Sachverständigenbeweis im Arzthaftungsprozeß

Ohne Zusammenfassung     

Long-term results (10 years) of intensive breast conserving therapy including a high-dose and large-volume interstitial brachytherapy boost (LDR/HDR) for T1/T2 breast cancer.

BACKGROUND AND PURPOSE: During the past 15 years many retrospective studies and prospective randomized trials have been published supporting the use of breast conserving treatment (BCT) including surgery and radiotherapy. However, there are still many controversies on the necessary amount of resection, the width of the resection margins and the optimal radiation technique, dose and volume, in particular of the boost. In this retrospective study a large cohort of 410 women with early breast cancer treated with BCT including an interstitial brachytherapy (BT) boost is evaluated after a long follow-up period. MATERIAL AND METHODS: In order to clarify the impact of the different treatment-related factors on local control, these were carefully discriminated, based on widely accepted classification and reporting systems for surgery as well as for radiotherapy. The surgical approach was classified according to EORTC criteria and a high rate of quadrantectomies (60%) was found. Dose and volume of interstitial BT is reported according to recommendations of ICRU 58, and reveals a significant radiation dose and volume: minimum target dose, mean central dose (MCD) and '85% of MCD' for low-dose rate (LDR) BT was mean 20, 28 and 24 Gy, for high-dose rate (HDR) BT it was mean '10, 15 and 13 Gy, respectively; the treated volume was 104 cc for LDR BT and 83 cc for HDR BT. RESULTS: The actuarial rates for overall survival, disease-free survival and disease-specific survival were 97, 90 and 98% at 5 years and 85, 79 and 92% at 10 years. There have been only 16 breast recurrences in 410 treated patients resulting in a 5- and 10-year actuarial local recurrence rate of 2 and 3.9%, respectively; six recurrences (1.5%) were in the original quadrant. Except age and menopausal status, all tumour- and patient-related risk factors had no significant impact on local control. CONCLUSIONS: Our data confirm that intensive BCT leads to excellent long-term results in terms of local control, masking classical risk factors. This high-dose and large-volume interstitial BT seems to be superior to classical BCT without BT.     

Ulzerierende Ileokolitis unter NSAR-Therapie

Zusammenfassung Anamnese und klinischer Befund: Eine 67-jährige Patientin wurde mit wochenlangen krampfartigen Mittel- und Unterbauchschmerzen sowie mit anhaltenden Durchfällen stationär aufgenommen. Sie hatte ca. 5 kg Körpergewicht verloren und fühlte sich kraftlos und müde. Aufgrund eines chronischen Schmerzsyndroms bestand seit 20 Jahren ein chronischer Analgetikaabusus. Untersuchungen: Laborchemisch imponierten neben einer Blutkörperchensenkungsbeschleunigung mit 70 mm/h eine Hyperalbuminämie mit 2,3 g/dl sowie eine Anämie mit einem Hämoglobin von 8,5 g/dl. Sonographisch war das Kolon flüssigkeitsgefüllt mit verdickter Darmwand. Koloskopisch lagen ausgedehnte Ulzera vor, die vom terminalen Ileum bis zum Sigma reichten, histologisch einer uncharakteristischen Ileokolitis mit Ulzera entsprechend. Diagnose, Therapie und Verlauf: Die bis zu diesem Zeitpunkt anhaltende NSAR-Einnahme wurde umgehend beendet und bei Bedarf durch Analgetika mit anderer Wirkweise ersetzt. Innerhalb weniger Tage normalisierten sich das Stuhlverhalten ebenso wie die abdominelle Schmerzsymptomatik vollständig. Die Anämie besserte sich, und es kam zu einem deutlichen Anstieg des Körpergewichts. Die im stationären Verlauf durchgeführte Umfelddiagnostik ergab keinen weiteren diagnostischen Ansatz. Somit sprach der klinische Verlauf in Verbindung mit den nachfolgenden Kontrollkoloskopien, die eine Abheilung der Ulzerationen zu erkennen gaben, für eine medikamentöse Nebenwirkung im Sinne einer NSAR-induzierten Ileokolitis. Schlussfolgerung: Dieser Verlauf weist darauf hin, dass NSAR-induzierte Nebenwirkungen nicht nur, wie allgemein bekannt, im oberen Gastrointestinaltrakt auftreten können. Das Wissen um potentielle Nebenwirkungen in Dünn- und Dickdarm ist neben einer sorgfältigen Medikamentenanamnese Voraussetzung für eine zügige Diagnosestellung und zielgerichtete Therapie. Abstract History and Physical Examination: A 67-year-old woman was admitted to our hospital for spasmodic abdominal pain, diarrhea, and general weakness. She had lost 5 kg of weight over the past few weeks. The patient had a 20-year history of chronic analgetic abuse, mainly consuming over-the-counter nonsteroidal anti-inflammatory drugs (NSAID). Examination: Laboratory examination was remarkable for a low serum albumin (2.3 g/dl), an increased erythrocyte sedimentation rate of 70 mm/h, and a profound anemia of 8.5 g/dl. Ultrasound of the abdomen showed thickening of the colonic wall and distended colon loops filled with fluid. On colonoscopy several ulcerations from the sigmoid to the ileum were seen. Histologic examination showed a nonspecific ileocolitis. Diagnosis, Therapy and Clinical Course: After cessation of NSAID intake diarrhea stopped within a few days. Abdominal pain resolved, anemia improved and the patient gained weight. A second colonoscopy revealed healing of the colonic ulcerations. Additional examinations regarding differential diagnoses showed no pathological results. Clinical course and subsequent clinical and endoscopic controls revealing further improvement confirmed the diagnosis of an NSAID-induced ileocolitis. Conclusion: This patient is a typical example for NSAID-induced colonic ulcerations. It should be recognized that NSAID induce ulcers not only in the upper gastrointestinal tract. A careful drug history may provide the clue for the cause of lower gastrointestinal tract ulcerations.     

