Befindlichkeitsstörungen ohne Befund—moderne Syndrome

Zusammenfassung Befindlichkeitsstörungen ohne pathologischen Befund stellen einen nicht unerheblichen Anteil des internen Krankengutes dar. Ein zunehmender Teil der Patienten führt diese Beschwerden auf Einflüsse aus dem Bereich der Arbeitswelt oder Umwelt zurück. Mangels vorliegender Pathologie neigt die Schulmedizin dazu, diese Syndrome eher dem psychiatrischen Formenkreis zuzuordnen oder psychologische Konzepte in die Kausalitätsüberlegungen einzubeziehen. Medien wie Alternativmedizin unterstützen in diesem Themenbereich meist nicht die Konzepte der faktenorientierten Schulmedizin, sie halten Organschäden durch Belastungen mit Umweltnoxen für durchaus möglich, selbst wenn diese in zulässiger Höhe liegen. Postuliert wird häufig eine gesteigerte Individualempfindlichkeit. Beispiele solcher modern interpretierter Syndrome sind das Sick Building Syndrome, das chronische Erschöpfungssyndrom oder die idiopathische Umweltunverträglichkeit. Infolge der Unspezifität dieser Beschwerden ähnelt sich die Symptomatik, wenngleich diesen Syndromen durchaus unterschiedliche Konzepte zugrunde gelegt werden. Deshalb ist die Überlegung, es handle sich immer um das selbe Krankheitsbild, unberechtigt. Eine breite differenzialdiagnostische Palette ist gefordert, da es sich meist um Ausschlussdiagnosen handelt. Zur realitätsnahen Beurteilung sind fallweise auch Verfahren des Biomonitorings oder Ambientmonitorings heranzuziehen.

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Prenatal diagnosis for paediatricians

In Ontario, approximately 140,000 women deliver newborn infants each year. Of these women, 60,000 to 70,000 have multiple marker screening, 10,000 undergo amniocentesis or chorion villus sampling and virtually all have at least one prenatal ultrasound. Multiple marker screening is not used in every province and territory; however, amniocentesis and prenatal ultrasound are used throughout Canada. Most paediatric patients will have been exposed to some form of prenatal diagnosis. If an abnormality is found prenatally, parents may have concerns to discuss with the paediatrician after the child is born. Likewise, if a child with a problem is born following a normal pregnancy, the parents will want to know why the problem was missed prenatally. Paediatricians should be aware of prenatal tests that have been performed to understand better their patients and their families.     

儿科加强医疗病房全身炎症反应综合征和多器官功能不全综合征的临床分析

目的应用新概念———全身炎症反应综合征（ＳＩＲＳ）和多器官功能不全综合征（ＭＯＤＳ）认识多器官功能衰竭（ＭＯＦ）。方法回顾性总结分析１９９５年１月～１９９７年１２月我院儿科加强监护病房收治的危重患儿，根据Ｈａｙｄｅｎ修订的ＳＩＲＳ诊断标准和全国小儿急诊学组拟定的ＭＯＦ诊断标准进行临床分析。结果全组３０４例患儿，符合ＳＩＲＳ标准２５２例，占８２．９％．原发病有感染性疾病和非感染性疾病。在ＳＩＲＳ和ＭＯＤＳ病程发展过程中部分患儿出现一过性肝、肾、胃肠道和脑等器官功能受损的表现，最终进展为ＭＯＤＳ共６５例，占２５．８％。ＭＯＤＳ的病死率为４３．１％（２８／６５）。发生ＭＯＤＳ的高危因素为入院危重评分＜７５分，明显高代谢反应和合并Ｃ反应蛋白，而与年龄无明显关系。结论ＳＩＲＳ和ＭＯＤＳ是小儿加强医疗病房中常见病症，病死率较高。ＳＩＲＳ和急诊学组制定的ＭＯＦ诊断标准简单实用，但应根据美国胸科协会和危重病医学会倡议将ＭＯＦ更名为ＭＯＤＳ。ＳＩＲＳ和ＭＯＤＳ进展至器官功能衰竭前存在器官功能受损的表现，应予高度重视并早期干预。     

新生儿窒息多脏器血流动力学研究

目的研究新生儿窒息多脏器损伤的机理，提供早期诊断方法。方法应用美国Ｕｌｔｒａｍａｒｋ－９型彩色超声诊断仪及丹麦ＡＢＬ－５００型血气分析仪等，对新生儿窒息全身性多脏器血流动力学变化进行有对照组的前瞻性研究。结果（１）窒息新生儿脑、肾上腺、肾、肝、脾、胃及肠道等各脏器血液灌流量均减少，尤以舒张期为甚；但各脏器减少的程度不一致。（２）肺动脉压力与阻力增高，严重者可致持续胎儿循环，是病情严重的标志。（３）心脏功能障碍是缺氧缺血性心肌损伤的结果，窒息性心功能障碍表现为舒张功能首先受累，而收缩功能障碍则右室重于左室。（４）低氧血症是新生儿窒息各脏器损伤的病理生理基础，且低氧血症的程度与各脏器血流速度减慢的程度呈高度正相关（ｒ＝０．９３～０．９８，Ｐ均＜０．０１），与左室射血分数降低的程度呈高度正相关（ｒ＝０．９１，Ｐ＜０．０１），与肺动脉压力增高的程度呈高度负相关（ｒ＝－０．９７，Ｐ＜０．０１）。ＱＴ离散度是评价新生儿缺氧缺血性心肌损伤特异而敏感的指标。结论血流动力学紊乱是新生儿窒息各脏器损伤的主要原因，肺动脉压升高是新生儿窒息的重要病理生理变化。超声检测各脏器血流动力学变化，可用于新生儿窒息多脏器损伤的早期诊断     

