Qualit?tsverbesserung von Koronardiagnostik und -intervention durch ?Virtual-Reality��-Simulation

Currently, more than 800,000 diagnostic procedures and 300,000 percutaneous coronary interventions are performed annually in 556 catheter laboratories in Germany. These numbers document the importance of training programs in interventional cardiology. However, this need is in sharp contrast to the time constraints for continuing medical education in Germany due to personnel and financial restrictions. A possible solution for this dilemma could be new training programs which partially supplement conventional clinical training by simulation-based medical education. Currently five virtual reality simulators for diagnostic procedures and percutaneous coronary interventions are available. These simulators provide a realistic hands-on training comparable to flight simulation in aviation.The simulator of choice for a defined training program depending on the underlying learning objectives could either be a simple mechanical model (for puncture training) or even a combination of virtual reality simulator and a full-scale mannequin (for team training and crisis resource management). For the selection of the adequate training program the basic skills of the trainee, the learning objectives and the underlying curriculum have to be taken into account. Absolutely mandatory for the success of simulation-based training is a dedicated teacher providing feedback and guidance. This teacher should be an experienced interventional cardiologist who knows both the simulator and the selected training cases which serve as a vehicle for transferring knowledge and skills.In this paper the potential of virtual reality simulation in cardiology will be discussed and the conditions which must be fulfilled to achieve quality improvement by simulation-based training will be defined.     

?Off label use�� von Methotrexat in der klinischen Rheumatologie

Methotrexate (MTX) is probably the most commonly used off-label drug in rheumatology. It is used as an immunosuppressant for a wide range of chronic inflammatory rheumatic diseases. In most cases there is limited evidence from controlled studies for the efficacy of MTX in this off-label scenario. Only a few controlled clinical trials exist for different types of connective tissue diseases and vasculitis. In most indications, however, MTX could help to avoid using steroids and/or to prevent relapses. Thus, there is a great deal of experience with MTX in an off-label use and MTX is employed in the daily practice by most rheumatologists with success. A commonly used register indexing the off-label use of MTX and also of other disease-modifying antirheumatic drugs (DMARDs) and biologicals would help to improve the acceptance and the safety of MTX as an orphan drug.     

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大动脉炎是继发性高血压的重要因素之一,为主动脉及其主要分支的慢性进行性非特异性炎变,可引起不同部位的狭窄或闭塞,少数病人因炎症破坏动脉壁的中层而致动脉扩张或动脉瘤。因病变部位不同,其临床表现各异,主要表现为受累部位的缺血症状。当大动脉炎累及胸腹主动脉和肾动脉时,可导致高血压。     

Aderlass und ?Rheuma��

Bloodletting was widely used in antiquity in the setting of a humoral-pathological concept as a general treatment for all ailments, as well as during the middle ages primarily as a remedy for the treatment of inflammatory and infectious diseases. The general population was convinced of the efficacy of this treatment for centuries, even requesting it on occasion on a prophylactic basis. Although questioned early in history, the number of sceptical voices increased in the 17th and 18th centuries. In 1835, P. Louis introduced statistics to medicine in Paris, thereby proving the inefficacy of bloodletting in inflammatory diseases. Today, bloodletting is used in scientific medicine in only a few rare disease.As long as rheumatic diseases remained undifferentiated, all cases were treated with bloodletting. After acute articular rheumatism 1591 was recognised as an independent disease entity, bloodletting remained the treatment of choice for most doctors right up to the end of the 19th century. Bloodletting was also the standard treatment for gout from antiquity up to the beginning of the 19th century. Following its differentiation in 1800, chronic articular rheumatism was no longer treated with venae sectio. Today, there is no indication for bloodletting therapy in rheumatology.     

Diagnostik von Motilit?tsst?rungen von ?sophagus und Magen

Gastric and esophageal motility disorders are a frequent cause of symptoms in the upper gastrointestinal tract. Impaired esophageal motoric function leads to impaired bolus transport, gastroesophageal reflux or reduced esophageal clearance, which in turn lead to dysphagia, chest pain, heart burn and/or regurgitation. Knowledge of the relevant pathophysiological mechanisms and an understanding of the merits and limitations of the various diagnostic procedures are essential for an efficient and targeted diagnostic approach to functional gastrointestinal disorders. Gastric function is a combination of gastric structure and motility as well as multiple neurohumoral feedback mechanisms, which themselves influence gastric motility and emptying. Impaired gastric function can lead to delayed gastric emptying, i.e. gastroparesis, which can cause early satiety, nausea/vomiting and, in extreme cases, weight loss. Currently, gastric function as a whole can not be assessed due to the lack of a global function test; however, a variety of diagnostic tools are available to assess partial aspects such as gastric emptying or accommodation. In addition to gastric scintigraphy, which currently represents the gold standard for the evaluation of gastric motility, the most important other methods, their limitations and their range of application are discussed.     

