Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach?

Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

[The diabetic foot]. / Der diabetische Fuss.

Neuropathy, arterial obstruction and infection are involved to varying degrees in the development of the "diabetic foot". A careful diagnosis is necessary in order to comprehend the various noxa and to introduce the adequate therapy. In case of the predominantly neuropathic foot with malum perforans, one must essentially proceed in a conservative way; only callosities and osteomyelitic parts must be removed. In case of the predominantly angiopathic foot, revascularizing measures are most important. After improving the blood flow, the necrotic parts of the foot are sparingly resected. As prevention of a possible relapse, two things are necessary: accurately fitted shoes in order to prevent pressure points, and extremely careful foot care in order to prevent infections.

[The diabetic foot]. / Der diabetische Fuss.

Neuropathy, arterial obstruction and infection are involved to varying degrees in the development of the 'diabetic foot'. A careful diagnosis is necessary in order to comprehend the various noxa and to introduce the adequate therapy. In case of the predominantly neuropathic foot with malum perforans, one must essentially proceed in a conservative way; only cornea callosities and osteomyelitic parts must be removed. In case of the predominantly angiopathic foot, revascularizing measures are most important. After improving the blood flow, the necrotic parts of the foot are sparingly resected. As prevention of a possible relapse, two things are necessary: accurately fitted shoes in order to prevent pressure points, and extremely careful foot care in order to prevent infections.

[Control of diabetes and late complications]. / Equilibre du diabète et complications tardives.

When insulin was introduced in medical therapy in 1922, it permitted to save diabetics from premature death; however, it has allowed, after a certain period of time, for the appearance of a cohort of chronic complications connected more or less specifically to the degree of hyperglycemia. After a short review of the pathophysiology of the microangiopathy, the authors have tried to demonstrate, on the basis of numerous prospective and retrospective studies in the human as well as in the animal, that an important relationship exists between the degree of glycemic control and the severity of the classical complications, retinopathy, neuropathy and nephropathy. However, the most recent studies have stressed the role of some other factors, not well established in the past, as for example the potential negative impact on retinopathy of rapid normalization of glycemia, following a long period of poor metabolic control. Likewise, high blood pressure, smoking, genetic background, as well as probably also excess of protein intake, do play an important etiopathogenic role. Thus, the simplistic equation hyperglycemia = complications is not completely valid. Microangiopathic risk in insulin-dependent diabetics seems to be low as long as their HbAlc is below 7.5%, and they do not have hypertension and do not abuse tobacco. Finally, the general approach to therapy is redefined: Try to get as close as possible to near-normoglycemia by multiple insulin injections, without causing, however, major hypoglycemia; this should be done very early after the onset of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neuropsychological assessment of the effectiveness of OROS-methylphenidate in attention deficit hyperactivity disorder]. / Evaluación neuropsicológica de la eficacia del metilfenidato-OROS en el trastorno por deficit de atención/hiperactividad.

INTRODUCTION: There is wide evidence about dopaminergic and noradrenergic mechanisms in fronto-striatal circuits which are thought to be related with attention deficit hyperactivity disorder (ADHD) neurobiology. That dysfunction may explain core symptoms and part of executive deficits in cognitive functioning. Methylphenidate is effective in alleviating core symptoms, enhancing dopaminergic and noradrenergic biodisponibility. Less evidence in improving executive functions, specially working memory is found. AIMS: To assess if methylphenidate-OROS has a potential effect increasing working memory and attention parameters in ADHD children, and to determine if initial working memory and attention differences between ADHD and control group disappear after one month of daily methylphenidate-OROS treatment. SUBJECTS AND METHODS: Eleven children with ADHD were selected and as control group was chosen eleven children compared in age, intelligence quotient, school grade, and social-demographic status. Neuropsychological battery was administered in naive ADHD patients at three times, before treatment, after the first methylphenidate-OROS dose, and after one month of daily treatment. Simultaneously neuropsychological battery was administered to control group. RESULTS. Statistically significant differences were found in neuropsychological variables of working memory after one month daily treatment with methylphenidate-OROS and attention parameters after only one dose in ADHD group. Differences between naive ADHD and control group in terms of working memory were statistically significant before treatment but not after one month daily treatment. CONCLUSION: Methylphenidate-OROS improves attention achievement after the first dose and working memory after one month of daily treatment.

