Das Verhalten der Herzfrequenz unter pulsatiler Betamimetika- Applikation (Bolustokolyse)

Ohne Zusammenfassung     

Back pain from the epidemiological point of view

Summary In the last decades back pain has reached dramatic proportions in industrialized countries. Disorders of the back are nowadays the leading cause of direct and indirect health care costs. Accurate prevalence estimates are needed to serve as a basis for health care evaluations. A review of epidemiologic studies in the general population reveals that back pain has reached a prevalence of 40 % for current pain. 7 to 18 % are “frequently”, “often”, “daily” or “constantly” affected. 75 % of the adult population suffers from back pain during the last year. 80 to 90 % of the adult population in industrialized countries experience back pain ever. Gender specific differences are only present in severe, chronic forms which are more often experienced by women. Back pain has a prevalence maximum at 50 to 64 years. Older persons display lower prevalence estimates. The prevalence maximum in men is one decade earlier than in women. There are several potential explanations for this prevalence pattern that are discussed in the article. Back pain can be classified by location, temporal characteristics, pain intensity and pain history. Currently, for none of these dimensions generally accepted, uniformly employed and validated definitions are available. In most of the industrialized countries back pain is one of the most expensive symptoms. 75–90 % of the direct and indirect health care costs were caused by those 5–10 % of patients who are disabled. As predictors of back pain a history of back pain and job satisfaction play by far a more important role than the extensively studied mechanical factors. For a first episode of back pain the prognosis is favorable. If the pain persist for more than three months the prognosis is unfavorable. After six months of absenteeism because of back pain more than half of the afflicted never return to work. Rarely back pain is present as a single symptom. In more than 80 % back pain is associated with pain in at least one joint. It remains to be studied if back pain may be viewed as an entity or as part of a more complex pain syndrome.      

Ten years of experience in 152 patients after modified fontan procedures

From 1980 to 1990 152 patients underwent Fontan operation at our institution. The following patient groups amenable for Fontan operation were identified: 1) patients with tricuspid atresia (n=82, 54.0%); 2) patients with single ventricle (n=31,20.3%), 3) patients with a wide variety of “complex”, non correctable cardiac malformations (n=39, 25.7%). Actuarial survival rate was 83.8±3.1% (mean±SEM) at 10 years. Follow up revealed, that more than 90.0% of the patients feel better than before operation, about 50.0% are without cyanosis, more than 70.0% are in sinus rhythm, and 90.0% of the patients are socialized according to their age. Considering the poor prognosis of these patients without an operation, the Fontan procedure offers a sufficient palliative method in the therapeutic approach up to now.     

Life satisfaction in patients with chest pain subsequently diagnosed as coronary heart disease – connection through depressive symptoms?

The aim of this study was to investigate factors associated with life dissatisfaction in symptomatic patients (n = 144) with chest pain subsequently diagnosed as coronary heart disease (CHD) by coronary angiography. Life dissatisfaction was assessed with a four-item life satisfaction scale (LS), depression with the 21-item Beck Depression Inventory (BDI) and other psychiatric symptoms with the symptom check list (SCL). DSM-III-R Axis I and Axis II psychiatric diagnoses were performed by means of the Structured Clinical Interview. All assessments took place one day before angiography. Twenty-four per cent of CHD patients were dissatisfied with their lives. Life dissatisfaction was associated with being unmarried. Dissatisfied patients had Axis I mental disorders and Axis II personality disorders more frequently than others. Psychiatric and depressive symptoms according to the SCL and BDI, respectively, were also higher among dissatisfied patients. In multiple logistic regression analyses, mental disorders were related to life dissatisfaction when age, sex, employment status, New York Heart Association class, duration of chest pain symptoms and work load were controlled in the model. Married subjects had a lower probability of being dissatisfied with their lives than other subjects (Odds Ratio, OR: 0.23). When BDI scores were included in the model, the only factor independently associated with life dissatisfaction was the severity of depressive symptoms (OR: 1.81). To conclude, life dissatisfaction is not primarily determined by the severity of CHD but by the existence of depressive symptoms.     

