Allgemeine Therapie

Ohne Zusammenfassung     

Clinical and familial study of arrhythmogenic right ventricular cardiomyopathy

Objective　To explore the characteristics of arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods　Seven patients with arrhythmogenic right ventricular cardiomyopathy and 34 members of three families were studied. All patients and family members underwent history collection, clinical examination, electrocardiogram (ECG), two-dimensional echocardiography (2-DE) and a signal averaging electrocardiogram. Programmed ventricular stimulation was performed in five patients. Results　All patients and family members had normal morphologic characteristics and normal function of the left ventricular by 2-DE. Fourteen persons had abnormal findings indicating ARVC. Five had enlargement of the right ventricular with diffused hypocontractility, eight had thin and systolic bulging in the focal anterior wall with hypokinesia and one had bulging of the inferior wall. Twenty-five persons (seven patients and 18 family members) had abnormal findings in ECG. Positive ventricular late potential was recorded in 13 persons (six patients). Two to three monomorphic ventricular tachycardia (VT) with left bundle branch block (LBBB) configurations were induced in five patients. Ventricular fibrillation was induced in two patients during the electrophysiologic study (EPS). Five patients had very high pacing threshold and/or ineffective pacing in one or many regions of the right ventricle. Two members of one family died suddenly. One member was a dwarf with ARVC. Spontaneous VT with a left bundle branch block (LBBB) configuration was recorded in five patients, polymorphic VT with extremely short coupling interval in one, and premature ventricular complexes with LBBB configuration in 12 (six patients). Conclusion　Our familial study strongly suggests that ARVC may be a hereditary disease and it is helpful in the diagnosis and detection of ARVC. The most common manifestations were abnormal structure and function of the right ventricle and abnormal ECG of repolarization and ventricular arrhythmia which originates from the right ventricle.     

The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Comparative studies of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine

OBJECTIVES: To compare the efficacy and safety of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine. DESIGN: Two multicenter, open-label, randomized 24-week studies. METHODS: Adults HIV-1 infection, HIV-1 RNA greater than 10000 copies/ml, and no prior lamivudine or protease inhibitor therapy were eligible. In a pilot study (Study A), patients received indinavir at 800 mg every 8 h, 1000 mg every 12 h, or 1200 mg every 12 h. In a subsequent study (Study B), patients received indinavir at 800 mg every 8 h or 1200 mg every 12 h. All subjects received zidovudine (300 mg) and lamivudine (150 mg) every 12 h. An intent-to-treat analysis was used. RESULTS: In Study A, which enrolled 88 patients, neither HIV-1 RNA nor CD4 cell responses differed significantly between treatment groups at 24 weeks when corrected for multiple comparisons. Study B enrolled 433 patients, but was prematurely discontinued when interim analysis suggested greater efficacy of three-times-daily indinavir. Of the first 87 patients reaching week 24, HIV-1 RNA was less than 400 copies/ml in 91% receiving three-times-daily versus 64% receiving two-times-daily indinavir (P < 0.01). CONCLUSION: Three-times-daily indinavir appears more efficacious than two-times-daily dosing when administered with zidovudine and lamivudine. Two-times-daily indinavir dosing should only be considered in situations characterized by favorable pharmacokinetic drug-drug interactions.     

Glucose control and the inflammatory response.

Though first introduced more than 130 years ago, the concept of stress diabetes or stress hyperglycemia has gained tremendous attention in recent years in view of the landmark article by van den Berghe and colleagues in 2001. As opposed to earlier work that suggested that hyperglycemia in the acute clinical setting may be beneficial, it now appears that lower glucose levels are associated with improved outcomes. The mechanisms behind the improved outcomes are numerous and seem to be tied to the inflammatory process. Both lower glucose values and insulin therapy seem to be anti-inflammatory, whereas hyperglycemia increases the proinflammatory process and negatively affects the innate immune system. Despite the numerous approaches to achieve normoglycemia described in the literature, only modest success has been achieved. Understanding the pathophysiology driving stress hyperglycemia--the stress response and modulation of the inflammatory process-seems to be the key to improving the care of the most critically ill and injured patients.