine treatment in PH type I may reduce oxalate excretion in about one third of the patients. In ESRD time on dialysis should be short to avoid severe systemic oxalosis, which would worsen transplantation outcome. Transplantation methods are different depending on the PH type and the individual clinical course, but combined or sequential liver/kidney transplantation is still the method of choice in PH I, whereas isolated kidney transplantation is performed in PH II. No patient with PH III has yet been reported to develop ESRD.     

Primäre und sekundäre Neutropenie

Severe chronic neutropenia (SCN) comprises a heterogeneous group of disorders with a common hematological and clinical phenotype characterized by absolute neutrophil counts (ANC) below 0,5???10⁹/l and increased risk of severe bacterial infections. The differentiation between primary and secondary neutropenia and the identification of causative gene mutations is of great importance for the estimation of prognosis. During childhood primary autoimmune neutropenia is the most frequent diagnosis, while secondary neutropenia predominates in adulthood. Despite the rarity, congenital, genetic neutropenias are of great value for research on normal and pathological hematopoiesis and have a fundamental impact on the current knowledge on hematopoiesis. To date mutations in more than 10 genes have been described which are mainly associated with an increased risk for leukemia. The treatment with hematopoietic growth factors has improved the long-term prognosis of SCN patients dramatically: Bacterial infections can be prevented and a normal participation in everyday life is possible.     

Primäre und sekundäre Osteoporose

Bone metabolism as an important part of internal medicine is covered by endocrinologists, rheumatologists and nephrologists. Primary osteoporosis is an inheritable metabolic bone disease, which can be strongly modified by lifestyle, ageing and underlying diseases. Chronic inflammatory diseases, disorders of metabolism and nutritional deficits enhance the risk. Secondary osteoporosis is caused by endocrinological disorders and drugs such as glucocorticoids. It is the task of internists to clinically recognise and diagnose prominent individual risk factors for primary osteoporosis and underlying diseases for secondary osteoporosis. The key competence of internal medicine in metabolism, hormone-related disorders, malignant diseases and in handling complex medical treatment modalities represents an indispensable segment of an interdisciplinary network approach in patient care, research and teaching. This network includes orthopaedic surgery, paediatrics and gynaecology in addition to other specialities.     

Therapie des akuten Herzversagens - Chirurgische M?glichkeiten

Zusammenfassung Die akute Herzinsuffizienz ist eine schwerwiegende Komplikation verschiedener kardialer Erkrankungen. Neben der koronaren Herzerkrankung sind entzündliche Läsionen der Herzklappen, Dekompensationen bei präexistentem Klappenfehler sowie Kardiomyopathien häufig beobachtete Ursachen. Eine strukturelle Schädigung des Myokards bzw. des Klappenapparates mit konsekutiver, rascher kardialer Dekompensation führt unabhängig von der Ursache der Erkrankung zu hohen Mortalitätsraten. Die Möglichkeit einer chirurgischen Therapie sollte daher als Ergänzung zur medikamentösen Stabilisierung geprüft werden. Als mögliche chirurgische Behandlungsverfahren in der Akutsituation werden am häufigsten koronare Revaskularisationen, Herzklappenersatz oder -rekonstruktionen durchgeführt. Dank technischer Weiterentwicklungen stellen heute auch intra- und extrakorporale kardiale Assistsysteme eine effektive Möglichkeit zur temporären Kreislaufstabilisierung dieser Patienten dar. Summary Acute heart failure represents a severe complication of several cardiac disorders. Coronary artery disease, acute bacterial endocarditis or acute decompensation of preexisting heart valve disease as well as endstage cardiomyopathies are the most frequent underlying causes. Because of the high mortality, surgical therapy should be always considered in addition to medical treatment. However, any therapeutical intervention must be based on an immediate diagnosis to evaluate type and severity of the disease. Surgical options comprise coronary revascularization, valve replacement or -reconstruction as well as a temporary support by means of mechanical assist devices.     

Therapie des akuten Herzversagens, medikament?se Strategie

Summary The leading pathophysiology of acute heart failure and cardiogenic shock is acute or subacute myocardial infarction. Reperfusion of the occluded coronary vessel accompanied by adequate support of cardiac function via assist systems, preferentially the intraaortic balloon counterpulsation, is the therapy of choice. Adjustment of preload (high pulmonary capillary pressure in acute myocardial infarction with small heart, low pulmonary capillary wedge pressure in patients with large ventricles and chronic heart failure, high central venous pressure in patients with right heart failure, and right ventricle myocardial infarction) and afterload (peripheral arterial vasodilatation, recommended systolic arterial pressure 80-90 mm Hg) but not maximization of cardiac output play an important role. Positive inotropic drugs should be considered when these strategies fail. In acute right heart failure in pulmonary hypertension, a preferential pulmonary vasodilatation with intravenous or inhalative prostaglandins or inhalative NO are of utmost importance. Systemic hypotension is not a contraindication in this pathophysiology. Zusammenfassung Das akute Herzversagen tritt meist auf dem Boden eines akuten oder subakuten Myokardinfarktes oder einer chronischen Herzinsuffizienz auf. Die unmittelbare Wiedereröffnung des Koronargefäßes mit gleichzeitiger Unterstützung der Herzfunktion mittels Pumpsystemen - v.a. der intraaortalen Ballongegenpulsation - ist die Therapie der Wahl. Daneben und bei anderen Pathophysiologien spielen eine Optimierung der Vorlast (hoher PCWP bei akutem Infarkt und kleinem Herzen, niedriger PCWP bei großem Ventrikel und chronischer Herzinsuffizienz, hoher ZVD bei Rechtsherzversagen und Rechtsherzinfarkt) und der Nachlastbedingungen (periphere arterielle Vasodilatation; systolischen arteriellen Druck von 80-90 mm Hg anstreben), nicht aber eine HZV-Optimierung eine bedeutende Rolle. Der Einsatz positiv inotroper Medikamente sollte erst nach Ausschöpfung dieser Maßnahmen in Betracht gezogen werden. Bei Rechtsherzversagen im Rahmen einer pulmonalhypertensiven Krise ist eine präferentielle pulmonale Vasodilatation mit intravenösen oder inhalativen Prostaglandinen oder inhalativem NO von größter Bedeutung. Eine systemarterielle Hypotonie ist in dieser Pathophysiologie keine Kontraindikation.     

