Diabetes im Alter

Zusammenfassung In Deutschland leiden 25% der über 70-Jährigen unter einem Diabetes mellitus. Biologisch ältere, multimorbide und in ihren Funktionen beeinträchtigte geriatrische Patienten benötigen spezielle Vorgehensweisen bei Zielplanung, Allgemeinmaßnahmen und Pharmakotherapie. Auf der Basis der vorhandenen Leitlinien werden gesicherte Erkenntnisse dargestellt und Empfehlungen zu den Besonderheiten der Therapie des geriatrischen Diabetespatienten gegeben. Besonderes Augenmerk liegt dabei auf der Interaktion von geriatrischen Syndromen und Diabetes sowie der Verbesserung der Lebensqualität.     

Bernard–Soulier syndrome in pregnancy

Bernard–Soulier syndrome (BSS) is a rare autosomal recessively inherited bleeding disorder. Pregnancy in patients with BSS is characterized by ante‐, intra‐, or postpartum haemorrhage, which may be delayed and severe. There is no consensus in the management of BSS in pregnancy and so far only 16 pregnancies in nine patients have been described. We report a further three pregnancies in two women with the syndrome. We also outline our management of pregnant patients with BSS.     

Multi-day radon signals with a radioactive decay limb -- occurrence and geophysical significance.

Multi-day signals, generally with duration of 2-10 days, are a prominent temporal variation type of radon (Rn) in geogas in the unsaturated zone. Rare multi-day Rn signals have been found which are characterized by: (a) a declining limb lasting up to 10 days which conforms to the radioactive decay of Rn, (b) recurs at the same location and (c) is recorded in diverse situations-volcanic and seismogenic. It suggested that a Rn blob is injected at a lower level on a steady upward flow of geogas whereby the rise and final fall of the signal are attributed to the edges of the blob while the central Rn-decay segment records the passing of the decaying blob itself. Rn-decay signals are a small subset of multi-day Rn signals which are considered as highly irregular and unusable for the understanding of geophysical processes. In difference, it is concluded that multi-day Rn signals are probably proxies of subtle geodynamic processes at upper crustal levels and are therefore significant for studying such processes.     

Nitrate administration increases blood flow in dysfunctional but viable myocardium, leading to improved assessment of myocardial viability: A PET study.

SPECT with 99mTc-labeled agents is better able to detect viability after nitrate administration. Nitrates induce vasodilation and may increase blood flow to severely hypoperfused but viable myocardium, thereby enhancing tracer delivery and improving the detection of viability. Quantitative data on the changes in blood flow are lacking in SPECT but can be provided by PET. The aim of the present study was to use PET to evaluate whether nitrate administration increases blood flow to chronically dysfunctional but viable myocardium. METHODS: 13N-Ammonia PET was used to quantitatively assess blood flow, and 18F-FDG PET was used as the gold standard to detect viable myocardium. Twenty-five patients with chronic ischemic left ventricular dysfunction underwent 13N-ammonia PET at rest and after nitrate administration. RESULTS: A significant increase in nitrate-enhanced blood flow was observed in viable segments (from 0.55 +/- 0.15 to 0.68 +/- 0.24 mL/min/g, P < 0.05). No statistically significant change in blood flow was observed in nonviable segments (0.60 +/- 0.20 vs. 0.55 +/- 0.18 mL/min/g). A ratio of at least 1.1 for nitrate-enhanced flow to resting flow allowed optimal detection of viable myocardium, yielding a sensitivity of 82% with a specificity of 100%. CONCLUSION: 13N-Ammonia PET showed a significant increase in nitrate-enhanced blood flow in viable myocardium, whereas blood flow remained unchanged after nitrate administration in nonviable myocardium. Nitrate use during myocardial perfusion imaging will lead to improved assessment of myocardial viability.     

Minimal-invasive Adrenalektomie beim Phäochromozytom

ZusammenfassungHintergrund Bedingt durch die intraoperative Katecholaminsekretion mit hämodynamischen Veränderungen, einem größeren Tumordurchmesser und einer deutlichen Neovaskularisation ist die Adrenalektomie beim Phäochromozytom im Vergleich zu anderen Nebennierenerkrankungen schwieriger und potenziell komplikationsträchtiger. Ziel unserer Studie war die Frage, ob das Risiko intraoperativer kardiovaskulärer Komplikationen durch das minimal-invasive Vorgehen potenziert wird.Patienten und Methodik Im Zeitraum zwischen Februar 1992 und Mai 2005 wurden in unserer Klinik 82 Eingriffe wegen eines Phäochromozytoms bei 71 Patienten durchgeführt. Davon wurden 8 (1) Patient(en) bi-(tri-)lateral adrenalektomiert und bei 2 Patienten erfolgte eine ipsilaterale Rezidivoperation. Eingeschlossen sind 5 weitere Patienten mit Rezidiv nach Erstoperation vor 1992. Sechsunddreißig Eingriffe erfolgten konventionell (transperitoneal n=35, retroperitoneal n=1) und 46 Operationen endoskopisch (transperitoneal n=28, retroperitoneal n=18), davon keine Konversion zum offenen Vorgehen.Ergebnisse Das mediane Alter zum Zeitpunkt der Operation betrug 45 (24–75) Jahre bei einer Anamnesedauer von 12 (0–180) Monaten. Die offen operierten Phäochromozytome waren mit 5,5 (1–19) cm vs. 3,5 (0,5–8) cm (endoskopisch) signifikant größer (p=0,0011). Patienten mit endoskopischer, insbesondere mit retroperitoneoskopischer Adrenalektomie hatten im Vergleich zum konventionellen Vorgehen intraoperativ höhere systolische und diastolische maximale Blutdruckwerte sowie Spitzen über 200 mmHg (statistisch nicht signifikant). Faktoren mit möglichem Einfluss auf intraoperative hämodynamische Veränderungen waren in der multivariaten Analyse das Geschlecht (p=0,0107), der operative Zugangsweg (p=0,0153), das Patientenalter (p=0,0364) und die Tumorgröße (p=0,0484). Die postoperative stationäre Verweildauer war nach endoskopischer Operation signifikant kürzer (p<0,0001).Schlussfolgerung Die endoskopische Adrenalektomie beim Phäochromozytom ist in der Routine ohne vermehrtes Risiko kardiovaskulärer Komplikationen die Methode der Wahl. Das offene Vorgehen sollte extraadrenalen Befunden oder sehr großen Tumoren mit Malignitätsverdacht vorbehalten bleiben.      

Image formation in vibro-acoustography with depth-of-field effects.

We study the image formation of vibro-acoustography systems based on a concave sector array transducer taking into account depth-of-field effects. The system point-spread function (PSF) is defined in terms of the acoustic emission of a point-target in response to the dynamic radiation stress of ultrasound. The PSF on the focal plane and the axis of the transducer are presented. To extend the obtained PSF to the 3D-space, we assume it is a separable function in the axial direction and the focal plane of the transducer. In this model, an image is formed through the 3D convolution of the PSF with an object function. Experimental vibro-acoustography images of a breast phantom with lesion-like inclusions were compared with simulated images. Results show that the experimental images are in good agreement with the proposed model.     

Operative Behandlung von Rektumkarzinomen im Vergleich

BACKGROUND: The laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients. METHODS: From 01/01/2000-31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection. RESULTS: 237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585). CONCLUSION: Laparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.