After myocardial infarction. How to determine future risk and what to do then

Management of the postinfarction patient should be directed toward identifying and treating individuals at risk of future coronary morbidity or mortality. The history, physical examination, resting ECG, and chest film, supplemented with ambulatory electrocardiographic monitoring, noninvasive assessment of left ventricular function, graded exercise testing, and sometimes angiography allow stratification of patients into high- and low-risk subgroups. A program of exercise training, risk factor modification, and prophylactic therapy with beta blockers would be warranted in most patients. Use of antiarrhythmic agents may alter prognosis in certain subgroups. Evidence is currently insufficient to warrant routine use of anticoagulant or antiplatelet agents in the postinfarction patient.     

New evidence for involvement of the entorhinal region in schizophrenia: a combined MRI volumetric and DTI study

Postmortem examinations and magnetic resonance imaging (MRI) studies suggest involvement of the entorhinal cortex (EC) in schizophrenic psychoses. However, the extent and nature of the possible pathogenetical process underlying the observed alterations of this limbic key region for processing of multimodal sensory information remains unclear. Three-dimensional high-resolution MRI volumetry and evaluation of the regional diffusional anisotropy based on diffusion tensor imaging (DTI) were performed on the EC of 15 paranoid schizophrenic patients and 15 closely matched control subjects. In schizophrenic patients, EC volumes showed a slight, but not significant, decrease. However, the anisotropy values, expressed as inter-voxel coherences (COH), were found to be significantly decreased by 17.9% (right side) and 12.5% (left side), respectively, in schizophrenics. Reduction of entorhinal diffusional anisotropy can be hypothesized to be functionally related to disturbances in the perforant path, the principal efferent EC fiber tract supplying the limbic system with neuronal input from multimodal association centers. Combinations of different MRI modalities are a promising approach for the detection and characterization of subtle brain tissue alterations.     

Personalbedarfsermittlung für eine leitliniengerechte stationäre Qualifizierte Entzugsbehandlung bei Alkoholabhängigkeit

The central element of the “qualified withdrawal treatment” of alcohol dependence is – in addition to physical withdrawal treatment – psychotherapy. The treatment of the underlying addictive disorder that is displayed by intoxication, harmful behaviour and withdrawal symptoms is only possible with a combination of somatic and psychotherapeutic treatment elements. The successfully established multimodal therapy of the “qualified alcohol withdrawal treatment”, postulated in the current S3-Treatment Guidelines, requires a multi-disciplinary treatment team with psychotherapeutic competence. The aim of the present work is to calculate the normative staff requirement of a guideline-based 21-day qualified withdrawal treatment and to compare the result with the staffing regulations of the German Institute for Hospital Reimbursement. The present data support the hypothesis that even in the case of a hundred per cent implementation of these data, adequate therapy of alcohol-related disorders, according to the guidelines, is not feasible. This has to be considered when further developing the finance compensation system based on the described superseded elements of the German Institute for Hospital Reimbursement.     

Untersuchungen zur Strahlenexposition von Beschäftigten und Patienten im Herzkatheterlabor und bei der vaskulären Brachytherapie

Zusammenfassung Interventionelle radiologische Ma?nahmen k?nnen zu hohen Strahlenexpositionen des medizinischen Personals führen. Zur Ermittlung der Strahlenexposition des Personals und des Patienten wurden bei 52 interventionellen Ma?nahmen im Herzkatheterlabor die resultierenden Strahlendosen gemessen. Neben der Bestimmung der Personendosis hinter der Bleischürze wurden zur Absch?tzung der Strahlenexposition der nichtabgeschirmten K?rperteile auch Dosimeter vor der Bleischürze sowie am Handgelenk des Arztes getragen. Die Absch?tzung der Strahlenexposition des Patienten erfolgte durch Platzierung eines Dosimeters neben dem Kopf des Patienten und durch Bestimmung der Einfalldosis aus dem Dosisfl?chenprodukt. Als Dosimeter kam ein neuartiges DIS (Direct Ion Storage) Dosimetriesystem zum Einsatz. Als Mittelwert der Personendosis des Arztes hinter der Bleischürze wurden 1,9μSv pro Ma?nahme bei einer Spannweite von 0–9μSv ermittelt. Vor der Bleischürze wurde ein Mittelwert von 53,9μSv (3–233μSv) erhalten. Der Mittelwert der Teilk?rperdosis am Handgelenk wurde zu 163,2μSv (12–603μSv) pro Ma?nahme ermittelt. Es konnte gezeigt werden, dass Ma?nahmen die mit einer Intervention verbunden sind im Vergleich zu solchen ohne Intervention, zu deutlich h?heren Strahlenexpositionen führen. Für die MTA ergab sich der Mittelwert der Personendosis hinter der Bleischürze zu 3,9μSv (0–58μSv) pro Ma?nahme. Für den Patienten wurden neben dem Kopf 800μSv (119–8642μSv) gemessen. Als mittlere Einfalldosis für den Patienten wurden 307mGy (70–1190mGy) erhalten. Aus diesen Daten wurde für den Arzt bei 1000 Untersuchungen pro Jahr eine zu erwartende Jahresdosis von 1,9mSv/a ermittelt. Dies liegt weit unter dem zul?ssigen Grenzwert von 20mSv/a. Auch bei den Absch?tzungen bzgl. der Dosis für die Augenlinse und der H?nde ist bei Einhalten der Schutzvorschriften keine überschreitung der geltenden Grenzwerte zu erwarten. Die Ergebnisse bei der vaskul?ren Brachytherapie zeigten gegenüber konventionellen Ma?nahmen mit Intervention (PTCA, Stent) keine zus?tzlichen signifikanten Erh?hungen der Strahlenexposition für die Besch?ftigten. Eingegangen: 16. Januar 2002 Akzeptiert: 2. April 2002     