[Neuropsychological assessment of memory in attention deficit hyperactivity disorder: the role of executive functions]. / Evaluación neuropsicológica de la memoria en el trastorno pordéficit de atención/hiperactividad: papel de las funciones ejecutivas.

INTRODUCTION: There is an important agreement on the consideration of attention deficit hyperactivity disorder (ADHD) as a condition characterized by neurodevelopmental dysfunction of fronto-striatal dopaminergic and noradrenergic circuits with resultant executive deficits in cognitive functioning. AIM: To assess the existence of memory deficits in children with ADHD associated with a poor performance executive. SUBJECTS AND METHODS: We assess 14 children diagnosed with ADHD combined type and 14 controls matched on intellectual coefficient, age and level of schooling, in a neuropsychological evaluation protocol designed to assess executive functions and memory skills using Auditory Verbal Learning Test, Memory for Stories Test -Test of Memory and Learning (TOMAL)-, Complex Figure Text, Visual Selective Reminding Test (TOMAL), Tower of Hanoi, Memory Phrases Test (Siegel and Ryan), Digit Span (Wechsler Intelligence Scale for Children-Revised) and Tapping Test (Wechsler Memory Scale III). RESULTS: The ADHD group showed deficits in the learning and free recall of verbal material, in procedural and working memory. No group differences were observed in the visual memory tasks. CONCLUSIONS: The results are analyzed in terms of difficulty in coding strategies, storage and search of information previously stored in the group with ADHD, at least for the kind of verbal information. These difficulties are associated with deficits in executive functioning.

[New insulins in diabetes therapy]. / Neue Insuline in der Diabetesbehandlung?

The new MC or RI insulins are critically reviewed and the indications for switching to MC or RI pork insulin are discussed. A new means of determining the insulin requirement of brittle diabetics is short-time use of an insulin infusion apparatus.

Deinstitutionalization: those left behind.

Whether a retarded child can be cared for at home depends primarily on the ability of his or her family to function as primary caretakers. Not surprisingly, then, the rate at which retarded children are deinstitutionalized is being slowed by this country's failure to emphasize programs that are supportive of these children's families. After examining the discrepancy between the needs of families with retarded children and services currently being provided, the author proposes various changes in policy to increase assistance and support to the family as a unit.

[Lupus erythematosus in old age]. / Lupus erythematodes im Alter.

Over a period of 2 months an 88-year-old man developed progressively more severe breathing-related pain under the right shoulder blade, loss of appetite, general weakness, depressive mood, sub-febrile temperature and nocturnal sweating. Various inflammation parameters were raised (sedimentation rate 43 mm in the first hour; C-reactive protein 26 mg/dl; white cell count 12,500/microliters). There also were pleural effusion and signs of mild nonspecific hepatitis. Antibiotics were administered because bacterial pneumonia was suspected. But the patient's condition deteriorated and he developed nightly periods of disorientation. There was no evidence for any advanced malignancy. Immunological tests pointed towards older-onset systemic lupus erythematosus: titre for antinuclear antibodies markedly raised to 1:20 480; anti-DNA titre moderately raised to 1:125 IU/ml. The patient's general condition and the pleuritic pain improved within 2 days under treatment with prednisone (50 mg daily); the depression, disorientation and fever receded within a week. The anti-DNA titre fell to 47 IU/ml after 8 weeks. He was able to resume his usual social activities and was kept on a maintenance prednisone dose of 5.0 mg daily.

[Adjustment of unstable diabetics with a simple insulin infusion program]. / Einstellung labiler Diabetiker mit einem einfachen Insulin-Infusionsprogramm.

