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We report a patient with autoimmune pancreatitis and cholangitis. During a period of 3 years and despite therapy with steroids and immunmodulatory drugs such as azathioprine and mycophenolate mofetil he suffered from multiple relapse episodes including bile duct stenoses requiring endoscopic interventions. After initiation of therapy with the monoclonal CD20 antibody Rituximab, steroids could be stopped completely and the patient remains in remission. Rituximab should be considered in therapy of relapsing autoimmune pancreatitis and cholangitis.
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Enfermedades Autoinmunes/tratamiento farmacológico , Colangitis/tratamiento farmacológico , Pancreatitis/tratamiento farmacológico , Pancreatitis/inmunología , Rituximab/administración & dosificación , Adulto , Enfermedades Autoinmunes/inmunología , Colangitis/inmunología , Enfermedad Crónica , Humanos , Inmunoglobulina G/inmunología , Factores Inmunológicos/administración & dosificación , Masculino , Resultado del TratamientoRESUMEN
HISTORY: A 71-year-old man with Richter's syndrome (transformation of chronic lymphocytic leukemia [CLL] to diffuse large B-cell lymphoma) was admitted to our hospital to get his second cycle of rituximab/bendamustin treatment. He had been diagnosed with Richter's syndrome three months earlier: a bulky tumor was seen on the backside of the stomach in a routine gastroscopy. Taking a biopsy had resulted in a major bleeding impossible to stop endoscopically. An emergency surgical multi-visceral resection was performed. The first cycle of chemotherapy was administered about 4 weeks prior to the present appointment. INVESTIGATIONS: In the physical examination the patient showed a bad orientation and confusion together with a skinny habitus. The initially performed lab tests and a CT-Scan of the brain did not show a significant finding. A mini-mental-state-examination (MMSE) showed moderate cognitive impairment. In a psychiatric consultation the patient was diagnosed with reactive depression and a corresponding medication was given. After the second cycle of chemotherapy the patient's state of mind decreased markedly within days. DIAGNOSIS, TREATMENT AND FURTHER COURSE: The further diagnostic investigation (MRI of the brain, lumbar puncture) brought the diagnosis of progressive multifocal leukoencephalopathy. The administration of chemotherapy was stopped then. Three weeks after the diagnosis the patient died in the hospice. CONCLUSION: If a patient develops neurological or psychiatric symptoms during therapy with rituximab clinicians should be aware of the potential diagnosis of PML and initiate further investigations.
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Anticuerpos Monoclonales de Origen Murino/efectos adversos , Anticuerpos Monoclonales de Origen Murino/uso terapéutico , Trastornos del Conocimiento/inducido químicamente , Trastornos del Conocimiento/diagnóstico , Leucoencefalopatía Multifocal Progresiva/inducido químicamente , Leucoencefalopatía Multifocal Progresiva/diagnóstico , Linfoma de Células B/tratamiento farmacológico , Anciano , Antineoplásicos/efectos adversos , Antineoplásicos/uso terapéutico , Trastornos del Conocimiento/prevención & control , Humanos , Leucoencefalopatía Multifocal Progresiva/prevención & control , Linfoma de Células B/prevención & control , Masculino , Rituximab , Resultado del TratamientoRESUMEN
There are conflicting results with regard to the use of catheter-based techniques for continuous paravertebral block. Local anaesthetic spread within the paravertebral space is limited and the clinical effect is often variable. Discrepancies between needle tip position and final catheter position can also be problematic. The aim of this proof-of-concept study was to assess the reliability of placing a newly developed coiled catheter in human cadavers. Sixty Tuohy needles and coiled catheters were placed under ultrasound guidance, three on each side of the thoracic vertebral column in 10 human cadavers. Computed tomography was used to assess needle tip and catheter tip locations. No catheter was misplaced into the epidural, pleural or prevertebral spaces. The mean (SD) distance between catheter tips and needle tips was 8.2 (4.9) mm. The median (IQR [range]) caudo-cephalad spread of contrast dye injectate through a subset of 20 catheters was 4 (4-5[3-8]) thoracic segments. All catheters were removed without incident. Precise paravertebral catheter placement can be achieved using ultrasound-guided placement of a coiled catheter.
