Adjuvante und additive Therapie beim Pankreaskarzinom

Recent advances have been made in the treatment of pancreas cancer. Specialized pancreas centres have reported an increasing rate of resections with reduced postoperative mortality. On account of the highly aggressive nature of pancreas cancer, there is a great challenge in identifying effective therapy concepts for advanced stages of the cancer as well as for the development of resection-associated measures. As large-scale, randomised, controlled studies are lacking, the additive therapy concepts after resection do not have a sufficiently scientific basis. The ESPAC-1 study, which included 600 patients, surpassed all previous studies on adjuvant therapy for pancreas cancer. This study has shown,for example, that the most promising adjuvant chemotherapy with 5-fluorouracil and folic acid leads to an equal if not better result than the multimodal regimen. This regimen can be superseded with the use of Gemcitabine, which will be evaluated in the ESPAC-3 study that includes 990 patients from various European countries including Germany, as well as from Canada and Australia. Participation in the large, phase-3 study therefore plays a key role in the continued development of the management of pancreas cancer.     

Iatrogenic injuries to ureter, bladder and urethra during abdominal and pelvic operations

Abdominal and pelvic operations at Departments of Obstetrics and Gynaecology, and General Surgery play an important role in ureteral, bladder and rarely urethral injuries. Fifty-nine patients with iatrogenic ureteral, bladder and urethral injuries were treated at the Department of Urology, Atatürk University Research Hospital, between 1985 and 1995. These injuries were urinary vaginal fistulas in 43 patients (vesicovaginal 33, ureterovaginal 7, urethrovaginal 2 and vesicovaginal plus urethrovaginal 1), ureteric ligation in 9, bladder laceration in 7. These injuries were treated by different methods. All patients were followed up by intravenous urography (IVU) and urine culture three months later. It must be borne in mind that iatrogenic urinary tract injuries are not rare. Bladder and ureteral catheterization must be performed to prevent these complications.     

Prolongierte Muskelschwäche des Intensivpatienten unter besonderer Berücksichtigung der sog. Intensiv-Polyneuromyopathie

Generalized muscle weakness in critically ill patients can result in prolonged periods of artificial ventilation and longer stays in the intensive care unit. Both neuropathic (critical illness polyneuropathy) and myopathic (critical illness myopathy) abnormalities seem to play an important role for this prolonged weakness. This article reviews its complex differential diagnosis with special emphasis on the current understanding of the neuromuscular syndromes. An efficient diagnostic plan is necessary for the exclusion of other curable causes of prolonged muscle weakness even in the presence of polyneuromyopathic changes. Psychological support of the patient and prophylaxis of secondary complications of prolonged immobilization are crucial when specific therapy is not possible.     

Different kinetics of lung clearance of technetium-99m labelled diethylene triamine penta-acetic acid in patients with sarcoidosis and smokers

The rate of clearance from the lungs of inhaled technetium-99m labelled diethylene triamine penta-acetic acid (^99mTc-DTPA) is often increased in interstitial lung disease as well as in smoking. In smokers a bi-exponential clearance course of ⁹⁹mTc-DTPA when measured over 3 h has previously been shown. This study was performed to compare the kinetics of clearance of ^99mTc-DTPA, measured for 3 h, in sarcoid patients and healthy smokers. Forty-one never-smoking patients with sarcoidosis and radiological signs of intrathoracic disease were studied. The results were compared with those of 16 healthy current smokers and of 14 healthy never-smokers reported previously. A mono-exponential clearance equation described the clearance in 22 of the sarcoid patients and all normal never-smokers, but with a shorter average tracer half-life in the patients (P<0.05). In 19 patients and all smokers a bi-exponential equation gave a significantly better curve fit. The rate of clearance of the slow component was higher in patients with sarcoidosis than in smokers (P< 0.05). The fraction of the tracer cleared by the fast clearance component was smaller in patients with sarcoidosis than in smokers (P<0.01). Differences in kinetics of clearance of ^99mTc-DTPA in sarcoidosis and smoking could thus be demonstrated, suggesting that the abnormal clearance is caused by diverging pathophysiological mechanisms.     

Treatment of hypertensive urgencies with oral nifedipine, nicardipine, and captopril

Sixty-five patients with uncomplicated hypertensive urgencies were treated in the emergency and cardiology departments with 20 mg nifedipine, 20 mg nicardipine, or 25 mg captopril in a randomized study. The study population consisted of 65 patients ranging in age from forty-one to seventy-one. Blood pressure and heart rate were assessed for six hours after intake of the antihypertensive agents. Within sixty minutes nifedipine reduced blood pressure by an average of 74.7 mmHg for the systolic and 35.4 mmHg for the diastolic. Average heart rate increased significantly by 11.6 beats/min at within thirty minutes. Nicardipine and captopril produced equivalent falls in systolic (-81.6 and -79.4 mmHg) and diastolic (-37.3 and -33 mmHg) blood pressure respectively, but did not increase heart rate significantly. The antihypertensive effect of each drug was maintained until six hours after medication. In conclusion, nifedipine, nicardipine, and captopril show similar efficacy in the treatment of hypertensive urgencies. The authors believe that these drugs can be used as first-line therapy in the treatment of hypertensive urgencies safely and effectively.     

