[Perspectives in the treatment of subarachnoid-hemorrhage-induced cerebral vasospasm]

Cerebral vasospasm is still the most important cause of death and disability after rupture of intracranial aneurysms. The therapeutic strategies in the treatment of subarachnoid hemorrhage induced vasospasm vasospasm include four groups: 1) prevention of vasospasm; 2) reversion of vasospasm; 3) improvement of cerebral perfusion; and 4) neuroprotection and rescue therapies. Recent experimental studies allowed the design of phase II clinical studies which demonstrated positive results with medications and compounds such as statins (simvastatin and pravastatin) and endothelin-1 receptor antagonists (clasozentan). Moreover, experimental and clinical evidences showed the advantages of early cerebrospinal fluid drainage, intrathecal administration of NO-donors, effects of Ca2+ protein kinase inhibitor (Fasudil) and catecholamines on the cerebral vessels. This review article summarizes the stage of investigation of these medications and therapeutic strategies which will be relevant in the treatment of cerebral vasospasm.

Sphincter incontinence: is regenerative medicine the best alternative to restore urinary or anal sphincter function?

Incontinence is a major public health concern in aging societies. It is caused by age-dependent spontaneous apoptosis of muscle cells in the urinary and fecal sphincters, and is aggravated in women due to birth trauma. Compared to other currently employed invasive surgical management techniques associated with morbidity and recurrence, replacement or regeneration of dysfunctional sphincter through stem cell therapy and tissue engineering techniques hold great promise. This review focuses on the pathophysiological analysis of urinary incontinence and the possible application of muscle-derived-stem cells, satellite cells, chondrocytes and adipose-derived-stem cells in restoring sphincter functions.

Clinical heterogeneity in mild chronic inflammatory demyelinating polyneuropathy

We describe the clinical presentation, progression and electrodiagnostic features of three patients with a mild form of chronic inflammatory demyelinating polyneuropathy (CIDP). The unusually mild but also variable clinical picture was a cause of diagnostic uncertainty in all, but CIDP was eventually confirmed by extensive electrophysiological studies in each case, as well as by histology in one. Cerebrospinal fluid protein was raised in only one patient. Two patients were treated by intravenous immunoglobulins and both improved. Awareness of the existence of this relatively benign form of CIDP in its various presentations is essential as it can be functionally disabling, progress to more severe symptomatology, and as patients may benefit from immunomodulatory therapy.

Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease

BACKGROUND

Q waves on a 12-lead ECG are markers of a prior myocardial infarction (MI). However, they may regress or even disappear over time, and there is no specific ECG sign of a non-Q-wave MI. Fragmented QRS complexes (fQRSs), which include various RSR' patterns, without a typical bundle-branch block are markers of altered ventricular depolarization owing to a prior myocardial scar. We postulated that the presence of an fQRS might improve the ability to detect a prior MI compared with Q waves alone by ECG.

METHODS AND RESULTS

A cohort of 479 consecutive patients (mean+/-SD age, 58.2+/-13.2 years; 283 males) who were referred for nuclear stress tests was studied. The fQRS included various morphologies of the QRS (<120 ms), which included an additional R wave (R') or notching in the nadir of the S wave, or >1 R' (fragmentation) in 2 contiguous leads, corresponding to a major coronary artery territory. The Q wave was present in 71 (14.8%) patients, an fQRS was present in 191 (34.9%) patients, and an fQRS and/or a Q wave was present in 203 (42.3%) patients. Sensitivity, specificity, and the negative predictive value for myocardial scar as detected by single photon emission computed tomography analysis were 36.3%, 99.2%, and 70.8%, respectively, for the Q wave alone; 85.6%, 89%, and 92.7%, respectively, for the fQRS; and 91.4%, 89%, and 94.2%, respectively, for the Q wave and/or fQRS.

CONCLUSIONS

The fQRS on a 12-lead ECG is a marker of a prior MI, defined by regional perfusion abnormalities, which has a substantially higher sensitivity and negative predictive value compared with the Q wave.

