Therapieprinzipien beim Lokalrezidiv des Rektumkarzinoms

The aim of treatment in isolated locally recurrent rectal cancer is R0 resection, which is possible in 30%. Because of the high rate of surgical complications after repeat surgery in the pelvis, preoperative staging has to be precise to estimate the extent and location of the recurrent rectal cancer. After exclusion of distant metastases, surgery should be considered following preoperative radiochemotherapy if possible. When a curative treatment concept is not indicated, radiotherapy is the best treatment choice. This paper presents various tabularised summaries about therapeutic strategies in isolated locally recurrent rectal cancer.     

选择性头部降温对胎羊缺血性脑损伤纹状体神经元凋亡和星形胶质细胞增殖的影响

目的研究选择性头部降温对缺血性脑损伤胎羊纹状体神经元凋亡和星形胶质细胞增殖的影响。方法胎羊于妊娠117~124d时通过双侧颈动脉阻塞30min造成双侧脑缺血损伤,损伤后将胎羊随机分为:损伤组(n=10)、2h低温组(损伤后2h开始亚低温治疗,n=7)和6h低温组(损伤后6h开始亚低温治疗,n=8),另设正常对照组(n=5)。通过冷循环水进行选择性头部降温,取脑组织用免疫组化法检测胎羊纹状体caspase-3(半胱天冬氨酸酶-3),GFAP(胶质纤维酸性蛋白)和PCNA(增殖细胞核抗原)的表达。结果①纹状体神经元凋亡:正常对照组中,caspase-3表达极少(11.00±13.77),损伤组caspase-3免疫阳性细胞为177.70±48.69,明显增加(P=0.000),损伤后2h治疗组(54.14±39.44,P=0.000)和损伤后6h治疗组(122.43±52.36,P=0.017)均能减少caspase-3免疫阳性细胞。②纹状体星形胶质细胞增殖:与正常对照组(163.40±21.98)相比,缺血性脑损伤组的GFAP免疫阳性细胞明显增多(433.25±66.69,P=0.000),损伤后2h开始亚低温治疗(219.50±35.31,P=0.000)和损伤后6h开始亚低温治疗(272.50±86.20,P=0.000)均能减少GFAP免疫阳性细胞。③纹状体PCNA阳性细胞的表达:在正常对照组中,PCNA免疫阳性细胞较少,为153.40±12.46,缺血性脑损伤组的PCNA免疫阳性细胞明显增多(353.70±45.60,P=0.000),损伤后2h开始亚低温治疗(187.14±26.26,P=0.000)和损伤后6h开始亚低温治疗(230.25±67.46,P=0.000)均能减少PCNA免疫阳性细胞。结论亚低温可以抑制纹状体神经元的凋亡和星形胶质细胞的增殖,该作用可能为选择性头部降温的脑保护作用机制之一。     

Effect of patient experience on the results of automated perimetry in clinically stable glaucoma patients

The first four automated visual field examinations of 20 patients with clinically stable chronic open-angle glaucoma who had previously undergone manual perimetry were studied for the presence of a learning effect on mean sensitivity, number of disturbed test locations, total loss, and short-term fluctuation. A learning effect, if present, would manifest itself as an improvement in the visual field as patients become more experienced with the test. There was no apparent effect of patient experience on the mean sensitivity, total loss, or the number of disturbed test locations. There was a significant (P less than 0.0001) decrease in short-term fluctuation as measured by the root mean square between the first and second visual field examinations. These results indicate that a learning effect did not play an important role in the clinical interpretation of automated perimetry in patients with glaucoma who have previous experience with manual perimetry. In most cases, it was not necessary to obtain more than one "baseline" examination unless a patient demonstrated unusually high short-term fluctuation or had visual field defects inconsistent with the rest of the clinical examination.     

Atherosclerotic occlusive disease of the superior mesenteric artery: Late results of reconstructive surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 23–24, 1989, Strasbourg, France.     

Kann die Telemedizin in der Schlafmedizin die Akzeptanz der nCPAP-Therapie verbessern?

The obstructive sleep apnea syndrome has considerable consequences for morbidity and mortality in affected patients. The continuous positive airway pressure (CPAP) therapy can reliably prevent the nocturnal disordered breathing and minimize health implications (high efficacy). However, the effectiveness of this therapy is restricted due to reduced adherence in the daily routine. Practical methods are urgently needed to improve adherence. Special problem groups, such as post-stroke patients or those with poor sleep efficiency in the first therapy night have already been identified. Up to date information technology enables remote monitoring and control of therapy devices and a centralized evaluation of the data. Usage time, residual breathing disorders, high mask leakage or high therapy pressure in the home environment can promptly be determined to arrange remedies in a timely manner. Scientific evidence regarding the effects of telemedical care of CPAP patients is limited, but the results of available studies are promising. Many practical questions have still not been answered. Furthermore, the danger of using the new technologies only with the aim of short-term cost reduction must explicitly be emphasized. If such information would only be used to discontinue funding of an allegedly insufficient treatment, no additional benefits would be achieved from the patient point of view. The aim of telemedical concepts has to be the improvement of therapy acceptance especially in risk groups. From the perspective of sleep medicine a primacy of physicians is promoted in order to achieve a real improvement for the patient due to telemedicine. The findings obtained so far are promising.     

Rückblick auf 10 Jahre Infektionsschutzgesetz

In 2001, the German Protection against Infection Act came into force, implementing a variety of new regulations. For the first time, obligatory infection control visits of the public health departments in surgical ambulatory practices were implemented, as well as optional infection control visits in all medical, dental and paramedical practices using invasive methods. Based on the data of the public health department of the city of Frankfurt am Main, Germany, an evaluation of this new regulation is given in this paper. First, prioritization of these new tasks was mandatory. First priority was given to the obligatory visits in surgical practices, second priority to the hygiene visits in practices performing endoscopy in gastroenterology as well as in urology and in practices of traditional healers, and third priority was given to all other doctors’ practices. After receiving preliminary information and further training of the doctors etc., the control visits were performed by members of the public health department, using a checklist based on the guidelines of the German Commission on Hospital Infection Prevention (“Kommission für Krankenhaushygiene und Infektionsprävention”). Since 2001, more than 1100 infection control visits in medical practices in Frankfurt am Main were documented. Not only in surgical, but also in gastroenterological and urological practices great improvement could be achieved, regarding not only hand hygiene and reprocessing surface areas, but especially in reprocessing medical devices. In practices for internal medicine and those of general practitioners, errors in hand hygiene, skin antiseptic and surface disinfection also decreased. According to our results, especially regarding the improved quality of structure as well as quality of process and with regard to the public discussion on this hygiene topic, our evaluation is absolutely positive. The new regulation proved worthwhile.     

Schmerztherapeutische Möglichkeiten in der Unfallchirurgie

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.