Strahlentherapie des Schilddrüsenkarzinoms

Zusammenfassung Beim differenzierten Schilddrüsenkarzinom besteht bei nicht Organkapsel überschreitendem Tumorwachstum und adäquater Operation keine Indikation zur postoperativen Bestrahlung. Bei Patienten mit Organkapsel überschreitendem Wachstum wird nach vollständiger Resektion der Nutzen einer zusätzlichen perkutanen Radiotherapie kontrovers diskutiert. Die MSDS-Studie (Multizenterstudie Differenziertes Schilddrüsenkarzinom), die eine Randomisierung genau zu dieser Fragestellung durchführte, musste aufgrund der mangelnden Rekrutierung vorzeitig beendet werden. Beim anaplastischen Schilddrüsenkarzinom wird die vollständige Resektion angestrebt. Die postoperative Bestrahlung ist dann obligat. Bei Therapieprotokollen mit zusätzlicher Adriamycingabe konnten erhöhte lokale Kontroll- und Überlebensraten beobachtet werden. Bei medullärem Schilddrüsenkarzinom und inkompletter Tumorresektion geht eine additive Radiotherapie mit einer verbesserten lokalen Kontrolle einher. Bei nicht Radiojod speichernden Metastasen des Schilddrüsenkarzinoms wird die Radiotherapie im Bereich des Knochens bei Schmerzen, Frakturgefahr oder Myelonkompression eingesetzt.     

Moderne immuntherapeutische Ansätze für die Behandlung von Lungen- und Kopf-Hals-Tumoren

Zusammenfassung Multimodale Therapiestrategien, die Chirurgie, Strahlen- und Chemotherapie kombinieren, haben die Behandlungsergebnisse bei Tumoren der Lunge und der Kopf-Hals Region verbessert. Die Ergänzung des Therapiespektrums um weitere Ansätze, die sich in der Wirkungsweise und möglichst durch reduzierte Toxizität von den konventionellen unterscheiden, erscheint jedoch zur Erzielung weiterer Fortschritte notwendig. Eine neue Generation immunologischer passiver (antikörperbasierter) und auch aktiver (Vakzinierungs-) Strategien erscheint aussichtsreich und befindet sich gegenwärtig in der klinischen Prüfung. Die Untersuchung der optimalen zeitlichen Sequenz in Kombination mit den konventionellen Therapieverfahren und die Individualisierung der Therapie auf Basis genomischer/proteomischer Daten muss die klinische Integration begleiten.     

Therapieprinzipien beim Lokalrezidiv des Rektumkarzinoms

The aim of treatment in isolated locally recurrent rectal cancer is R0 resection, which is possible in 30%. Because of the high rate of surgical complications after repeat surgery in the pelvis, preoperative staging has to be precise to estimate the extent and location of the recurrent rectal cancer. After exclusion of distant metastases, surgery should be considered following preoperative radiochemotherapy if possible. When a curative treatment concept is not indicated, radiotherapy is the best treatment choice. This paper presents various tabularised summaries about therapeutic strategies in isolated locally recurrent rectal cancer.     

选择性头部降温对胎羊缺血性脑损伤纹状体神经元凋亡和星形胶质细胞增殖的影响

目的研究选择性头部降温对缺血性脑损伤胎羊纹状体神经元凋亡和星形胶质细胞增殖的影响。方法胎羊于妊娠117~124d时通过双侧颈动脉阻塞30min造成双侧脑缺血损伤,损伤后将胎羊随机分为:损伤组(n=10)、2h低温组(损伤后2h开始亚低温治疗,n=7)和6h低温组(损伤后6h开始亚低温治疗,n=8),另设正常对照组(n=5)。通过冷循环水进行选择性头部降温,取脑组织用免疫组化法检测胎羊纹状体caspase-3(半胱天冬氨酸酶-3),GFAP(胶质纤维酸性蛋白)和PCNA(增殖细胞核抗原)的表达。结果①纹状体神经元凋亡:正常对照组中,caspase-3表达极少(11.00±13.77),损伤组caspase-3免疫阳性细胞为177.70±48.69,明显增加(P=0.000),损伤后2h治疗组(54.14±39.44,P=0.000)和损伤后6h治疗组(122.43±52.36,P=0.017)均能减少caspase-3免疫阳性细胞。②纹状体星形胶质细胞增殖:与正常对照组(163.40±21.98)相比,缺血性脑损伤组的GFAP免疫阳性细胞明显增多(433.25±66.69,P=0.000),损伤后2h开始亚低温治疗(219.50±35.31,P=0.000)和损伤后6h开始亚低温治疗(272.50±86.20,P=0.000)均能减少GFAP免疫阳性细胞。③纹状体PCNA阳性细胞的表达:在正常对照组中,PCNA免疫阳性细胞较少,为153.40±12.46,缺血性脑损伤组的PCNA免疫阳性细胞明显增多(353.70±45.60,P=0.000),损伤后2h开始亚低温治疗(187.14±26.26,P=0.000)和损伤后6h开始亚低温治疗(230.25±67.46,P=0.000)均能减少PCNA免疫阳性细胞。结论亚低温可以抑制纹状体神经元的凋亡和星形胶质细胞的增殖,该作用可能为选择性头部降温的脑保护作用机制之一。     

Weisheitszähne — Stationär behandlungsbedürftige Komplikationen

Background

In view of the conflicting guidelines issued by national and international scientific societies, debate about the indications for prophylactic extraction of wisdeom teeth is ongoing. This prospective study was therefore set up to explore the complications associated with wisdom teeth and requiring in-patient treatment.