In view of the importance of knowing exactly how much insulin is required by diabetics who are difficult to control with subcutaneous insulin, an insulin infusion program has been tried in such patients. The apparatus, which was produced by Siemens as a prototype, works according to the following simple and flexible principle: During the day a basal rate of insulin is continuously infused. During the three main meals an additional rectangular insulin infusion is initiated by turning a knob. After an hour the apparatus switches automatically back to the basal ratio. We have used this machine in 13 patients who are fully mobile. 11 of them showed an almost ideal blood sugar profile after 4 days. After switching back to subcutaneous insulin 8 of these 11 patients did better than before but not as well as on the insulin infusion program.

[Candida endophthalmitis: diagnosis, course and therapy in 8 patients]. / Candida-Endophthalmitis: Diagnostik, Verlauf und Therapie bei 8 Patienten.

Over a two-year period 8 patients were hospitalized with a presumptive diagnosis of Candida endophthalmitis. 6 patients were heroin addicts, while in the 2 other patients no risk factor could be identified. The presumptive diagnosis was based on the typical findings of retinohyalitic exudate and exclusion of other factors causing endophthalmitis. Intravenous therapy with amphotericin-B and flucytosin resulted in definitive scar healing. In 1 patient vitrectomy was necessitated by recurrence of endophthalmitis resistant to antifungal therapy.

Optimal blood sugar control in labile diabetics using a portable open-loop insulin infusion system with a flexible program.

11 labile diabetics were well controlled after 2 days of an i.v., open-loop insulin infusion program consisting of constant, empirically determined, basal infusion rates (mean: 1.1 U/h) and superimposed rectangular one-hour insulin infusions between 2 and 8 U/h during the main meals. The steering unit switches automatically back to the basal infusion rate after one hour. An almost optimal blood sugar profile was already obtained on the third day of the infusion program. We believe that such a flexible, open-loop insulin infusion program would render long-term optimal blood sugar control in "labile" diabetics possible if the technological development ever allows implantation of the infusion pumps.

[Control of the juvenile diabetic with the insulin dosage device: indications and uses]. / Die Einstellung des juvenilen Diabetikers mit dem Insulindosiergerät: Indikation und Nutzen.

The Clinitest was used to assess the effect of inpatient treatment in 24 labile insulin-dependent diabetics with a portable open loop insulin infusion device. The Clinitest results one month prior to hospitalization were compared with those during 3 months following inpatient treatment. During the first month after the hospital stay 21 patients (88%) were better controlled. Only 15 (63%) maintained better control for the whole period of 3 months. After the hospital stay the patients experienced an average of 4 more slight hypoglycemic episodes than before hospitalization. In patients who were better controlled for the whole period of 3 months the insulin dose had been adjusted considerably. Besides inadequate daily adjustment of the insulin dose, half the patients were not sufficiently motivated and did not cooperate with their diabetologists. One third of the patients did not follow a diet and one fifth practiced inadequate insulin injection techniques. These were the major causes of poor control prior to hospitalization. The results show that short term treatment with an open loop insulin infusion device is worth while for all diabetics in whom less than one third of all Clinitests are sugarfree, and also for all those in whom there are doubts about the actual insulin requirement.

[Idiopathic thrombocytopenic purpura in pregnancy. Interdisciplinary care, demonstrated on a case report with a review of the literature]. / Idiopathische thrombozytopenische Purpura in der Schwangerschaft. Interdisziplinäre Betreuung, dargestellt an einem Fallbeispiel mit Literaturübersicht.