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盐敏感性高血压是基因机制、离子转运机制、内皮功能障碍机制、肾脏机制、交感神经系统和中枢神经系统机制、肾素-血管紧张素-醛固酮机制、内分泌机制、胰岛素抵抗机制等等共同作用的结果。除了限盐治疗以外,其他针对盐敏感性高血压的降压措施包括补充钾离子和钙离子,降压药治疗,免疫疗法,基因疗法等等。降压药物包括利尿剂、钙离子拮抗剂、血管紧张素转化酶抑制剂、血管紧张素受体拮抗剂都是治疗盐敏感性高血压的适用药物,改变我国高盐饮食习惯是盐敏感性高血压一级预防的关键性措施。     

Welche Informationsbed��rfnisse haben pflegebed��rftige ?ltere Menschen und pflegende Angeh?rige?

Background

The recent reform of the German Care Insurance Law (2008) was expanded to include independent consultancy for care issues. The goal of this study was to explore the informational needs of people in need of care and their informal caregivers.

Method

A semi-structured questionnaire was used to document 89?consultation conversations. The data were analyzed using qualitative content analysis.

Results

The findings identified that information was needed about (1) the German health care insurance system, (2) access to care, (3) local care services, and (4) situation and disease-specific concerns.

Conclusion

Consultancy services for people in need of care and informal caregivers require detailed knowledge about local care services and, therefore, should be integrated into the neighborhoods of the users.     

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假性高血压和假性高血压现象是指袖带间接法测定的血压低于血管内直接的定值的临床上的疾病和现象。及时发现和确诊是关键。老年人、糖尿病病史较长、慢性肾脏病及动脉硬化严重等患者中易发生假高血压。正确的血压测定对确诊至关重要。一些辅助检查可以帮助诊断,如:直接血压测定、血管影像学检查等,而传统的Olser法可能对诊断的意义有限。假性高血压在降压治疗时应避免过度降压。     

Pregnancy and delivery in women with von Willebrand��s disease and different von Willebrand factor mutations

Background

Pregnancy in von Willebrand’s disease may carry a significant risk of bleeding. Information on changes in factor VIII and von Willebrand factor and pregnancy outcome in relation to von Willebrand factor gene mutations are very scanty.

Design and Methods

We examined biological response to desmopressin, changes in factor VIII and von Willebrand factor and pregnancy outcome in a cohort of 23 women with von Willebrand’s disease characterized at molecular level and prospectively followed during 2000–2007.

Results

Thirty-one pregnancies occurred during the study period. Remarkably, similar changes of factor VIII and von Willebrand factor were observed after desmopressin and during pregnancy in nine women with R854Q, R1374H, V1665E, V1822G and C2362F mutations. Women with von Willebrand’s disease and R1205H and C1130F mutations (17 pregnancies in 12 women) had only a slight increase of factor VIII and von Willebrand factor during pregnancy while their response to desmopressin was marked but short-lived. For these women, two to three desmopressin administrations within the first 48 hours were sufficient to successfully manage vaginal delivery. Two women with recessive von Willebrand’s disease due to compound heterozygosity for different gene mutations had a spontaneous, major increase in factor VIII while von Willebrand factor remained severely reduced. Desmopressin increased factor VIII and was clinically useful in the first case, while a factor VIII/von Willebrand factor concentrate was required in the second patient not responsive to the compound. Factor VIII/von Willebrand factor concentrate was also required for two women with type 2 A von Willebrand’s disease with V1665E mutations who had no von Willebrand factor activity change during pregnancy. In one of them, delayed bleeding occurred 15 days later requiring treatment with Factor VIII/von Willebrand factor concentrate. No miscarriages or stillbirths occurred.

Conclusions

Close follow-up and detailed guidelines for the management of parturition have produced a very low rate of immediate and late bleeding complications in this setting. Desmopressin was effective and safe in preventing significant bleeding at delivery in most of these patients.     

?Erinnerungen an meine kranken H?nde��

Alexej von Jawlensky (1864-1941), one of the most important expressionist painters and a member the artist group "The Blue Four", suffered from severe rheumatoid arthritis. He was the first painter in the twentieth century to create extensive series of paintings especially of human faces. The medical history of Jawlensky as documented in his letters, is a harrowing document of a great artist who suffered from rheumatoid arthritis at a time when medical treatment was limited to physical therapy, pain medication and other relatively ineffective modalities, including the unnecessary extraction of teeth. Jawlensky's disease was characterized by a rapidly progressive course with severe pain, rapid onset of disability and ending up with complete immobilization and paralysis for several years until his death.The artistic processing and sublimation of his illness and suffering resulting in a series of over 1,000 small format meditations are the impressive and touching example of creative coping with rheumatoid arthritis. The meditations are unique in the history of art and often compared with icons. However, knowing the medical condition of Jawlensky these paintings can also be seen as metaphors of suffering and in each image the great physical and mental effort is reflected in the artistic details. Therefore, his art agent Galka E. Scheyer formulated in a letter to him: "You are the painter of the human soul. I know of no other modern painter of the human soul."     

