A history of arterial hypertension does not affect mortality in patients hospitalised with congestive heart failure.

OBJECTIVES: To evaluate the importance of a history of hypertension on long-term mortality in a large cohort of patients hospitalised with congestive heart failure (CHF). DESIGN: Retrospective analysis of 5491 consecutive patients, of whom 24% had a history of hypertension. 60% of the patients had non-systolic CHF, and 57% had ischaemic heart disease. SETTING: 38 primary, secondary and tertiary hospitals in Denmark. MAIN OUTCOME MEASURES: Total mortality 5-8 years after inclusion in the registry. RESULTS: Female sex and preserved left ventricular systolic function was more common among patients with a history of hypertension. 72% of the patients died during follow up. A hypertension history did not affect mortality risk (hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.92 to 1.07). Correction for differences between the normotensive and hypertensive groups at baseline in a multivariate model did not alter this result (HR 1.08, 95% CI 1.00 to 1.17, p = 0.06). The hazard ratio was similar in patients with and without a history of ischaemic heart disease. Hence, a specific effect of hypertension in the group of patients with CHF with ischaemic heart disease, as suggested in earlier studies, could not be confirmed. CONCLUSION: A history of arterial hypertension did not affect mortality in patients hospitalised with CHF.

Renal and cardiac function during alpha1-beta-blockade in congestive heart failure.

UNLABELLED: The kidney and the neurohormonal systems are essential in the pathogenesis of congestive heart failure (CHF) and the physiologic response. Routine treatment of moderate to severe CHF consists of diuretics, angiotensin-converting enzyme (ACE) inhibition and beta-blockade. The need for control of renal function during initiation of ACE-inhibition in patients with CHF is well known. The aim of this study was to investigate whether supplementation by a combined alpha1-beta-blockade to diuretics and ACE-inhibition might improve cardiac function without reducing renal function. METHODS: Fourteen patients treated for moderate to severe CHF with diuretics and ACE inhibitors were investigated at baseline, after 4 months of maximum carvedilol treatment and after withdrawal of carvedilol. RESULTS: Carvedilol lowered blood pressure and heart rate but increased left and right ventricular ejection fractions without changing cardiac output or pulmonary blood volume. At the same time, a minor fall was seen in glomerular filtration rate (GFR). but renal blood flow was unchanged and effective renal plasma flow slightly increased. Carvedilol also lowered the plasma levels of angiotensin II and aldosterone. All changes were reversed after withdrawal of carvedilol. CONCLUSIONS: Carvedilol augments ACE-inhibitor-induced vasodilation by lowering blood pressure, and angiotensin II beside reducing heart rate. The heart adapts to the haemodynamic alterations without changes in cardiac output and pulmonary blood volume. GFR is slightly lowered despite no changes in renal blood flow and a slight increase in effective renal plasma flow. The study emphasizes the need for control of renal function during treatment with carvedilol in patients with CHF.

Use of left ventricular ejection fraction or wall-motion score index in predicting arrhythmic death in patients following an acute myocardial infarction. The TRACE Study Group.

All-cause mortality and morbidity following an acute myocardial infarction (AMI) are correlated to LV systolic dysfunction. The correlation is closest with mortality and morbidity associated with congestive heart failure (CHF). Prediction of arrhythmic death in patients with AMI relies on the correlation between arrhythmic death and "sudden unexpected death" defined as death within 1 hour of onset of new symptoms. Assessment of late potentials, heart rate variability (HRV), T wave alternans, arrhythmias seen on Holter monitoring or during exercise testing, electrophysiological testing, and baroreceptor assessment have all proven to be useful in the prediction of sudden death even when LV systolic function is known. In selected populations HRV is superior to LV systolic function assessment in predicting sudden death and/or arrhythmic events, and may even predict all-cause mortality with the same precision. Comparisons of other methods with LV function assessment should be interpreted with care because most methods have been evaluated in subgroups of infarct patients with a low risk of death. Results from a large series of high risk patients with AMI (the TRAndolapril Cardiac Evaluation study) have shown that even in patients with severe depressed LV systolic function around one-third of the patients will die suddenly. The current situation is that LV function appears to be the best method of predicting death whereas other methods appear very promising for detecting arrhythmic death in more selected populations. The optimal method for selecting patients at high risk of arrhythmic death has not yet been developed, but a combination of LV function and another method, i.e., HRV, appears promising. This may ensure that the enrolled patients have an increased risk of death and that this risk will be due to arrhythmic events. Patients with LVEF of 10% or less can be excluded as they will most likely not die suddenly.

Glucose tolerance status and severity of coronary artery disease in men referred to coronary arteriography.

