Dynamic LVOT Obstruction and Aortic Stenosis in the Same Patient: A Case of Challenging Doppler Hemodynamics

We present a patient with both dynamic left ventricular outflow tract obstruction and valvular aortic stenosis. The aortic valve was calcified, and velocities and gradients measured by continuous‐wave Doppler met standard criteria for severe aortic stenosis. The increased subvalvular velocities invalidated assumptions of the simplified Bernoulli equation; correction using the longer form of the Bernoulli equation suggested a lower but still significant gradient. The complex shape of the subvalvular spectral Doppler envelope indicated supranormal systolic function and dynamic left ventricular outflow obstruction. Left heart catheterization with an end‐hole catheter was required to determine the subvalvular and valvular components of the obstruction.     

Chronische Transplantatdysfunktion

Chronic transplant dysfunction is a complex dynamic pathogenic process. Clinically, a decrease in glomerular filtration rate (GFR) becomes apparent leading to chronic renal insufficiency and dialysis or death from cardiovascular events. Chronic transplant dysfunction can develop into a chronic alIograft nephropathy (CAN) as a specific entity with dynamic progression. CAN includes a collection of immunologic and non-immunologic factors, rejection, ischemia time, donor and recipient characteristics and toxicity of calcineurin inhibitors. Despite improvements in immunosuppression, the long-range prognosis of renal allografts has not improved. Whether modern immunosuppressive concepts with reduction or avoidance of calcineurin inhibitors and a therapy based on antimetabolites, such as mycophenolate or mTOR-inhibitors could lead to a prolongation of transplant survival, remains to be seen.     

Extreme Photosensitivität seit der Kindheit

Ohne Zusammenfassung     

Multimodal—was ist das überhaupt?

In chronic pain syndromes multimodal treatment has proved its efficacy. However, multimodal treatment does not mean randomly combining different interventions in a potpourri of methods. Multimodal treatment must closely follow a well-proved conceptual framework. Those concepts may be well illustrated by therapy of back pain. The most elaborate model for understanding the transition from acute to chronic pain is fear avoidance. Based on this model chronic pain status is understood as a learned consequence, which resulted from patients’ anxious avoidance of body movements. In these cases, treatment of a physical pathology is not the main aim of therapy but rather functional restoration. Those multimodal programs meanwhile have demonstrated their effectiveness. However, good results not only depend on recognition of imperative elements in therapy but also on adhering to essential principles (avoidance of negative anticipation, adequate information with assurance techniques, no training of avoidance, recognition of elements of fear therapy).