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Catéteres , Bloqueo Nervioso/instrumentación , Cateterismo/métodos , Humanos , Bloqueo Nervioso/métodos , Columna Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Paravertebral regional anaesthesia is used to treat pain after several surgical procedures. This study aimed to improve on our first published ultrasound-guided approach to the paravertebral space (PVS) and to investigate a possible discrepancy between the needle, catheter, and contrast dye position. METHODS: In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches combined with loss of resistance (LOR) and after an interim analysis performed 36 novel, pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was controlled by a first computed tomography (CT) scan. After placement of the catheters, the tips were assessed by a second CT and the spread of injected contrast dye was assessed by further CT scans. The part of the PVS near the intervertebral foramen was defined as the primary target to reach. RESULTS: The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34 (94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed: three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected in the epidural space. In two cases, insertion of the catheter was not possible. In cases with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (sd)] vertebral segments. CONCLUSIONS: Our new PUSG technique has a high success rate for paravertebral needle placement. Although needles were correctly positioned, catheters were usually found distant from the needle-tip position.
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Bloqueo Nervioso/métodos , Ultrasonografía Intervencional/métodos , Cadáver , Cateterismo/instrumentación , Cateterismo/métodos , Competencia Clínica , Medios de Contraste/farmacocinética , Disección/métodos , Humanos , Agujas , Bloqueo Nervioso/instrumentación , Punción Espinal , Vértebras Torácicas/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
AIM: Sentinel lymph node mapping has been used in colon cancer to improve prognosis. This study aimed to determine the accuracy of in vivo SLNM in patients with colon carcinoma undergoing surgery with curative intent. METHOD: Thirty-one patients operated for colon carcinoma underwent in vivo sentinel lymph node mapping using patent blue dye. Each sentinel lymph node (SLN) was marked intraoperatively, and histological examination was performed after en bloc resection. If no metastasis was found, step sectioning with immunohistochemistry was performed. RESULTS: The SLN was successfully identified in 28 (90%) of 31 patients. The false-negative rate to identify stage III disease was 66% (eight of 12), the negative predictive value was 46% (19 of 27) and the accuracy was 14% (four of 28). One patient negative on routine histopathology had micrometastasis on step sectioning of the SLN. CONCLUSION: Sentinel lymph node mapping in colon carcinoma cannot accurately predict nodal status.
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Carcinoma/patología , Neoplasias del Colon/patología , Metástasis Linfática , Biopsia del Ganglio Linfático Centinela/métodos , Anciano , Anciano de 80 o más Años , Carcinoma/cirugía , Neoplasias del Colon/cirugía , Reacciones Falso Negativas , Reacciones Falso Positivas , Humanos , Inmunohistoquímica , Persona de Mediana Edad , Valor Predictivo de las Pruebas , PronósticoRESUMEN
OBJECTIVES: The effect of hydrostatic infiltrations for subperichondrial dissection is controversial. Classical textbooks promote it as the "key step in elevating the flaps" or consider its practicability "a mere fable". Moreover, case reports describe fatal side effects. Up to now, experimental tests are missing. DESIGN: Experimental study. MATERIALS AND METHODS: Three surgeons simulated subperichondrial hydrodissection with 20 mineral salt fixed human cadaver heads. One ml lidocaine 5% with 1:105 adrenaline and India ink was infiltrated. Each septum was examined histologically using serial 3 microm sections in 150 microm intervals. Tissue cleavage containing the ink deposits with minimal distance to the proposed subperichondrial zone, intravasal spread and tissue deposition were analyzed. RESULTS: Every injection produced a physical dissection (n = 20). However, dissected planes were localized mostly in the supra-perichondrial connective tissue (n = 8) or within the perichondrium (n = 4). Only five cases showed the propagated correct dissection in a subperichondrial zone. Three anomalous septa were excluded from quantitative analysis. Infiltrated matter did not only accumulate within the dissection plane but also penetrated the surrounding vessels of the septal intumescentia (n = 8). CONCLUSION: Hydrostatic infiltrations represent an unreliable surgical technique for dissection of an anatomical correct subperichondrial plane but can be useful for anesthesia and hemostasis, however, using high pressure and high volume infiltrations might foster serious side effects.