Fixation of osteotomies of the distal femur with absorbable, self-reinforced, poly-L-lactide plates

Osteotomies of the distal femur were fixed with two self-reinforced poly-L-lactic acid (SR-PLLA) plates and metallic screws placed through the plates on each side of the femur in 23 adult rabbits. They were followed-up after 3, 6, 12 and 24 weeks. After killing, radiological, histological, microradiographic and oxytetracycline fluorescence studies were performed. Except for one histologically confirmed fibrotic non-union at 24 weeks, the osteotomies healed, including one involving a rabbit which had suffered an ipsilateral femoral shaft fracture of unknown cause. No malformations were observed, and the macroscopically detected swelling was a normal postoperative reaction. This study showed that SR-PLLA plates implanted on both sides on the bone are suitable for the fixation of weight-bearing cancellous bone osteotomies in rabbits.     

Morphological changes in chest radiographs of patients with acute respiratory distress syndrome (ARDS)

Objective: To determine whether the quality of infiltrations in chest radiographs can accurately predict the histological extent of fibrotic change in patients with acute respiratory distress syndrome (ARDS). Design: Retrospective clinical investigation. Setting: Intensive care unit (ICU) of a university teaching hospital. Patients and methods: Of 47 patients treated with extracorporeal membrane oxygenation (ECMO) for severe ARDS over a 5-year period, 23 patients underwent open lung biopsy at thoracotomy for treatment, mostly of pneumothorax. Chest films obtained by portable chest roentgenography preceding the operation were reviewed retrospectively and compared to the histomorphological results of the lung specimen. Results: Chest radiographs displayed mixed alveolar-reticular opacification in 60.2 %, alveolar patterns in 22.9 % and reticular opacities in 10.5 %. In 0.4 % there were no infiltrates, 6 % could not be evaluated because of insufficient quality. There was no relevant difference between the right and left lungs. Subdividing patients into two groups according to the histological results of either absent or mild (1) or severe (2) lung fibrosis, we found an alveolar haziness in 12.3 % in group 1 compared with 28.2 % in group 2, while reticular characteristics were identified in 13 % and 11 %, respectively. Conclusions: The most common opacity in chest radiographs of patients with severe ARDS treated with ECMO is mixed alveolar-reticular opacification. Severe lung fibrosis is not positively correlated with a reticular radiographic pattern. ECMO does not lead to specific radiological changes in conventional radiograms, contrary to clinical findings that treatment with ECMO might induce pleural or pulmonic haemorrhage, especially in the earlier days when systemic heparinization had to be used instead of the heparin-coated tube-surfacing. Received: 24 November 1997 Accepted: 20 July 1998     

Clinical epidemiology and survival of progressive multifocal leukoencephalopathy in the era of highly active antiretroviral therapy: Data from the Italian Registry Investigative Neuro AIDS (IRINA)

Human immunodeficiency virus (HIV)-associated progressive multifocal leukoencephalopathy (PML) remains a relevant clinical problem even in the era of highly active antiretroviral therapy (HAART). Aims of the study were to analyze clinical and treatment-related features and the survival probability of PML patients observed within the Italian Registry Investigative Neuro AIDS (IRINA) during a 29-month period of HAART. Intravenous drug use, the presence of focal signs, and the involvement of white matter at neuroradiology increased the risk of having PML. A reduced probability of PML was observed when meningeal signs were reported. Patients starting HAART at PML diagnosis and previously naïve for antiretrovirals showed significantly higher 1-year probability of survival (.58), compared to those continuing HAART (.24), or never receiving HAART (.00). Higher CD4 cell count were associated with a higher survival probability (.45). At multivariate analysis, a younger age, higher CD4, starting HAART at PML diagnosis, the absence of previous acquired immunodeficiency syndrome (AIDS)-defining events, and the absence of a severe neurologic impairment were all associated with a reduced hazard of death. The use of cidofovir showed a trend towards a reduced risk of death.     

