Hannover, Germany
Hannover, Germany

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Neuzner J.,Medizinische Klinik II | Carlsson J.,Medicinska Kliniken Kardiologi
Clinical Research in Cardiology | Year: 2012

The preferred use of dual-coil implantable defibrillator lead systems in current implantable defibrillator therapy is likely based on data showing statistically lower defibrillation thresholds with dual-coil defibrillator lead systems. The following review will summarize the clinical data for dual- versus single-coil defibrillator leads in the left and right pectoral implant locations, and will then discuss the clinical implications of single- versus dualcoil usage for atrial defibrillation, venous complications, and the risks associated with lead extraction. It will be noted that there are no comparative clinical studies on the use and outcomes of single- versus dual-coil lead systems in implantable defibrillator therapy over a long-term follow-up. The limited long-term reliability of defibrillator leads is a major concern in implantable defibrillator and cardiac resynchronization therapy. A simpler single-coil defibrillator lead system may improve the long-term performance of implanted leads. Furthermore, the superior vena cava coil is suspected to increase interventional risk in transvenous lead extraction. Therefore, the need for objective data on extractions and complications will be emphasized. © Springer-Verlag 2012.

Schneider B.,Medizinische Klinik II | Athanasiadis A.,Robert Bosch GmbH | Sechtem U.,Robert Bosch GmbH
Heart Failure Clinics | Year: 2013

Takotsubo cardiomyopathy (TTC) predominantly occurs in elderly women. Men comprise 10% of the patients, with a similar clinical profile. In contrast to myocardial infarction, age distribution; symptoms, such as angina; and prehospital delay in TTC are not different between genders. In men, physical stress as a triggering event and shock or cardiac arrest on presentation are more frequent. Gender-related differences in TTC need to be carefully investigated at the clinical and experimental levels to explain the evident gender discrepancy in the prevalence of TTC, to clarify the pathogenetic background, and to develop preventive and therapeutic means against this life-threatening disease. © 2013 Elsevier Inc.

Gross V.,Medizinische Klinik II
Digestive diseases (Basel, Switzerland) | Year: 2012

Topical therapy with mesalazine and/or corticosteroids is the standard treatment for patients with distal ulcerative colitis. Rectal mesalazine is more effective than rectal systemically active corticosteroids or topically active corticosteroids like budesonide. In patients with mild to moderately active distal ulcerative colitis, topical mesalazine is therefore the treatment of choice. Doses of 1 g or higher are equally effective. The period of treatment is important (4 weeks are more effective than 2 weeks). In the case of nonresponse or nontolerability of rectal mesalazine, rectal budesonide is indicated. The standard dose of budesonide is 2 mg/day. This does not usually induce any corticosteroid-associated adverse events. Treatment with rectal mesalazine plus rectal topically active corticosteroids is even more effective than treatment with either substance alone. To overcome adherence problems with rectal therapy, rectal foam preparations have been developed which are usually better tolerated than enemas. Copyright © 2012 S. Karger AG, Basel.

In 2005, Bob Hauser published a paper in the Journal of the American College of Cardiology entitled “The growing mismatch between patient longevity and the service life of Implantable Cardioverter-Defibrillators”. Now, nearly a decade later, I would like to perform a second look on the problem of a mismatching between ICD device service life and the survival of ICD recipients. Since 2005, the demographics of the ICD population has changed significantly. Primary prevention has become the dominant indication in defibrillator therapy and device implantation is indicated more and more in earlier stages of cardiac diseases. In former larger scale ICD trials, the patient average 5-year survival probability was in a range of 68–71 %; in newer CRT-D trials in a range of 72–88 %. Due to a progressively widened ICD indication and implantation preferentially performed in patients with better life expectancy, the problem of inadequate device service life is of growing importance. The early days of defibrillator therapy started with a generator volume of 145 ccm and a device service life <18 months. In this early period, the device miniaturization and extension of service life were similar challenges for the technicians. Today, we have reached a formerly unexpected extent of device miniaturization. However, technologic improvements were often preferentially translated in further device miniaturization and not in prolonging device service life. In his analysis, Bob Hauser reported a prolonged device service life of 2.3 years in ICD models with a larger battery capacity of 0.54 up to 0.69 Ah. Between 2008 and 2014, several studies had been published on the problem of ICD longevity in clinical scenarios. These analyses included “older” and currently used single chamber, dual chamber and CRT devices. The reported average 5-year device service life ranged from 0 to 75 %. Assuming today technology, larger battery capacities will only result in minimal increase in device volume. Selected ICD patients may further benefit from device miniaturization—but the vast majority may much more benefit from a significant prolongation in device service life. All published cost-effectiveness analyses in ICD therapy show that device costs and device service life are the dominant determinants of the results. The performed “second look—nearly a decade later” revealed that there are still relevant limitations regarding the device service life in current defibrillator therapy. Technical improvements were preferentially transformed into device miniaturization but not into prolonging device service life. But this optimization is strongly enforced. The most feasible solution might be the use of device batteries with larger capacities. The economic burden, mainly caused by non-adequate device service life, may limit the future realization of ICD therapy in a progressively growing patient population. In the former years, physicians and device manufacturers have ignored the patient perspective in defibrillator therapy. However, it is the patient viewpoint that prolonged device service life is much more important than smaller generator size. © 2015, Springer-Verlag Berlin Heidelberg.