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Disección/métodos , Tabique Nasal/cirugía , Rinoplastia/métodos , Anciano , Anciano de 80 o más Años , Cadáver , Femenino , Humanos , Presión Hidrostática , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Estadísticas no Paramétricas , Colgajos QuirúrgicosRESUMEN
BACKGROUND AND OBJECTIVE: Despite numerous publications on the epidemiology of inflammatory bowel diseases (IBD) there is a lack of systematic investigations on live-threatening complications of IBD and their causes. This study evaluates risk factors, course and outcome in intensive-care patients which were related to complications of IBD. PATIENTS AND METHODS: Among 6071 admissions to the intensive-care unit (ICU) of a gastroenterological department (university hospital with IBD-outpatient unit) between 1.1.1991 and 31.1.2008 36 ICU admissions of 28 patients with IBD were documented and prospectively analysed from 1996 onwards, using a structured questionnaire on causes for ICU admission as well as risk factors regarding death, organ failure and length of ICU stay. RESULTS: ICU admissions of IBD patients mainly resulted from three causes: complications specific to IBD (44 %), including acute flare-up, perforation and electrolyte imbalance, septic complications (22 %) and thromboembolic complications (17 %). Five patients died, all from septic complications related to immunosuppression including candida sepsis, varicella pneumonia during treatment with infliximab, and pneumocystis pneumonia related to treatment with azathioprine. The most important risk factors according to uni- and multivariate analyses were old age on ICU-admission and first diagnosis of IBD, previous surgery related to IBD and Crohn's disease. CONCLUSIONS: Complications of both IBD and immunosuppressive therapy may be live-threatening in patients with IBD. Better characterization of patients with a high probability of improved outcome by immunosuppressive and/or antibody-therapy seems to be preferable to noncritical early use of these drugs.
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Colitis Ulcerosa/complicaciones , Enfermedad de Crohn/complicaciones , Unidades de Cuidados Intensivos , Adulto , Anciano , Causas de Muerte , Colitis Ulcerosa/mortalidad , Colitis Ulcerosa/terapia , Enfermedad de Crohn/mortalidad , Enfermedad de Crohn/terapia , Femenino , Alemania , Mortalidad Hospitalaria , Hospitales Universitarios , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pronóstico , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The concept of initiating fibrinolytic therapy in patients who cannot undergo immediate percutaneous coronary intervention (PCI) in the setting of acute ST-segment-elevation myocardial infarction (STEMI) has been proposed as a strategy to improve outcomes. However, evidence supporting the use of this strategy is not conclusive, and the results of recent randomized controlled trials are apparently contradictory. Probably, the time points of administration of the adjunctive thrombolytics and antiplatelet agents and the time loss until coronary intervention have a major influence on the discrepancy of outcomes in different trials. Therefore, the relationship between therapeutic time intervals and outcome in patients treated with facilitated PCI has been analyzed. METHODS: In this single center retrospective study, 131 patients with STEMI were treated with a combined pharmaco-mechanical reperfusion strategy using half-dose r-tPA combined with a glycoprotein (GP) IIb/IIIa antagonist prior to PCI. Specific time points were recorded for each patient, including the time of symptom onset, the time of first medical contact, the start of intravenous thrombolysis, the time of administration of the GP IIb/IIIa antagonist and the start of coronary intervention. We then examined the relationship between the time delay from symptom onset to the initiation of various steps of treatment