Dysfunktionelle respiratorische Symptome bei Kindern und Jugendlichen

Dysfunctional respiratory symptoms are easily overlooked. They are characterized by recurrent or chronic respiratory symptoms, which are not explained by structural abnormalities and which may mimic symptoms of somatic disease (somatoform respiratory disorders). Typical dysfunctional respiratory symptoms include habit cough, sighing dyspnea, hyperventilation syndrome, vocal cord dysfunction, and primary psychogenic respiratory symptoms. Diagnosis should be based on clinical symptoms and be made according to positive diagnostic criteria. Careful discrimination from somatic disease is mandatory, also because co-existence of somatic disease and somatoform disease is not unusual. Therapy should be prompt to avoid development of maladaptation. In established dysfunctional respiratory disorder, interdisciplinary care by physician, speech therapist and psychologist may be warranted for successful therapy.     

Schwere Dysphagie und flammende Hautrötung bei einem 59-jährigen Patienten

A 59-year-old man presented with a history of dysphagia and generalized myalgia and muscle weakness and a rash on the face, neck, and upper arms. Serum muscle enzymes, myoglobin, C-reactive protein, and erythrocyte sedimentation rate were elevated and antinuclear antibodies positive. Electromyographic conduction studies showed pathological changes on arm and leg muscles and magnetic resonance imaging of the oral and neck muscles. A diagnosis of dermatomyositis with severe esophageal involvement was established. Treatment with prednisolone was started and methotrexate added. Enteral feeding with a percutaneous endoscopic gastrostomy was started and a therapy with intravenous immunoglobulin (IVIG) initiated, which caused a rapid improvement of the patient’s ability to swallow. This case demonstrates a patient with polymyositis/dermatomyositis who showed steroid-resistent life-threatening esophageal impairment. IVIG resulted in a dramatic improvement of symptoms.     

Hämatoonkologische Krankheitsbilder

Acquired inhibitors of coagulation cause a life-threatening disease. Clinically newly occurring hemorrhagic diathesis combined with prolonged activated partial thromboplastin time (aPTT) time is diagnostically indicative and can be confirmed by a positive plasma exchange test. For thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (TTP-HUS) the diagnosis of Coombs negative hemolytic anemia together with thrombocytopenia should lead to the detection of fragmentocytes in peripheral blood smears. Hairy cell leukemia is a rare subgroup of chronic B-cell neoplasia with the clinical signs of pancytopenia and splenomegaly which characteristically stain positive for CD103. The gastrointestinal stromal tumor (GIST) has nothing in common with classical soft tissue sarcoma based on the activating mutation of the KIT or PDGFRA gene (positivity for CD117). In all of these disorders the correct diagnosis has a major influence on patient outcome. For the case of acquired inhibitors of coagulation immunosuppressive therapy and substitution of coagulation factors (e.g. recombinant factor VIIa) or for TTP-HUS the immediate start of plasma exchange are mandatory. For hairy cell leukemia a very effective treatment exists with purine analogs (e.g. cladribine) and for metastatic inoperable GIST with tyrosine kinase inhibitors (e.g. imatinib).     

Was ist gesichert in der Therapie der chronischen Virushepatitis?

Background

In the last 10 years, a dramatic change has occurred in the treatment of chronic viral hepatitis, particularly in the area of hepatitis B and hepatitis C.

Objectives

Which treatment options of viral hepatitis are scientifically validated and can be recommended for practical use in consideration of current studies on the treatment of viral hepatitis and the German and European guidelines, respectively.

Current data

The treatment of chronic hepatitis B continues to be based either on a long-term therapy with nucleos(t)ide analogues or a finite therapy with pegylated interferon alpha (PEG-IFN). Treatment of hepatitis D is also based on PEG-IFN; however, the relapse rate is high. The treatment of hepatitis C is currently based on the combination of PEG-IFN and ribavirin (RBV). To estimate the optimal duration of therapy and dosage, knowledge of previous treatments, genotype, and presence of cirrhosis is crucial. For genotype 1, the first direct acting antiviral drugs were approved in 2011. These drugs led to a significant increase in treatment success. In the upcoming years another dramatic change in the treatment of hepatitis C is anticipated, including an improved side effect profile, increased efficacy, and a greater degree of customization in difficult-to-treat patients. Acute hepatitis E is usually self-limiting, but can become chronic in immunocompromised patients, i.e., after organ transplantation. Reduction of immunosuppression may clear HEV and RBV shows antiviral efficacy.