Background: Chronic constipation is a frequent symptom among the general population in Germany. Because of the demographic development, the prevalence of chronic constipation will increase in the near future. Chronic constipation represents a typical 'iceberg disease' with a smooth transition from normal to morbid. Method: A generalized classification of chronic constipation has not been established yet. Classification of chronic constipation may differentiate between primary or secondary (drug-induced, neurologic/endocrine diseases) causes. A clinically useful classification may differentiate between delayed colonic transit, outlet obstruction, and other causes. Other classifications differentiate between constipation with or without colonic dilatation. Results: The pathophysiology of slow transit constipation is often difficult to specify in the clinic because of neuromuscular and/or neurosecretoric abnormalities associated with sensori-motoric disturbances. It is crucial to differentiate between slow transit constipation and outlet obstruction already in the beginning. Conclusion: In the routine follow-up of slow transit constipation further diagnostic work-up (transit emptying time, gastrointestinal motility investigated by various techniques such as manometry, breath tests, scintigraphy, MRI, barostat, laparoscopic whole-mount biopsies for immunohistochemical staining) is usually not mandatory. In contrast, outlet obstruction requires early proctologic and sometimes proctoscopic investigation. Sometimes, further investigations (anorectal manometry, anal electromyography, electromyography of the pudendus nerve, defecography, defeco-MRI, balloon expulsion test) are necessary. © 2012 S Karger GmbH, Freiburg.

Self-expandable metal stents (SEMS) are well known and established in the therapy of malignant stenosis of the gastrointestinal tract. But they are also used for the treatment of benigne stenosis, fistulas, perforations or bleeding. SEMS are categoried by the material they are made of, the covering, the length, the diameter and other special features like drug-eluting stents, biodegradable stents or thermoplastic stents. The releasing system is differentiated between through the scope systems (TTS) or guide-wire system with fluoroscopy. SEMS are used in the esophagus, the esophago-gastral-junction, the gastric outlet, the duodenum, the bile or pancreatic duct, colon and rectum. Early complications are rare. Stent-migration and occlusion are the main late complication of SEMS. © 2013 Georg Thieme Verlag KG Stuttgart . New York.

Fischbach W.,Medizinische Klinik II
Best Practice and Research: Clinical Gastroenterology | Year: 2010

The therapeutic strategy in gastric lymphoma has completely changed over the last two decades. This change is mainly characterised by the abandonnement of surgery in favour of conservative therapies and the introduction of Helicobacter pylori eradication therapy. It became evident that conservative treatment with radiation and/or chemotherapy is at least as effective as surgical resection and additionally offers the advantage of stomach preservation and better quality of life. The therapeutic goal is undoubtedly complete remission of the lymphoma as a necessary basis for cure of the disease. Both radiotherapy and chemotherapy have a high curative potential in gastric MALT lymphoma and diffuse large B-cell lymphoma (DLBCL), respectively. An open question is the additional benefit of radiation following Rituximab-CHOP chemotherapy in DLBCL. In patients with gastric MALT lymphoma of stage I H. pylori eradication offers complete remission rates of up to 80% with excellent long-term prognosis and a real chance of cure. Patients with MALT lymphoma of stage II and those with DLBCL of stage I may also respond to eradication therapy in the individual case. It also emerged recently that there is no need for any oncological therapy in patients revealing minimal histological residuals after successful H. pylori eradication. A watch-and-wait strategy is the adequate management of this condition. In summary, therapy of gastric lymphoma is nowadays individualised with lymphoma type, stage, and H. pylori status as the determinants of the choice of treatment. Efficacy and quality of life are strong arguments for a definite conservative approach encompassing H. pylori eradication, radiation and chemotherapy. © 2010 Elsevier Ltd. All rights reserved.