and the residual myocardial damage as expressed by the severity of both global and regional myocardial dysfunction calculated from a left ventriculography study performed 3 months later. RESULTS: The median time from symptom onset to the first medical contact, with 25th and 75th percentiles in parentheses, was 1.25 h (0.75, 3), from symptom onset to initiation of thrombolytic therapy 2.25 h (1.25, 3), to initiation of GP IIb/ IIIa inhibitor therapy 3.5 h (2, 5.69), and to the start of coronary intervention 4.81 h (2.85, 7.91). The time between symptom onset and initiation of both thrombolytic therapy and coronary intervention was significantly related to the global ejection fraction and to the extent of regional hypokinesia at the 3-month follow-up (p<0.05). The time to the initiation of GP IIb/IIIa inhibitors was only significantly related to the global ejection fraction (p<0.05), while the time to the first medical contact did not show a similar relationship (p>0.05). Furthermore, we observed a significant relationship between the infarct-related artery (IRA) patency at the initial angiogram and the residual regional myocardial damage at follow-up; normokinesia at follow-up was found in 61.3% of patients with an initially patent IRA and in 41.2% of patients with an initially occluded IRA, whereas severe hypokinesia was found in 13.8% and 37.3%, respectively (p<0.05). CONCLUSION: In patients with STEMI treated with a facilitated PCI strategy using half dose r-tPA in combination with a glycoprotein IIb/IIIa receptor blocker, the 3-month global and regional residual myocardial dysfunction is significantly related to the time elapsed between the onset of symptoms and the start of both fibrinolytic therapy and coronary intervention.
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Angioplastia Coronaria con Balón/métodos , Electrocardiografía , Infarto del Miocardio/terapia , Función Ventricular Izquierda , Adulto , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Quimioterapia Combinada , Femenino , Fibrinolíticos/uso terapéutico , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/fisiopatología , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: In contrast to standard video endoscopy, magnifying endoscopy after local acetic acid application enables recognition of mucosal surface architecture. OBJECTIVE: To investigate the diagnostic yield of magnifying endoscopy with acetic acid-targeted biopsies compared to random, 4-quadrant biopsies. DESIGN: Prospective randomized trial (ratio 1:1) with crossover design. SETTING: Two referral hospitals in Germany. PATIENTS: Thirty-one patients with Barrett's esophagus or visible columnar-lined lower esophagus. INTERVENTIONS: Patients were randomized to undergo either standard video endoscopy with 4-quadrant biopsies or magnifying endoscopy in conjunction with acetic acid application. All patients were re-examined 14 days after the initial endoscopy with the corresponding procedure. MAIN OUTCOME MEASUREMENTS: Primary outcome analysis (per protocol and per biopsy) was the histological proof of Barrett's epithelium. Secondary outcome analysis was the correlation between the surface architecture and the presence of Barrett's epithelium and the needed number of biopsies to confirm Barrett's epithelium for the 2 different procedures. RESULTS: Magnifying endoscopy enabled the prediction of Barrett's epithelium with a sensitivity of 100% and a specificity of 66%, respectively (accuracy 83.8%). Acetic acid-guided biopsies obtained a significantly higher percentage of tissues containing SCE (78%; 188/241) compared to random biopsies (57%; 159/280). LIMITATIONS: No data on the diagnosis of Barrett's dysplasia. CONCLUSION: Magnifying endoscopy with acetic acid-guided biopsies is superior to standard video endoscopy with random biopsies, and the number of biopsies needed to confirm Barrett's epithelium is half as much when compared to random biopsies.