Conclusion

Currently available therapies have a high disease control or chance for cure in hepatitis B and C. In Hepatitis C treatment, a massive change in future therapies is foreseeable. The hepatitis D co-infection remains difficult to treat. For hepatitis E, RBV is a promising off-label treatment option.     

Bildgebende Verfahren bei Psoriasisarthritis

This review presents an overview of the range of imaging modalities used in the diagnostic evaluation of patients with psoriatic arthritis (PsA). Conventional radiography is used to detect structural changes of the joints and tendon attachments. These changes occur late in the course of PsA hence conventional radiography contributes little to the early detection of PsA; however, the detection of periosteal proliferations on radiographs allows a relatively specific diagnosis of PsA. Skeletal scintigraphy and computed tomography are rarely used in PsA. Arthrosonography (ultrasound of the joints) is gaining increasing importance in the early identification of inflammatory soft tissue signs of PsA in the peripheral joints. Sonography enables early detection of synovitis and tenosynovitis as well as superficial erosions and also inflammatory processes of the tendon attachments. Magnetic resonance imaging (MRI) is indispensable for identifying possible involvement of the axial skeleton. Moreover, it allows good visualization of periostitis and arthritis. High resolution microcomputed tomography is an interesting novel diagnostic tool which allows highly sensitive evaluation of the bone structure and can detect very tiny bone lesions where typical signs of PsA are omega-shaped erosions and small corona-like spikes. Another interesting new diagnostic technique is fluorescence optical imaging (FOI) with the Xiralite system which is highly sensitive for detecting inflammatory processes of the hands.     

Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease

Objective

We performed a meta-analysis of randomized controlled trials to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of de novo unprotected left main disease.

Background

Although CABG is accepted to be standard of care for revascularization of unprotected left main stenosis, PCI is increasingly being used as an alternative primary approach.

Methods

We searched for randomized, controlled trials comparing CABG and PCI for the treatment of unprotected left main disease. Major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeat revascularization) were analyzed.

Results

The search strategy identified 4 randomized controlled trials enrolling a total of 1,611 patients. Follow-up ranged between 1 and 2 years. There were no significant differences in the risk of death or myocardial infarction between the two treatment modalities. While the risk of stroke was significantly lower in patients undergoing PCI (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.10–0.69, p?=?0.007), the risk of repeat revascularization was higher among patients undergoing PCI (RR 1.94, 95% CI 1.43–2.61, p?<?0.001). No relevant statistical heterogeneity across studies could be found.

Conclusion

In this largest series of randomized patients with unprotected left main stenosis to date, the risk of death and myocardial infarction was comparable between CABG and PCI. However, patients undergoing CABG had a higher risk of stroke, whereas patients undergoing PCI were at a higher risk for repeat revascularization.     

Warm winter is associated with low incidence of ST elevation myocardial infarctions and less frequent acute coronary angiographies in an alpine country

Background

Weather conditions influence symptoms in chronic stable coronary artery disease (CAD). Whether the ongoing climate change, with continuous and rapid temperature increases, also has an impact on the incidence and outcome of non-ST elevation (NSTEMI) and ST elevation (STEMI) myocardial infarctions referred for acute coronary angiography (CA) is less clear.

Methods

According to weather data from the Institute of Meteorology and Geophysics, Innsbruck University, the 2005/2006 winter was very cold (CW) and the 2006/2007 winter extraordinarily warm (WW). As the overall invasive management of patients with acute coronary syndromes did not change substantially within these winters, we compared patients referred for acute CA suffering an acute STEMI or NSTEMI, their risk factors and in-hospital mortality rates between these two consecutive winters.

