Outcome after surgical embolectomy for acute pulmonary embolism

AIMS

Patients with pulmonary embolism (PE) and contraindications for or failed thrombolysis are at the highest risk for PE-related fatal events. These patients may benefit from surgical embolectomy, but data concerning this approach are still limited.

METHODS

The method used here was retrospective data analysis of 103 patients who underwent surgical embolectomy from 2002 to 2020 at our department.

RESULTS

Mean age was 58.4 (±15.1) years. Fifty-eight (56.3%) patients had undergone recent surgery; the surgery was tumor associated in 32 (31.1%) cases. Thirty (29.1%) patients had to be resuscitated due to PE, and 13 (12.6%) patients underwent thrombolysis prior to pulmonary embolectomy. Fifteen (14.5%) patients were placed on extra corporeal membrane oxygenation (ECMO) peri-operatively. Five patients (4.9%) died intra-operatively. Neurological symptoms occurred in four patients (3.9%). Thirty-day mortality was 23.3% ( n  = 24). Re-thoracotomy due to bleeding was necessary in 12 (11.6%) patients. This parameter was also identified as an independent risk factor for mortality.

CONCLUSION

Surgical pulmonary embolectomy resulted in survival of the majority of patients with PE and contraindications for or failed thrombolysis. Given the excessive mortality when left untreated, an operative approach should become a routine part of discussions concerning alternative treatment options for these patients.

Cardiac Myxomas Resembling Malignant Neoplasia: Incidentally Diagnosed vs. Cerebral Embolized Myxomas

Background: Cardiac myxomas (CM) are the most common primary cardiac tumors in adults. They are usually benign; however, malignant changes are known to occur but are extremely rare. Embolization is a common complication of cardiac myxomas and can cause neurological deficits before their surgical removal. The current study analyzed the outcomes after operative myxoma excision in patients, with and without cerebral embolic events prior to excision. Methods: All 66 consecutive patients who underwent a surgical excision of CM between 2005 and 2019 at our department were analyzed retrospectively. Patients with (n = 14) and without (n = 52) preoperative strokes caused by cerebral tumor embolization were compared. Results: The mean age was 58.4 ± 12.7 years in the stroke group (SG) and 62.8 ± 11.7 years in the non-stroke group (N-SG) (p = 0.226). Gender (35.7% vs. 61.5% female; p = 0.084) did not differ significantly, and comorbidities were comparable in both groups. The left hemisphere in the territory of the middle cerebral artery was affected by preoperative cerebral infarction most commonly (28.6%). The time from diagnosis to cardiac surgery procedure was 7 (3−24) days in the SG and 23 (5−55) days in the N-SG (p = 0.120). Cardiac myxomas were localized in the left atrium in both groups more frequently (SG: 92.9% vs. N-SG: 78.8%; p = 0.436). In the SG, 57.1% of CM had a non-solid surface, were localized in the left heart, and had a pedunculated attachment away from the fossa ovalis. In the N-SG, 92.3% of CM did not meet all these criteria (p < 0.001). The maximal diameters of CM were comparable (SG: 3.4 ± 1.5 cm vs. N-SG: 3.8 ± 2.1 cm; p = 0.538). The operation times (192.5 (139.3−244.5) min vs. 215.5 (184.5−273.3) min; p = 0.046) and the cross-clamp times (54.5 (33.3−86.5) min vs. 78.5 (55−106.8) min; p = 0.035) were significantly shorter in the SG. Only in the N-SG were reconstructions of the endocardium with bovine pericardium required after resection (51.9% vs 0%; p < 0.001). In the N-SG, CM were explored via the right atrium more often (57.7% vs. 14.3%; p = 0.007). Patients in the N-SG required significantly shorter ICU care after surgery (p = 0.020). Other postoperative courses did not differ significantly. After tumor removal, 1.9% of the N-SG suffered their first stroke and 14.3% of the SG had a cerebral re-infarction (p = 0.111). The 30-day mortality rates were 1.9% in the N-SG and 7.1% in the SG (p = 0.382). In one case in the N-SG, a tumor recurrence was diagnosed. The Kaplan−Meiercurves showed a significantly better long-term prognosis for patients in the N-SG (p = 0.043). Conclusions: After the surgical removal of CM, the outcome is compromised if preoperative cerebral embolization occurs. Surgical treatment is therefore indicated as soon as possible, especially when CM have a non-solid surface, are localized in the left heart, and have a pedunculated attachment away from the fossa ovalis.