Increasing attention is being paid to disturbances in glucose metabolism as key explanatory factors for the development of coronary artery disease. We studied the prevalence of impaired glucose tolerance and non-insulin-dependent diabetes and the levels of plasma insulin after an oral glucose tolerance test in 99 men with heart disease but without a history of diabetes referred to coronary arteriography; we also compared the outcome with a matched control group (n = 116). The severity of atherosclerosis in coronary angiograms was evaluated according to glucose tolerance status. Among the 99 patients with coronary artery disease, 37.4% had an abnormal oral glucose tolerance test result, whereas only 18.1% of the control group had an abnormal result (p < 0.01). Moreover, patients with heart disease and normal glucose tolerance were hyperinsulinemic compared with the control group (p < 0.01). By analysis of variance no statistically significant difference in severity of coronary atherosclerosis on coronary angiograms was found. In conclusion, we demonstrated frequent disturbances in glucose metabolism indicating insulin resistance in patients with ischemic heart disease without a history of diabetes, but we could not demonstrate a relation between these disturbances and degree of coronary atherosclerosis.

[The multi-point contact (MPC) osteosynthesis plate. 2: Initial clinical results of therapy of forearm fracture with MPC plates]. / Die Multi-Point-Contact-(MPC-)Osteosyntheseplatte. Teil 2: Erste klinische Ergebnisse zur Therapie der Unterarmfraktur mittels MPC-Platten.

Plate osteosynthesis is a method of choice in the treatment of forearm fractures with senso-motorical impairment, poorly or non-reduceable, retained, fragmented and open fractures. Dislocated fractures of the forearm frequently cause problems because of their poor reduction and retention. In such cases, exclusively conservative treatment requires reduction and change of therapeutical approach to avoid functional limitations resulting from axial malpositioning. The sincere contact of bone fragments, accompanied by sufficient anatomical axial and conservative reduction techniques that maintain parossal perfusion as well as a limited osteosynthesis plate contact should be the aim of the operative strategy. The use of a new titanium osteosynthesis plate system with multi-point contact between bone and plate promotes the incorporation of vessels and callus formation at the bone-plate interface and leads to the realization of the aforementioned aim, which was revealed in animal studies before. In order to examine the results, 18 patients with forearm fractures were studied, which underwent reduction and internal fixation using this new titanium osteosynthesis plate, the multi-point contact plate (MPC) system. In these patients, functional and radiological results after plate removal were studied. Our initial clinical experiences with the MPC-plate for internal fixation confirm the animal study results. The in-growth of parossal vessels into the multiple inter-point spaces enhances the subimplant (bio-logical) formation of callus, which can be visualized radiographically and intraoperatively after plate removal. These results indicate that the MPC plate has marked advantages over conventional plates.

Influence of age on the prognostic importance of left ventricular dysfunction and congestive heart failure on long-term survival after acute myocardial infarction. TRACE Study Group.

The aim of this study was to assess the importance of congestive heart failure and left ventricular (LV) systolic dysfunction after an acute myocardial infarction (AIM) on long-term mortality in different age groups. A total of 7,001 consecutive enzyme-confirmed AMIs (6,676 patients) were screened for entry into the TRAndolapril Cardiac Evaluation (TRACE) study. Medical history, echocardiographic estimation of LV systolic function determined as wall motion index, infarct complications, and survival were documented for all patients. To study the importance of congestive heart failure and wall motion index independent of age, we performed Cox proportional-hazard models in 4 different age strata (< or = 55 years, 56 to 65 years, 66 to 75 years, and > 75 years). Patients in these strata had 1-year mortality rates of 5%, 11%, 21%, and 32%, respectively. Three-year mortality rates were 11%, 20%, 34%, and 55%, respectively. The risk ratios (and 95% confidence limits) associated with congestive heart failure in the same 4 age strata were 1.9 (1.3 to 2.9), 2.8 (2.1 to 3.7), 1.8 (1.5 to 2.2) and 1.8 (1.5 to 2.2), respectively. The risk ratios associated with decreasing wall motion index were 6.5 (3.6 to 11.4), 3.3 (2.3 to 4.6), 2.7 (2.2 to 3.4), and 2.1 (1.7 to 2.6), respectively. In absolute percentages, there was an excess 3-year mortality associated with congestive heart failure in the 4 age strata of 14%, 24%, 25%, and 28% respectively. The absolute excess in 3-year mortality associated with LV systolic dysfunction in the 4 age strata was 15%, 19%, 25%, and 21%, respectively. Thus, the relative importance of LV systolic dysfunction and congestive heart failure diminished with increasing age. However, the absolute excess mortality associated with congestive heart failure and LV systolic dysfunction was more pronounced in the elderly than in the young.

