Thromboembolieprophylaxe bei minimal-invasiven Eingriffen und kurzstationärer Behandlung Ergebnisse einer multicentrischen, prospektiven, randomisierten, kontrollierten Studie mit einem niedermolekularen Heparin

Zusammenfassung. Mit dem Ziel, die Incidenz tiefer Venenthrombosen bei selektierten Patienten nach laparoskopischer Cholecystektomie und anderen minimal-invasiven chirurgischen Eingriffen zu bestimmen, sowie die Sicherheit und Wirksamkeit eines niedermolekularen Heparinpr?parats (NMH) in der postoperativen Thromboseprophylaxe zu belegen, wurde eine prospektive, randomisierte, kontrollierte klinische Studie durchgeführt. Dabei wurden 718 Patienten nach Randomplan einer von 2 Prüfgruppen zugeordnet: Eine Gruppe erhielt physikalische Ma?nahmen zur Thromboseprophylaxe, wie Kompressionsstrümpfe mit graduiertem Andruck (n = 359), die 2. Gruppe erhielt ebenfalls physikalische Ma?nahmen und zus?tzlich ein NMH (Reviparin-Natrium, Clivarin) s. c. einmal t?glich (n = 359). Aus Sicherheitsgründen mit Hinblick auf die medikament?s unbehandelte Kontrollgruppe wurden Patienten mit 3 oder mehr Risikofaktoren für eine ven?se Thromboembolie nicht in die Studie aufgenommen. Die Diagnostik tiefer Beinvenenthrombosen erfolgte mittels Duplexscan. In dieser, eher künstlichen Niedrigrisikoselektion war die Gesamtincidenz thromboembolischer Ereignisse überraschend gering: 5 Verdachtsf?lle einer Lungenembolie, von denen nur 1 Lungenembolie szintigraphisch verifiziert werden konnte, sowie eine phlebographisch best?tigte Unterschenkelthrombose. Die Anwendung von Reviparin zur Prophylaxe ven?ser Thromboembolien war sicher und anwenderfreundlich – die Incidenz postoperativer Blutungskomplikationen betrug nur 2,3 % in der NMH-Gruppe und war somit sogar geringfügig niedriger als in der Kontrollgruppe (3,2 %). Die tats?chliche Incidenz tiefer Venenthrombosen bei Patienten nach laparoskopischer Cholecystektomie bleibt jedoch nach wie vor unklar. Weitere klinische Studien müssen in einem unselektierten Patientengut durchgeführt werden.      

Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus?

Summary Thirteen patients with normal pressure hydrocephalus were operated upon with an externally manoeuvrable shunt system (Sophy SU8) in order to investigate its influence on clinical outcome, intracranial pressure and cranial CT parameters. The opening pressure was set at high at surgery and lowered stepwise at intervals of three months to medium and low. The clinical condition, intracranial pressure and cranial CT parameters were examined at the end of the 3 months interval on each pressure level.The patients improved within the first 3 months inspite of an unchanged mean intracranial pressure and remained in a stable clinical condition during the rest of the study period. The intracranial pressure was significantly reduced at 9 months. The ventricular index, Evans index, temporal horn and third ventricle width were reduced 3 months post-operatively and did not change significantly during the rest of the study. The pre-operative third ventricle width was correlated to high psychometric test results after shunt surgery. Reduction in ventricular index, Evans index and third ventricle width after surgery correlated to improvement in psychometric scoring.The clinical improvement after shunt surgery for normal pressure hydrocephalus is seen within 3 months and is independent of the adjusted valve pressure.     

Ionic rhenocene derivatives with antitumor activity

Summary The antitumor activity of the three air-stable bis(cyclopentadienyl)rhenium derivatives [(C₅H₅)₂ReCL₂]⁺Cl^–,[(C₅H₅)₂ReCl₂]⁺[AsF₆]^–, and [(C₅H₅)₂ReCl₂]⁺[SbF₆]^– was tested against Ehrlich ascites tumor in female CF₁ mice. All three compounds contain the group-7 transition metal rhenium in the +5 oxidation state as their central metal atom. They are ionic, salt-like complexes that are composed of the cationic [(C₅H₅)₂ReCl₂]⁺ moiety and one of the negatively charged counterions Cl^–, AsF₆ ^–, or SbF₆ ^–. Both the chloro and the hexafluoroarsenate complexes induced a maximal cure rate of 100% when given either in a dose range of 120–160 mg/kg (rhenocene trichloride) or at a single dose of 180 mg/kg (hexafluoroarsenate derivative). The hexafluoroantimonate complex effected a maximal cure rate of only 50% at 60 mg/kg. For the two former compounds, the values for the therapeutic index (Tl) amounted to 1.7 and 2.1, respectively. No impairment of the general condition or pathologic symptoms in the viscera could be detected by observation of the animals during the days following treatment with therapeutic doses or by autopsy of the surviving animals on the key data (day 90). The rhenocene derivatives investigated in the present study represent a new class of antitumor metallocene compounds as well as the first rhenium(V) complexes exerting cytostatic activity.     

