purpose: Advanced age is considered to be associated with a more severe prognosis in infective endocarditis (IE), which is of relevance in view of a change in epidemiology of the disease with an ...increasing proportion of elderly people. We wanted to examine whether in the era of improved diagnostic sensitivity for IE by transesophageal echocardiography the clinical course in elderly persons would be still more severe than in younger patients.
patients: During the period from 1989 to 1993, 104 patients with 106 episodes of IE were treated at our university hospital. Three groups were compared: group A with 28 patients younger than 50 years, group B with 58 patients aged 50 to 70, and group C with 20 patients older than 70. Transesophageal echocardiography was performed in 78% of the patients; it was not performed in 22% of the patients with a conclusive transthoracic examination. The patients were followed up for an average of 25 months after the diagnosis.
results: No significant differences were observed among the age groups with respect to the possible source of infection, the frequency of positive blood cultures, and the type of infective organisms. Elderly patients more often had predisposing valvular conditions (eg, degenerative and calcified lesions and prosthetic valves), which decreased the sensitivity of transthoracic echocardiography to 45% as compared with 75% in group A. Transesophageal echocardiography improved the diagnostic yield by 45% in group C and by 47% in group B. Vegetations were smaller in group C and B as compared with group A, whereas other echocardiographic characteristics were similar. Fever and leukocytosis were less frequent in group C (55% and 25%, respectively) than in group A (82% and 61%, respectively). The interval between the onset of symptoms and the diagnosis of IE was similar in all groups. Elderly patients underwent surgical therapy as frequently (65%) as the other groups. The 1-year survival in group C (26%) was comparable with that in group A (22%) and group B (22%). The major determinant of survival was the occurrence of embolic complications.
conclusion: Infective endocarditis in elderly patients caused less severe clinical symptoms than in young patients. The early diagnosis in elderly patients was facilitated by the high sensitivity of transesophageal echocardiography, which enabled the timely initiation of an appropriate medical and surgical therapy. This led to a clinical outcome similar to that for younger patients.
Package inserts are the most frequent source of patient information about medicines aside from doctors and pharmacists.
A representative selection of 271 German package inserts available in 2005 was ...investigated, using 152 validated quality criteria and by measuring 242 further values.
A significant increase in package insert texts over recent years was found; standing at an average of 2,005 words. This is associated with the significant increase in complicated medical information being communicated; with on an average of 114.1 difficult words and 46.3 non quantifiable phrases per package insert. Only 60.1% of the package inserts offered all dosages as number of tablets or other amounts of the ready to use medicine, while just 29.5% listed the maximum daily dose for all users. 54.6% provided actions for all possible side effects and 24.2% the frequencies of side effects in numerical form.
The significantly increased volume of medical information provided in package inserts does not meet the requirements of patients. Major efforts are required by pharmaceutical companies, authorities and legislative bodies in order to reduce information to that which is essential for patients and to ensure that this is provided in short, precise and easily comprehensible texts.
