Diagnostik und Stadieneinteilung bei Non-Hodgkin-Lymphomen

Non-Hodgkin's lymphomas represent a clinically and biologically heterogeneous group of diseases. Over the last few years, new treatment approaches such as humoral immunotherapy and high dose therapy with stem cell rescue have improved the chances for a cure in most patients with malignant lymphoma. However, only with the correct diagnosis and staging, including the evaluation of novel prognostic factors, are treating physicians able to choose the optimal treatment for their patients. This review focuses on conventional staging procedures and their role in the management of lymphoma patients, as well as on some new aspects of the molecular classification of lymphomas.     

Diagnostik und Therapie bei therapieresistenter Hypertonie

Criteria for hard-to-control or resistant hypertension are met by about 10 % of the antihypertensive drug treated population. Resistant hypertension is defined as failure to lower blood pressure below 140/90 mmHg with triple antihypertensive medication including a diuretic. Patients with resistant hypertension are at high risk for the development of hypertensive end-organ damage, particularly in patients with diabetes, lipid disorders and smokers. Causes include cuff-related artefacts, non-adherence to treatment (about 20 % of cases) and secondary forms of hypertension (about 10 % of cases). The aim of treatment is normalization of blood pressure often by a multifactorial approach. An optimized dosing regimen of antihypertensive drugs is crucial. Newer device-based forms of therapy (e.g. renal sympathetic denervation) are promising but are awaiting further clinical and risk profile substantiation.     

Sinnvolle Diagnostik und Therapieplanung bei organischer und relativer Mitralklappeninsuffizienz

While morphologic alteration of parts of the mitral valve apparatus (ventricular wall, papillary muscles, chordae tendineae, valve annulus and leaflets) may result in a loss of its functional integrity (primary mitral regurgitation, MR) mitral annulus dilatation following left ventricular enlargement or change in chamber geometry and consecutive opening of the angle between papillary muscles and valve annulus cause secondary MR. Irrespective of these etiologies MR is chronically progressive and much more than the severity of MR the grade of myocardial adaptation to the chronic volume overload is of prognostic significance. Inadequate myocardial adaptation is demonstrated by an increase of the echocardiographically determined radius (r) to wall thickness (Th) ratio (r/Th > 3.0), indicating increasing left ventricular wall stress or by an insufficient increase of the left ventricular ejection fraction (<5% of resting values) under exercise conditions, e. g. with radionuclid angiocardiography (RNV). Stressecho may replace RNV in the future for this indication. Actually, stress echo is not reliable to determine changes in left ventricular ejection fraction at rest versus exercise because of systematic errors and error reproduction. There are preliminary reports on biochemical markers like noradrenalin or tumor necrosis factor alpha being helpful to determine the breakdown of myocardial adaptation mechanisms. Surgical intervention is indicated in chronic MR irrespective of the hemodynamic severity, if myocardial adaptation is inadequate. If mitral reconstruction, the surgical technique of choice, remains insufficient to restore normal valve function, mitral valve replacement with preservation of the subvalvular apparatus is unavoidable. For a deceleration of the progressive volume overload in chronic MR for which a surgical intervention is not yet indicated, a long-term afterload reducting medical therapy preferably with long acting ACE-inhibitors seem to be prognostically favorable.     

Diagnostik und Therapie des Aszites bei Leberzirrhose

Zum Thema Man kann davon ausgehen, da? bei ca. 80% der Patienten mit Aszites eine parenchymat?se Lebererkrankung in fortgeschrittenem Stadium vorliegt. Im Vordergrund der Diagnostik stehen Anamnese, klinischer Befund und Ultraschalluntersuchung, mittels derer in der geeigneten Rechts-Seiten-Lage Aszitesmengen ab 300 ml dargestellt werden k?nnen. Zur weiteren differentialdiagnostischen Abgrenzung von malignem bzw. entzündlichem und nicht malignem bzw. nicht entzündlichem Aszites ist eine Parazentese notwendig. Untersucht werden sollten: Zellzahl und Differenzierung, zytologische Untersuchung, Gesamteiwei?, Cholesterin und bateriologische Untersuchungen unter Einschlu? von aeroben und anaeroben Blutkulturen. Die diagnostischen Kriterien zur Untersuchung des Aszites und die daraus abgeleiteten therapeutischen Konsequenzen werden in der vorliegenden Arbeit eingehend und mit praxisnahen Algorithmen, Tabellen und Abbildungen erl?utert. Klinik und Laboruntersuchungen der spontanen bakteriellen Peritonitis k?nnen im Rahmen dieser übersicht nur marginal behandelt werden. Dazu wird ausdrücklich auf die Arbeit von J. Sch?lmerich et al. in diesem Heft des INTERNIST verwiesen.     

