Esophageal perforation after catheterization of the subclavian vein

The insertion of a central venous catheter (CVC) via the subclavian vein is often associated with complications. We report a case in which a patient suffered an esophageal lesion with severe bleeding and a pneumothorax with mediastinal shift induced by the insertion of the dilator of a CVC. The pneumothorax had to be treated immediately by pleural drainage, and the esophageal lesion was successfully corrected by means of an endoclip. The patient survived the complication. However, he died 1 week later from multiple organ failure not associated with the CVC insertion.     

Current status of multiple sclerosis therapy in Germany: a national survey

We conducted a semi-standardized enquiry concerning diagnostic, immunotherapeutic and supportive care strategies for multiple sclerosis (MS). A questionnaire was sent to all German neurological departments in December 1996, with 63% (n = 244) responding before May 1997. As might be expected, MS therapy in Germany is not very standardized. Most clinics use intravenous steroids for treating relapses, although with different dosing regimens. Nevertheless, oral steroids are also used. Interferon-beta and azathioprine are both used for the treatment of relapsing-remitting MS at the same frequency. Only 33% of German neurological departments said that they used an immunomodulating agent for chronic-progressive cases, indicating it in about 50% of cases. Azathioprine is the drug of first choice, followed by methotrexate. Regarding supportive care measures, the technique of intermittent self-catheterization is widely under-represented. Despite the lack of conclusive evidence from prospective studies for the value of azathioprine, it is still one of the most commonly used drugs for the treatment of relapsing-remitting and chronic-progressive MS. There was no evidence of a consensus on treatment standards for chronic-progressive disease courses.     

AIDE–Acute Illness and Depression in Elderly Patients. Cognitive Behavioral Group Psychotherapy in Geriatric Patients With Comorbid Depression: A Randomized,Controlled Trial

Background

Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression.

Sequential map-guided endocardial resection for ventricular tachycardia improves outcome.

OBJECTIVE: Surgery for ventricular tachycardias late after myocardial infarction is frequently associated with high mortality including sudden death, and arrhythmia recurrences. We examined our results of sequential map-guided endocardial resection at normothermia in patients with ventricular tachyarrhythmias late after myocardial infarction to assess the efficacy of this technique as well as the early and long-term outcome. METHODS: From 1995 to 1999, 22 patients underwent normothermic sequential map-guided endocardial resection for ventricular tachyarrhythmias late after myocardial infarction. Mean age was 61.2+/-6.5 years and left ventricular ejection fraction 32.5+/-8.7%. Adjunctive procedures included endoventricular patch repair of left ventricular aneurysm in 21 patients, coronary artery bypass grafting in 15 patients, and mitral valve replacement in one patient. Inducibility of ventricular tachycardia was evaluated postoperatively and patients were treated with sotalol or defibrillator implantation. RESULTS: The intraoperative number of inducible different ventricular tachycardia morphologies was 4.0+/-2.7. More than one mapping-resection sequence was needed in ten patients. In only one patient, sustained ventricular tachycardia was induced postoperatively, sotalol was not tolerated and a defibrillator was implanted. Five patients with inducible non-sustained ventricular tachycardia became non-inducible while on sotalol. There was one operative death (4.5%). During a median follow-up of 26 (1--62) months, there were neither cardiac deaths nor ventricular tachycardia recurrences. Two patients died from non-cardiac causes. Cumulative probability of survival at 5 years was 0.83+/-0.09. CONCLUSIONS: Sequential map-guided endocardial resection at normothermia was associated with low operative mortality and low postoperative inducibility of sustained ventricular tachycardia. The selected therapeutic approach resulted in freedom of arrhythmia recurrence and cardiac mortality including sudden death, during long-term follow-up.     

Schmerzerkennung bei geriatrischen Patienten durch ein interdisziplin?res Team: Urteilssicherheit und Einflussfaktoren

Die Pr?valenz von chronischen Schmerzen nimmt im Alter zu. Gleichzeitig ist das Erkennen von Schmerzbeschwerden bei geriatrischen Patienten aus verschiedensten Gründen schwieriger als bei jüngeren Menschen. M?glicherweise unterscheiden sich die im geriatrischen Team t?tigen Berufsgruppen in Hinblick auf die Erkennung von Schmerzbeschwerden.    Die Erhebung wurde mit 126 geriatrischen Patienten durchgeführt, die nach ihren Schmerzen am Untersuchungstag und in den letzten sieben Tagen befragt wurden. Zeitgleich gaben die betreuenden Teammitglieder (Alten- und Krankenpfleger, ?rzte, Physio-, Logo-, Ergotherapeuten) ihre Einsch?tzung zum Vorliegen von Schmerzbeschwerden ab. Auf Patientenseite wurden die potentiellen Einflussfaktoren Alter, Minimentalstatus nach Folstein (MMSE) und station?re Behandlungstage vor Befragung erhoben. Auf Mitarbeiterseite erfolgte die Erfassung von Alter, Tage der Zust?ndigkeit für den Patienten in den letzten 7 Tagen, w?chentliche Arbeitszeit, Besch?ftigungsjahre in der Einrichtung und Jahre im Beruf.    Bei den Mitarbeitern zeigten sich deutliche Unterschiede hinsichtlich der Beurteilungsgüte in Abh?ngigkeit von der Berufsgruppe, der H?ufigkeit der Zust?ndigkeit, der w?chentlichen Arbeitszeit sowie der Berufserfahrung. Mitarbeiterwechsel in der Betreuung der Patienten wirkten sich in jeder Berufsgruppe negativ aus. Weitere, in Abh?ngigkeit von der Berufsgruppe festgestellte Besonderheiten werden im Einzelnen diskutiert. Informationen bezüglich der Schmerzsituation des geriatrischen Patienten innerhalb der Berufsgruppen sollten besser übergeben werden.     

Immunophenotypic Characteristics of Monocytes in Elderly Subjects

Since ageing is accompanied by various alterations of the immune system, the aim of the present study was to investigate the effect of age on the expression of surface markers in peripheral blood monocytes. We studied 28 healthy young subjects and 28 elderly subjects fulfilling the criteria of the SENIEUR protocol. Peripheral blood mononuclear cells were isolated and the expression of various surface markers was analysed by double colour flow cytometry. The mean fluorescence intensity of the intercellular adhesion molecule-1 (CD54), CD29, CD45RO and CD32 was increased significantly in CD14+ cells of elderly people when compared with the young subjects. No significant differences were found in the expression of CD11a, CD11b, CD15, CD26, CD27, CD33, CD45RA, CD45RB, CD49d, HLA-DR and CD65. In summary, we demonstrated significant increase in four monocyte surface markers in subjects of old age; this finding may be related to certain immune phenomena observed in ageing subjects such as auto-immunity.