[Heart transplantation: indications and results]. / Indikationen und Erfolge der Herztransplantation.

Heart transplantation has been established as therapy in patients with terminal heart failure who remain severely symptomatic (NYHA III-IV) despite optimal drug therapy and surgical interventions other than transplantation. In addition to symptoms, various objective criteria are used to determine the patients most suitable for transplantation. Of these, peak oxygen consumption below 12-14 ml/kg/min, no irreversibly elevated pulmonary resistance, and no major concomitant disease are most important. However, conventional therapy of advanced heart failure has considerably improved over the last decade. Thus, heart transplantation may be avoided or at least postponed in many patients. Nevertheless, continuous treatment at a heart failure/heart transplantation clinic in collaboration with the general practitioner is essential in these patients. This may allow to closely monitor these severely ill patients and to select the optimal point of time for transplantation. Prognosis after heart transplantation is relatively good with a 10-year survival of 63%. However, graft coronary artery disease and lymphomas are still unresolved problems which limit the success of heart transplantation. Competent clinical monitoring, aggressive therapy of conventional risk factors and good co-operation of patients and doctors are the basis for a successful outcome.

Incidence, progression and functional significance of cardiac allograft vasculopathy after heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy after heart transplantation leads to an accelerated form of atherosclerosis with marked and often diffuse vessel wall changes that limit long-term survival. Previous studies showed contradictory results relating vessel wall changes to endothelial vasodilator response. METHODS: A total of 30 cardiac transplant recipients were studied 3, 12, and 24 months after heart transplantation. Coronary angiography was performed at rest, during supine bicycle ergometry, and after 1.6 mg sublingual nitroglycerin. Coronary cross-sectional area (biplane coronary angiography) and coronary artery wall changes (intravascular ultrasound) were assessed and extent of intimal changes correlated to vasodilator responses to nitroglycerine and bicycle ergometry. RESULTS: Intravascular ultrasound showed significant intimal thickening in 43, 64, and 58% of patients at 3, 12, and 24 months. Intimal thickening 3 months after transplantation was related to donor age (r=0.70, P<0.01) but did not predict progression of disease that manifested itself angiographically as a decrease in coronary cross-sectional area at 12 and 24 months (P<0.005) and significant coronary stenosis in 12% of patients after 24 months. Endothelium-independent vasodilatation after nitroglycerin (33+/-15, 44+/-20, and 43+/-24%) was normal. Endothelium-dependent, flow-induced vasodilatation during exercise was decreased (14+/-11, 18+/-14, and 16+/-17%) but did not correlate to intimal changes assessed by ultrasound. CONCLUSIONS: The study confirms the high incidence of intimal thickening after heart transplantation as assessed by intravascular ultrasound. Impaired exercise-induced vasodilatation suggests diminished bioavailability of endothelium-derived nitric oxide to physiological stimulation but the lack of relationship between coronary wall changes and this functional impairment suggests intermittent and presumably reversible endothelial injury in graft atherosclerosis.

Acute cardiovascular effects of insulin-like growth factor I in patients with chronic heart failure.

Insulin-like growth factor I (IGF-I) enhances myofibrillar development in cardiomyocytes of rats in culture and in vivo. In addition, IGF-I has vasodilatory effects and improves cardiac function in healthy volunteers. This study was conducted to evaluate the acute hemodynamic effects of IGF-I in patients with chronic heart failure Eight patients with chronic heart failure were randomized to receive recombinant human IGF-I (60 micrograms/kg) or placebo, i.v., over 4 h in a cross-over, double blind study on 2 consecutive days. Electrocardiogram as well as systemic hemodynamics were continuously monitored over 7 h by flow-guided thermodilution and radial artery catheters. IGF-I was well tolerated by all patients, and no pathological changes on electrocardiogram were recorded. Compared with placebo, IGF-I increased the cardiac index by 27 +/- 3.7% (+/- SE; P < 0.0005) and the stroke volume index by 21 +/- 5.6% (P < 0.05), and decreased systemic vascular resistance by 28 +/- 4.4% (P < 0.0002), right atrial pressure by 33 +/- 9.0% (P < 0.003), and pulmonary artery wedge pressure by 25 +/- 6.1% (P < 0.03). Mean systemic and pulmonary artery pressure as well as heart rate and pulmonary vascular resistance were not significantly influenced by IGF-I treatment. Insulin and C peptide levels were decreased by IGF-I, whereas glucose and electrolyte levels remained unchanged. Urinary levels of norepinephrine decreased significantly (P < 0.05) during IGF-I infusion. Thus, acute administration of IGF-I in patients with chronic heart failure is safe and improves cardiac performance by afterload reduction and possibly by positive inotropic effects. Further investigations to establish whether the observed acute effects of IGF-I are maintained during chronic therapy appear to be warranted.

Endothelial control of vascular tone in chronic heart failure.