Immunologic responses in human recipients of osseous and osteochondral allografts.

A multiinstitutional study was carried out to evaluate immunologic responses for human recipients of massive frozen (-80 degrees C) osseous and osteochondral allografts. Allografts were used to reconstruct skeletal defects associated with a variety of traumatic degenerative and neoplastic disorders. Serum samples were obtained before surgery and from 1 month to 4 years after surgery. Sera were tested by microcytotoxicity against T cells from 60 donors for human leukocyte antigen Class I antibodies and against beta 2-microglobulin treated B cells from 40 donors for human leukocyte antigen Class II antibodies. Panels were selected to represent the majority of known human leukocyte antigen specificities. Of the 84 cases evaluated, 62 (74%) received blood transfusions and 28 of 44 (64%) female recipients had been previously pregnant. Sensitization before transplant was shown in 33 of 84 (39%) patients. After grafting, 49 of 84 (58%) recipients showed evidence of sensitization to Class I antigens and 46 of 84 (55%) recipients showed evidence to sensitization to Class II antigens. Overall sensitization was 67%.

Effects of selected thermal variables on the mechanical properties of trabecular bone.

Osteoarticular allografts are commonly used in the treatment of segmental bone loss due to a wide resection of tumour. While the use of such grafts has met with considerable clinical success, fractures are a recognized complication of allograft use. Although trabecular bone can play an important structural role in the function of segmental allografts, few data exist on the effects of common storage and sterilization procedures on the mechanical properties of trabecular bone. To this end, we investigated with these experiments the effects of freezing at -20 degrees C, freezing at -70 degrees C, eight freeze-thaw cycles at -20 degrees C, freeze-drying, boiling and autoclaving on the compressive modulus and strength of bovine trabecular bone. Of these treatments, boiling and autoclaving were the only treatments to alter the properties of bovine trabecular bone, resulting in 26 and 58% reductions in strength, respectively. Autoclaving also significantly reduced the compressive modulus by 59%. From these data, freezing at temperatures between -20 and -70 degrees C does not appear to compromise the structural integrity of trabecular bone.

Sonographical findings in Whipple's disease. A case report with regard to the literature.

We present a case report of a 60-year-old male patient and subsequently discuss sonographical findings in Whipple's disease. This particular patient showed an intraabdominal tumorous mass. Symptoms of a malabsorption disorder were absent. Computer-assisted tomography and radiological examination could not determine the origin of the tumor. Sonography demonstrated a polycyclic hyperechoic mass in the root of the mesentery. The small intestine was not distended and showed normal peristalsis. Its wall was hyperechoic concentrically thickened. Final diagnosis was established from a diagnostic laparotomy showing enlarged lymph nodes and distended lymphatic vessels. Based on the literature the described sonographical findings seem to be typical in cases of Whipple's disease.

[Bowenoid papulosis in men. Sexually transferred intra-epithelial neoplasia of the ano-genital region]. / Bowenoid papulose hos maend. Seksuelt overførbar intraepitelial neoplasi i genito-analregionen.

The clinical picture in three cases of Bowenoid papulosis is reported. Histology indicates carcinoma in situ changes and koilocytosis. Evidence points to the role of human Papillomavirus in the etiology of the disease.

Freeze-dried segmental fibular allografts in azathioprine-treated dogs.

The successful use of a bone allograft may be negated by the host's immune response. This investigation assessed the efficacy of combining freeze-dried cortical allografts in three to six weeks azathioprine-immunosuppressed dogs. Forty-eight of 94 adult mongrel dogs were initiated for this study, and 46 of 94 were previously published and recompiled. The dogs were divided into five groups and followed for six months: Group I consisted of bilateral fresh autografts as an external control; Group II assessed the effect of freeze-drying on autogenous bone; Group III compared fresh autografts with fresh allografts; Group IV assessed the effect of freeze-drying on allografts; and Group V assessed the combined effect of placing freeze-dried allografts in immunosuppressed hosts. Biweekly roentgenograms were made to evaluate the time to union and the incidence of graft fatigue failure. Mechanical graft strength was assessed by rapid torsional loading to failure at the time of sacrifice. Biologic repair was assessed with the use of tetracycline and microradiographic techniques. The incorporation and repair of a fresh cortical autograft is better than that of a freeze-dried autograft because of fractures, nonunion, or delayed union of graft-host junctions; freeze-dried autografts have increased peripheral and internal resorption, yet an increased peripheral bony callus maintains normal graft strength; freeze-dried and fresh allografts are similar in roentgenographic characteristics, mechanical strength, and in the mechanism of graft incorporation; the use of three or six weeks azathioprine therapy did not improve the fate of freeze-dried allografts.

