Intra-pericardial thrombin injection as bailout strategy in iatrogenic pericardial tamponade.

BACKGROUND: Cardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as a sealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as a bailout strategy for pericardial tamponade following percutaneous cardiac interventions. METHODS: In a 5-year single-centre retrospective analysis we identified 31 patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as a bailout strategy was administered in 5 of 31 patients (16.1%). RESULTS: Patients receiving intra-pericardial thrombin were in a more critical state when thrombin was applied, as demonstrated by a higher rate of resuscitation (40% versus 26.9%) and a trend toward a prolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30 days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin. CONCLUSION: Intra-pericardial thrombin injection could be considered as a bailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.

Hormonal Prostaglandin F2α Mediates Behavioral Responsiveness to a Species-Specific Multi-component Male Hormonal Sex Pheromone in a Female Fish.

Although hormonally-derived female sex pheromones have been well described in approximately a dozen species of teleost fish, only a few male sex pheromones have been characterized and the neuroendocrine underpinnings of behavioral responsiveness to them is not understood. Herein, we describe a study that addresses this question using the goldfish, Carassius auratus, an important model species of how hormones drive behavior in egg-laying teleost fishes. Our study had four components. First, we examined behavioral responsiveness of female goldfish and found that when injected with prostaglandin F2α (PGF2α), a treatment that drives female sexual receptivity, and found that they became strongly and uniquely attracted to the odor of conspecific mature males, while non-PGF2α-treated goldfish did not discern males from females. Next, we characterized the complexity and specificity of the male pheromone by examining the responsiveness of PGF2α-treated females to the odor of either mature male conspecifics or male common carp odor, as well as their nonpolar and polar fractions. We found that the odor of male goldfish was more attractive than that of male common carp, and that its activity was attributable to both its nonpolar and polar fractions with the later conveying information on species-identity. Third, we hypothesized that androstenedione (AD), a 19-carbon sex steroid produced by all male fish might be the nonpolar fraction and tested whether PGF2α-treated goldfish were attracted to either AD alone or as part of a mixture in conspecific water. We found that while AD was inactive on its own, it became highly attractive when added to previously unattractive female conspecific water. Lastly, in a test of whether nonhormonal conspecific odor might determine species-specificity, we added AD to water of three species of fish and found that while AD made goldfish water strongly attractive, its effects on other species holding water were small. We conclude that circulating PGF2α produced at the time of ovulation induces behavioral sensitivity to a male sex pheromone in female goldfish and that this male pheromone is comprised of AD and a mixture of body metabolites. Because PGF2α commonly mediates ovulation and female sexual behavior in egg-laying fishes, and AD is universally produced by male fishes as a precursor to testosterone, we suggest that these two hormones may have similar roles mediating male-female behavior and communication in many species of fish.

Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

The German CPU registry: Comparison of smokers and nonsmokers.

BACKGROUND: Chest pain is a major reason for admission to an internal emergency department, and smoking is a well-known risk factor for coronary artery disease (CAD) and acute coronary syndrome (ACS). The aim of this analysis is to illustrate the differences between smokers and nonsmokers presenting to German chest pain units (CPU) in regard to patient characteristics, CAD manifestation, treatment strategy, and prognosis. METHODS: From December 2008 to March 2014, 13,902 patients who had a complete 3­month follow-up were enrolled in the German CPU registry. The analysis comprised 5796 patients with ACS and documented smoking status. RESULTS: Of all the patients in the CPU registry, 35.2% were smokers. Compared with nonsmokers, they were 13.5 years younger (58.2 vs. 71.7 years, p < 0.001), predominantly men (77.1% vs. 65.2%, p < 0.001), and were more frequently diagnosed with single-vessel disease (32.1% vs. 25.2%) as well as ST-elevation myocardial infarction (STEMI; 23.8% vs. 15.5%, p < 0.001). Although the Global Registry of Acute Coronary Events (GRACE) Risk Score for hospital mortality was lower in the group of smokers (106.1 vs. 123.3, p < 0.001), we did not observe any differences in CPU death (0.4% vs. 0.4%, p = 0.69) and CPU major adverse cardiac event (MACE) rates (3.8% vs 2.9%, p = 0.073) between the groups. In the 3­month follow-up, we documented higher mortality rates in the nonsmoker group (1.9% vs. 2.9%, p = 0.035) in correlation with the GRACE Risk Score (80.3 vs. 105.2, p < 0.001). MACE rates were similar during the follow-up (3.1% vs. 4.1%, p = 0.065). CONCLUSION: Observations from the German CPU registry demonstrate that smoking is a strong predictor of acute CAD manifestation early in life, especially STEMI. In spite of a lower GRACE Risk Score and fewer comorbidities, smokers had a rate of hospital mortality similar to the older group of nonsmokers.