Imaging of blunt chest trauma

In western European countries most blunt chest traumas are associated with motor vehicle and sport-related accidents. In Switzerland, 39 of 10,000 inhabitants were involved and severely injured in road accidents in 1998. Fifty two percent of them suffered from blunt chest trauma. According to the Swiss Federal Office of Statistics, traumas represented in men the fourth major cause of death (4 %) after cardiovascular disease (38 %), cancer (28 %), and respiratory disease (7 %) in 1998. The outcome of chest trauma patients is determined mainly by the severity of the lesions, the prompt appropriate treatment delivered on the scene of the accident, the time needed to transport the patient to a trauma center, and the immediate recognition of the lesions by a trained emergency team. Other determining factors include age as well as coexisting cardiac, pulmonary, and renal diseases. Our purpose was to review the wide spectrum of pathologies related to blunt chest trauma involving the chest wall, pleura, lungs, trachea and bronchi, aorta, aortic arch vessels, and diaphragm. A particular focus on the diagnostic impact of CT is demonstrated. Received: 29 November 1999; Accepted: 28 January 2000     

多胎妊娠晚期1胎死亡后的期待疗法

目的 探讨多胎妊娠晚期l胎死亡后期待疗法的价值。方法 回顾性分析1997年1月至2002年12月住院分娩多胎孕妇344例，分析19例多胎妊娠晚期l胎死亡的临床处理。结果 19例多胎妊娠晚期l胎死亡后的存活胎儿在临床观察、超声、胎心监护及实验室检查监测下，期待1～8周均成活并分娩，母体凝血功能未发现异常。结论 在严密监测下，无产科并发症的多胎妊娠晚期l胎死亡后的活胎可以期待，从而降低成活胎儿的病死率。     

Steriods for multiple sclerosis and optic neuritis: a meta-analysis of randomized controlled clinical trials

We conducted a meta-analysis of randomized controlled clinical trials on steroid treatment for multiple sclerosis and optic neuritis. Of the 25 trials comparing steroids and controls without steroid treatment that we identified 12 were selected for this review. A meta-analysis was conducted to calculate the overall odds ratio across the studies for the numbers of patients without functional improvement and with new relapses. The trials included a total of 1714 patients: 998 with multiple sclerosis and 716 with optic neuritis. Any type of corticosteroids or adrenocorticotropic hormone (ACTH) treatment was considered, as was any dosage, route of administration, and length of treatment. Main outcome measures were: (a) number of multiple sclerosis patients who did not improve by at least one point on the EDSS or equivalent scale, or number of optic neuritis patients without complete recovery of visual acuity at 8 or 30 days and at longer follow-up; (b) number of multiple sclerosis patients with at least one new relapse, or number of optic neuritis patients in whom definite multiple sclerosis was diagnosed at longer follow-up. We found that corticosteroids or ACTH produced a significant improvement in disability or visual acuity at 30 days (odds ratio 0.49; 95 % CI 0.37–0.64). The improvement was not statistically significant at longer follow-up (0.85; 95 % CI 0.67–1.09). The treatment did not significantly reduce the number of patients with relapses (0.74; 95 % CI 0.54–1.01). Both low and high doses were effective for 30-day improvement, but only high-dose and short-term therapy were factors that identified subgroups with some reduction in the risk of new relapse. However, the power of the statistical analysis to detect a reliable difference in the subgroups was low. Steroid treatment is therefore effective in accelerating short-term recovery in patients with multiple sclerosis or optic neuritis. Whether steroids are also effective in reducing the risk of relapse, and the optimal dose and length of treatment must still be determined. Received: 5 August 1999, Received in revised form: 29 December 1999, Accepted: 22 January 2000     

Local synthesis of IgA in the cerebrospinal fluid of patients with neurological diseases

To date qualitative studies of IgA in the cerebrospinal fluid in neurological disease, particularly multiple sclerosis, have been few and given mixed results. The aim of this study was to identify local synthesis of IgA by detection of clonal IgA bands, in a large cohort of patients with a variety of neurological disorders, using polyacrylamide gel electrophoresis, transfer of protein to nitrocellulose membranes and specific staining. Of 2,097 sequentially analysed patients with suspected neurological disease 54 (2.6%) had locally synthesised IgA; most notably, IgA was present in 39 of 291 (13%) patients with suspected multiple sclerosis. The latter group also had a significant excess of light-chain production, particularly free kappa, when compared to multiple sclerosis patients without local synthesis of IgA. Locally synthesised IgA was also demonstrated in inflammatory, infectious and autoimmune diseases of the central nervous system. This qualitative technique is simple and suitable for routine analysis of cerebrospinal fluid, and further qualitative studies of IgA may be useful in investigating the pathophysiology of certain neurological disorders.     

Multiple myeloma presenting as stridor: A case report

Extrame dullary plasmacytoma of larynx is extremely rare. We report a case of multiple myeloma which presented as extrame dullary manifestation in larynx. The rarity of incidence and difficulty in diagnosis of the disease is discussed.     

The pathogenesis of multiple sclerosis: a commentary

A series of recently published articles by a group of Austrian, German and American neuropathologists have proposed the existence of several different pathogenetic pathways in multiple sclerosis (MS). These studies were based on both biopsy and autopsy material. A review of the available published clinical, imaging and cerebrospinal fluid data suggest that some the cases used in those studies were more probably instances of disseminated encephalomyelitis rather than MS. This has serious implications regarding the specificity and significance of the findings in regard to MS pathogenesis. The specific myelinoclastic sequence and the variable clinical course of MS are determined by the individual's genetic endowment and immunologic history. Regardless of pathogenetic pathway and clinical course, the final pathologic picture of MS is always the same. The MS brain is genetically programmed to produce a unique, pathognomonic change, the plaque with sharply demarcated borders.