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Esófago de Barrett/patología , Endoscopía Gastrointestinal/métodos , Ácido Acético , Adolescente , Adulto , Anciano , Biopsia/métodos , Color , Estudios Cruzados , Esófago/patología , Femenino , Humanos , Aumento de la Imagen , Indicadores y Reactivos , Masculino , Metaplasia , Microscopía , Persona de Mediana Edad , Membrana Mucosa/patología , Estudios Prospectivos , Sensibilidad y Especificidad , Propiedades de SuperficieRESUMEN
BACKGROUND: Endothelial dysfunction is found both in patients with chronic heart failure and in patients with insulin-treated type 2 diabetes mellitus. This endothelial dysfunction leads to a significant reduction in endothelium-derived vasodilation. Physical exercise can have a positive effect on endothelial dysfunction in patients with coronary artery disease, chronic heart failure and diabetes mellitus. It is not clear, however, whether an exercise program influences endothelial function in diabetics with chronic heart failure. Our study was thus aimed at investigating whether a special exercise program would affect endothelial function. Comparisons were made with insulin-treated type 2 diabetics and with non-diabetics suffering from chronic heart failure. METHODS: 42 patients with severe chronic heart failure (LVEF < or = 30%), insulin-dependent diabetics (n=20, mean age 67+/-6 yrs, 16 male, 4 female), non-diabetics (n=22, mean age 68+/-10 yrs, 20 male, 2 female) participated in a 4-week exercise program consisting of ergometer and special muscle strength training. Before (T1) and at the end (T2) of the training program endothelium-dependent and endothelium-independent vasodilatory capacity were assessed by brachial artery diameter measurement. RESULTS: At the end of the training program, there were no significant results within the two groups. The endothelium-dependent vasodilation changed between T1 and T2 as follows: In the diabetic group, the endothelium-dependent vasodilation at T1 and T2 was 5.1+/-3.6 and 4.9+/-2.5%, respectively. For the non-diabetics, the endothelium-dependent vasodilation was 6.8+/-4.5 and 7.6+/-4.0% at T1 and T2, respectively. The endothelium-independent vasodilation in the diabetics was 10.5+/-5.6 at T1 and dropped to 8.7+/-4.1% at T2. The results for the non-diabetics were 13.2+/-5.8 and 12.3+/-6.3% at T1 and T2, respectively. The LVEF in the diabetics was 24.2+/-3.4% at T1, increasing to 27.8+/-5.8% at T2. In the non-diabetics, the LVEF was 22.9+/-3.8 at T1 vs. 28.6+/-6.9% at T2. In the groups of diabetics, the maximum oxygen uptake (VO2-max) was 10.3+/-3.9 at T1 vs. 11.4+/-2.8 ml/kg/min at T2 and in the group of non-diabetics 10.0+/-3.1 vs. 13.5+/-5.0 ml/kg/min. No correlations were found between the change in endothelium-dependent vasodilation and the increase in oxygen uptake. CONCLUSION: In our study, a program of physical exercise had no influence on endothelium-dependent or endothelium-independent vasodilation in insulin-treated type 2 diabetics or in non-diabetics with considerably reduced ejection fraction. In both groups, however, an exercise-related influence on medical parameters and physical performance could be observed.
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Diabetes Mellitus Tipo 2/complicaciones , Endotelio Vascular/fisiopatología , Ejercicio Físico , Insuficiencia Cardíaca/terapia , Anciano , Arteria Braquial/metabolismo , Enfermedad Crónica , Ergometría , Prueba de Esfuerzo , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Persona de Mediana Edad , Oxígeno/metabolismo , Vasodilatación/fisiología , Función Ventricular Izquierda/fisiologíaRESUMEN
It was studied bluetongue virus antibodies prevalence for sheep and cattle in Southwest and Southeast regions of Rio Grande do Sul State. A total of 2613 serum samples (1272 bovine and 1341 ovine) were tested by agar gel immunodiffusion. Eight bovine and two ovine samples were positive meaning a prevalence of 0.63 percent and 0.15 percent, respectively. These results show that most of animals in these regions are negative to bluetongue.