[Acute coronary syndrome with ST-elevation]. / Akutes Koronarsyndrom mit ST­Strecken-Hebung.

The current guidelines of the European Society of Cardiology have up-dated and confirmed the role of a primary percutaneous coronary intervention (PCI) as the preferred reperfusion therapy in patients with acute coronary syndrome and ST-elevation. The establishment of regional network structures for implementation of this reperfusion strategy is recommended and described. Primary PCI should preferably be carried out via the transradial route and should include the implantation of modern drug-eluting stents. In most cases of coronary multivessel disease, primary PCI should be limited to the treatment of the infarcted artery. Routine mechanical thrombus aspiration during primary PCI is no longer recommended. Recommendations for a specific anti-thrombotic and secondary prophylactic medication after primary PCI are highlighted.

[Management of valvular heart disease : ESC/EACTS guidelines 2017]. / Management von Herzklappenerkrankungen : ESC/EACTS-Leitlinie 2017.

After 5 years the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery have released an update on the guidelines for the management of valvular heart diseases. In recent years published results of randomized trials in patients with aortic valve stenosis have resulted in updated recommendations for catheter-based prosthesis implantation (TAVI), which is now extended to patients presenting without a low risk for conventional surgical valve replacement. In mitral or tricuspid valvular disease, the recommendations for catheter-based therapies are less strong because of a lack of supportive scientific data. A special focus of these updated guidelines is on concomitant antithrombotic therapy in valvular heart disease and in the context of a combination with coronary artery disease and/or accompanying arrhythmia. Special emphasis was again put on the multidisciplinary heart team for the diagnostics and treatment of patients with valvular heart disease. In order to support the quality of treatment for patients with valvular heart disease, it is suggested that heart valve centers of excellence should be established, which have to fulfil complex personnel, structural and technological prerequisites.

[Coronary sinus devices for treatment of functional mitral valve regurgitation. Solution or dead end?]. / Koronarsinus-Devices zur Behandlung der funktionellen Mitralklappeninsuffizienz. Ausweg oder Sackgasse?

In this article we review the currently available data on percutaneous mitral valve annulorrhaphy devices using the coronary sinus in patients with functional mitral valve regurgitation (MR). Of these devices the greatest clinical experience exists for the Carillon mitral contour system which has gained increasing application also outside trials in the last 2 years. The advantages include the ease of use with an effective reduction in functional MR and a subsequent improvement of echocardiographic and clinical parameters. A limitation is the compromise of flow in the circumflex artery in some patients especially with a crossing of the coronary sinus with this artery. Future investigations need to focus on the evaluation of this coronary sinus-based technology versus mitral valve clipping technology for the treatment of functional MR.

A multi-component species identifying pheromone in the goldfish.

Although it has been established that sexually-immature goldfish and their relatives recognize members of their own species by using chemicals that they release, the identity of this cue(s) and whether it might be produced and used by other life stages is not yet known. To address this question, this study tested the behavioral responses of sexually immature and mature goldfish to each other's body washings, their sensitivity to this cue, the role of the olfactory sense in detecting it, and whether it is comprised of either polar and/or non-polar compounds. Tests that used two-choice mazes discovered that juvenile, immature, mature male, and mature female goldfish all release and respond to a common chemical cue(s). Dilution studies next demonstrated that this cue is active when diluted over 10 times and thus capable of functioning as a short range attractant/identifier. Olfactory occlusion demonstrated that it is detected by the olfactory sense. Finally, chemical fractionation demonstrated that it is comprised of both polar and non-polar components but likely does not include bile acids. Together, these results suggest that all life stages of goldfish use a complex multicomponent pheromonal odor to discern species identity, and that this odor has the potential to function with hormonal metabolites to identify sexual condition in behaviorally active fish of many species.