Neue Aspekte zum Management asymptomatischer Patienten mit Mitralinsuffizienz

With 31%, mitral insufficiency (MI) represents the second most common valve lesion and is most commonly of degenerative etiology. Sudden death is rare, in asymptomatic patients with flail leaflet and in sinus rhythm it occurs at a rate of 0.8%/year, and increases to a rate of 4.8%/ year when atrial fibrillation occurs. The effective regurgitant orifice area (ERO) is an important determinator of severity of MI and is of prognostic importance. An ERO of >or=40 mm(2) implies severe MI. These patients require further evaluation with exercise testing to determine functional and objective symptom status and exercise hemodynamics to identify pulmonary hypertension at rest or during exercise. This is of particular importance in patients with absent tricuspid insufficiency. Coronary angiography is indicated when symptoms or pathologic hemodynamics occur during exercise.Surgery in asymptomatic, severe MI is recommended when ejection fraction drops to <60%; left ventricular end-systolic diameter (LVESD) increases to >45 mm (LVESD index >26 mm/m(2)), when atrial fibrillation occurs or pulmonary hypertension with PAP syst >50 mmHg at rest and >60 mmHg during exercise), and if the valve is reparable.Patients without an indication for surgery need careful cardiac follow-up. Patients who underwent surgery according to guidelines had an 8-year survival rate of 89%.Clinical assessment together with echocardiography and exercise hemodynamics determine the optimal timing of surgery in asymptomatic patients with severe MI.     

Aortenklappenstenose: von der Valvuloplastie zum perkutanen Klappenersatz

Calcified aortic stenosis is the predominant valve disease. Patients affected are most commonly elderly people, who often show associated comorbidities like reduced left ventricular function, impaired renal function, and pulmonary hypertension. The risk of open-heart surgery is elevated. Balloon aortic valvuloplasty enables a reduction of symptoms, an increase in physical performance, and, therefore, an improved quality of life. However, a reduction in mortality cannot be reached with this method. New techniques and improved equipment induced a "revival" of balloon aortic valvuloplasty, which has been introduced almost 20 years ago. In addition, brachytherapy after balloon valvuloplasty has recently been investigated and represents an interesting approach to reduce early restenosis. The technical improvement of balloon valvuloplasty is the percutaneous heart valve, which is under present clinical investigation. The antegrade/transseptal and retrograde approaches are used, as is the transapical access to the left ventricle. Even if long-term results are not yet available and the procedures still require technical improvement, especially minimization of catheter size, percutaneous valve replacement is a new chapter in the treatment of the calcified aortic stenosis.     

Kurative Therapie bei symptomatischer atrialer Extrasystolie

A female patient without underlying heart disease was highly symptomatic from short runs of atrial ectopy. Sustained atrial tachycardia or atrial fibrillation never occurred. Due to ineffective pharmacological therapy, catheter ablation combined with electroanatomic mapping (CARTO) was performed effectively. Characteristics of ectopic atrial tachycardia and the electrophysiological techniques are described.     

Neues zu Diagnostik und Monitoring bei akutem Koronarsyndrom und Aortendissektion

Background

Acute chest pain is very frequent in medicine and caused by several cardiac disorders or disorders of the great vessels. In addition, chest pain is also well known as “noncardiac chest pain” or due to functional abnormalities. For prognosis and long-term followup, acute coronary syndromes (ACS) and ascending aortic dissections (AoDis) are important disorders.

Results

The ACS represents a heterogeneous group of pts along a continuum of risk from unstable angina (UA) to non-ST-segment elevation (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). The 12-lead surface ECG is able to identify myocardial size and location of the involved coronary artery. Acute AoDis has a poor prognosis with mortality rates of 60% <24 h, 75% <one week and 90% <three months. Therefore, immediate diagnosis of AoDis is necessary and the methods of choice are echocardiography and cardiac nuclear magnetic resonance imaging.

