Operative Prophylaxe und Therapie der chronisch venösen Insuffizienz

Zum Thema Die chronisch ven?se Insuffizienz beschreibt als klinisches Syndrom alle Folgeerkrankungen sowohl der prim?ren Varikosis als auch der Phlebothrombose. Der nachfolgende Beitrag stellt die Indikationen und Erfolgsraten der operativen Therapie bei prim?rer Varikosis, Thrombophlebitis bzw. Varikophlebitis, Ulcus cruris venosum und akuter Thrombose der tiefen Becken- und Beinvenen vor. W?hrend die Chirurgie der Varicosis und des Uleus cruris weitgehend standardisiert ist, bedarf die operative Therapie der Phlebothrombose einer individuellen Indikationsstellung. Es wird gezeigt, dass durch sorgf?ltige pr?operative Diagnostik, zus?tzliche intraoperative Ma?nahmen wie Phlebographie, lokale Thrombolyse und Stenting und geeignete postoperative Vorkehrungen hinsichtlich Antikoagulation und Kompressionstherapie die Langzeitergebnisse der operativen Therapie der Phlebothrombose deutlich verbessert werden k?nnen.     

Antikoagulationstherapie bei venöser Thromboembolie

Venous thromboembolism (VTE) is a common cause of morbidity and mortality with an estimated annual incidence of 1 : 1,000. Patients show individual risk profiles with regard to recurrent VTE and treatment-associated bleeding, which are characterized by the presence of endogenous factors (such as hereditary thrombophilic disorders), but much more by exogenous factors (underlying disease). This results in risk-adapted therapeutic recommendations, which will be discussed in the following review.     

Diagnostik venöser Erkrankungen

Venous disease of the lower extremities comprises several common conditions such as varicose veins, superficial thrombophlebitis, deep venous thrombosis and chronic venous insufficiency. The high prevalence and increasing incidence with age of these disorders impose relevant diagnostic and therapeutic concerns. Varicose veins and superficial thrombophlebitis are easily diagnosed clinically and additional diagnostic means, i. e., duplex scan, is needed for documentation or planning of surgery. Deep venous thrombosis cannot be confirmed clinically and further imaging based on clinical probability is usually required for correct diagnosis. Color-coded duplex and compression sonography have emerged as the means of choice in skilled hands. Phlebography still remains the gold standard based on its investigator-independent characteristics. However, it is becoming more and more a research tool. CT scan and magnetic resonance imaging are too expensive for broad application, but may be helpful in cases of uncertainty such as iliac vein thrombosis. CT scans, magnetic resonance imaging and sonography reveal additional information compared to phlebography about surrounding tissue and may help in establishing a differential diagnosis. Limitations of CT scan and phlebography are radiation exposure and contrast media application. Chronic venous insufficiency is basically established by medical history and clinical findings. Functional and imaging tests such as plethysmography, color-coded duplex sonography and phlebography are essential for confirming the diagnosis, evaluating a surgical intervention or defining the cause of chronic venous insufficiency.     

Mundhygiene, Prophylaxe und Therapie bei entzündlich-rheumatischen Erkrankungen

Inflammatory disorders of the periodontium are often associated with chronic systemic diseases, which can demonstrate a reciprocal influence. Within the adult population at present, 74% of younger adults and 88% of older individuals require periodontal treatment. Due to inflammatory processes, patients with rheumatoid arthritis or other chronic polyarthritides frequently suffer from pain in the temporomandibular joint and, since finger mobility is often limited, their ability to perform oral hygiene measures is impeded. However, diligent and constant oral hygiene is of crucial importance both for maintaining a healthy periodontium and to prevent the development of caries. For their daily dental care, these patients should favor the use of electric toothbrushes, products for interdental cleaning and mouth rinses. The dentist should be informed immediately about increased and constant gingival bleeding, gingival hyperplasia, loosening or migration of teeth associated with gingival recession or other irritations in the oral cavity. Professional dental cleaning should be routinely performed at 3- to 6-month intervals in order to prevent an increase in the risk for periodontal disease.     

