Risikoevaluation der Aortendissektion Typ B

Acute aortic syndrome (AAS) is a modern term used to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges including aortic dissection, intramural hematoma (IMH) and penetrating aortic ulcer (PAU). Population-based studies suggest that the incidence of aortic dissection ranges from 2.6 to 3.5 cases per 100,000 inhabitants per year; hypertension and a variety of genetic disorders with altered connective tissue are the most prevalent risk conditions. In general, open surgical repair is recommended when dissection involves the ascending aorta, whereas medical management and endovascular stent graft repair is the best option when the ascending aorta is spared. Pathological conditions involving the aortic arch may be treated using a hybrid approach combining debranching of supra-aortic vessels and stent graft placement. Stent graft-induced remodeling of a dissected aorta seems to have long-term benefits in complicated and so-called uncomplicated type B dissections as almost every case reveals a risk profile and one in eight patients diagnosed with acute type B aortic dissection has either an IMH or a PAU. Pain is the most commonly presenting symptom of AAS and should prompt immediate attention including diagnostic imaging modalities, such as multislice computed tomography, transesophageal ultrasound and magnetic resonance imaging. A specific therapeutic approach is necessary for IMH and PAU because without treatment they have a very poor outcome, are unpredictable in evolution and can be more severe than acute aortic dissection. All patients must receive the best medical treatment available at admission. High-risk but asymptomatic patients with IMH and PAU can probably be monitored without interventions. All symptomatic patients will need treatment. In many of these patients a direct surgical approach is often prohibitive due to age and multiple comorbidities. Endovascular treatment offers superior results and is becoming a recognized indication for such patients. Irrespective of the treatment modality close surveillance is mandatory in order to monitor disease progression.     

Renin–angiotensin system inhibition is not associated with increased sudden cardiac death,cardiovascular mortality or all-cause mortality in patients with aortic stenosis

Background

Renin–angiotensin system inhibition (RASI) is frequently avoided in aortic stenosis (AS) patients because of fear of hypotension. We evaluated if RASI with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) increased mortality in patients with mild to moderate AS.

Methods

All patients (n = 1873) from the Simvastatin and Ezetimibe in Aortic Stenosis study: asymptomatic patients with AS and preserved left ventricular (LV) ejection fraction were included. Risks of sudden cardiac death (SCD), cardiovascular death and all-cause mortality according to RASI treatment were analyzed by multivariable time-varying Cox models and propensity score matched analyses.

Results

769 (41%) patients received RASI. During a median follow-up of 4.3 ± 0.9 years, 678 patients were categorized as having severe AS, 545 underwent aortic valve replacement, 40 SCDs, 103 cardiovascular and 205 all-cause deaths occurred. RASI was not associated with SCD (HR: 1.19 [95%CI: 0.50–2.83], p = 0.694), cardiovascular (HR: 1.05 [95%CI: 0.62–1.77], p = 0.854) or all-cause mortality (HR: 0.81 [95%CI: 0.55–1.20], p = 0.281). This was confirmed in propensity matched analysis (all p > 0.05). In separate analyses, RASI was associated with larger reduction in systolic blood pressure (p = 0.001) and less progression of LV mass (p = 0.040).

Conclusions

RASI was not associated with SCD, cardiovascular or all-cause mortality in asymptomatic AS patients. However, RASI was associated with a potentially beneficial decrease in blood pressure and reduced LV mass progression.     

Kardiale Probleme in der Schwangerschaft

All women of child-bearing age suffering from congenital cardiac valve malformations or acquired valvular disease, pulmonary hypertension or arterial hypertension and who are at risk for coronary heart disease should receive early counseling and optimal treatment before pregnancy. They should be treated by an interdisciplinary team composed of gynecologists, cardiologists, geneticists and, if necessary, cardiac surgeons. This interdisciplinary approach should be used for all pregnant women with cardiac disease in order to minimize maternal and fetal mortality. As physicians will only rarely be confronted with such critically ill patients, guidelines and access to worldwide information from databanks are particularly important (http://www.safetus.com und http://www.emryotox.de).     

Hand,foot and mouth disease in China: evaluating an automated system for the detection of outbreaks

Objective

To evaluate the performance of China’s infectious disease automated alert and response system in the detection of outbreaks of hand, foot and mouth (HFM) disease.

Methods

We estimated size, duration and delay in reporting HFM disease outbreaks from cases notified between 1 May 2008 and 30 April 2010 and between 1 May 2010 and 30 April 2012, before and after automatic alert and response included HFM disease. Sensitivity, specificity and timeliness of detection of aberrations in the incidence of HFM disease outbreaks were estimated by comparing automated detections to observations of public health staff.

Findings

The alert and response system recorded 106 005 aberrations in the incidence of HFM disease between 1 May 2010 and 30 April 2012 – a mean of 5.6 aberrations per 100 days in each county that reported HFM disease. The response system had a sensitivity of 92.7% and a specificity of 95.0%. The mean delay between the reporting of the first case of an outbreak and detection of that outbreak by the response system was 2.1 days. Between the first and second study periods, the mean size of an HFM disease outbreak decreased from 19.4 to 15.8 cases and the mean interval between the onset and initial reporting of such an outbreak to the public health emergency reporting system decreased from 10.0 to 9.1 days.

Conclusion

The automated alert and response system shows good sensitivity in the detection of HFM disease outbreaks and appears to be relatively rapid. Continued use of this system should allow more effective prevention and limitation of such outbreaks in China.     