[Management of a catheter-induced rupture of a pulmonary artery]. / Vorgehen bei einer katheterinduzierten Pulmonalarterienperforation.

HISTORY AND ADMISSION FINDINGS: A 72-year-old woman presented with progressive dyspnea on exertion. There was no chest pain. A 4/6 systolic murmur was detected on auscultation. INVESTIGATIONS: Echocardiography demonstrated a combined aortic valve defect with severe stenosis and moderate insufficiency, additionally a persistent foramen ovale. The coronary angiography revealed coronary heart disease with severe stenosis of the left anterior descending (LAD) and the right coronary artery (RCA). The stenosis of the aortic valve was severe (Pmax 91 mm Hg, Pmean 52 mm Hg). During catheterization of the right heart iatrogenic perforation of a pulmonary artery occurred, resulting in diffuse pulmonary bleeding. The patient suffered from progredient dyspnea and hemoptysis. DIAGNOSIS, TREATMENT AND COURSE: Catheter-induced rupture of an artery of the right inferior pulmonary lobe was diagnosed. Because of bleeding into this lobe an immediate intubation with a double-lumen bronchial tube was necessary to ensure ventilation of the contralateral lung. Several attempts to occlude the arterial leak by ballon failed. Bleeding stopped after embolisation of the vessel by injection of thrombin. CONCLUSION: Iatrogenic rupture of a pulmonary artery is a rare and life-threatening complication of the catheterization of the right heart and demands rapid therapy. The protection of the contralateral lung by intubation with a double-lumen tubes is of highest priority. Selective embolization of the affected vessel via thrombin can be a lifesaving alternative to lobectomy or conservative therapy.

Distal embolic protection during percutaneous intervention of aorto-coronary venous bypass grafts: the FIRST Trial.

OBJECTIVE: Interventions in aorto-coronary venous bypass grafts (CABG) can cause acute procedural complications due to distal embolization of debris. In the FIRST (First European Investigation Regarding the Systematic use of the TriActiv device) multicenter trial the distal endovascular protection system TriActiv (Kensey Nash) was evaluated during intervention of CABG. METHODS: 195 patients in 17 centers in Germany with significant disease of a vein graft were enrolled. Inclusion and exclusion criteria were comparable to the SAFER trial. RESULTS: Acute procedural success was achieved in 98% of cases. Aspirated debris was found in 96.5% of patients. Primary endpoints (MACE at 30 days) occurred in 8.7% of all pts. (ITT). No patient died and 7.2% of patients suffered from MI. The rate of early revascularization was 1.5%. Secondary endpoints (MACCE at 30 days) were found in 9.2% and at hospital discharge in 8.7% of patients. CONCLUSIONS: The TriActiv system is safe and effective. Normal post procedural flow can be preserved and the MACE rate is with 8.7% considerably low. The FIRST trial supports the growing belief that PCI of CABG should be performed with protection systems.

Growth depression in socially subordinate rainbow trout Oncorhynchus mykiss: more than a fasting effect.