Eingeladener Kommentar zu: „Einmal- versus wiederverwendbare Instrumente in der laparoskopischen Cholezystektomie — Kostenkalkulation und Nutzwertbestimmung”

Schlu?folgerungen Unser Motto in der Chirurgie sollte hei?en: „An erster Stelle steht die Qualit?t, erst sekund?r kommen die Kosten.“ In diesem Sinne verstehen wir auch die vorgelegte Arbeit vonKriwanek et al. (1). Durch den Gebrauch von wiederverwendbaren Instrumenten (oder Kombinationen davon) konnten die Kosten der LC um 50 bis 70% reduziert werden. Die Qualit?t für den Chirurgen litt jedoch unter dem reinen Gebrauch von wiederverwendbaren Instrumenten. Deshalb erachten es die Autoren für sinnvoll, eine Kombination zwischen Wegwerfinstrumenten und wiederverwendbaren Instrumenten anzuwenden. Damit entsteht unter leichter Erh?hung der Kosten keine Qualit?tseinbu?e und demzufolge ein maximaler Nutzen für die Patienten (nicht jedoch für die Spital?konomen). Jede Kosten-Nutzen-Analyse unterliegt jedoch einem stetigen Flu? und ver?ndert sich demzufolge auch mit der Einführung neuer Produkte und Technologien von Seite der Industrie. Interessant für die gesamte Laparoskopie wird es jedoch dann, wenn solche Kosten-Nutzen-Analysen auf andere Gebiete wie z. B. die Therapie der Leistenhernie oder der Gallengangssteine übertragen werden. Diese Ergebnisse werden die weitere Zukunft der laparoskopischen Chirurgie wesentlich beeinflussen. Deshalb gilt es für uns Chirurgen, eine Sensibilit?t für ?konomische Aspekte zu entwickeln und Kosten-Nutzen-Analysen für das eigene Spital (wie hier gezeigt) zu erarbeiten.     

MRI gadolinium enhancement of bone marrow: age-related changes in normals and in diffuse neoplastic infiltration

 Objective: To quantify gadolinium-related enhancement in the bone marrow of the spine in normals and in patients with homogeneous diffuse malignant bone marrow infiltration. Design and patients: The patients consisted of two groups: group 1 comprised 94 healthy adults (18–86 years) without bone marrow disease and group 2 comprised 30 patients with homogeneous diffuse malignant bone marrow infiltration due to myeloma (n=20) or breast carcinoma (n=10). All patients received intravenous gadopentetate dimeglumine (Gd-DTPA), 0.1 mmol/kg body weight. Pre- and postcontrast signal intensity (SI) on T1-weighted spin-echo (SE) images (TR/TE: 572 ms/15 ms) was measured over a region of interest (ROI) and the percentage SI increase was calculated. The results were confirmed by bone marrow biopsy (n=20) and clinical parameters (n=10). Dynamic contrast-enhanced studies using a spoiled gradient-recalled-echo (GRE) sequence (TR/TE/α: 68 ms/6 ms 75°) were performed in 10 controls with normal bone marrow. Results and conclusion: Contrast material enhancement in healthy persons can vary greatly (range 3–59%, mean 21%, SD 11%). With increasing age there is a significant decrease in contrast enhancement (Pearson’s correlation, P<0.01). The percentage SI increase in patients with intermediate-grade (biopsy 20–50 vol%) and high-grade (biopsy >50 vol%) diffuse malignant bone marrow infiltration was significantly higher than in normals (mean 67%, SD 34%, P<0.001). Low-grade (biopsy <20 vol%) diffuse malignant bone marrow infiltration can not be assessed by non-enhanced T1-weighted SE images or Gd-DTPA application. In conclusion, contrast material enhancement in healthy persons can vary greatly and is dependent on age, while intermediate-grade and high-grade diffuse malignant bone marrow infiltration can be objectively assessed with SI measurements.