Frieling T.,Medizinische Klinik II
Deutsche Medizinische Wochenschrift | Year: 2016

Fecal incontinence is defined by the unintentional loss of solid or liquid stool, and anal incontinence includes leakage of gas and / or fecal incontinence. Anal-fecal incontinence is not a diagnosis but a symptom. Many patients hide the problem from their families, friends, and even their doctors. Epidemiologic studies indicate a prevalence between 7-15 %, up to 30 % in hospitals and up to 70 % in longterm care settings. Anal-fecal incontinence causes a significant socio-economic burden. There is no widely accepted approach for classifying anal-fecal incontinence available. Anal-fecal continence is maintained by anatomical factors, rectoanal sensation, and rectal compliance. The diagnostic approach comprises muscle and nerve injuries by iatrogenic, obstetric or surgical trauma, descending pelvic floor or associated diseases. A basic diagnostic workup is sufficient to characterize the different manifestations of fecal incontinence in most of the cases. This includes patient history with a daily stool protocol and digital rectal investigation. Additional investigations may include anorectal manometry, anal sphincter EMG, conduction velocity of the pudendal nerve, needle EMG, barostat investigation, defecography and the dynamic MRI. Therapeutic interventions are focused on the individual symptoms and should be provided in close cooperation with gastroenterologists, surgeons, gynecologists, urologists, physiotherapeutics and psychologists (nutritional-training, food fibre content, pharmacological treatment of diarrhea/constipation, toilet training, pelvic floor gymnastic, anal sphincter training, biofeedback). Surgical therapy includes the STARR operation for rectoanal prolapse and sacral nerve stimulation for chronic constipation and anal-fecal incontinence. Surgery should not be applied unless the diagnostic work-up is complete and all conservative treatment options failed. © Georg Thieme Verlag KG. Stuttgart New York .

Frieling T.,Medizinische Klinik II
Zeitschrift fur Gastroenterologie | Year: 2011

The demographic development will lead to a disproportionate increase of older people and to a significant increase of functional gastrointestinal disorders including dysphagia due to motility and reflux-related disorders, nausea and vomiting by gastrointestinal dysfunction and abdominal and pelvic pain caused by chronic obstipation, stool impaction and incontinence. This implies significant consequences with regard to the development of weight loss, anorexia, social disadvantages and increased mortality with serious socio-economic burden. Ageing processes are determined by differentiated neurogeneration of the myenteric plexus (cholinergic degeneration) through reactive oxygen and nitrogen species and alteration of protective and regenerative processes. Age-related gastrointestinal dysfunctions may be caused by the ageing gastrointestinal tract itself or by other age-related diseases such as tumour, neurological or inflammatory diseases, anatomic changes, therapeutic medication, polymorbidity or malnutrition. Because of the significant therapeutic options, differential diagnosic work-up is mandatory also in elderly patients. © 2010 Georg Thieme Verlag KG Stuttgart · New York.

Malignant central airway obstruction is a common problem in lung cancer. A symptomatic stenosis can often be treated successfully using endoscopy. Different approaches for recanalisation are available. The goal of treating exophytic obstruction is to remove the endobronchial tumour growth. Mechanic debulking, electrocautery/diathermy, argon plasma coagulation, laser resection and cryoextraction are techniques that can provide immediate relief. Cryotherapy, brachytherapy and photodynamic therapy show delayed recanalisation effects. Silicone or self-expanding metallic airway stents can be used for the treatment of airway obstruction due to extrinsic disease to restore and maintain airway patency. © Georg Thieme Verlag KG Stuttgart · New York.

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