Stationäre medizinische Rehabilitation bei erwachsenen Patienten mit atopischer Dermatitis

Atopic dermatitis is a chronic inflammatory skin disease which often persists until adulthood. In severe cases, eczematous lesions and pruritus are resistant to therapy and result in depression, impairment of professional activities and social withdrawal. The goal of inpatient rehabilitation measures is to keep the patient involved and active in professional and social activities. Rehabilitative measures include diagnostics and medical therapy according to current guidelines, instruction in basic medical information, psychological intervention (relaxation techniques, improvement of self-confidence), dietetic measures, exercise, and social advice. Patients with atopic dermatitis often have work-related problems which should be identified as early as possible during rehabilitation.     

Persistent and/or late complications of combined radiation therapy and hyperthermia.

Persistent and/or late complications were analysed in 64 patients (183 fields) that were treated with combined hyperthermia and radiation therapy for advanced, recurrent or metastatic cancer. The incidence and type of complications were evaluated over a minimum follow-up period of 2 years from the onset of treatment (mean 38.7 months; range 24-82.5 months). The primary malignancies included: breast (39), melanomas (6), adenoid cystic carcinomas of salivary glands (4), prostate (4), soft tissue sarcomas (3), squamous cell carcinoma of head and neck (3), lymphomas (3), transitional cell carcinoma of bladder (1) and basal cell carcinoma of the skin (1). The persistent complications noted included induration and fibrosis (39 hyperthermia fields, 22 patients), ulceration at the site of prior tumour (three patients, three fields), and ulceration in normal tissue (one patient, one field). Brachial plexopathy developed in one patient treated for recurrent breast cancer, but she had active disease at that time. A squamous cell carcinoma of the skin developed within the treatment field in a breast cancer patient. Radionecrosis of the mandible was seen in one patient treated for a floor of the mouth cancer, and osteomyelitis with septic arthritis developed in one patient treated for a soft tissue sarcoma of the thigh. Univariate logistic regression analyses of pretreatment and radiation-hyperthermia treatment parameters revealed that maximal tumour temperature had a borderline significant correlation with the development of complications (p = 0.07). Multivariate analyses of the pretreatment and treatment parameters revealed the best-two-covariate model to predict complications included mean maximal tumour temperature and tumour type (macroscopic tumours had greater incidence of complications than for microscopic residual disease). The rate and type of persistent and/or late complications seen following combined radiation and hyperthermia did not appear to dramatically differ from those that would be anticipated from irradiation alone in this patient population, with the exception of an increased incidence of areas of induration and tumour necrosis.     

Peripheral neuropathy and myonecrosis following hyperthermia and radiation therapy for recurrent prostatic cancer: correlation of damage with predicted SAR pattern.

During the past 10 years, numerous phase I-II studies were conducted and provided clinical experience with combined radiation therapy and hyperthermia treatments. Among the rare complications reported in these combined radiation therapy-hyperthermia trials were myonecrosis and peripheral neuropathy which were felt, mainly on a clinical basis, to be caused by local heat damage. Recently, such complications were noted in two patients with recurrent prostatic cancer treated in our department with radiation therapy combined with deep regional hyperthermia delivered by the Sigma-60 applicator of the BSD 2000 hyperthermia system (Salt Lake City, UT, USA). Analysis of the results of three-dimensional modelling of the SAR (specific absorption rate, W/kg) pattern in these patients indicated high SAR at the sites of the complications. Pretreatment three-dimensional modelling or other methods of predicting potential areas of high power deposition may have a role for future hyperthermia treatment planning aiding in the prevention of possible local heat damage and providing improved delivery of heat to the target volume.     

Forcing services on at-risk older adults: when doing good is not so good

This essay examines the interplay between the ethical principles of autonomy and beneficence in the context of deciding whether to intervene in the life of an at-risk older adult by providing health and human services over the older person's objection. The need to distinguish between the rights and welfare of the older client, on one hand, and the interests and drives of the professional caregiver, on the other hand, is emphasized.     

Decision making by and for nursing home residents. A legal view

The law is concerned with a panoply of issues affecting the care and lives of nursing home residents. This article has outlined one area, that of decision making, which in many respects is the embodiment of and key to all other fundamental resident rights. The doctrine of informed consent applies with full force in the nursing home, both for mentally competent residents and for cognitively impaired residents for whom decision making rights must be exercised through a proxy. Long-term care institutions and professionals are obligated to insure that decisions made by or for residents are made voluntarily, competently, and knowingly.     

Histamine release during induction of anaesthesia and preparation for operation in patients undergoing general surgery: Incidence and clinically severe cases

Histamine release events were shown in a prospective randomized controlled trial in patients undergoing elective general surgery with an extraordinarily high incidence: 73 per cent. This high incidence was explained by several factors: — the sample size which was much greater than in previous studies — the improved plasma histamine assay — the precise definition of histamine release in clinical conditions and its measurement at the top of Bateman functions — the standardized induction of anaesthesia and preparation of the surgical patient — and finally the considerable number of cancer patients since more than 60% of the reactions >5 ng/ml occurred in this group which comprised only 20% of the study population.

Two cases of life-threatening anaphylactoid reactions occurred in this trial corresponding to an incidence of 1 per cent. This was — again — very high compared to previous epidemiological studies. Both cases were again cancer patients and occurred in the placebo group — information given by the external study advisory group for further treatment of the individual patient.

The data on the high incidence of histamine release including the high incidence of life-threatening reactions favourrationally a preoperative H₁ ⁻+H₂-prophylaxis with the drugs used in this study: dimetindene and cimetidine. The question of the incidence was one of the unsettled problems which led to this trial. Analysis of the first 180 patients already answered this question more than we had ever expected.

     

Multihormonal,amyloid-producing tumour of the islets of Langerhans in a twelve year old boy

Summary Clinical, pathological and biochemical data from a twelve year old boy with hypoglycaemic attacks and hyperinsulinism are presented. A pancreatic islet cell adenoma was diagnosed by ultrasonic scanning and enucleated from the head of the pancreas. Histological study revealed a mixed cellular population consisting of A₁- and B-cells. Large amounts of extravascular amyloid deposited were found between the cell strands. The tumour extract produced a prompt elevation of gastric acid secretion in the rat gastrin bio-assay. It is concluded that this islet cell tumour was a combined gastrinoma-insulinoma. The possible pathogenesis of this variety of the multiple endocrine adenoma syndrome is discussed. Monocellular-multihormonal islet cell tumours might arise from biochemically multipotent endocrine stem cells, whereas the multicellular-multihormonal type could either be a regulatory neoplasia or be derived from different neuroendocrine cells.

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Zusammenfassung Bei einem übergewichtigen 12jährigen Knaben mit Hypoglykämieanfällen und erhöhtem Blutinsulinspiegel konnte durch Ultraschall ein Tumor des Pankreaskopfes dargestellt werden. Das exstirpierte Gewebe erwies sich histologisch als ein aus A₁- und B-Zellen aufgebautes Inselzelladenom mit ausgedehnten extravasculären Amyloidablagerungen. Ein Extrakt aus dem Tumorgewebe bewirkte eine sofortige Zunahme der Magensäuresekretion am perfundierten Rattenmagen. Diagnose: Insulinom-Gastrinom. Monocellulärplurihormonelle Inselzelltumoren leiten sich möglicherweise von biochemisch pluripotenten Stammzellen der Langerhansschen Inseln her. Pluricellulär-plurihormonelle Adenome sind hingegen eher als Regulationsgeschwülste aufzufassen, könnten aber auch von verschiedenen neuroendokrinen Zellen abstammen.