Biology of bone transplantation.

A problem with bone grafting is the availability of the appropriate material and its acquisition. Thus, autogenous materials are obtained with certain costs to the patient. The alternative, allografting, has achieved moderate success, while synthetic implants as another alternative can be easily manufactured, but these materials are susceptible to wear, tear, and fixation. The intent of this article is to describe the biology of autogenous bone graft repair and its correlative biomechanics; to describe the biologic aspects of allograft repair; and to describe the alternatives when autogenous bone proves insufficient.

A roentgenographic, biomechanical, and histological evaluation of vascularized and non-vascularized segmental fibular canine autografts.

Advocates of vascularized bone grafts believe that these grafts should have a decreased time to graft-host union, and that they should be mechanically stronger than conventional (non-vascularized) grafts. The objectives of the present study were to determine the rate and pattern of repair in vascularized autogenous cortical bone grafts, to determine the mechanical strength of the grafts, and to correlate the mechanical strength with the biological repair. Forty-nine adult male mongrel dogs were divided into six groups to evaluate conventional (non-vascularized), cuff (periosteal-encased, non-vascularized), and vascularized segmental grafts. The fibula was the site of experimentation and all grafts were four-centimeter cortical segments. The vascularized and conventional grafts were analyzed at two, six, twelve, and twenty-four weeks. The cuff grafts were analyzed at twenty-four weeks and were compared with conventional grafts to assess the effect of the periosteal soft tissue. Roentgenograms were made every two weeks to evaluate the time to union. The mechanical strength of each graft was assessed by determining rapid torsional load to failure. Biological repair was assessed by tetracycline labeling for new-bone formation and by microradiographic techniques for porosity and cross-sectional areas. The study showed that conventional and cuff grafts were similar in terms of mechanical and biological repair at six months. At all sampling intervals, the vascularized grafts exhibited histological findings that were consistent with viability. The conventional and vascularized grafts underwent different mechanisms of repair. The conventional, non-vascularized grafts healed by peripheral and internal resorption followed by callus encasement and osteonal remodeling.(ABSTRACT TRUNCATED AT 250 WORDS)

Electromagnetic stimulation of canine bone grafts.

We evaluated the use of pulsed electromagnetic-field stimulation to affect the rate of healing or incorporation of segmental autogenous cortical bone grafts in the dog in vivo. This non-invasive method of electrical stimulation has been implicated in increasing bone osteogenesis or augmentation of the repair process in the canine fibular osteotomy. We utilized two-month and six-month stimulation protocols. At six months, all of the animals were evaluated biomechanically using rapid-loading torsional testing. Histological evaluation using tetracycline labeling was used to evaluate cumulative new-bone formation and porosity, while graft-host time to union was evaluated roentgenographically every two weeks. Recent reports have implied that particular pulse configurations might be effective in improving graft revascularization and incorporation. The results of our investigation indicated that there was no significant effect on the biomechanical strength, histological presentation, or time to union with either two months or six months of pulsed electromagnetic-field stimulation using the particular waveform described.

The biology of bone graft repair.

Cancellous and cortical autografts histologically have three differences: (1) cancellous grafts are revascularized more rapidly and completely than cortical grafts; (2) creeping substitution of cancellous bone initially involves an appositional bone formation phase, followed by a resorptive phase, whereas cortical grafts undergo a reverse creeping substitution process; (3) cancellous grafts tend to repair completely with time, whereas cortical grafts remain as admixtures of necrotic and viable bone. Physiologic skeletal metabolic factors influence the rate, amount, and completeness of bone repair and graft incorporation. The mechanical strengths of cancellous and cortical grafts are correlated with their respective repair processes: cancellous grafts tend to be strengthened first, whereas cortical grafts are weakened. Bone allografts are influenced by the same immunologic factors as other tissue grafts. Fresh bone allografts may be rejected by the host's immune system. The histoincompatibility antigens of bone allografts are presumably the proteins or glycoproteins on cell surfaces. The matrix proteins may or may not elicit graft rejection. The rejection of a bone allograft is considered to be a cellular rather than a humoral response, although the humoral component may play a part. The degree of the host response to an allograft may be related to the antigen concentration and total dose. The rejection of a bone allograft is histologically expressed by the disruption of vessels, an inflammatory process including lymphocytes, fibrous encapsulation, peripheral graft resorption, callus bridging, nonunions, and fatigue fractures.