[Coercive Measures in Child and Adolescent Psychiatry]. / Zwangsmaßnahmen in der Kinder- und Jugendpsychiatrie.

Coercive Measures in Child and Adolescent Psychiatry To keep the use of coercive measures in child and adolescent psychiatry low or reduce them completely, there needs to be a specific knowledge of the starting point. The study provides an overview of the current situation using a systematic literature review of published studies from the European and the outer European regions between 2005 and 2015. In summary only twelve publications addressed the topic, differentiated in four studies from inner and eight studies from outer European countries. In the studies from Europe, girls in their late adolescence experienced coercive measures more often, whereas the outer European studies identified more boys in early school age. Regarding the diagnoses of the respective patients, no distinct trend could be identified, as coercive measures were applied with a range of different diagnoses. In the European studies, coercive measures were more often used with children and adolescents fitting in the ICD-10-category F9. Results point to a lack of empirical studies concerning coercive measures in the context of child and adolescent psychiatry. Besides, clinical practice between the countries varies tremendously, resulting in difficulties comparing the findings. One possibility to address these issues might be a central register for every kind of coercive measure, as it was introduced in Baden-Württemberg lately and is currently in development for North Rhine-Westphalia.

[Prescriptions of psychotropic drugs to children and adolescents in Germany]. / Verordnungshäufigkeiten von Psychopharmaka bei Kindern und Jugendlichen mit psychischen Erkrankungen in Deutschland.

Pharmacotherapy of children and adolescents with psychotropic medication ongoing public debate in Germany. Increasing use of psychotropic medication was sometimes interpreted as overprescribing. In this systematic review prescribing patterns of stimulants, antidepressants and antipsychotics for children and adolescents and its development from 2000 to 2012 have been analyzed. An increase of prescriptions was observed in stimulants, antidepressants and antipsychotics. Compared with international data frequency of prescribed medication cannot be considered as overprescribing in general. Antipsychotics seem to be used mainly in behavioral use with an increasing frequency. Data indicates a trend towards more prescribing based on guidelines and evidence based treatments. Next to child and adolescent psychiatrists, pediatricians are most important prescribers.

[62-year old male patient with position-depending dyspnoe after hemipneumectomia]. / 62-jähriger Patient mit lageabhängiger Dyspnoe nach einseitiger Pneumektomie.

BACKGROUND: Dyspnoe is a symptom with a huge differential diagnostic spectrum. According to patients hemodynamic, acute forms can be caused by myocardial infarction, pulmonary embolism, pulmonary edema and heart rhythm disturbances while chronic forms can be caused by restrictive myocardial and pericardial diseases, hematooncological diseases, orthopedic deformations and chronic pulmonary diseases. The platypnea-orthodeoxia syndrome with underlying interatrial connection is a rare cause and need a special diagnostic work-up. CASE REPORT: A 62-year old male patient with previously known pneumectomy on right side due to underlying cancer presented with a 6-months history of increasing dyspnoe (NYHA III) on exertion and upright position. The physical examination just revealed a lack of ventilation on right side. The saturation drops from 97% in supine position to 68% in upright position. Transesophageal echocardiography revealed a compressed right atrium with a persisted foramen ovale (PFO) and atrial septal aneurysm resulting in a right-left shunt. After completing diagnostic work-up and excluding other possible causes for dyspnoe an interventional closure of interatrial connection was performed. Subsequently the symptoms of the patients resolved (NYHA I). CONCLUSION: The Platypnea-Orthodeoxia-Syndrome isa rare cause of dyspoe. The diagnosis can be made by echocardiography. Medical treatment of such disease is of less success, thus a closure of interatrial connection is recommended.

Prognostic Power of Pulmonary Arterial Compliance Is Boosted by a Hemodynamic Unloading Test With Glyceryl Trinitrate in Heart Failure Patients With Post-capillary Pulmonary Hypertension.

Background: Pulmonary hypertension (PH) is an established risk factor in patients with heart failure (HF). However, right heart catheterisation (RHC) and vasoreactivity testing (VRT) are not routinely recommended in these patients. Methods: The primary objective of the present study was to explore the impact of VRT using sublingual glyceryl trinitrate (GTN) on transplant/ventricular assist device-free survival in HF patients with post-capillary PH. RHC parameters were correlated retrospectively with the primary outcome. Results: The cohort comprised 154 HF patients with post-capillary PH undergoing RHC with GTN-VRT at a tertiary heart failure centre. Multiple parameters were associated with survival. After adjustment for established prognosis-relevant clinical variables from the MAGGIC Score, variables with the most relevant odds ratios (OR) obtained after GTN-VRT were: calculated effective pulmonary arterial (PA) elastance (adjusted OR 2.26, 95%CI 1.30-3.92; p = 0.004), PA compliance (PAC-GTN; adjusted OR 0.45, 95%CI 0.25-0.80; p = 0.006), and total pulmonary resistance (adjusted OR 2.29, 95%CI 1.34-3.93; p = 0.003). Forest plot analysis including these three variables as well as PAC at baseline, delta PAC, and the presence of combined post- and pre-capillary PH revealed prognostic superiority of PAC-GTN, which was confirmed by Kaplan-Meier analysis. Conclusions: In our cohort of symptomatic HF patients with post-capillary PH, improved PAC after administration of GTN was associated with survival independent of established hemodynamic and clinical risk factors. VRT using GTN may be better described as unloading test due to GTN's complex effects on the circulation. This could be used for advanced prognostication and should be investigated in further studies.

