„Critical illness myopathy“ bei Intensivpatienten

Intensive care patients are at increased risk of developing sepsis with multi-organ failure during treatment (severe sepsis) possibly leading to complications of the central and peripheral nervous system. Among these, septic encephalopathy, critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are the most important. Neuromuscular complications in particular are difficult to diagnose as they mostly become apparent only when sedation has ceased and the awakening patient experiences difficulties in weaning from the respirator and reduced voluntary strength. CIP and CIM are generally self-limiting, however, they greatly prolong ICU stay and rehabilitation, thus nowadays also imposing a real budget threat. The diagnostics, especially the differentiation between CIM and CIP is difficult and a multi-disciplinary approach involving ICU physicians, anesthetists and neurologists is needed. Our knowledge of the causes of the primary ICU myopathy, although rapidly evolving during recent years, is still in its infancy and specific treatment of CIM is not yet available. The present overview summarizes insights into clinical and new diagnostic strategies for early detection of neuromuscular dysfunction in ICU patients. This article focuses on current concepts and results revealing the pathomechanism(s) of CIM and some simple therapeutic or preventive measures have been deduced which are summarized and discussed.     

Leben erhalten und Sterben ermöglichen

Intensive care has achieved major breakthroughs in handling gravely ill patients. However, this has, at least in part, been overshadowed by problems relating to ethical values as well as general psychological conflicts among patients and hospital staff. When dealing with such problems, distinct criteria are required which address the patient's dignity and will to survive. A four-step scheme is suggested, ranging from maximum therapy, via maintenance therapy without adjustments to increased demand and therapy reduction, to cessation of therapy. In the case of therapy reduction, balanced support is maintained ensuring that dehydration is avoided, the respiratory tract is kept clear, pain killers are used to good effect, personal attention is provided, and care is provided to a high standard. A questionnaire tailored to the practical need of how to arrive at an ethically weighted and accepted decision is presented. When searching for a solution involving ethic issues, it is particularly important to involve all individuals concerned in a dialogue until a consensus is reached.     

Condylomata acuminata

HPV infection is one of the most common sexually transmitted infections worldwide. Although most infections are transient, persistent ones can lead to condylomata acuminata, genital intraepithelial neoplasia and genital cancer. The recent approval of vaccines against HPV has raised great hopes. Since 1990, 5,392 urological investigations for HPV were carried out in 1,792 men in special HPV centres. We report on the epidemiology and natural course of condylomata, techniques for HPV detection, treatment surveillance and long-term sequelae. Condylomata acuminata proved to be pathognomonic; partner infections were diagnosed in 50% and more. Systematic HPV DNA analyses in partner investigations or as screening investigations cannot be recommended. Ultimately, within the spectrum of therapeutic options for condylomata, no method is really superior to others; recurrences occurred in 30-70% of cases. We definitely need the HPV vaccination programme to get rid of one of the oldest and up to now unsolved problems of mankind.     

Chemotherapie des Hodentumors

Platinum-based polychemotherapy has increased the cure rate in testicular cancer dramatically: at first, chemotherapy was mainly used in advanced disease. Recently it has also become common in low-stage disease, though other therapeutic options are equivalent. Risk factors might help to find the right decision.The success of treatment in patients with metastatic disease results from the combination of chemotherapy and secondary surgery. High-dose chemotherapy for patients with poor prognosis or recurrent disease is being evaluated in clinical trials. Concerning the success in these stages prognostic factors are of special importance. Patients with advanced-stage nonseminoma need residual tumor resection after chemotherapy if no complete remission could be achieved.The therapist should be aware of the indication for and schedule of chemotherapy, its side effects, and supportive care.     