Patients with chronic heart failure (CHF) are hemodynamically characterized by increased vasoconstriction and a reduced vasodilator response to exercise. In addition to various compensatory neurohumoral mechanisms, there is evidence that the endothelium plays an important role in the abnormal vasodilator response. This evidence comes from studies investigating the microvascular response to regional, intra-arterial administration of the endothelium-dependent vasodilator acetylcholine, which found that the vasodilator response and therefore the bioavailability of nitric oxide (NO) was impaired in the microcirculation of the leg, forearm, and myocardium of patients with CHF. The mechanisms underlying this abnormal response are not entirely clear but may reflect a muscarinic receptor abnormality. Because conduit artery vasodilatation during hyperemic blood flow is also impaired and because this response is not dependent on muscarinic receptor activation, this possibility appears to be unlikely. However, impaired smooth muscle responsiveness to NO stimulation, impaired L-arginine availability or utilization, endothelial release of vasoconstricting prostanoids, increased NO degradation and reduced NO synthase activity have all been implicated in this impaired response. In addition, the vasoconstrictor activity of endothelin (ET)-1 appears to play an important role in the regulation of tone in CHF, although the importance of different ET receptors is not yet clear.

Cardiovascular and metabolic effects of insulin-like growth factor I at rest and during exercise in humans.

To determine whether insulin-like growth factor I (IGF-I) has systemic cardiovascular effects in humans, 60 micrograms/kg IGF-I or saline were injected sc in a cross-over, randomized, double blind fashion into eight healthy male volunteers. Cardiac function and performance were evaluated by echocardiography and exercise test. In parallel, the metabolic effects of IGF-I during exercise were investigated. IGF-I improved cardiac performance with a significant increase in stroke volume and cardiac output by 14% and 18% (P < 0.03 and P < 0.04), respectively. Ejection fraction increased by 9% after IGF-I treatment (P < 0.05). Heart rate was not significantly increased at rest or during exercise. Systolic blood pressure was slightly increased by IGF-I, whereas diastolic blood pressure was slightly decreased, resulting in a continuous increase in the blood pressure amplitude at rest and during exercise, but without reaching statistical significance. Maximal exercise duration and peak oxygen consumption were not changed. Exercise was uneventful, without pathological changes on electrocardiogram records. Glucose levels were unchanged, whereas insulin and C peptide levels were decreased by IGF-I at rest. During exercise, insulin levels were further decreased, and the insulin-sparing effect of exercise resulted in a further enhancement of tissue sensitivity to insulin. GH levels were suppressed by IGF-I treatment at rest, but were still stimulated by exercise. In conclusion, IGF-I has positive inotropic effects in man. Further investigation of the potential role of IGF-I in cardiac conditions such as heart failure appears to be warranted.

[Assessment of risk status using nutrition diagnostic studies in surgical patients. 1. Determination of preoperative risk status in patients with stomach cancer]. / Erfassung der Gefährdungslage mit Hilfe ernährungsdiagnostischer Untersuchungen bei chirurgischen Patienten. 1. Mitteilung. Bestimmung der präoperativen Gefährdungslage bei Patienten mit Magenkarzinom.

The diagnosis of the nutritional state is an essential component in determining the risk in patients with carcinoma of the gastrointestinal tract. Based on the results of multivariate, statistical analyses of numerous biochemical, anthropometric and immunologic parameters in 63 patients with gastric carcinoma, we can now simplify the determination of the nutritional state considerably. With the help of cluster analysis and together with clinical aspects, the nutritional state can be divided into 2 groups ('normal' and 'disturbed'), in contrast to the former classification ('normal' and several degrees of disturbed). Using discrimination analysis, a combination of parameters was found which allows a sufficiently good classification of subjects into either the 'normal' group or the 'disturbed' group, and in this way characterizes the nutritional state. Classification of the patients is accurate in 97% of the cases. 6 practically relevant parameters were determined with the discrimination analysis: serum albumin, serum transferrin, hemoglobin, upper arm circumference, triceps skin fold thickness, and the intracutaneous skin test quotient. The nutritional quotient, EQ2, can be determined from these values (in comparison to the nutritional quotient, EQ1, which is based on the 33 point evaluation scale), thus enabling a quantification of the nutritional state. The use of only individual parameters yields major differences from the results obtained with 6 parameters. However, a relation between the nutritional state and the existing immuno-competence can be suspected when the results - especially of the skin test reactions - are in agreement with the results of the lymphocyte transformation. The test results of cell-mediated immunity in particular represent the extent of a reduced immunological reaction as opposed to the results of humoral immunity. Inclusion of less complex immunological investigation procedures must be reserved for future studies. The determination of daily urea production (urea production rate; dependent on protein supply) can be implemented as a practically relevant and reliable supplemental test for the evaluation of the existing metabolic state.

[Behavior of immunoglobulins in non-A/non-B hepatitis--a contribution to prognostic evaluation]. / Das Verhalten der Immunglobuline bei der Non-A/Non-B-Hepatitis--Beitrag zur prognostischen Einschätzung.

It is reported on immunoglobulin long-term courses in 107 female patients with non-A/non-B-hepatitis. There were statistically significant differences between the group with healing (n = 35) and the group with chronic persisting hepatitis (n = 70) in the IgG- and IgA-values. The immunoglobulin courses in the chronic aggressive hepatitides (n = 2) were not statistically evaluated on account of the small number of cases. It is concluded (in analogy to the investigations of the behaviour of immunoglobulins in hepatitis B) that particularly the IgG course analysis is suitable to reveal the chronification of the non-A/non-B-hepatitis prognostically with high probability.