Conclusions

Chest pain is caused in many pts by acute coronary syndrome or aortic dissection. To avoid poor prognosis in these pts, rapid diagnosis and treatment is necessary. 12-lead electrocardiography, echocardiography and cardiac nuclear magnetic resonance imaging are excellent methods for the diagnosis of these diseases.     

Das Inhalationstrauma bei Verbrennungspatienten: Diagnostik und Therapie

Das Inhalationstrauma (IHT) der Lunge bietet ein variables Erscheinungsbild als Folge der Komplexität der verschiedenen schädigenden Rauchgase. Etwa 30% der Verbrennungspatienten erleiden ein begleitendes Inhalationstrauma, welches die Prognose des Brandverletzten erheblich verschlechtert.In dieser Übersichtsarbeit werden Vorkommen, Diagnostik und Therapie des thermischen und des chemischen IHT dargestellt. Die physiologischen Wirkungen von Kohlenmonoxid (CO) und Cyanid (HCN) sowie Symptome und Therapie der systemischen Inhalationsvergiftung mit diesen Substanzen werden erläutert.     

Diagnostik und Therapie bei akut dekompensierter Herzinsuffizienz und kardiogenem Schock

As the population of elderly people is increasing, the number of patients requiring hospitalization for acute exacerbations is rising. Traditionally, these episodes of hemodynamic instability were viewed as a transient event characterized by systolic dysfunction, low cardiac output, and fluid overload. Diuretics, along with vasodilator and inotropic therapy, eventually became elements of standard care. In a multicenter observational registry (ADHERE – Acute Decompensated Heart Failure National Registry) of more than 275 hospitals, patients with acute decompensated heart failure were analyzed for their characteristics and treatments options. These data have shown that this population consists of multiple types of heart failure, various forms of acute decompensation, combinations of comorbidities, and varying degrees of disease severity. The challenges in the treatment require multidisciplinary approaches since patients typically are elderly and have complex combinations of comorbidities. So far only a limited number of drugs is currently available to treat the different groups. Over the past years it was shown that even “standard drugs” might be deleterious by induction of myocardial injury, worsening of renal function or increasing mortality upon treatment. Therefore, based on pathophysiology, different types of acute decompensated heart failure require specialized treatment strategies.     

Das Inhalationstrauma bei Verbrennungspatienten: Diagnostik und Therapie

Zusammenfassung Das Inhalationstrauma (IHT) der Lunge bietet ein variables Erscheinungsbild als Folge der Komplexität der verschiedenen schädigenden Rauchgase. Etwa 30% der Verbrennungspatienten erleiden ein begleitendes Inhalationstrauma, welches die Prognose des Brandverletzten erheblich verschlechtert.In dieser Übersichtsarbeit werden Vorkommen, Diagnostik und Therapie des thermischen und des chemischen IHT dargestellt. Die physiologischen Wirkungen von Kohlenmonoxid (CO) und Cyanid (HCN) sowie Symptome und Therapie der systemischen Inhalationsvergiftung mit diesen Substanzen werden erläutert.Die Therapie und die Prognose der verschiedenen Formen des IHT werden beschrieben. Ein schweres IHT begleitend zur kutanen Verbrennung kann ein ARDS (adult respiratory distress syndrome) hervorrufen. In diesem Zusammenhang wird der aktuelle Stand der Respiratortherapie bei dem Verbrennungspatienten mit IHT diskutiert.Serie: Die Notfalltherapie und Intensivtherapie beim Verbrennungstrauma Herausgegeben von B. Hartmann (Berlin)     

Untersuchungen zur Diagnostik des Orthostase-Syndroms bei Kindern und Jugendlichen