Outcome of Unilateral Pulmonary Edema after Minimal-Invasive Mitral Valve Surgery: 10-Year Follow-Up

The study was approved by the institutional review board (IRB) at the University Medical Center Campus Kiel, Kiel, Germany (reference number: AZ D 559/18) and registered at the German Clinical Trials Register (reference number: DRKS00022222).

OBJECTIVE

Unilateral pulmonary edema (UPE) is a complication after minimally invasive mitral valve surgery (MIMVS). We analyzed the impact of this complication on the short- and long-term outcome over a 10-year period.

METHODS

We retrospectively observed 393 MIMVS patients between 01/2009 and 12/2019. The primary endpoint was a radiographically and clinically defined UPE within the first postoperative 24 h, secondary endpoints were 30-day and long-term mortality and the percentage of patients requiring ECLS. Risk factors for UPE incidence were evaluated by logistic regression, and risk factors for mortality in the follow-up period were assessed by Cox regression.

RESULTS

Median EuroSCORE II reached 0.98% in the complete MIMVS group. Combined 30-day and in-hospital mortality after MIMVS was 2.0% with a 95, 93 and 77% survival rate after 1, 3 and 10 years. Seventy-two (18.3%) of 393 patients developed a UPE 24 h after surgery. Six patients (8.3%) with UPE required an extracorporeal life-support system. Logistic regression analysis identified a higher creatinine level, a worse LV function, pulmonary hypertension, intraoperative transfusion and a longer aortic clamp time as predictors for UPE. Combined in hospital mortality and 30-day mortality was slightly but not significantly higher in the UPE group (4.2 vs. 1.6%; p = 0.17). Predictors for mortality during follow-up were age ≥ 70 years, impaired RVF, COPD, drainage loss ≥ 800 mL and length of ventilation ≥ 48 h. During a median follow-up of 4.6 years, comparable survival between UPE and non-UPE patients was seen in our analysis after 5 years (89 vs. 88%; p = 0.98).

CONCLUSIONS

In-hospital outcome with UPE after MIMVS was not significantly worse compared to non-UPE patients, and no differences were observed in the long-term follow-up. However, prolonged aortic clamp time, worse renal and left ventricular function, pulmonary hypertension and transfusion are associated with UPE.

Active Infective Native and Prosthetic Valve Endocarditis: Short- and Long-Term Outcomes of Patients after Surgical Treatment

Background: Active infective endocarditis (IE) is a serious disease associated with high mortality. The current study represents our experience over 18 years with surgical treatment for active infective native and prosthetic valve endocarditis (INVE, IPVE). Method: Analysis of 413 patients (171 with IPVE vs. 242 with INVE) who underwent cardiac surgery due to IE between 2002 and 2020. Results: Patients with IPVE were significantly older (64.9 ± 13.2 years vs. 58.3 ± 15.5 years; p < 0.001) with higher EuroSCORE II (21.2 (12.7; 41.8) vs. 6.9 (3.0; 17.0); p < 0.001)) and coronary heart disease (50.6% vs. 38.0%; p < 0.011). Preoperative embolization was significantly higher within INVE (35.5% vs. 16.4%; p < 0.001) with high incidence of cerebral embolization (18.6% vs. 7.6%; p = 0.001) and underwent emergency curative surgery than the IPVE group (19.6% vs. 10.6%; p < 0.001). However, patients with IPVE were significantly represented with intracardiac abscess (44.4% vs.15.7%; p < 0.001). Intraoperatively, the duration of surgery was expectedly significantly higher in the IPVE group (356 min vs. 244 min.; p = 0.001) as well as transfusion of blood (4 units (0–27) vs. 2 units (0–14); p < 0.001). Post-operatively, the incidence of bleeding was markedly higher within the IPVE group (700 mL (438; 1163) vs. 500 mL (250; 1075); p = 0.005). IPVE required significantly more permanent pacemakers (17.6% vs. 7.5%: p = 0.002). The 30-day mortality was higher in the IPVE group (24.6% vs. 13.2%; p < 0.003). Conclusion: Patients with INVE suffered from a higher incidence of cerebral embolization and neurological deficits than patients with IPVE. Surgical treatment in INVE is performed mostly as an emergency indication. However, patients with IPVE were represented commonly with intracardiac abscess, and had a higher indication of pacemaker implantation. The short- and long-term mortality rate among those patients was still high.