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Anticuerpos Antivirales , Inmunodifusión/métodos , Prevalencia , Virus ARN , Virus de la Lengua Azul/aislamiento & purificaciónRESUMEN
We report about a 67-year old man, who was submitted to our clinic with acute coronary syndrome. The cardiac catheterization showed a proximal thrombus in the left anterior descending (LAD). The other coronary arteries did not have significant lesions. After percutaneous transluminal coronary angioplasty with stent-implantation into the proximal LAD the patient remained clinically stable. Cardiac enzymes confirmed no myocardial necrosis. Three days after the acute coronary syndrome the patient developed a podagra, which was treated with colchicinum, diclofenac and local cooling. Five hours after initial therapy the patient developed severe symptoms of angina pectoris and electrocardiographical signs of an acute posterior and anterior myocardial infarction. Immediate coronary angiography demonstrated extended vasospasm of the right coronary artery. Intracoronary application of verapamil and nitroglycerin resolved the coronary spasm. The patient reported about a self-indicated application of diclofenac six hours before hospital admission. This case demonstrates that oral application of diclofenac can provoke coronary vasospasm.
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Angina Inestable/inducido químicamente , Angina Inestable/diagnóstico , Enfermedad Coronaria/inducido químicamente , Enfermedad Coronaria/diagnóstico , Diclofenaco/efectos adversos , Infarto del Miocardio/inducido químicamente , Infarto del Miocardio/diagnóstico , Enfermedad Aguda , Anciano , Angina Inestable/tratamiento farmacológico , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/uso terapéutico , Enfermedad Coronaria/tratamiento farmacológico , Diclofenaco/uso terapéutico , Gota/tratamiento farmacológico , Humanos , Masculino , Infarto del Miocardio/tratamiento farmacológico , Síndrome , Resultado del TratamientoRESUMEN
A 38-year-old man with a history of chronic alcohol abuse had suffered from numerous acute episodes of chronic pancreatitis in the last 7 years. Those episodes were complicated by the formation of a pseudocyst in the pancreatic head. He presented himself with vomiting and abdominal pain as well as diarrhoea for 10 days. In the ultrasound examination of the liver numerous circumscribed hypoechoic formations in both lobes of the liver were found. A subsequent computerised tomography scan confirmed multiple hypodense liver lesions. Because of suspected metastasis or abscesses in the liver, sonographically guided fine needle biopsies of these liver structures were carried out. The histological examination of the liver specimens showed bile infarcts and proliferated bile ducts; there were no signs of a malignant or infectious process. The bacteriological cultures of the biopsy specimens were negative.
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Enfermedades de la Vesícula Biliar/diagnóstico por imagen , Infarto/diagnóstico por imagen , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Adulto , Alcoholismo , Diagnóstico Diferencial , Humanos , Masculino , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
We report about a 47-year-old woman, who presented with a history of cardiac failure. Echocardiography showed an impaired left ventricular function, clinically significant mitral regurgitation and pulmonary hypertension. Diagnosis of a Bland- White-Garland syndrome was made by coronary angiography. Subsequent therapy consisted of ligation of the anomalus origin of the left coronary artery, implantation of a Mammaria interna graft to the left coronary artery and replacement of the mitral valve by a mechanical prosthesis. One year after operation, left ventricular function was still impaired. At a 3-year follow-up, left ventricular function improved continuously.