Results

As expected, the average temperature was lower (??1.6 vs. +?5.9°C; p?<?0.001) and humidity was higher (82 vs. 79%; p?<?0.012) in CW compared to WW, with no significant differences in other weather conditions (rainfall: 59 vs. 39 days; sunshine: 3.9 vs. 4.3 h/day; air pressure: 713.04 vs. 713.76 hPa). There were no differences in the number of overall CA (987 vs. 983) between these two winters, whereas the number of acute CA (12.9 vs. 10.4% of overall CA; p?=?0.046) and the diagnosis of STEMI as an indication of acute CA (74.0% vs. 62.7%; p?=?0.046) were higher in CW. Furthermore, patients in CW were younger (58.2?±?12.4 vs. 61.7?±?11.7 years; p?<?0.03), had higher LDL cholesterol (134.8?±?44.6 vs. 116.7?±?36.0 mg/dl; p?<?0.003) and were less frequently hypertensives (52.8 vs. 70.6%; p?<?0.01). Other traditional risk factors were not different between WW and CW. In addition, there were no differences in in-hospital mortality rates in invasively diagnosed CAD, patients’ nationalities (Austrians: 78.0 vs. 77.5%) and time from pain to arrival in the cath lab in STEMI patients (3.9?±?3.5 vs. 3.8?±?3.1 h).

Conclusion

The average temperature increase of 7.5°C from the cold to the warm winter was associated with a decrease in acute coronary angiographies, in particular due to a lower incidence of STEMI referred for primary percutaneous intervention.     

Prävalenz chronischer Schmerzen in Deutschland

Background

There are no up to date data from representative samples of the general German population on the prevalence of debilitating pain and of pain diseases available.

Methods

A cross-sectional survey of a representative sample of the German general population including persons ≥?14 years of age was conducted in 2012 based on face-to-face interviews using standardized questionnaires. Chronic pain was assessed by the widespread pain index (WPI), disability by the subscales physical functioning and role function of the European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30) and psychological distress by the patient health questionnaire (PHQ-4). Chronic pain with associated physical and social impairments was defined by at least one pain site over 3 months in the WPI and at least one response of a moderate or severe impairment in both subscales of the EORTC 30 QLQ-C30. Chronic pain with associated physical, mental and social impairment (pain disease) required in addition a probable depressive and/or anxiety disorder in the PHQ-4.

Results

A total of 2,515 out of 4,480 (56.1 %) of contacted persons finished the study of which 32.9 % reported chronic pain, 5.4 % reported chronic pain with associated physical and social impairments and 2.3 % associated physical, mental and social impairments. No participants with local pain (only one pain site) but 24.0 % of participants with widespread pain (6–19 pain sites) met the criteria of a pain disease.

Conclusions

The reports of chronic pain in epidemiological studies do not necessarily imply a suffering (physical, psychological and social impairment) from pain.     

Implementierung des Querschnittsbereichs 13

Background

In 2013 palliative medicine (PM) will be integrated into the undergraduate curriculum as part of the mandatory education in German medical universities. The aim of this study is to determine the current state of implementation at German medical faculties (MF).

Methods

All German MFs were contacted using a written postal survey in June 2012.

Results

A total of 32 out of 36 MFs participated. Teaching staff consists of 15 or more lecturers in 8 MFs (30?%) and includes psychologists in 24 MFs (75?%) and also nurses in 18 MFs (56?%). Participating physicians are specialized in anesthesiology, internal medicine and general medicine. Teaching staff include palliative outpatient (20 MFs, 63?%) and consultation services (22 MFs, 69?%). Bedside teaching is provided in 15 MFs (47?%). Multiple choice tests are the major form of assessment (29 MFs, 84?%). The total number of teaching units in PM is between 12 and 43 and is usually provided at the end of medical school education. Nurses are employed in the education significantly more in MFs with a chair in PM. General practitioners were engaged only by faculties without a chair in PM.

Conclusions

The implementation of the mandatory training in PM at MFs in Germany is inhomogeneous. Further steps include in particular the development of a competence-based curriculum and assessment.