Patients and Methods

From January /2003 to December 2003, 21 subjects were admitted for treatment of complications associated with wisdom teeth. The medical history was recorded for each of these patients, as were the cause and type of the complications. The parameter used to quantify the severity of any infections was the CRP, and the overall clinical complexity level of each case was assessed by the length of stay in hospital (and the duration of intensive care if this had been necessary). The characteristics of patients in the group with postoperative complications were compared to those of patients with complications attributable to pericoronitis. Moreover, complications in patients who had undergone prophylactic extraction of wisdom teeth that had not been causing any symptoms were compared with those in patients whose wisdom teeth had been extracted because of morbidity.

Results

Overall, 18 deep-space infections (15 abscesses, 2 inflammatory infiltrations, 1 case of phlegmonous cellulitis), 2 mandibular fractures and 1 lingual nerve injury were noted within 1 year. The complications resulted from surgical procedures in 15 of the 21 cases, while in 6 they had their origin in pericoronitis. Extensive surgery or intensive care was required only for patients with postoperative complications. The length of stay in hospital was significantly greater for patients with postoperative complications (p= 0.007, U-test). However, 9 of these 15 patients reported preoperative episodes of infection. Thus, more than two thirds of the complications could be traced back to wisdom teeth that were causing symptoms.

Conclusion

In our clinic’s catchment area, infectious complications were more frequent and more severe and required more intensive and longer treatment in hospital than complications arising from pericoronitis. However, complications of prophylactic extraction of wisdom teeth were decidedly less frequent than direct or indirect complications of extraction of symptomatic teeth. Thus, our data tend to support the concept of elective extraction of wisdom teeth with the aim of preventing serious infections.     

Kann die Telemedizin in der Schlafmedizin die Akzeptanz der nCPAP-Therapie verbessern?

The obstructive sleep apnea syndrome has considerable consequences for morbidity and mortality in affected patients. The continuous positive airway pressure (CPAP) therapy can reliably prevent the nocturnal disordered breathing and minimize health implications (high efficacy). However, the effectiveness of this therapy is restricted due to reduced adherence in the daily routine. Practical methods are urgently needed to improve adherence. Special problem groups, such as post-stroke patients or those with poor sleep efficiency in the first therapy night have already been identified. Up to date information technology enables remote monitoring and control of therapy devices and a centralized evaluation of the data. Usage time, residual breathing disorders, high mask leakage or high therapy pressure in the home environment can promptly be determined to arrange remedies in a timely manner. Scientific evidence regarding the effects of telemedical care of CPAP patients is limited, but the results of available studies are promising. Many practical questions have still not been answered. Furthermore, the danger of using the new technologies only with the aim of short-term cost reduction must explicitly be emphasized. If such information would only be used to discontinue funding of an allegedly insufficient treatment, no additional benefits would be achieved from the patient point of view. The aim of telemedical concepts has to be the improvement of therapy acceptance especially in risk groups. From the perspective of sleep medicine a primacy of physicians is promoted in order to achieve a real improvement for the patient due to telemedicine. The findings obtained so far are promising.     

Rückblick auf 10 Jahre Infektionsschutzgesetz

In 2001, the German Protection against Infection Act came into force, implementing a variety of new regulations. For the first time, obligatory infection control visits of the public health departments in surgical ambulatory practices were implemented, as well as optional infection control visits in all medical, dental and paramedical practices using invasive methods. Based on the data of the public health department of the city of Frankfurt am Main, Germany, an evaluation of this new regulation is given in this paper. First, prioritization of these new tasks was mandatory. First priority was given to the obligatory visits in surgical practices, second priority to the hygiene visits in practices performing endoscopy in gastroenterology as well as in urology and in practices of traditional healers, and third priority was given to all other doctors’ practices. After receiving preliminary information and further training of the doctors etc., the control visits were performed by members of the public health department, using a checklist based on the guidelines of the German Commission on Hospital Infection Prevention (“Kommission für Krankenhaushygiene und Infektionsprävention”). Since 2001, more than 1100 infection control visits in medical practices in Frankfurt am Main were documented. Not only in surgical, but also in gastroenterological and urological practices great improvement could be achieved, regarding not only hand hygiene and reprocessing surface areas, but especially in reprocessing medical devices. In practices for internal medicine and those of general practitioners, errors in hand hygiene, skin antiseptic and surface disinfection also decreased. According to our results, especially regarding the improved quality of structure as well as quality of process and with regard to the public discussion on this hygiene topic, our evaluation is absolutely positive. The new regulation proved worthwhile.     

Schmerztherapeutische Möglichkeiten in der Unfallchirurgie

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.