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Anomalías de los Vasos Coronarios/diagnóstico , Insuficiencia Cardíaca/etiología , Hipertensión Pulmonar/etiología , Insuficiencia de la Válvula Mitral/etiología , Arteria Pulmonar/anomalías , Disfunción Ventricular Izquierda/etiología , Angiografía Coronaria , Anomalías de los Vasos Coronarios/cirugía , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/cirugía , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Revascularización Miocárdica , Complicaciones Posoperatorias/diagnóstico , Arteria Pulmonar/cirugía , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/cirugíaRESUMEN
BACKGROUND: Evidence is now evolving of the importance of team management for patients with chronic heart failure. This includes education, patient self-care and physical exercise training. How such programs should be implemented is still under discussion. AIM: To assess the efficacy of an in-hospital rehabilitation clinic-based program, we studied its influence on cardiopulmonary parameters and quality of life in an outpatient setting. METHODS AND RESULTS: 75 patients (62 male, 13 female, mean age 65+/-8 years) underwent an exercise program including education, bicycle ergometer, muscle strength training and the 6-min walk test as a training unit for 4 weeks. Patients were studied at baseline (T1), before discharge (T2) and after a follow-up period of 29.9+/-5.5 weeks (T3). Baseline data (T1): left ventricular ejection fraction (LVEF): 33.8+/-7.6%, left ventricular end-diastolic volume (LVEDV): 130+/-51 ml, peak VO(2): 12.3+/-4.3 ml/kg, maximum work load (Watt max): 71+/-27 W. At discharge (T2) and follow-up (T3) LVEF increased to 36.8+/-8% and 41.8+/-9.2%, LVEDV decreased to 127+/-43 ml and 114+/-40 ml, peak VO(2) increased to 14.1+/-5.1 ml/kg and 15.2+/-5 ml/kg, and Watt max increased to 84+/-28 Wand 98+/-42 W (all p<0.01). Quality of life improved significantly at discharge and follow-up in nearly all domains and in the summary score for physical health. There were no significant changes for anxiety and depression at T2 and T3. CONCLUSION: A specialized in hospital rehabilitation program including education, patient self management and training has a sustained positive effect on cardiopulmonary parameters and physical well-being.
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Ejercicio Físico , Insuficiencia Cardíaca/rehabilitación , Educación del Paciente como Asunto , Autocuidado , Anciano , Volumen Cardíaco/fisiología , Enfermedad Crónica , Comorbilidad , Prueba de Esfuerzo , Femenino , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/psicología , Humanos , Estilo de Vida , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Admisión del Paciente , Grupo de Atención al Paciente , Calidad de Vida/psicología , Centros de Rehabilitación , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiologíaRESUMEN
A microbiopsy system for fast excision and transfer of biological specimens from donor to high-pressure freezer was developed. With a modified, commercially available, Promag 1.2 biopsy gun, tissue samples can be excised with a size small enough (0.6 mm x 1.2 mm x 0.3 mm) to be easily transferred into a newly designed specimen platelet. A self-made transfer unit allows fast transfer of the specimen from the needle into the specimen platelet. The platelet is then fixed in a commercially available specimen holder of a high-pressure freezing machine (EM PACT, Leica Microsystems, Vienna, Austria) and frozen therein. The time required by a well-instructed (but not experienced) person to execute all steps is in the range of half a minute. This period is considered short enough to maintain the excised tissue pieces close to their native state. We show that a range of animal tissues (liver, brain, kidney and muscle) are well preserved. To prove the quality of freezing achieved with the system, we show vitrified ivy leaves high-pressure frozen in the new specimen platelet.