Influence of Age on Postoperative Neurological Outcomes after Surgery of Acute Type A Aortic Dissection

BACKGROUND

Acute type A aortic dissection (AAAD) is considered a fatal disease which requires an emergent surgical intervention. This study focuses onthe neurological outcome after surgical repair in cases of AAAD in comparison between elderly and young patients.

METHODS

a retrospective analysis of 368 consecutive patients who underwent emergency surgery of ascending aorta in moderate hypothermic circulatory arrest (MHCA) (20-24 °C) and antegrade cerebral perfusion after AAAD between 2001 and 2016. Patients were divided into two groups: those aged 75 years and older (68 (18.5%)) and those younger than 75 years (300 (81.5%)).

RESULTS

Comparing both groups, average age was 79.0 ± 3.2 vs. 59.2 ± 10.7 years (p < 0.001); female gender represents 58.8% of elderly patients vs. 28.7% in younger patients (p < 0.001). Intraoperatively, cardiopulmonary bypass time (155 min (131; 187) vs. 171 min (137; 220); p = 0.012), cross-clamping time (79 min (60; 105) vs. 93 min (71; 134); p = 0.001] and circulatory arrest time (29 min (22; 40) vs. 33 min (26; 49); p = 0.011) were significantly shorter in elderly than younger group. Postoperatively, there was no significant difference in delirium (11.8% vs. 20.5%; p = 0.0968) or stroke (11.8% vs. 16.1%; p = 0.369). The 30-day mortality was satisfactory for both groups but significantly higher in the elderly group (27.9% vs. 14.3%; p = 0.007).

CONCLUSION

The current study concluded that surgical treatment of AAAD in elderly patients can be applied safely without increasing risk of neurological complication. However, minimizing operation time may help limit the occurrence of postoperative neurological complication.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults

Objectives

Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients.

Methods

We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n  = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n  = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery.

Results

The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P  = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P  = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P  = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P  = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P  = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P  = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P  = 0.12).

Conclusions

Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Iatrogenic Catheter-Induced Acute Aortic Dissection Type A after Coronary Angiography-A Retrospective Consecutive Case Series

Background Acute aortic dissection type A (AADA) is one of the most life-threatening situations and surgical demanding procedures even today. Usually AADA develops spontaneously, but it can be related also to interventional procedures. Methods We analyzed the data of 14 patients surgically treated in our institution with catheter-induced AADA (ciAADA) during coronary angiography between January 2004 and December 2014. Data were compared with overall AADA patients in this time period (n = 288). Results Nine of the 14 patients were female. Subjects were significantly older compared to the AADA patients (69 ± 11 vs. 62 ± 11; p = 0.021). At admission, ciAADA patients were more often hemodynamically instable and mechanically ventilated. Twelve patients underwent replacement of the ascending aorta and two patients received a modified Bentall operation. Cardiopulmonary bypass time (210 ± 92 vs. 172 ± 51 min) and cross-clamp time (122 ± 63 vs. 92 ± 40 min) were significantly longer due to additional coronary artery bypass grafts in 71.4 versus 3.1% due to myocardial ischemia. Operative mortality (7.1 vs. 2.1%, p = 0.29) and 30-day mortality (50.0 vs. 10.7%, p < 0.001) were higher in the ciAADA group. Conclusion Coronary angiography-induced AADA is a rare but severe complication. Due to additional myocardial ischemia and preoperative hemodynamic instability, patients with ciAADA have adverse outcome compared to overall AADA patients.

Transatrial left-ventricular cannulation in acute aortic dissection type A: a novel cannulation technique

Despite improvements in surgical and perfusion techniques, surgery for acute aortic dissection type A (AADA) remains associated with high mortality rates. All cannulation techniques currently used to establish arterial flow are associated with a varying but considerable risk of organ malperfusion, neurological complications or additional access site trauma. We introduce Rahimi's transatrial cannulation of the left ventricle via the right upper pulmonary vein as an innovative alternative for antegrade, arterial return in AADA.