The case is reported of a 30-year-old primigravida presenting with idiopathic thrombocytopenic purpura (ITP) at 31 weeks gestation. Because the thrombocytopenia became progressively resistant to steroids, pregnancy was terminated at 36 weeks gestation by primary caesarean section after platelet transfusion. Subsequent therapy with high-dose intravenous gammaglobulin transiently reversed the thrombocytopenia. However, 3 weeks after delivery splenectomy was performed because of relapse of ITP. The baby showed only very mild, transient thrombocytopenia without clinical symptoms. Based on a literature survey covering 159 deliveries of women with ITP described in 18 publications in the period 1973-1982, the following points are discussed: 1. risk of ITP in pregnancy for mother and child (maternal mortality 0.6% per delivery, perinatal mortality 2.4%, risk of neonatal intracranial hemorrhage 2.4%), 2. therapy of ITP in pregnancy and its effects on the fetus; 3. mode of delivery; 4. perinatal management of the mother; 5. management of the newborn.

Effect of prolonged optimal blood sugar control by i.v. insulin administration on plasma free fatty acid and glycerol concentrations of insulin-dependent diabetics during exercise.

Four type I diabetics were kept close to normoglycemic during a period of 1 month by means of a an open loop i.v. insulin infusion system (Siemens). During submaximal physical exercise their metabolic response was nearly normal. No hypoglycemic episodes during exercise were registered despite the fact that the regular basal infusion rate was not changed. The level of free fatty acids rose approximately to the same extent as in normal subjects. A slight inhibition of lipolysis during i.v. insulin therapy was apparent from the less marked rise of the glycerol levels. The feasibility of a simple open loop i.v. insulin regimen over a prolonged period of time is underscored by these results which show that the basal insulin infusion rate can be kept constant during exercise.

[Progress and developments in insulin therapy]. / Fortschritte und Entwicklungen in der Insulintherapie.

BANTING and BEST revolutionized diabetes therapy with the discovery of insulin 57 years ago. Since then, progress in this area has been slow despite tremendous reseach efforts. The subcutaneous injection of a depot insulin does not provide optimal control of blood sugar. True progress has been brought about by intravenous insulin administration for the management of diabetic coma. The authors do not recommend ultra low dose therapy. The prognosis of diabetic coma is much better than 20 years ago, in particular because of much improved and continuous supervision of the circulation (CVP, ECG, K+ etc.). Pancreas and islet transplantation fail in man due to immunological rejection. The "artificial pancreas" with a glucose sensor is useful for research purposes, and for controlling blood sugar for a few days at most. The implantable glucose sensor is not yet in sight. The authors have treated diabetics successfully with a programmable flexible open loop infusion program. The basal insulin infusion rate can be varied from 0.25 to 2 U/h, and rectangular one hour extra insulin infusions between 2 and 10 U/h are superimposed by pushing a button on the steering unit. The pump automatically switches back to the basal rate after one hour. No hypoglycemic reactions have been observed in patients on ths program on the ward or at home. At present, technical problems with the catheter remain to be solved before this simple therapeutic approach can be applied routinely.

[Improvement in the treatment of diabetes by means of a portable insulin-infusion apparatus. Preliminary results in 4 unstable juvenile diabetics]. / Verbesserung der Diabetesbehandlung durch tragbare Insulin-Infusionsgeräte. Vorläufige Resultate bei 4 labilen juvenilen Diabetikern.

Four type 1 diabetics, 10 to 21 years after onset of diabetes and with no detectable levels of plasma C-peptide, were kept on intravenous insulin for 4 months by a portable open-loop insulin infusion system (Siemens, Germany). Using this system, a constant basal rate of insulin was continuously infused into the superior vena cava. During meals additional insulin was delivered for one hour. The patients went home after a few days on the ward, during which time the doses of insulin (basal and extra rates) were established. All four patients maintained the same diet, went to work and continued their personal habits as before. Blood sugar (Glucoquant) and glucosuria (Clinitest) were regularly controlled before, during and after this period. During long-term ambulatory treatment with the insulin pump improved metabolic control was achieved, as shown by lower mean blood glucose values, decreased urinary glucose excretion and by lowering of hemoglobin AIc. All four patients felt well and the number of complications, all technical, was relatively small.