Zusammenfassung Die Diagnose und Behandlung des Orthostase-Syndroms bei Kindern und Jugendlichen spielt in der täglichen Praxis eine nicht unerhebliche Rolle. Es sollte deshalb an einem größeren Untersuchungsgut die Wertigkeit der diagnostischen Methoden (Anamnese, allgemeine Untersuchung, Steh-Ekg, Steh-Versuch nachSchellong) bestimmt werden. Zu diesem Zweck wurden aus dem Archiv der Universitäts-Kinderklinik Gießen die Elektrokardiogramme und Krankenblätter von 182 Kindern (Grundkollektiv) ausgewertet, bei denen ein Steh-Ekg angefertigt worden war. 88 dieser ehemaligen Patienten konnten nach durchschnittlich 3,1 Jahren nachuntersucht werden (Nachuntersuchte). Außerdem wurde bei 16 Kindern, die sich kurz vor ihrer Entlassung aus der Klinik befanden und als gesund anzusehen waren, das Blutdruckverhalten und das Steh-Ekg unter der Einwirkung eines Beta-Rezeptorenblockers geprüft. — Von den insgesamt 286 Kindern sind 21000 Meßwerte ermittelt worden. Die statistischen Berechnungen wurden, nach Übertragung der Daten auf Maschinenlochkarten, im Deutschen Rechenzentrum Darmstadt und mit Hilfe der programma 101 (Olivetti) durchgeführt. — Nach Unterteilung der Kollektive in die Gruppen Nicht-Kollabierte und Kollabierte und Auswertung der Meßdaten ergab sich, daß die Kinder, die wegen der Ausprägung ihrer orthostatischen Dysregulation kollabierten, einen signifikant niedrigeren systolischen Ruhe-Blutdruck und signifikant geringere EKG-Abweichungen hatten. Der diastolische Druck schwankte stark und war häufig nicht feststellbar. (Korotkoff-Töne bis zu einem Manometerwert von 0 mmHg), weshalb seine Beurteilung während des Steh-Versuches und auch die Beurteilung der Blutdruckamplitude schwierig war. Immerhin hatten die kollabierten Kinder häufiger sehr kleine (15 mmHg und darunter) Blutdruckamplituden als die nicht-kollabierten. — Aus den Untersuchungen wird gefolgert, daß das Steh-Ekg nichts zur Diagnostik des Orthostase-Syndroms im Kindesalter beitragen kann; der Steh-Versuch gibt vor allem im Hinblick auf den systolischen Blutdruck Aufschluß; die Blutdruckamplitude muß mit Zurüchkaltung beurteilt werden. Für die Diagnose des Orthostase-Syndroms sind nach den vorliegenden Untersuchungen die sorgfältig erhobene Anamnese und die eingehende allgemeine Untersuchung ganz offensichtlich die wichtigsten Kriterien.

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Summary The diagnosis and treatment of the orthostatic syndrome in children and adolescents play a significant role in everday practice. For this reason the value of the diagnostic methods (case-history, general examination, ECG in standing position, Schellongs orthostatic test) should be ascertained on a large number of cases. For this purpose the electrocardiograms and case reports of 182 children (sample) who had a ECG in standing position traced out were selected from the archive of the University Childrens Hospital, Gießen. 88 of these former patients were able to undergo a follow-up examination after an average period of 3.1 years (follow-up examinees). Moreover the behavior of the blood-pressure and the ECG in standing position were examined under the influence of a beta receptor blocker (Dociton^®-tests) in 16 children who were shortly to be discharged from the hospital and were regarded healthy.—From the total amount of 286 examinees 21 000 values of measurements were obtained. After the datas were transfered on punched cards, the statistical evaluation was carried out with the aid of the programma 101 (Olivetti) and with the aid of the German Centre of Calculation, Darmstadt.—On subdividing the samples in not collapsed and collapsed groups and evaluating the dates of measurement, it was seen that those children who had collapsed because of their pronounced orthostatic dysregulation had a significantly lower systolic blood-pressure after resting and a significantly lesser diversion in the ECG. The diastolic blood-pressure varied considerably and was often not measurable (Korotkoff-sounds audible down to a manometer value of 0 mmHg), so that it was difficult to assess it and the amplitude during the orthostatic test. Nevertheless, the collapsed children often had a smaller (15 mmHg and below) blood-pressure amplitude than the not collapsed. — It can be concluded from these studies that the ECG in standing position can make no contribution to the diagnosis of the orthostatic syndrome in childhood; the orthostatic test renders above all information with regard to the systolic bloodpressure; the amplitude of the blood-pressure must be interpreted with reservation. —According to this study the carefully obtained anamnesis, is obviously the most important criteria for the diagnosis of the orthostatic syndrome.

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Mit 3 Abbildungen und 22 Tabellen