Prosthetic valve endocarditis is considered to be associated with a more severe prognosis than native valve endocarditis. Among other factors, inappropriate visualization of vegetations in prosthetic ...valve endocarditis by transthoracic echocardiography is responsible for this observation. Since the introduction of transoesophageal echocardiography into clinical practice the diagnostic sensitivity and specificity of the detection of vegetations located on prosthetic valves have been enhanced. Therefore we aimed to determine and compare the prognosis of prosthetic valve endocarditis and native valve endocarditis in the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104 patients were seen at our institution between 1989 and 1993. Eighty patients (77%) had native valve endocarditis and 24 (23%) had late prosthetic valve endocarditis. In the latter group two patients had recurrent infective endocarditis. Patients with prosthetic valve endocarditis were older (mean age 64 vs 54 years in native valve endocarditis; P<0.00l) and the majority was female (62% vs 38% in native valve endocarditis; P<0.001 In prosthetic valve endocarditis, infection of a valve in the mitral position predominated (65% vs 30% in native valve endocarditis; P<0.0l), whereas in native valve endocarditis more than half the cases had isolated aortic valve endocarditis (51% vs 27% in prosthetic valve endocarditis; P<0.01). In prosthetic valve endocarditis more cases were caused by Staphylococcus aureus (31% vs 14% in native valve endocarditis; P<0.08), whereas in native valve endocarditis the most frequent organisms were streptococci (29% vs l9% in prosthetic valve endocarditis; P<0.12). Differences in the clinical features of native valve endocarditis and prosthetic valve endocarditis could not be found except for a higher rate of embolism in native valve endocarditis (40% vs l9% in prosthetic valve endocarditis; P<0.05). Vegetations could be detected by transthoracic echocardiography more frequently in native valve endocarditis (71% vs 15% in prosthetic valve endocarditis; P<0.0001). Transoesophageal echocardiography visualized vegetations in 95% of the episodes of native valve endocarditis and in 80% of the episodes of prosthetic valve endocarditis (P<0.09). Thus, the diagnostic gain by transoesophageal echocardiography was greatest in prosthetic valve endocarditis. Patients with native valve endocarditis had significantly larger vegetations than patients with prosthetic valve endocarditis (P<0.05 for length, P<0.00l for width). The median time to diagnosis was similar in native valve endocarditis and prosthetic valve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditis and in 58% of those with prosthetic valve endocarditis; the median time delay between the diagnosis of infective endocarditis and surgery tended to be shorter in prosthetic valve endocarditis than in native valve endocarditis (45 vs 60 days). The in-hospital mortality and the mortality during a follow-up of 22± 10 months did not significantly differ between native valve endocarditis and prosthetic valve endocarditis (21% vs 17% 28% vs 25%). In summary in the era of transoesophageal echocardiography, late prosthetic valve endocarditis does not seem to carry a worse prognosis than native valve endocarditis. This can be attributed in part to the improved diagnostic accuracy achieved by transoesophageal echocardiography leading to comparable diagnostic latency periods in both patient groups. Finally, better characterization of vegetations on prosthetic valves by transoesophageal echocardiography allows early lifesaving surgery in patients with prosthetic valve endocarditis.
Im folgenden werden wichtige Veränderungen der letzten Jahre zusammengefaßt.
1. Die spezifischen Drogenprobleme wie Entzugssymptomatik und Überdosierung sind zwar nach wie vor vorhanden, ...unspezifische Probleme wie Infektionen etc. nehmen heute den größeren Teil in der Drogenarbeit ein (Tab. 1).
2. Die akute Behandlung eines intoxizierten Abhängigen in der Praxis bietet heute nicht unbeträchtliche differentialdiagnostische Schwierigkeiten. Beim intravenös-injizierenden Drogenkonsumenten kommt es zu vielfältigen Überlappungen eines toxikomanen, eines psychischen und eines somatischen Syndroms (Tab. 2).
3. Eine Abhängigkeit nur von einer Substanz wird bei i. v .-Drogenkonsumenten in der Adoleszenz und im jungen Erwachsenenalter nur noch selten angetroffen. In der Regel werden verschiedene Substanzen gleichzeitig
Table of Contents Werner J. Fuchs; Annette Kleinfeld-Wernicke; Christian Koboldt ...
Wirtschaftsethische Perspektiven des Drogenproblems,
03/2022
Book Chapter
Front Matter Werner J. Fuchs; Annette Kleinfeld-Wernicke; Christian Koboldt ...