Increased Lipoprotein (a) concentrations in patients with chronic venous leg ulcers: a study on patients with or without postthrombotic syndrome.

Chronic venous leg ulcers are common and cause considerable burden of disease for affected patients with significant costs for health care systems worldwide. The complex pathophysiology of chronic venous leg ulcers is still not entirely understood. In addition, reliable pathogenic and/or prognostic parameters are not known. Published data suggest that patients with chronic venous leg ulcers reveal congenital or acquired thrombophilia. We examined the serum Lipoprotein (a) [Lp(a)] level, a proatherogenic and prothrombotic risk factor, in patients with chronic venous leg ulcers (n=210, stratified into patients with postthrombotic syndrome or without) and in a healthy control group (n=341). Forty-two percent of all patients, compared with 20% of healthy controls, revealed significantly increased Lp(a) serum concentrations above 0.3 g/L. Furthermore, 49% without postthrombotic syndrome but only 35% with postthrombotic syndrome showed increased Lp(a) levels. The increase of Lp(a) level was significantly different between all three groups (p<0.001). There was no correlation of Lp(a) levels and CRP values in all groups. Based on these data, it is conceivable that Lp(a) plasma level is a novel pathogenic parameter for chronic venous leg ulcers. Elevated concentrations may contribute to the pathogenesis through induction of thrombogenic microcirculatory dysregulations, impaired extravascular fibrinolysis, or other mechanisms like proinflammatory effects.

Dissection of the Left Coronary Artery after Surgical Aortic Valve Replacement.

Our report presents a 73-year-old female patient with severe aortic stenosis who was admitted to our department for a surgical aortic valve replacement. After an uneventful surgery, a worsening low cardiac output syndrome with signs of myocardial ischemia occurred. Immediate angiography revealed a diffuse left coronary dissection starting from the ostium extending to the periphery of the left coronary system. The diffuse nature of the dissection ruled interventional management out and thus has been treated with urgent coronary bypass surgery. However, after an antecedent favorable course, the patient died 2 months later due to pneumonia resulting in septic shock.

General measures and supportive therapy for pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018.

In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to general measures (i.e. physical activity/supervised rehabilitation, pregnancy/contraception, elective surgery, infection prevention, psychological support, travel) and supportive therapy (i.e. anticoagulants, diuretics, oxygen, cardiovascular medications, anaemia/iron deficiency, arrhythmias) for PAH. While the European guidelines provide detailed recommendations for the use of targeted PAH therapies as well as supportive care, detailed treatment decisions in routine clinical care may be challenging, and the relevance of supportive care is often not sufficiently considered. In addition, new evidence became available, thus requiring a thorough reevaluation of specific recommendations. The detailed results and recommendations of the working group on general measures and supportive therapy for PAH, which were last updated in the spring of 2018, are summarized in this article.

Chronic thromboembolic pulmonary hypertension (CTEPH): Updated Recommendations from the Cologne Consensus Conference 2018.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.

Chronic thromboembolic pulmonary hypertension (CTEPH): updated Recommendations of the Cologne Consensus Conference 2011.

In the 2009 European Guidelines on the diagnosis and treatment of pulmonary hypertension (PH), one section covers aspects of pathophysiology, diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). The practical implementation of the guidelines for this disease is of crucial importance, because CTEPH is a subset of PH which can potentially be cured by pulmonary endarterectomy (PEA). Nowadays, CTEPH is commonly underdiagnosed and not properly managed. Any patient with unexplained PH should be evaluated for the presence of CTEPH, and a ventilation/perfusion (V/Q) lung scan is recommended as screening method of choice. If the V/Q scan or CT angiography reveals signs of CTEPH, the patient should be referred to a specialized center with expertise in the medical and surgical management of this disease. Every case has to be reviewed by an experienced PEA surgeon for the assessment of operability. In this updated recommendation, important contents of the European guidelines were commented, and more recent information regarding diagnosis and treatment was added.

Immunohistochemical localization of insulin-like growth factor-II and its binding protein-6 in human epithelial cells of Malassez.

So-called epithelial rests of Malassez are derived from the Hertwig's root sheath and are located in the periodontal ligament, with still unknown functions. Different pathological conditions may lead to proliferation of these otherwise non-proliferative cell clusters. The insulin-like growth factor (IGF) system is an important growth factor system controlling proliferation and differentiation. In our study on Malassez cells from extracted human deciduous teeth, we investigated their structure by means of light and electron microscopy. Although they appeared as cellular clusters with a uniform epithelial phenotype, immunohistochemical analyses of components of the IGF system revealed an unique pattern: weak immunoreactivity could be seen for IGF-II while among all IGF binding proteins (IGFBPs) only IGFBP-6 and weakly IGFBP-4 were detectable in epithelial cells of Malassez. Since IGFBP-6 has a very high affinity for IGF-II and can inhibit its functions, we discuss that, in the normal periodontal ligament, autocrine IGFBP-6 may function as an antiproliferative molecule suppressing mitogenic effects of IGFs on Malassez cells.