Langstrecken-Intensivtransport der Bundeswehr

Zusammenfassung Die Teilnahme der Bundeswehr an internationalen Missionen erfordert ein an die Bedingungen militärischer Einsätze angepasstes Konzept zur intensivmedizinischen Repatriierung. Die umfassende Transportkapazität des auf den Airbus A-310 gestützten Systems von bis zu 44 liegenden Patienten bedingte bereits mehrfach den Einsatz im Rahmen ziviler Großschadensereignisse. Der Transport der häufig vital gefährdeten Patienten erfordert sowohl eine dem Inlandsstandard anzupassende medizintechnische Ausstattung der Luftfahrzeuge als auch entsprechend qualifiziertes medizinisches Begleitpersonal, das aufgrund der Sitzplätze zahlenmäßig begrenzt ist. Dieser Umstand verlangt vom Personal Umsicht bei der Betreuung von zeitgleich mehreren Patienten sowie Befähigung zum eigenständigen Arbeiten. Die Patienten-Transport-Einheiten (PTE) entsprechen in der technischen Ausstattung dem Intensivbehandlungsplatz einer modernen Klinik und gewährleisten auch über eine längere Transportzeit eine Intensivtherapie auf höchstem Niveau. Die Arbeit mit dieser Ausrüstung, die Besonderheiten des Langstreckenlufttransportes und die spezielle Situation des militärischen Einsatzes stellen zusätzliche Anforderungen an das Personal. Um dem gerecht zu werden, erfolgt, ergänzend zur täglichen Arbeit im Rettungsdienst, in den Notaufnahmen und auf den Intensivstationen der Bundeswehrkrankenhäuser eine spezielle Schulung von Rettungsassistenten und Ärzten am Flugmedizinischen Institut der Luftwaffe.     

Radiological detection of bone and bone marrow metastases

Bone scintigraphy is the primary method for the diagnosis of skeletal métastases. This investigation is sensitive, but the interpretation must be performed in the knowledge that it is also nonspecific. Despite this, a correct diagnosis can usually be achieved. The first-hand supplementary investigation, after a doubtful scintigraphic finding, is radiography. In most cases this is sufficient for a diagnosis. When a scintigraphic abnormality cannot be adequately explained, usually because of a negative radiographic examination, a more sensitive modality must be used. Computerized tomography offers increased sensitivity and specificity, and is primarily used for this purpose. In this way contrast resolution is increased and problems caused by obscuring tissue and complicated anatomy are reduced. Since bone metastases migrate via the active bone marrow an alternative supplementary investigation is bone marrow scintigraphy. Its usefulness is restricted by disturbing activity, from the liver and the spleen, which obscures a significant part of the active marrow, and by the fact that a lesion must be of a certain size to become apparent. Magnetic resonance imaging yields excellent images of the extension of a tumor in soft tissue. Owing to high costs and restricted availability it is still mainly used for preoperative location of metastases.     

Surgery of calculous hydrocalyx (Calyceoplastic surgery)

A modified surgical technique for calculous hydrocalyx, based on partial calyceal resection with simultaneous correction of the morphological abnormality responsible for stone formation is described. Access to the calyx is gained by a modified marginopolar resection. The modification developed by the authors consists in carrying the resection line laterally to the vertical axis of teh kidney. The parenchyma is closed by U-shaped “hair-pin” stitches. Preparation of the limbic, pelvic and ureteral areas is abstained from, thus avoiding scarring which might affect renal lymph and blood flow and interfere with urinary transport. The results obtained in 85 cases of calculous hydrocalyx over an 8-year period were satisfactory. The rate of calculous recurrences was not higher than 3.5 per cent.     

Reliability of Cord Formation in BACTEC 12B/13A Media for Presumptive Identification of Mycobacterium tuberculosis Complex in Laboratories with a High Prevalence of Mycobacterium tuberculosis

A total of 1208 positive BACTEC vials were examined for the presence or absence of serpentine cording. A very high (92.9%) rate of laboratory prevalence was obtained for Mycobacterium tuberculosis complex. The sensitivity, specificity, positive and negative predictive values of this test were 92.7%, 95.3%, 99.6% and 50.0%, respectively. It was concluded that testing cord formation in laboratories that have a high prevalence of Mycobacterium tuberculosis complex is an exceptionally reliable method for preliminary reporting of cording-positive cases; however, for cording-negative cases, preliminary reports based solely on cord formation are not reliable. It was also observed that the length of the incubation period has a significant effect on cord formation. Incubation periods of 4 days or less are not sufficient to determine noncording in smears prepared from positive BACTEC vials. Electronic Publication     

Assistierte Reproduktion

Assisted reproduction (IVF/ICSI) is an established method for the treatment of infertility, though it entails a number of risks and limiting factors for the children and their families that really have to be considered and resolved. They also must be part of informative consultations before applying the selected (methods)/techniques. The following risks are of prime importance: 1. The increasing number of multiple pregnancies. Every multiple pregnancy has to be regarded as a complication of reproductive medicine: the rate of neonatal morbidity and mortality is higher compared to single pregnancies, and the emotional, logistic, and financial factors are significant for the concerned families. To limit these risks, it is preferable to perform only a single embryo transfer even though a lower rate of resulting pregnancies is to be expected. Of course it must be simultaneously provided that methods are developed and applied to transfer an embryo with high implantation potency. Based on existing/present results, the highest priority should not be given to pregnancy rates as high (as possible) but to the lowest possible complication rate for the infant with an acceptable pregnancy rate comparable to that achieved in fertile couples. 2. In assisted reproduction, the risk of fetal abnormalities seems to be elevated, but in some studies, according to the German IVF register, the selected method (ICSI) and other factors such as family abnormalities and environmental factors are relevant. Additional studies are required to clarify this subject and develop possible preventive strategies. 3. The children's psychomotoric development is normal as a rule. The risk of handicaps (retarded development spastic cerebral palsy) increases in accordance with the reduction of gestational period/age and the decrease of birth weight. This in turn is of particular significance in multiple pregnancies.