Wirtschaftsethische Perspektiven des Drogenproblems,
03/2022
Book Chapter
The assessment of left ventricular diastolic function by Doppler echocardiography shows both a nonrestrictive and restrictive type of filling in idiopathic dilated cardiomyopathy. These different ...filling patterns are related to the symptoms of cardiac failure and the prognosis. It remains to be established whether changes of Doppler parameters during follow-up procedures were of clinical relevance. Doppler echocardiography of left ventricular filling was done in 45 patients with idiopathic dilated cardiomyopathy at the time of their diagnosis and repeatedly during a follow-up study of 38 ± 19 months. The deceleration time of early filling, the maximum early and atrial Doppler velocities and their ratios, as well as echocardiographic parameters of cardiac dimensions and systolic function, were measured. During the follow-up period, seven patients died and four patients underwent heart transplantation because of progressive heart failure. The deceleration time was shorter in patients who died or had to undergo heart transplantation as compared with survivors (119 ± 43 ms vs 188 ± 63 ms;
P <.005). There was no difference in changes of clinical symptoms in survivors and nonsurvivors. The systolic function improved only in survivors. The difference in deceleration time remained significant between both groups, and it also remained a prognostic discriminator. Peak early velocity increased in nonsurvivors (from 0.66 ± 0.20 m/s to 0.95 ± 0.21 m/s;
P < .01), while it remained constant in survivors (0.65 ± 0.17 m/s and 0.67 ± 0.25 m/s). The peak early/atrial velocity ratio varied widely in either group during the follow-up study, its changes were closely related to the concomitant changes of clinical symptoms (
r = .59;
P < .005) with a decrease of the peak early/atrial velocity ratio in patients with clinical improvement and an increase of the peak early/atrial velocity ratio in those without clinical improvement. The Doppler echocardiographic deceleration time discriminated between survivors and nonsurvivors in idiopathic dilated cardiomyopathy at the time of the initial diagnostic procedure, and this difference was persistent during the follow-up study. The serial evaluation of patients with idiopathic dilated cardiomyopathy showed a close association of changes in diastolic filling with changes in clinical symptoms.
Hengstler, J. G., Bockisch, A., Fuchs, J., Grimm, W., Görges, R., Oesch-Bartlomowicz, B., Zapf, A-O., Lade, K., Tanner, B., Teichmann, E., Thelen, M., Gebhard, S. and Oesch, F. Induction of DNA ...Single-Strand Breaks by 131I and 99mTc in Human Mononuclear Blood Cells In Vitro and Extrapolation to the In Vivo Situation. The radionuclides 131I and 99mTc are frequently used for therapy of benign and malignant thyroid disease (131I) and for diagnosis of thyroid and other diseases (99mTc). However, the levels of DNA single-strand breaks (SSBs) induced in cells of patients after administration of 131I and 99mTc are not known. In this study, we measured the number of SSBs per cell induced by 131I and 99mTc in vitro, extrapolated the results to the clinical situation, and assessed their biological relevance by comparing levels of SSBs induced after therapeutic administration of 131I and 99mTc to those induced by endogenous processes or by occupational exposure to genotoxic substances. A linear dose–response relationship between the radioactivity concentrations of 131I and 99mTc and SSBs in human mononuclear blood cells (determined by alkaline elution) was obtained after incubation at 4 and 37°C. At 4°C, where almost no repair of SSBs takes place, 131I and 99mTc induced 81 and 7 SSBs per cell per hour/(MBq/ml), respectively. At 37°C, only 20 and 1.6 SSBs per cell per hour/(MBq/ml) were observed after incubation with 131I and 99mTc. To estimate the induction of SSBs in vivo in cells of patients after administration of 3700 MBq 131I (oral) or 60 MBq 99mTc (i.v.), the rates of induction of SSBs obtained in vitro were extrapolated to the concentrations of 131I and 99mTc measured in blood of patients. The total number of SSBs (mean ± standard deviation) accumulated after oral administration of 3700 MBq 131I up to 70 h after administration was calculated as 200 ± 59 SSBs/cell. After administration of 60 MBq 99mTc (i.v.), 0.032 ± 0.009 SSBs per cell (total SSBs up to 2 h after administration) were cumulated. The induction of SSBs by endogenous processes (estimated 2,000 SSBs per cell per hour) and by occupational exposure to genotoxic substances (125–430 SSBs per cell) has been estimated in earlier studies. In conclusion, the frequency of SSBs induced by thyroid diagnosis with 60 MBq 99mTc is approximately 5 orders of magnitude smaller than the frequency of spontaneous SSBs and thus is most probably without biological relevance. Since the frequency of induction of SSBs by therapy with 131I (3700 MBq) is about 6000-fold higher compared to thyroid diagnosis by 99mTc, its biological relevance is more difficult to assess. Nevertheless, the number of SSBs induced by therapy with 131I is substantially lower than that induced by endogenous processes.
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