Med Klin
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Back pain has become quite a health problem in today's modern industrial society. Even though an excellent network of doctors and efficient treatments is available and most of the patients need only a few treatments, back pain is a common cause of illness and inability to work. This amounts to a considerable reduction in quality of life for those affected, additionally this also leads to a high economic burden for the national economy and the solidarity of the insured. ⋯ Savings through restrictive prescriptions for medications therefore have no great impact on total costs. Only a more efficient therapy, which reduces sick days, number of recurrences and development of chronic illness as well as a more effective prevention, is able to limit the costs of back pain in the long-run. Therefore, more research on a broader base may result in a significant benefit in this area.
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The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. ⋯ An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.
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Hypertrophic cardiomyopathy is defined as a primary, sometimes familial and genetically fixed myocardial hypertrophy. In the obstructive form of the disease (HOCM) a dynamic outflow tract obstruction of the left, occasionally also the right ventricle can be found. HOCM is the most frequent cause of stress-induced syncope or sudden cardiac death in younger patients. ⋯ Due to remodeling after circumscribed myocardial necrosis further gradient reduction has been observed during follow-up. Optimization of ablated septal area by echocardiographic monitoring resulted in reduction of the most important complication (trifascicular block with need of permanent pacemaker implantation) and improvement of acute and follow-up results. Long-term follow-up and comparison with established treatment options are necessary to evaluate the definitive importance of the promising new treatment.
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The main feature of idiopathic dilated cardiomyopathy is the dilation and impaired contractility of the left ventricle or both ventricles. The clinical picture with forward and backward failure is based on the pump impairment of the left ventricle. However, the clinical presentation of patients with dilated cardiomyopathy is indistinguishable from any other secondary form of heart failure. ⋯ According to cardiac catheterization and evaluation of the endomyocardial biopsy idiopathic left ventricular dysfunction can be further stratified using the criterion of a myocardial virus persistence and the presence/absence of inflammatory infiltrates. Idiopathic dilated cardiomyopathy (approximately 70 to 75%), virus-associated dilated cardiomyopathy (approximately 20 to 25%), myocarditis (approximately 7%) and autoimmune myocarditis (approximately 3%) are the 4 possible resulting forms of idiopathic left ventricular dysfunction. Beside conventional medical therapy there are new therapeutic concepts e.g. using interferon for enterovirus-positive patients and immunosuppression for autoimmune, virus-negative patients with a cellular infiltrate.
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The most recent WHO/ISFC classification of cardiomyopathies (1995) describes as cardiomyopathies all heart muscle diseases, which demonstrate a disturbance of cardiac function. It distinguishes primarily according to hemodynamic criteria the following 5 forms: 1. dilated (DCM), 2. hypertrophic (HCM), 3. restrictive (RCM) from 4. arrhythmogenic right ventricular (ARVCM) and assembles in 5. non-classified cardiomyopathies (NKCM) the non-classifiable forms. When compared to the 18-year-old former classification several points have been altered: 1. ⋯ Hypertensive cardiomyopathy corresponds to left ventricular hypertrophy in hypertensive patients, valvular cardiomyopathy identifies cardiomegaly, which cannot sufficiently be explained by the valvular dysfunction (stenoses or insufficiency) alone. For the first time the term inflammatory cardiomyopathy has been used and defined as acute or chronic myocarditis associated with cardiac dysfunction, for which etiological and pathogenetic factors, e.g. viral or microbial infection or autoimmune processes have been made responsible. Two ISFC task forces have just recently clarified in consensus conferences the immunohistopathological criteria for chronic myocarditis or dilated cardiomyopathy with inflammation (DCMi: > 14 lymphocytes or macrophages/mm3) and set standards for molecular and virological diagnoses in endomyocardial biopsies.