[Current aspects of the diagnosis of the nutritional status in surgery]. / Moderne Aspekte der Diagnostik des Ernährungszustandes in der Chirurgie.

An exact nutritional assessment is a prerequisite for parenteral, enteral or parenteral-enteral nutrition, especially after extended operations or during conservative therapy. By using biochemical methods (visceral proteins), anthropometric measurement (body mass, triceps skinfold, arm muscle circumference, creatinine-index) and immunological procedures (total lymphocyte count and skin testing with recall-antigens) it is possible to determine exactly the nutritional status, severity and type of malnutrition. Furthermore the patients immunocompetence can be evaluated. Determining the digestion and resorption capacity enables the route of application to be chosen.

[Nutrition diagnosis and therapy in chronic inflammatory intestinal diseases]. / Ernährungsdiagnostik und -therapie bei chronisch entzündlichen Darmerkrankungen.

Malnutrition can be detected by evaluating the nutritional situation of the patient. It can be influenced by special nutritional support in the pre- and postoperative period. A good nutritional status will lower the rate of postoperative complications.

[Behavior of plasminogen in prostatic carcinoma treated with cytonal]. / Das Verhalten des Plasminogens beim Prostatakarzinom unter dem Einfluss der Cytonaltherapie.

With the help of the lysis time method after Blix as well as of the radial immune diffusion after Mancini in blood donors and in patients with histologically ascertained carcinoma of the prostate estimations of plasminogen were performed. In the group of patients the controls were repeated after having finished the initial therapy. While with the help of the two methods plasminogen values were established before therapy which essentially were within the normal, after the initial therapy with cytonal a significant increase of plasminogen developed. The importance of these findings is discussed in connection with a possible increased rate of fibrinolysis in carcinoma of the prostate.

[Parenteral nutrition - present status and modern trends]. / Parenterale Ernährung -- Stand und moderne Trends.

In the present paper practical references for the use of aimed balanced nutrition, particularly of parenteral nutrition, in surgery are given. The complete and total parenteral nutrition is an intervening therapeutic form for the patient. Before the beginning of the nutrition a possibly comprehensive diagnosis of the condition of the nutrition with the help of the state of nutrition is necessary, the volume of which will be depend on the existing diagnostic possibilities of an institution. Moreover, the success and the effectivity of the parenteral nutrition depend on the optimum composition of the nutrient and on a good nutritional technique as well as on an optimum control of the course of nutrition. Taking into consideration the high use for the improvement of the results of treatment a considerable expenditure must be put up with. This means a very strong indication.

[Immunoglobulin D--peculiarities, biological function and clinical importance (author's transl)]. / Immunglobulin D--Eigenschaften, biologische Funktion und Bedeutung in der Klinik.

In the following paper an introducing survey about the properties of the immunoglobulin D is given, dealing with a possible biological function of this immunoglobulin as a triggering receptor on the surface of B-lymphocytes at the immune response. Moreover the at present advocating hypothesis of the maturation of the B-lymphocytes is explained. The importance of IgD by various diseases is discussed. High IgD-levels are a reference to a chronic antigenemia in the organism.

[Cholestatic hepatosis caused by Talinolol (Cordanum)?]. / Cholestatische Hepatose durch Talinolol (Cordanum)?

It is reported on a 38-year-old female patient who was treated for 18 days with 150 mg cordanum (talinolol) each and then fell ill with a dyspeptic clinical picture and signs of cholestase. The result of a liver biopsy was the picture of a cholestatic hepatosis. According to the results of the lymphocyte transformation test and the monocyte test as well as to the reexposition with following clinical recidivation the talinolol medication is to be regarded as cause. Pathogenetically is referred to the structural relations of talinolol to substances with paragroups as well as to a possible summation of different loads of the liver function.

[Critical remarks on the monocyte test]. / Kritische Bemerkungen zum Monozytentest.

The application of the monocyte test in the diagnostics of drug allergy is considered from a critical point of view. Further hospital application of the test and its evaluation are discussed.

[Macrophage-lymphocyte contact in peripheral blood smears. Brief report]. / Makrophagen-Lymphozyten-Kontakt im peripheren Blutausstrich. Kurze Originalmitteilung.

In the brief report the contact of macrophagues and lymphocytes which up till now was only observed in the bone-marrow, spleen, lymph nodes and in lymphocyte cultures as an expression of a beginning immunoreaction was also demonstrated photographically for the peripheral blood and in vivo.

[Lymphocyte transformation test used for the diagnosis of delayed reaction bacterial allergies]. / Der Lymphozyten-Transformations-Test in der Diagnostik der bakteriellen Allergie vom Spät-Typ

The results obtained show firstly, that, when allergy testing is performed, a positive delayed reaction indispensably has to be taken into consideration. Secondly, that there is a good correspondence between positive skin tests and the LTT. Thirdly, that, after 1 year's desensibilisation treatment, a specific tolerance has not appeared yet.