Stellenwert der antibiotischen Therapie bei infektiöser Enteritis

Die akute infekti?se Enteritis ist ein h?ufiges Krankheitsbild, welches von einer harmlosen Lokalinfektion bis hin zu lebensbedrohlichen Septik?mien reichen kann. Immunsupprimierte, alte oder sehr junge Patienten stellen dabei die Problemgruppen dar, bei denen h?ufig schwere Krankheitsverl?ufe zu beobachten sind. Die Reisediarrh? ist die h?ufigste Form der infekti?sen Diarrh? des Erwachsenen. Abh?ngig von den angestrebten Reisezielen und dem allgemeinen Gesundheitszustand des Reisenden sollten diesem entsprechende Empfehlungen hinsichtlich Prophylaxe und Therapie mit auf den Weg gegeben werden. Relativ h?ufig treten unter einer antibiotischen Therapie Durchf?lle auf (20–50%). Dabei muss unterschieden werden zwischen einer Diarrh? ohne Clostridium difficile-Infektion und einer seltenen Clostridium difficile-Infektion mit Toxinbildung (auf Grund einer Clostridium difficile-Selektion durch Ver?nderung der Darmflora unter Antibiotika), die mit einer hohen Letalit?t einhergeht. Im folgenden werden einige Richtlinien aufgezeigt, durch die eine Entscheidung für oder gegen die antibiotische Therapie bei der infekti?sen Enteritis erleichtert werden soll.     

Therapie der venösen Thromboembolie

The main objectives in the treatment of venous thromboembolism are to prevent clot extension and pulmonary embolism, to reduce mortality and to prevent recurrent thromboembolic events as well as postthrombotic disorders. Initial and effective anticoagulation with heparin, preferably with low molecular weight heparin (LMWH), or with fondaparinux is the most important measure. Unfractioned heparin (UFH) is as effective as LMWH, but requires coagulation-monitoring and is associated with a higher risk of heparin-induced thrombocytopenia. In patients with renal insufficiency direct determination of anti-factor Xa activity and dose adjustment is recommended, since drug accumulation can occur over time. In those patients UFH instead of LMWH might be favored. Long-term treatment should be administered with vitamin K-antagonists (INR-target range 2–3) for a duration of 3 to 6 months. In case of recurrent venous thromboembolism, indefinite therapy is recommended. Additional treatment with compression stockings is reasonable. Patients who do not require hospital treatment for other conditions, who have a low bleeding risk, no excessive venous congestion and no symptomatic pulmonary embolism can safely be treated at home. In most cases bed rest is not necessary. Thrombolysis or surgical thrombectomy is seldomly indicated in severe thromboembolism.     

Therapie und Sekundärprophylaxe der venösen Thromboembolie mit Vitamin-K-Antagonisten

Oral anticoagulation with vitamin-K-antagonists is very effective in secondary prevention of venous thromboembolism. In Germany, most commonly Phenprocoumon is used, while most of the evidence-based data are available for Warfarin. The initial treatment of acute venous thromboembolism requires immediate anticoagulation with heparin and a subsequent overlapping treatment with oral anticoagulants. During this phase, anticoagulation may be unstable with increased risk for bleeding. An INR target range between 2 and 3 provides effective protection with minimal risk for major bleeding. The individual risk for bleeding may be estimated by a clinical score. Six months of oral anticoagulation is the standard duration for a first episode of venous thromboembolism, while recurrencies are treated for at least one to two years. The duration may be tailored to the individual patient according to underlying risk factors for recurrencies and for bleeding. Because of a plethora of practical problems and the narrow therapeutic window, there is a need for new antithrombotic agents. These may allow a longer duration of secondary prevention with improved protection against recurrencies without sacrificing safety.     

Nichtmedikamentöse und medikamentöse Therapie bei arterieller Hypertonie

A permanent and successful treatment of high blood pressure is based on a combination of non-pharmacological treatment measures and pharmacological therapy. The most proven non-pharmacological measures are physical and sports activities, weight reduction, dietary adaption and reduction of salt intake as well as nicotine abstinence and moderate alcohol consumption. A blood pressure reducing effect of evidence grade A was demonstrated for these 4 pillars of non-pharmacological therapy in studies. For pharmacological treatment five main substance groups are available: thiazide diuretics, ACE inhibitors, AT1 blockers, calcium channel blockers and beta blockers. A very good blood pressure reducing effect with an advantageous side effect profile has been proven for all substances. The initial high blood pressure therapy can be carried out with monotherapy but therapy with several antihypertensives is often necessary for the very varied combination of compounds which are available in a meaningful combination and dosage of effective ingredients. For the treatment of comorbid hypertensive patients recommendations are available for an individualized pharmacological treatment corresponding to the specific cardiovascular risk and comorbidity. High blood pressure therapy must be continuously carried out over many years. For permanent success of the therapy good compliance is indispensible which can be encouraged by integration in the therapy and should be regularly controlled.     