Pharmakotherapie des Diabetes mellitus Typ 2

Patients with diabetes type 2 are not directly endangered by dysglycemia but they suffer vascular complications. The diabetic patient with existing cardiovascular disease has a particularly high risk for further cardiovascular complications and therefore requires specific attention. This is not only due to the hyperglycemia, but due to the coexistence of further cardiovascular risk factors, such as hypertension, dyslidemia, visceral fat accumulation, chronic inflammation and coagulopathy, also clinically described as the metabolic syndrome. These patients need an intense and multi-modal therapeutic approach, not only for improvement of glycemic control. Also other vascular risk factors should be handled aggressively, such as blood pressure, coagulopathy and dyslipidemia. Recent studies--as STENO 2--indicate that a multi-modal and aggressive approach in diabetic patients can markedly improve their prognosis. Therefore, the current practice of a glucocentric approach should be changed towards a more vascular approach.

Herz-Diabetes-Netz—

Diabetic patients with heart disease are high risk patients for further vascular complications and therefore need an intensive and multimodal, interdisciplinary intervention. Due to the "segmentation" of medical care into primary care physician, specialists, acute and secondary care (rehabilitation) clinics, the patients will be taken care of on each individual segment with regard to the current requirements and specialties of the care provider. Such--each section, the GP, the cardiologist and the diabetologist, the heart centre and the rehabilitation clinic, represent individual and often strictly separate segments, which each will focus only on the acute problem and will collect (only) data required for the care in their particular segment. A multimodal approach can improve the chronic care and prognosis of these patients, as shown in several studies. The proposed network model should increase multi-disciplinary cooperation of the different levels of health care segments and overcome current barriers. It is thus necessary to provide common guidelines for diagnostic and therapeutic procedures and to improve communication between each individual sector. This could help to improve the secondary prevention in these high risk patients.

Die Bedeutung der Rehabilitation beim herzkranken Diabetiker nach chirurgischen Eingriffen

Patients with diabetes nowadays are not directly endangered by dysglycemia, but they suffer vascular complications. The diabetic patient with existing cardiovascular (CV) disease has a particularly high risk for further CV complications and, therefore, requires specific attention. These patients need an intense and multimodal therapeutic approach which includes a strong interdisciplinary cooperation between the cardiologist and the diabetologist. Cardiac rehabilitation can effectively improve prognosis of CV patients with numbers needed to treat (NNT) comparable to standard pharmacological treatment. In diabetics, after coronary surgery, metabolism frequently and markedly deteriorates, and this requires strict metabolic monitoring and close cooperation between the diabetes team and the other professionals (cardiologist, nurses, physiotherapists, psychologists . . .) to reduce complications arising from hyperglycemia and also hypoglycemia and to improve the CV risk factors by lifestyle changes. Frequently, diabetes is only diagnosed during the hospital stay for CV complication; therefore, in these patients, specific attention is required for teaching and inauguration of therapy. Due to the high risk of these patients and the need of qualified metabolic co-treatment, following CV surgery, diabetic patients should be treated preferentially in rehabilitation centres specialised in both cardiac and metabolic care. Recent studies indicate that a multimodal and aggressive approach in CV diabetic patients can markedly improve their prognosis.

Bronchocutaneous fistula after chest-tube placement: A rare complication of tube thoracostomy

Bronchocutaneous fistula is a pathologic communication between the bronchus, pleural space, and subcutaneous tissue. It can occur as a complication of positive pressure ventilation and pneumonectomy. Diagnosis is made by imaging studies. Treatment options are endoscopic repair, parietal pleurectomy, and pleurodesis. Our patient is a 53-year-old woman who had a difficult chest-tube placement for complicated parapneumonic effusion. Computed tomography scan revealed a fistulous tract from the bronchus to the skin at the site of the original chest tube, and chest x-ray film revealed a subcutaneous fistulous air tract in the lateral chest. It is usually an acquired condition; congenital bronchocutaneous fistula is rare. We report a case of bronchocutaneous fistula after chest-tube placement.

[Practice guidelines: conservative treatment of fibroids]

The conservative treatment of uterine fibroids is essentially based on symptomatology and patient's choice of treatment. The gynaecologist must develop a clear therapeutic protocol based on clinical examination, available test results and consideration of patient preference. The therapeutic options include close surveillance, hormonal treatments, conservative operative endoscopy and arterial embolization.