Aktuelle Aspekte der Thrombozytenfunktionshemmung

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Dynamics stress echocardiography for evaluating anti-ischemic drug profiles in post-MI patients

Exercise ECG is an established method of evaluating the anti-ischemic properties of drugs. However, there are considerable methodologic limitations to this procedure and its use is restricted to patients with exercise-provoked ECG alterations which can be interpreted as ischemia. The principal, earlier onset of wall motion abnormalities according to the ischemic cascade can be detected by stress echocardiography and might be utilized as a pharmacological stress testing modality. Sixteen consecutive patients (15 men, one woman; 53 ± 9 years old) with angiographically proven coronary artery disease (8 with one-, 5 with two-, and 3 with three-vessel disease) and exercise-induced wall motion abnormalities were examined by dynamic stress echocardiography (50 watt followed by 20-watt increases/min). Anti-ischemic drugs were withdrawn prior to and on day 1; on the following day 2, 0.2 µg/kg/min nisoldipine was infused intravenously during the test after a 3 µg/kg bolus was given. At maximum comparable workload 15/16 patients showed an improved wall motion score on treatment (day 1: 22.9 ± 4.9 vs day 2: 20.0 ± 3.9; normal score: 12; one-sided binomial test: p = 0.0003). Eight of 16 patients demonstrated ST-segment deviations on day 1 and day 2. The double product did not differ at any workload stage until the maximum of 130 watt (day 1: 14101 ± 3140 vs day 2: 13365 ± 2865; n.s.). Dynamic stress echocardiography seems to be a valuable tool in pharmacologic stress testing and in terms of accuracy is supposed to be superior to conventional exercise ECG. Nisoldipine reduces exercise-induced wall motion abnormalities in patients with and without exercise-induced ECG alterations. The data result from a controlled pilot study, and further studies are required to confirm these promising methodological and therapeutic findings.     

冠状动脉造影正常伴心前区疼痛患者冠状动脉微血管功能的无创性超声多普勒评估

目的　经胸多普勒超声心动图 (TTDE)与冠状动脉内多普勒 (ICD)相对照 ,分析TTDE探测冠状动脉造影正常者左前降支 (LAD)远端血流的准确性 ;分析冠状动脉造影正常者冠状动脉微血管功能的变化。方法　利用TTDE探测 3 5例冠状动脉造影正常者LAD远端的基础状态及经静脉注入腺苷后的最大血流速度 ,计算冠状动脉血流速度储备 (CFVR)、冠状动脉阻力 (CVR )和最小冠状动脉阻力指数 (CVRI)。分析比较 2 0例心前区疼痛患者 (A组 )和 15例正常人 (B组 )上述冠状动脉血流参数测值。结果　 3 5例冠状动脉造影正常者TTDE所探测的基础状态血流速度 (APVb)、最大充血反应状态血流速度 (APVh)和CFVR与ICD的探测结果密切相关 (r分别为 0 .79,0 .83 ,0 .85 )。A组与B组APVb、APVh和CVR的差异均无显著性意义 (P >0 .0 5 ) ,但A组CFVR低于B组 ,而CVRI高于B组 (均P <0 .0 5 )。结论　TTDE是一项可行、可信的无创性探测CFVR的方法。冠状动脉造影正常伴心前区疼痛患者存在冠状动脉微循环功能障碍。