„Multi-targeting drugs“ und „multi-drug targeting“ beim metastasierten Nierenzellkarzinom

Ohne ZusammenfassungD. Rohde: Vorstandsmitglied der AUO.Association for Urogenital Oncology (AUO): Multi-targeting drug and multi-drug targeting in metastatic renal cell carcinoma. Co-inhibition of EGF-R     

Ergebnisse der sakralen Neuromodulation bei Therapie der überaktiven Blase

Currently, sacral nerve modulation (SNM) is an effective treatment for overactive bladder symptoms which are refractory to anticholinergic or muscarinergic treatment. However, SNM requires the implantation of stimulation electrodes at the sacral nerves and a subcutaneous impulse generator. The SNM procedure can be divided into three phases: the acute phase comprising the implantation of the test stimulation electrodes, the subchronic stimulation phase over a period of 7-14 days during which neurostimulation takes place by means of an external impulse generator, and finally chronic SNM after implantation of the final impulse generator.In 1981 the SNM technique for treatment of bladder dysfunctions was first developed by Tanagho and Schmidt and has since been refined, while the range of indications has been extended continuously. It has been shown that patients with neurogenic bladder dysfunctions are able to gain the greatest benefit from SNM. The long-term results of SNM are very encouraging so far. In addition, a highly innovative and promising technique is the implantation of a miniaturized impulse generator with integrated stimulation electrode at the n. pudendus. However, the outcome of these trials has not fully been capable of living up to the expectations so far.     

Nierentransplantation im Kindes- und Jugendalter

The reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.     

Klinische Erfahrungen mit dem Siremobil Iso-C3D-Bildwandler in der Beckenchirurgie

In pelvic and acetabular surgery intraoperative control of reduction and implant position is sometimes hard to achieve with conventional C-arm technology. The Siemens C-arm Iso-C(3D) imaging system enables axial cuts and two- or three-dimensional reconstructions to be generated. Following the good experience in surgery of the spine and extremities, its clinical applicability in pelvic surgery was evaluated in 30 patients in a prospective clinical trial. In all 20 patients with acetabular fractures reduction quality and implant position could be well assessed. In one postoperative examination an intraarticular screw placement was evident, which intraoperatively was not as clear and was revised. In one procedure an intraarticular fragment was visualized, and was extracted in the same procedure. In one procedure the use of the Iso-C(3D) system enabled the approach to be limited.In all ten pelvic ring injuries the osseous structures in the posterior pelvic ring could be visualized with an adequate image quality. Reduction quality and implant position could be assessed in all open and closed procedures. On two occasions the SI screws were navigated based upon the Iso-C(3D) dataset. Overall the use of the Iso-C(3D) system was successful in all cases. Image quality, which is clearly inferior to that of CT, was sufficient for the assessment of reduction quality and implant position. One revision was indicated, and one avoided. However, in spite of its advantages in pelvic surgery, handling, sterile covering and data transfer need to be improved. For bilateral pelvic injuries the image size is too small.     

Minimal-invasive Versorgung monokondylärer Tibiakopffrakturen

BACKGROUND: Treatment of displaced tibial plateau fractures is often complicated by high-energy trauma and soft tissue damage. Therefore, numerous techniques such as indirect or arthroscopically controlled reduction and percutaneous osteosynthesis have been described to reduce the additional surgical trauma. MATERIAL AND METHODS: Twenty-three fractures (AO type 41-B2/3, Schatzker type II-IV) were treated with percutaneous, fluoroscopically guided reduction combined with small fragment osteosynthesis using a radius T-plate. In none of the patient was cancellous bone graft performed. Only in one case was arthrotomy necessary because of uncertain image intensification findings in an obese patient. One revision was done for a 4-mm step caused by an over reduced rim fragment. Fracture healing and full weight bearing were achieved after 8-12 weeks. Neither secondary displacement nor implant loosening was seen under primary functional treatment without immobilization. RESULTS: Functional recovery showed a mean ROM of 114 degrees after 6 weeks and 121 degrees after 3 months. The radius T-plate offers enough stability to allow primary functional treatment due to early recovery of joint motion. Percutaneous reduction and small fragment osteosynthesis is a less invasive approach in the treatment of displaced monocondylar tibial plateau fractures.