?Treat-to-Target�� aus Sicht der Betroffenen

The international treat-to-target initiative including rheumatoid arthritis (RA) patients has defined remission or alternatively low disease activity as treatment goals. In Germany representatives of the medical profession, such as doctors, nurses and including the Deutsche Rheuma-Liga, are deliberating how to adapt and realize these goals in practice. The patient's perspective has to be taken into consideration as an outcome variable. Until now no combined patient reported outcome (PRO) score exists which is generally accepted by the scientific community and which puts the patient's perspective as the main primary outcome.Patients and doctors ought to decide jointly about the therapy goal remission/low disease activity and about other PROs and the planned strategy to achieve these goals. A precondition is that a sufficient timeframe is still available for this. The joint target of the medical profession and the Deutsche Rheuma-Liga is 1 rheumatologist per 50,000 adult inhabitants. An interdisciplinary and multidisciplinary treatment of RA patients is just as imperative as the expansion of patient training, information and self-management programs.     

Prim?re Katheterablation von Vorhofflimmern

Hintergrund: Die primäre Katheterablation von Vorhofflimmern stellt eine neue, kurative Behandlungsoption für Patienten mit therapieresistentem Vorhofflimmern dar. Sie hat den langfristig stabilen Sinusrhythmus zum Ziel, mit daraus folgernder koordinierter Vorhofkontraktion. Ablationsmethoden: Zwei verschiedene Ablationsstrategien haben sich in den letzten Jahren etabliert: Die Triggerelimination versucht auslösende atriale Extrasystolen (meistens innerhalb der Pulmonalvenen) zu identifizieren und durch fokale Hochfrequenzstromapplikation auszuschalten oder innerhalb der Pulmonalvenen zu isolieren. Durch die Substratmodifikation sollen mittels Anlage langer Ablationslinien die Eigenschaften des Vorhofmyokards so verändert werden, dass Vorhofflimmern nicht mehr aufrechterhalten werden kann. Bewertung: Beide Behandlungskonzepte müssen ihre Effektivität noch im Rahmen von sorgfältigen Nachbeobachtungsstudien unter Beweis stellen, bevor sie für den generellen Einsatz bei Patienten mit Vorhofflimmern empfohlen werden können. Background: Primary catheter ablation of atrial fibrillation is a new and curative option for the treatment of patients with drug-refractory atrial fibrillation. It is aiming at a long-term restoration of sinus rhythm and thereby causing a coordinated atrial contraction. Ablation Methods: Two different ablation strategies have been established: The "trigger elimination" tries to identify triggering atrial extrasystoles (mostly within the pulmonary veins), followed by focal ablation or isolation within the pulmonary veins. The "substrate modification" changes by long linear radiofrequency-induced lesions the ability of the atrial myocardium to sustain atrial fibrillation. Valuation: Both treatment options still have to prove their effectiveness in carefully monitored follow-up, before they can be offered to the general patient population with atrial fibrillation.     

Diagnostische Evaluation der D��nndarmmotilit?t

Investigations of small bowel motility are performed relatively infrequently partly because of impaired accessibility of the small bowel. For diagnostic evaluation transit measurements and manometric techniques are generally available. Scintigraphy is regarded as the reference method for evaluation of small bowel transit but is rarely performed in Europe. Clinically, the lactulose hydrogen breath test is most frequently used for estimation of orocecal transit time. Apart from this radiological techniques can be used to roughly estimate small bowel transit. Capsule techniques and the lactulose-¹³C-ureide breath test represent potential alternatives. In contrast to transit measurements small bowel manometry reveals information on the contractile patterns of the small bowel and thus on pathophysiological mechanisms. However, small bowel manometry is relatively complex and labor-intensive and is therefore reserved for special indications and specialized centres.     

��KDOQI��KDIGOָ�Ͻ���������ಡ�����ʺ͹��쳣

慢性肾脏病(CKD)已成为威胁全人类健康的一类重大疾病。在CKD患者中,矿物质和骨代谢紊乱十分常见。以往临床诊疗规范采用美国肾脏基金会于2004年制定的肾脏疾病患者生存治疗(KDOQI)指南。2009年,改善全球肾脏病预后组织(KDIGO)颁布了适用于全球的慢性肾脏病-矿物质和骨异常(CKD-MBD)的诊断、评估、预防和治疗的临床实践指南。文章从CKD-MBD的生化指标异常、骨组织学改变和血管钙化3个方面,对两个指南中存在的不同点逐一进行解读。