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Criopreservación/instrumentación , Criopreservación/métodos , Animales , Biopsia , Encéfalo/ultraestructura , Crioultramicrotomía , Substitución por Congelación , Congelación , Riñón/ultraestructura , Hígado/ultraestructura , Microscopía Electrónica , Músculos/ultraestructura , Hojas de la Planta/ultraestructura , Presión , Ratas , Manejo de Especímenes/métodos , Factores de TiempoRESUMEN
INTRODUCTION: In a prospective study initiated in 1982, we have been investigating the question as to whether - and if so, which - pT1 carcinomas of the colorectum can be treated exclusively via the endoscope. METHOD: In the period between February 1, 1982 and April 30, 2001, a total of 5,470 polyps were removed endoscopically at the Medical Department I of the Klinikum Ludwigsburg. Among these lesions, a total of 144 (2.6 %) pT1 carcinomas were found in 141 patients. We were able to follow 120 patients with 123 pT1 carcinomas over a mean follow-up period of 46 months (range: 1-60). In low-risk situations (definitive removal in healthy tissue, G1-G2, no lymphatic involvement), endoscopic treatment alone usually represented sufficient treatment. In high-risk cases (removal in healthy tissue uncertain or negative, and/or lymphatic vessel involvement, and/or G3/G4), subsequent surgical resection was carried out. RESULTS: 64 cases were classified as high-risk, 59 as low-risk. Nevertheless, 9 patients with 10 low-risk carcinomas were submitted to surgery (young age, patient's own request). In none of these 10 cases was residual tumour or lymph node metastasis detected in the surgical specimen. 47 patients with 49 low-risk carcinomas were treated solely by endoscopic polypectomy using the diathermy snare, and 45 patients with 47 carcinomas remained recurrence-free during the follow-up period. In a single case, a local recurrence was detected 2 months after polypectomy and underwent curative resection. In another case, peritoneal carcinosis with tumour infiltrating into the colon developed 8 months after initial treatment; this, however, was most probably a recurrence of a previously operated carcinoma of the uterus. Among the high-risk cases, 10 were not submitted to surgery on account of advanced age and/or rejection of an operation by the patient; all remained recurrence-free. Among the surgically treated high-risk carcinomas, 3 surgical specimens contained residual tumour, while 2 revealed a lymph node metastasis. In our group of patients, no tumour-related mortality was seen among endoscopically treated patients. DISCUSSION: In the light of the fact that the reported mortality rate associated with open surgery for colorectal carcinoma is 3 % as compared with about 1 % risk of lymph node metastasis and 0,1 % mortality rate for the endoscopic modality, endoscopic removal of a pT1 tumour in a low-risk situation followed by appropriate surveillance can be considered as adequate treatment.
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Adenoma/cirugía , Carcinoma/cirugía , Neoplasias Colorrectales/cirugía , Endoscopía , Pólipos Intestinales/cirugía , Anciano , Pólipos del Colon/cirugía , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estudios Prospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: The aim of this study was to establish whether Chlamydia pneumoniae is implicated in the development of restenosis in patients with coronary heart disease (CHD) after percutaneous transluminal coronary angioplasty (PTCA). PATIENTS AND METHODS: 67 patients were selected for study after they underwent control angiography after PTCA. Sera were tested for anti-chlamydial antibodies with a genus specific ELISA and a species-specific microimmunofluorescence test (MIFT). Oropharyngeal specimens were examined for the presence of antigen with a Chlamydia immunofluorescence test (IFT), C. pneumoniae IFT and semi-nested PCR. In addition, anamnestic findings were also included. To determine the general level of antibodies, an age- and sex matched control group of 180 persons was also examined for Chlamydia and C. pneumoniae serology. RESULTS: Coronary angiography revealed that 31 of the 67 patients had developed a restenosis. There was no significant correlation between serological and angiographic findings. However, the MIFT showed a higher positive rate, especially in IgA, in the restenosis group. C. pneumoniae was detected in the oropharynx by PCR and/or IFT in 20.8% and 16.0% of the cases in patients with and without a restenosis. PCR found more C. pneumoniae-positive cases in the restenosis patients than IFT. No association was found between the detection of Chlamydia antigen and serology. The women with restenosis were more frequently smokers (p = 0.012). Men with restenosis were significantly older (p = 0.015). C. pneumoniae serology based on the rELISA or the MIFT did not show any correlation with restenosis. CONCLUSION: No evidence was found to suggest that positive C. pneumoniae serology is a risk factor for the development of restenosis. However, whether the species-specific serological test, especially for IgA-antibodies, and the detection of C. pneumoniae in oropharyngeal specimens by PCR might be reliable diagnostic markers in these cases remains to be determined.