Therapie des akuten Herzversagens, medikament?se Strategie

The leading pathophysiology of acute heart failure and cardiogenic shock is acute or subacute myocardial infarction. Reperfusion of the occluded coronary vessel accompanied by adequate support of cardiac function via assist systems, preferentially the intraaortic balloon counterpulsation, is the therapy of choice. Adjustment of preload (high pulmonary capillary pressure in-acute myocardial infarction with small heart, low pulmonary capillary wedge pressure in patients with large ventricles and chronic heart failure, high central venous pressure in patients with right heart failure, and right ventricle myocardial infarction) and afterload (peripheral arterial vasodilatation, recommended systolic arterial pressure 80-90 mm Hg) but not maximization of cardiac output play an important role. Positive inotropic drugs should be considered when these strategies fail. In acute right heart failure in pulmonary hypertension, a preferential pulmonary vasodilatation with intravenous or inhalative prostaglandins or inhalative NO are of utmost importance. Systemic hypotension is not a contraindication in this pathophysiology.     

Therapie des akuten Herzversagens - Chirurgische M?glichkeiten

Acute heart failure represents a severe complication of several cardiac disorders. Coronary artery disease, acute bacterial endocarditis or acute decompensation of preexisting heart valve disease as well as endstage cardiomyopathies are the most frequent underlying causes. Because of the high mortality, surgical therapy should be always considered in addition to medical treatment. However, any therapeutical intervention must be based on an immediate diagnosis to evaluate type and severity of the disease. Surgical options comprise coronary revascularization, valve replacement or--reconstruction as well as a temporary support by means of mechanical assist devices.     

Primäre Prävention des Typ-2-Diabetes durch Lebensstilmodifikation

Background

Large landmark studies, such as the Finnish Diabetes Prevention Study (DPS) and the American Diabetes Prevention Program (DPP) could conclusively show that prevention of type 2 diabetes or a significant delay in the manifestation of diabetes is possible by lifestyle modifications in persons with an increased risk of diabetes. However, the lifestyle interventions in these studies were carried out in a relatively resource-intensive individual setting and measures were employed which are far too costly to be implemented in practice. A group approach is clearly more economical and less resource-intensive.

Aim

The objective of this prospective, randomized trial was to investigate whether the results of the large, high-quality clinical trials for the prevention of type 2 diabetes could be translated into practical affordable interventions that are deliverable in the real world healthcare system in Germany. The effectiveness of the newly developed Prevention of Diabetes Self-Management Program (PREDIAS) for groups was investigated for people with increased risk of diabetes with respect to a successful weight reduction after 1 year.

Material and methods

The PREDIAS group program for lifestyle modification and primary prevention of type 2 diabetes consists of 12 course-hours extending over a period of 12 months. A total of 182 persons with an elevated diabetes risk participated in this study and were randomly assigned to the intervention group (PREDIAS) or the control group (CG). Patients in the CG received written information about diabetes prevention.

Results

After 12 months participants in the PREDIAS program achieved a significantly higher average weight loss than the CG (??3.8?±?5.2 kg versus ??1.4?±?4.0 kg, p?=?0.001). Fasting glucose was reduced in the PREDIAS group, whereas it rose slightly in the CG (??4.3?±?11.3 mg/dl versus 1.8?±?13.1 mg/dl, p?=?0.001). The duration of physical activity per week was significantly increased in the PREDIAS group than in the CG (46.6?±?95.5 min/week versus 17.9?±?63.8 min/week, p=0.034). Indicators of a modified eating behavior also showed a significantly greater improvement in PREDIAS than in the CG (cognitive restraint 3.9?±?3.8 versus 1.5?±?4.7, p?=?0.001 and disinhibition ??1.2?±?2.7 versus ??0.4?±?2.6, p?=?0.049). There were no significantly greater improvements with regard to lipids or blood pressure in the PREDIAS group compared with the CG.

Conclusion

The improvements in the risk factors achieved with the PREDIAS group program were broadly equivalent to the 1 year data of the DPP or the DPS, which were both conducted in an extensive and time-consuming individual setting.     

Meilensteine in der Therapie des akuten HerzinfarktesDer Nächste bitte!

Ohne Zusammenfassung     

Primäre Lymphome im Gastrointestinaltrakt

Gastointestinal lymphomas represent a heterogeneous group. The various subtypes are characterized by histological, immunohistochemical and molecular genetic properties. After arriving at a diagnosis a staging procedure is necessary as the histological type and stage of the lymphoma determine the therapeutic strategy which comprises eradication of Helicobacter pylori, chemotherapy, radiation or a combination of these. Surgery no longer plays a role.