Impact of Gender on Outcome in Octogenarians after Coronary Artery Bypass Grafting

Background Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. In this study, the impact of gender on outcome of octogenarians after coronary artery bypass grafting (CABG) was assessed.

Materials and Methods We retrospectively studied 485 octogenarians (176 females: mean age 82.4 ± 2.2 years vs. 306 males: mean age 82.2 ± 2.4 years) who underwent isolated CABG using extracorporeal circulation between January 2005 and December 2012.

Results No significant differences were noted between both gender groups with regard to preoperative risk factors. At baseline, the groups differed significantly with respect to mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (women: 22.3 ± 17.4% vs. men: 17.5 ± 13.3%; p < 0.001). Likewise, EuroSCORE II differs significantly between women and men in our cohort (women: 16.7 ± 11.9% vs. men: 13.9 ± 10.7%; p = 0.008). Intraoperatively, the number of distal anastomoses (3.1 ± 0.9 vs. 3.2 ± 0.8), the mean extracorporeal circulation time (99 ± 31 vs. 102 ± 29 minutes), and the mean aortic cross-clamp time (63 ± 31 vs. 60 ± 19 minutes) were similar in both groups. Postoperatively, no significant differences in complications and major morbidity were observed between the groups. The 30-day mortality (women 8.0 vs. men 9.7%; p = 0.62) were without statistical significance between the groups.

Conclusion Outcome of octogenarians after CABG resulted in acceptable mortality. Female gender was not associated with increased risks for morbidity and mortality after surgery. Satisfactory outcomes encourage the offering of surgery in octogenarians.

Transatrial Cannulation of the Left Ventricle for Acute Type A Aortic Dissection: A 5-Year Experience

BACKGROUND

Acute type A aortic dissection (AAD) is a life-threatening disorder with a high rate of mortality and complications. All cannulation techniques currently used to establish arterial flow for cardiopulmonary bypass are associated with a considerable risk of organ malperfusion, stroke, or access site trauma. Here, we report the impact of transatrial cannulation of the left ventricle on patient outcome after surgical treatment of AAD.

METHODS

Between 2010 and 2013, 46 patients underwent emergency surgery for AAD using transatrial cannulation of the left ventricle. Their outcome was retrospectively compared with that of 73 age- and sex-matched patients operated on for AAD between 2006 and 2010 before introduction of the new technique.

RESULTS

No differences concerning preoperative details were found. Arterial flow before 2010 was established after preparation of the femoral artery in 46 patients (63.0%) or by direct cannulation of the ascending aorta in 27 patients (37.0%). Operation times were significantly lower in the transatrial cannulation group (271.2 ± 75.4 versus 308.3 ± 78.2; p = 0.02). Postoperatively, we observed a significantly reduced stroke rate in the group with transatrial cannulation (6.5% versus 26.5%; p = 0.007) and a decreased rate of acute renal failure (20.0% versus 32.4%; p = 0.003). Intraoperative mortality (0% versus 6.8%; p = 0.16), 30-day mortality (8.9% versus 10.3%; p = 1.00), and mortality during follow-up (9.8% versus 34.4%; p = 0.08) did not differ. However, overall mortality was significantly lower in the group after transatrial cannulation (17.7% versus 45.2%; p = 0.003).

CONCLUSIONS

In patients undergoing surgery for AAD, transatrial cannulation of the left ventricle proved to be a safe and easy cannulation method that significantly reduced postoperative complications.

Highly flexible nitinol mesh to encase aortocoronary saphenous vein grafts: first clinical experiences and angiographic results nine months postoperatively

Saphenous vein graft patency is frequently limited by degeneration. Experimental studies have indicated that rigid external support of venous grafts by a flexible, tubular nitinol mesh may improve graft patency. The study presented was part of a prospective, randomized, multicenter first-in-man trial investigating the safety and effectiveness of nitinol-supported venous grafts in coronary artery bypass graft (CABG) surgery. From our clinic, 25 subjects with multivessel coronary artery disease requiring saphenous vein graft CABG of the right coronary artery (RCA) and the circumflex artery were entered into the trial. Subjects were randomized to receive a mesh-supported graft on one of these arteries; the other vessel received an untreated vein graft. Graft patency was assessed by coronary angiography nine months after surgery. The implantation of mesh grafts was simple and safe. In 10 cases, a nitinol mesh-supported venous graft was anastomosed to the circumflex artery and in 15 cases to the RCA. All patients survived the observation period. A total of 72% of the patients underwent control coronary angiography. The patency rate of mesh-supported grafts was 27.8% nine months postoperatively. Conventional vein grafts showed an 85.7% patency, and arterial grafts had a 100% patency. No complications directly related to the implantation of mesh-supported grafts were observed. The promising experimental results of mesh-supported venous grafts could not be reproduced in the study presented. A critical item seems to be correct selection of nitinol mesh diameter, the anastomotic method and fixation of the mesh tube to the venous graft.