儿童癌症幸存者成年后的慢性疾病

由于治疗方法的进步,近80%的儿童和青少年癌症患者能够长期生存。在美国,约有270000例儿童癌症的幸存者,即每640名20至39岁成年人中就有一名幸存者。大量的幸存者有利于儿童癌症治疗后长期健康结果的研究。现在可以明确的是,化疗和放疗所致的儿童各器官系统损害在临床上可能潜伏多年。为了全面了解治疗儿童癌症而继发的健康问题,重要的是衡量三项长期结果:健康状况、死亡率和患病率。这三项中,关于前两项已有相当好的研究报道。在一项对20227例癌症5年生存者的回顾性分析中,Mertens等发现以下原因导致的超额死亡率具有统计学意义:继发癌症(…     

Acute management and outcome of multiple trauma patients with pelvic disruptions

ABSTRACT: INTRODUCTION: Data on pre-hospital and trauma room fluid management of multiple trauma patients with pelvic disruptions are rarely reported. Present trauma algorithms recommend early haemorrhage control and massive fluid resuscitation. By matching the German Pelvic Injury Register (PIR) with the TraumaRegister DGU(R) (TR) for the first time, we attempt to assess the initial fluid management for different Tile/OTA types of pelvic ring fractures. Special attention was given to the patient's post traumatic course, particularly ICU data and patient outcome. METHODS: A specific match code was applied to identify certain patients with pelvic disruptions from both PIR and TR anonymous trauma databases, admitted between 2004 and 2009. From the resulting intersection set, a retrospective analysis was done of pre-hospital and trauma room data, length of ICU stay, days of ventilation, incidence of multiple organ dysfunction syndrome (MODS), sepsis, and mortality. RESULTS: In total 402 patients were identified. Mean ISS was 25.9 points and the mean ratio of patients with ISS [greater than or equal to]16 was 85.6%. The fracture distribution was as follows: 19.7% type A, 29.4% type B, 36.6% type C, and 14.3% isolated acetabular and/or sacrum fractures. The type B/C, compared with type A fractures, were related to constantly worse vital signs that necessitated a higher volume of fluid and blood administration in the pre-hospital and/or the trauma room setting. This group of B/C fractures were also related to a significantly higher presence of concomitant injuries and related with increased ISS. This was related to increased ventilation and ICU stay, increased rate of MODS, sepsis and increased rate of mortality at least for the type C fractures. Approximately 80% of the deceased had sustained type B/C fractures. CONCLUSIONS: The present study confirms the actuality of traditional trauma algorithms with initial massive fluid resuscitation in the recent therapy of multiple trauma patients with pelvic disruptions. Low volume resuscitation seems not yet accepted in practice in managing this special patient entity. Mechanically unstable pelvic ring fractures type B/C (according Tile's/OTA classification) form a distinct entity that has to be considered notably in future trauma algorithms.     

腹腔镜外科和妇科联合手术的临床应用

目的：探讨腹腔镜技术在外科和妇科疾病治疗中联合应用的临床价值。　
方法：总结近7年来施行腹腔镜联合手术治疗妇、外科疾病229例的临床资料,其中腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合输卵管造口术5例,LC联合卵巢囊肿剥除术28例,LC联合子宫肌瘤剔除术25例,LC联合子宫次全切除术39例,LC联合子宫全切除术26例,LC联合子宫内膜异位症手术6例;腹腔镜阑尾切除术(laparoscopicappendectomy,LA)联合输卵管手术38例,LA联合卵巢囊肿切除术32例,LA联合子宫全切除术或子宫次全切除术24例,腹腔镜肝囊肿开窗引流术联合卵巢囊肿切除术6例。
结果：229例妇、外科联合腹腔镜手术均获成功,无中转开腹手术。手术时间40~220 min,平均120 min;住院1~6 d,平均3.4 d。仅1例术后10 d阴道残端出血非手术疗法治愈。175例随访3~24个(平均19.5)月,1例术后2个月发现阴道残端息肉,经手术切除治愈。　
结论：严格掌握联合手术指征,充分术前准备,多科室良好配合,腹腔镜联合手术能够有效地同时处理外科和妇科并存疾病,在基层医院具有良好的应用前景。     

牙列缺损的计算机三维建模

目的 建立牙列缺损的计算机三维模型。方法 采用表面绘制法,依据CT扫描头颅骨标本获得的二维断层图像数据在3D Studio Max中沿牙体长轴放样、微调并赋以材质,得到牙列缺损的计算机三维模型。结果 能在计算机中方便快速地模拟任意类型的牙列缺损,并可全方位地旋转、放大和缩小。结论 提供了一种牙列缺损三维建模的新方法,有利于三维义齿专家系统的开发和计算机辅助教学。     

Balanced massive transfusion ratios in multiple injury patients with traumatic brain injury

Introduction  

Retrospective studies have demonstrated a potential survival benefit from transfusion strategies using an early and more balanced ratio between fresh frozen plasma (FFP) concentration and packed red blood cell (pRBC) transfusions in patients with acute traumatic coagulopathy requiring massive transfusions. These results have mostly been derived from non-head-injured patients. The aim of the present study was to analyze whether a regime using a high FFP:pRBC transfusion ratio (FFP:pRBC ratio >1:2) would be associated with a similar survival benefit in severely injured patients with traumatic brain injury (TBI) (Abbreviated Injury Scale (AIS) score, head ≥3) as demonstrated for patients without TBI requiring massive transfusion (≥10 U of pRBCs).