Who benefits from endoscopic sclerotherapy of bleeding oesophageal varices? Proposal for differential indications. The Copenhagen Esophageal Varices Sclerotherapy Project.

The value of early sclerotherapy for variceal haemorrhage remains unsettled, possibly because the treatment may be beneficial to some patients and harmful to others. On the basis of a randomized clinical trial of sclerotherapy in 187 patients presenting with their first variceal haemorrhage, we examined the relationship between clinical, endoscopic and biochemical characteristics at admission and the treatment effect on mortality. As previously published, sclerotherapy had no overall effect on the very high mortality during the first 6 weeks (47%), but thereafter the mortality and risk of rebleeding were reduced. The analysis showed that in the 48% of the patients with disturbed consciousness and/or elevated plasma creatinine, sclerotherapy considerably increased short-term mortality, and this was not compensated for by increased long-term survival. Among patients without these characteristics, sclerotherapy reduced mortality in the 25% with ascites, but did not affect short-term mortality in the 27% without. Sclerotherapy significantly improved the long-term survival of these patients. The results suggest that sclerotherapy should not be used in patients with disturbed cerebral or renal function, whereas it may be beneficial in patients without these characteristics.     

Thrombocyte function in children with Type I diabetes mellitus. Cross-sectional study]

Platelet count, spontaneous platelet aggregation, ADP- and collagen-induced platelet aggregation platelet adhesion, platelet volume, shape change, beta-thromboglobulin and von-Willebrand-factor have been investigated in 51 insulin dependent diabetic children without clinical signs of diabetic angiopathy. Compared to an age matched healthy control group diabetic children showed a significant enhancement of spontaneous platelet aggregation, elevated plasma levels of von-Willebrand-factor, increased platelet shape change and adhesion. No alterations could be found in ADP--and collagen--induced platelet aggregation and in beta-thromboglobulin levels. Significant correlations could be found between the total glycosylated haemoglobin concentrations (Hb A1) and spontaneous platelet aggregation, as well as between duration of diabetes Hb A1, and platelet volume. In this study we could demonstrate changes in platelet function in diabetic children without clinical signs of diabetic angiopathy. However these changes could be due to metabolic adjustment and may precede diabetic vasculopathy.     

Cerebral primitive neuro-ectodermal tumour following treatment of a unilateral retinoblastoma

Summary Cerebral primitive neuro-ectodermal tumour (PNET) occurring as a second primary malignancy in childhood is exceedingly rare. We present a 7-year-old boy who developed a proven supratentorial PNET five years after enucleation and radio-/chemotherapy for a sporadic, unilateral retinoblastoma with optic nerve invasion. The association with this malignant eye disease as well as the effect of irradiation and multi-agent chemotherapy on second tumour induction are evaluated.     

Postoperative Resistenzentwicklung gegenüber Atracurium

Zusammenfassung Zwei F?lle einer postoperativ aufgetretenen Atracuriumresistenz werden vorgestellt. In beiden F?llen handelte es sich um Patienten, welche nach einem intrathorakalen Elektiveingriff eine septische Komplikation entwickelten. Kasuistik: Beim ersten Patienten (39 Jahre) entwickelte sich wenige Tage nach einer Pneumonektomie eine Bronchusfistel mit einer Superinfektion der Thoraxresth?hle. Zum Zeitpunkt des Revisionseingriffs war die Wirkung von Atracurium im Vergleich zur Prim?roperation deutlich ver?ndert: Die Anschlagzeit war verl?ngert (7 vs. 3,5 min), die Erholungszeit (DUR 10%) war verkürzt (14 vs. 28 min), und die Infusionsrate zur Aufrechterhaltung der Relaxation mu?te um ca. das 3fache gesteigert werden (14,3 vs. 5,0 μg/kg·min). Beim zweiten Patienten (56 Jahre) kam es im Anschlu? an eine Oberlappenresektion rechts zu einer Gangr?n des Mittellappens, welcher operativ entfernt werden mu?te. Die zur Intubation erforderliche Atracuriumdosis mu?te im Vergleich zur Prim?roperation deutlich gesteigert werden (70 vs. 40 mg), ohne da? hierdurch eine komplette neuromuskul?re Blockade zu erzielen war. Darüber hinaus war zur Ruhigstellung des Patienten eine wesentlich h?here Erhaltungsdosis als beim Ersteingriff erforderlich (11,8–16,5 vs. 5,5 μg/kg·min). Schlu?folgerung: Die Beispiele zeigen, da? sich innerhalb relativ kurzer Zeit eine Resistenz gegenüber Atracurium entwickeln kann, und wir nehmen an, da? diese Ver?nderungen durch die schweren, entzündlichen Komplikationen ausgel?st wurden.