Body experience and mental representation of body image in patients with haematological malignancies and cancer as assessed with the Body Grid

The domain of body image plays a central role in the quality of life of patients with haematological malignancies and metastasized cancer, since the disease itself as well as the enrolled therapies interfere with psychological and bodily well-being. We approached this highly subjective field by using the repertory grid technique and hypothesized that patients would display a restricted body image, focusing on functional aspects of the body. In all, 55 in-patients (27 men, 28 women, M age = 45.7 yrs, N = 46 with haematological malignancies, N = 9 with metastasized cancer), at the time of initial diagnosis, were included in the study and assessed with the Body Grid, an instrument specifically designed by us for the exploration of body image. The data were analysed by principal component analysis (PCA) and construct categorization. Further, 42 chronic tinnitus sufferers (20 male, 22 female, M age = 46.5 yrs) served as a comparison group. Based on the constructs elicited, six construct categories were formulated in the sense of a first attempt of a hierarchical model (emotion, control, activity, strength, function, appearance). The central constructs (373 construct pairs) were assigned to these categories by three inter-raters. The categories appeared in the following order of frequency: function (27.1%), emotion (20.4%), strength (20.1%), activity (15%), control (10.2%) and appearance (7.2%). PCA indicated that the patients mainly demonstrated a restricted view of their body. In the tinnitus group, the most frequent category proved to be activity (21.3%), closely followed by function (21.1%) and control (20.9%). The body image was also restricted (PCA). The restriction of body image, together with the specific construct choice, seen in the haematology and cancer patients reflects the existential threat of the disease and may serve as a coping strategy. The high percentage of emotional constructs may mirror the patients' need for further support. The distinct distribution of construct categories in the two different patient samples supports the applicability of the proposed preliminary model.

[The impact of morbid obesity on the peri- and postoperative course after aortocoronary bypass surgery]

BACKGROUND AND OBJECTIVE

Excessive obesity is considered to be a risk factor in coronary bypass grafting. The aim of the current study was to examine if grossly overweight patients with a body mass index (BMI) > 35 suffer from higher morbidity and mortality when compared with patients with normal body weight (BMI = 20-25).

PATIENTS AND METHODS

206 extremely obese patients (group A) and 206 patients with normal body weight (group B) originating from a total of 5614 patients undergoing coronary bypass grafting in the time span between 1.4.1996-1.10.2000 were studied retrospectively and consecutively. The data were obtained from case histories, questionnaires and interviews. Statistical analysis was performed by the chi 2 test after Pearson, the t test and the Kaplan-Meier method depending on the statistical problem analysed using the SPSS software v. 8.0.

RESULTS

The comparison of group A with group B revealed a significantly higher incidence of diabetes mellitus (p < 0.001), hypertension (p < 0.001) and hyperlipidaemia (p < 0.01) in group A. The only significant differences regarding the surgical procedure were the longer operation time (212.3 +/- 44.6 min, mean +/- SD) and aortic cross-clamp time (53.8 +/- 17.4 min, mean +/- SD) in group A (p < 0.05). The duration of mechanical ventilation, the incidence of respiratory insufficiency and the stay in the intensive care unit were not significantly different. The disorders of wound healing both in the sternal and the graft removal regions occurred significantly more frequently in group A (p < 0.001). The 30 days mortality rate in group A (1.5%) was not significantly different from group B (p < 0.001). The 30 days mortality rate in group A (1.5%) was not significantly different from group B (2.9%). The follow-up analysis of the 30 days mortality rate in different age groups revealed no significant differences in patients aged between 60 and 75 years. The mean survival rate after 4 years was 87.2% in group A and 86.4% in group B.