Möglichkeiten und Grenzen der konservativen Therapie bei Spondylitis und Spondylodiszitis

BACKGROUND AND AIM OF THE STUDY: For many years the treatment of spondylitis and spondylodiscitis has been discussed controversially. The aim of this study is to report on objective and subjective mid-term results of therapy of spondylitis and to present a differentiated concept of treatment. METHODS: Between 1988 and 1996, 58 patients were treated with spondylitis or spondylodiscitis. Nine of these patients had to be operated. A biopsy was taken in all of the cases. According to the antibiogram obtained by the biopsy, antibiotics were applied intravenously. The patients were immobilized by a plaster bed for at least 6 weeks and were then treated by a spinal orthosis for another 3 months. Patients were re-examined clinically and radiographically and by a questionnaire (including Roland-Morris score), after 8 years on average. RESULTS: Patients were diagnosed correctly 4 months after the begin of the disease. Spondylitis was predominantly localized in the lumbar spine. A positive bacteriological culture was derived from one third of the biopsies; none of them was a specific culture. C-reactive protein was revealed as appropriate for diagnosis and follow-up of spondylitis. In 84% of the patients a total or partial bony fusion was demonstrated radiographically. Questionnaire assessment revealed a significant decrease of the Roland-Morris score (17.8-7.4) and a significant relief of pain (8.9-2.5). CONCLUSIONS: We recommend surgical treatment on patients with major vertebral body destruction, epidural abscess and progressive neurological impairment. These indications for operation can be prevented by a rapid diagnosis, so that spondylitis can be successfully treated by consequent immobilization in a plaster bed and appropriate antibiotics.     

Diagnostik und Therapie gastrointestinaler Funktionsstörungen bei Diabetes mellitus

Gastrointestinal functional disturbances frequently cause abdominal symptoms in patients with diabetes mellitus and have been shown to impair the quality of life. Autonomic neuropathy is an important pathomechanism but other disturbances affecting the enteric nervous system, interstitial cells of Cajal (ICC), smooth muscle cells, release of insulin and other regulatory peptide hormones and glucose homeostasis also contribute to the pathogenesis. Diagnostic procedures should start with exclusion of infectious and structural diseases by laboratory investigations, endoscopy, abdominal sonography and/or radiological methods. If the diagnosis remains unclear individual parameters decide whether a therapeutic trial can be started or whether functional diagnostic procedures are needed for further clarification. Optimization of blood glucose control is generally of importance but frequently difficult to achieve due to interactions between gastrointestinal dysfunction and blood glucose control. Apart from this, symptom-oriented therapy is usually performed as established for patients without diabetes. Moreover, diabetes-associated functional disturbances, particularly those affecting the proximal gastrointestinal tract, may cause few symptoms but may still impair blood glucose and therefore need therapy. In this article the diabetes-associated diseases dysphagia, reflux disease, gastropathy, exocrine pancreatic insufficiency, gallbladder dysfunction, diarrhea, constipation and stool incontinence are discussed with respect to the diagnostic procedures and therapy     

Therapie und Prophylaxe von Endorganschäden der Niere

The number of patients with end-stage renal disease is constantly growing. If patients at risk are identified early enough, currently available therapeutic options allow a potent primary and secondary prevention of progressive renal failure. If the underlying disease can not be eliminated, the mainstay of the therapy are supportive measures such as antihypertensive and, in case of an underlying diabetes mellitus, antidiabetic therapy, dietary restrictions as well as avoidance of additional nephrotoxic agents. Furthermore, even a mild renal insufficiency has been identified as a potent cardiovascular risk factor. The second major goal of supportive therapy therefore is a reduction of the markedly increased cardiovascular morbidity of these patients. This can be achieved through treatment of various consequences of renal failure, such as hyperparathyroidism, renal anemia etc. Supportive therapy thus represents a highly complex and interdisciplinary treatment, which should prompt an early inclusion of a nephrologist into the therapeutic strategy.     

Medikamentöse Prophylaxe während intensivierter Immunsuppression bei Kindern und Jugendlichen

The goal of modern antirheumatic therapy is to achieve an optimized disease control. This is individually achieved by an intensified immunosuppression (IS) frequently combining different immunosuppressive agents. Intensified IS should be accompanied by a standardized protocol to monitor immunological changes in the patient. This should include checklists (see Part 1 Screening during intensified IS in children and adolescents). An individual risk stratification according to the planned IS allows a prediction of infectious disease risks for the patient and, thus, individual infection prophylaxis. In addition, standardized management of patients with fever while receiving intensified IS may prevent further complications.     

Möglichkeiten und Grenzen der interventionellen Therapie bei akuter Herzinsuffizienz bei koronarer Herzerkrankung

Acute heart failure and especially its most severe form, cardiogenic shock, remain the final common pathway to death in a substantial number of patients with acute myocardial infarction (MI). Several studies demonstrated that mechanical reperfusion of occluded coronary arteries by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery improves survival in patients with acute MI and cardiogenic shock. There is strong evidence that intraaortic balloon pump (IABP) support and ventricular assist devices can stabilize hemodynamics in these patients so that revascularization procedures can be safely performed. This article provides an overview of the therapeutic strategies for acute MI with cardiogenic shock, with focus on the role and particularities of different devices used as mechanical circulatory support in these patients.