Impact of exogenous beta-adrenergic receptor stimulation on hepatosplanchnic oxygen kinetics and metabolic activity in septic shock

OBJECTIVE: To investigate the impact of exogenous beta-adrenergic receptor stimulation on splanchnic blood flow, oxygen kinetics, glucose-precursor flux, and liver metabolism in septic shock. DESIGN: Prospective trial. SETTING: University hospital intensive care unit. PATIENTS: Six patients with hyperdynamic (cardiac index >4.0 L/min/m2) septic shock, all requiring norepinephrine to maintain blood pressure >65 mm Hg. INTERVENTIONS: We compared norepinephrine and phenylephrine titrated to achieve similar systemic hemodynamics and gas exchange. Splanchnic hemodynamics, oxygen kinetics, and metabolic parameters were measured before, during, and after replacing norepinephrine with phenylephrine. MEASUREMENTS AND MAIN RESULTS: Splanchnic blood flow and oxygen kinetics were derived from the steady-state indocyanine-green clearance based on hepatic dye extraction and arterial and hepatic venous blood gases. Endogenous glucose production rate was derived from the plasma appearance rate of stable-isotope-labeled glucose using a primed-constant infusion. Splanchnic lactate, alanine (high-performance liquid chromatography) uptake, and hepatic monoethylglycinexylidide (MEGX) (fluorescence polarization immunoassay) formation rates were calculated from splanchnic blood flow and arterial-hepatic venous concentration differences. Replacing norepinephrine with phenylephrine induced no change in systemic hemodynamics or gas exchange. While splanchnic oxygen consumption and alanine uptake rate remained unaffected, splanchnic blood flow, oxygen delivery, and lactate uptake rate were significantly decreased. Glucose production rate also decreased significantly. A return to norepinephrine restored splanchnic blood flow, oxygen delivery, and lactate uptake rate to baseline values, while glucose production rate remained depressed. Hepatic MEGX formation rate was not influenced during the investigation. CONCLUSIONS: Exogenous beta-adrenergic receptor stimulation determines splanchnic blood flow, oxygen delivery, and glucose precursor flux but not splanchnic oxygen utilization in septic shock. Gluconeogenesis is not directly affiliated to hepatosplanchnic oxygen kinetics. The different response of glucose and MEGX production rates, metabolic pathways of the periportal and perivenous region, may document intrahepatic heterogeneity associated with hepatocellular metabolic compartmentation.     

Comparison of ventral corpectomy and plate-screw-instrumented fusion with dorsal laminectomy and rod-screw-instrumented fusion for treatment of at least two vertebral-level spondylotic cervical myelopathy

The objective of the article is to verify the hypothesis that the dorsal multilevel laminectomy and rod-screw-instrumented fusion (DLF) for multilevel spondylotic cervical myelopathy (MSCM) is less strenuous for patients, and less prone to perioperative complications, than ventral multilevel corpectomy and plate-screw-instrumented fusion (VCF), while clinical outcome is comparable. One hundred and three successive patients were treated for at least two vertebral-level MSCM, 42 of them by VCF and 61 by DLF. The two patients groups were retrospectively compared. VCF patients were slightly younger than DLF patients (62.5 ± 10.61 years versus 66 ± 12.4 years, P = 0.012). In VCF patients, a median of 2 (2–3) corpectomies and in DLF patients a median of 3 (2–5) laminectomies were performed. In VCF patients, surgery lasted longer than in DLF patients (229 ± 60 min versus 183 ± 46 min, P ≤ 0.001). Between the VCF and the DLF patients groups, no significant difference was found in perioperative complications (e.g. hardware failure rates of 16.7% in VCF and of 6.6% in the DLF patients) and mortality rates. The postoperative outcome, as assessed by the postoperative change of the Nurick scores, the change of neck pain, the patients’ satisfaction, and the change of the subaxial Cobb angle of the spine did not differ between the two patients groups. However, when comparing the postoperative Nurick scores directly, VCF patients fared somewhat better than DLF patients [median of 2 (0–5) versus 3 (1–5), P = 0.003]. The hypothesized advantages of DLF over VCF in the surgical treatment of at least two vertebral-level MSCM could not be confirmed in this retrospective study. A prospective randomized study is warranted to clarify this issue.