CONCLUSION

In spite of higher morbidity our results did not reveal significantly higher mortality in extremely obese patients. After operation the patients considered their state improved, therefore elective coronary surgery in grossly overweight patients seems to be indicated also without previous weight reduction.

Personality and object relations in patients with affective disorders: idiographic research by means of the repertory grid technique

BACKGROUND

This paper presents an idiographic approach to evaluate the self concept and the self-object-relationship of patients suffering from affective disorders.

METHODS

Significant dimensions of the personality and the object relations of 127 depressive patients and 34 orthopaedic patients were investigated with the repertory grid-technique. The self concept and the object relations were compared by means of nomothetically used idiographic results after recovery from manifest depression.

RESULTS

'Low self esteem' was frequently found in patients with a long lasting course of illness and the ICD-10-diagnoses of 'bipolar affective disorder' and 'dysthymia'. The object relations of the depressive sample were characterised by the dimension 'symbiotic near'; 'ambivalent' and 'indifferent' partnership relationships were found much more frequently in the controls.

CONCLUSIONS

The idiographic results help to differentiate the spectrum of affective disorders. They underline the importance of the interpersonal dimension of depression and may be used as a basis of a therapeutic appraisal.

LIMITATIONS

The repertory grid-technique may not be used as a diagnostic instrument. However, the combination of idiographic results with further clinical informations enables the multidimensional assessment of the self concept and psychosocial coping mechanisms.

[Narcissism inventory-90 (NI-90). Empirically-based reduction and identification of items sensitive for change--a questionnaire particularly suited for measuring self-regulatory parameters]

By analysing Narcissism Inventories [1] gathered by the admission from 639 consecutive in-patients, as well as a related sample of inventories gathered from 397 consecutive patients (7/93-7/96) by admission and discharge, we examined the possibility of reducing the number of items of the Narcissism Inventory without losing significant information. This examination shows that reducing the inventory to a total of 5 items per scale is reasonable, without a relevant loss of metric quality in the item-reduced scales. In addition, items particularly sensitive to change could be identified and pointedly kept in the new, reduced scales. Through the deliberate selection of these items, it was possible to produce an empirically-guided short-version of the Narcissism Inventory, suited particularly for the examination of clinical process and regulatory parameters. With persistence of the original 18 scales proposed by the authors of the original test, a reduction to a total of 90 items results. The name "Narcissism Inventory-90 (NI-90)" is, therefore, suggested for this new version.

[Self concept and object relations of patients with affective disorders--individual centered diagnosis with the repertory-grid technique]

Significant dimensions of the self concept and the object relations of 127 depressive patients and 34 orthopaedic patients were investigated with the repertory-grid-technique. Self concept and object relations were compared by means of nomothethically used idiographic results after recovery from manifest depression. The object relations of the depressive sample were characterised by the dimension "symbiotic near"; "ambivalent" and "indifferent" partnership relationships were found much more frequently in the controls. The idiographic results contribute to a differentiation of the spectrum of affective disorders. They underline the importance of the interpersonal dimension of depression and may be used as a basis of a therapeutic orientation.

Severe anorexia nervosa associated with osteoporotic-linked femural neck fracture and pulmonary tuberculosis: a case report

We report a case study of a 38-year-old woman who had been suffering from anorexia nervosa (AN) since the age of 26. Before admittance to our clinic, she weighed 23.8 kg (at a height of 164 cm, 8.8 body mass index [BMI]) but still carried out strenuous physical activities. After good psychotherapeutic response and weight gain (34.4 kg), she accidentally fell and broke her femoral neck-favored as it was by osteoporosis. The X-ray taken before dynamic hip screw implantation coincidentally showed signs of pulmonary tuberculosis (TB), which could then be proven by computed tomography (CT) scans and cultures from a bronchoscopy. Other than lack of appetite and loss of weight, which we attributed to AN, there were no other clinical or biochemical indicators which could have pointed to an earlier TB diagnosis. As a result, the need for screening procedures is discussed. The manifestation of TB during the first weight gain after 12 years of severe malnutrition, during which there were no serious infections, seems to endorse former observations that AN patients appear to be "resistant" to some extent against infectious diseases, a "protection" which may be lost with convalescence and weight gain.