To assess the effects of subordinate social status on digestive function, metabolism, and enzyme activity in salmonid fish, juvenile rainbow trout Oncorhynchus mykiss were paired with size-matched conspecifics (<1.5% difference in fork length) for 5 d. Fish that were fasted for 5 d and fish sampled directly from the holding tank were used as control groups. Both subordinate and fasted fish experienced significant decreases in intestine mass (P = 0.043), and the gall bladder showed marked and significant changes in both size (P = 0.004) and appearance. These findings suggest that the negative effect of social subordination on digestive function reflects in large part a lack of feeding. Hepatic phosphoenolpyruvate carboxykinase activity was significantly higher in subordinate fish relative to dominants, whereas subordinate hepatic pyruvate kinase activity was significantly lower; activities of both enzymes were significantly correlated with plasma cortisol concentrations and behavior scores. Dominant-subordinate differences in the activities of these enzymes were eliminated by administration of the glucocorticoid receptor antagonist RU486, underlining a role for circulating cortisol in eliciting the differences. Significant increases relative to control fish were also detected in red and white muscles from subordinate fish in the activities of protein catabolic enzymes (aspartate aminotransferase, alanine aminotransferase, glutamate dehydrogenase). These differences occurred in the absence of any change in plasma free amino acid or ammonia concentrations, supporting an enhanced turnover of amino acids in muscle in subordinate fish. The results support the hypothesis that changes in metabolism, beyond those elicited by low food consumption, may be responsible at least in part for the low growth rates typical of subordinate fish and that these changes may be related specifically to circulating cortisol levels in subordinate fish.

Post-interventional homocysteine levels: failure as a predictive biomarker of in-stent restenosis.

OBJECTIVES: Purpose of our study was to determine if homocysteine plasma levels are related to the risk of in-stent restenosis after percutaneous coronary stent implantation in de novo lesions. BACKGROUND: The putative role of homocysteine as a predictive cardiovascular biomarker of coronary artery disease is well established. The impact of homocysteine levels in the development of in-stent restenosis, however, is controversially discussed. METHODS: A total of 177 patients with stable angina pectoris undergoing stent implantation in coronary de novo lesions were included. Laboratory determination comprised blood sample evaluation for homocysteine and other conventional risk factors before baseline coronary intervention and prior to six months control catheterization. Binary restenosis, late lumen loss, and late loss index after six months were assessed by quantitative coronary angiography. Endpoints included target lesion and target vessel failure, homocysteine levels as well as major adverse cardiac events. RESULTS: There was a significant correlation between the length of the implanted stent (p<0.006), the percentage of stenosis (p<0.003) and the pre-interventional luminal diameter (p<0.0001) with late loss index. Linear regression analysis demonstrated no significant impact of the initial or six months homocysteine levels on angiographic restenosis, late lumen loss, or late loss index. CONCLUSIONS: In contrast to homocysteine levels, luminal diameter, stent length and percentage of stenosis correlated with the appearance of restenosis. Taking our data into consideration, we hypothesise that homocysteine may not serve as a safe and independent biomarker of in-stent restenosis after a six months period following percutaneous coronary stenting.

Insulin sensitivity and coronary vasoreactivity: insulin sensitivity relates to adenosine-stimulated coronary flow response in human subjects.

OBJECTIVE: Diabetes is associated with coronary microvasculature abnormalities and impaired coronary flow reserve (CFR). CFR is the ratio of coronary flow under maximal vasodilation to basal flow and is a measure for coronary vasoreactivity. Insulin resistance is the central defect in the development of type 2 diabetes, preceding its onset by 10-20 years. Thus, the relationship between insulin sensitivity and CFR in nondiabetic subjects is particularly interesting. The aim of the study was to investigate this relationship. DESIGN: Cross-sectional study. PATIENTS: The study population consisted of 18 nondiabetic subjects without coronary artery stenosis on coronary angiography. We excluded patients with structural heart disease or with conditions affecting CFR or insulin sensitivity such as low density lipoprotein (LDL)-cholesterol > or = 4.14 mmol/l, smoking, hypertension or obesity with a body mass index (BMI) > 28 kg/m(2). MEASUREMENTS AND RESULTS: CFR was 3.1 +/- 0.8 (range 1.7-4.8), as assessed by intracoronary Doppler measurements in the left anterior descending coronary arteries after adenosine stimulation. Intravascular ultrasound revealed zero to moderate coronary atherosclerotic changes. Whole-body insulin sensitivity (M-value) was 7.5 +/- 2.9 mg/kg/min (range 2.2-12.6), as assessed by the hyperinsulinaemic-euglycaemic clamp test. Subjects with low CFR (< 3.0) had a significantly lower M-value than subjects with normal CFR (> 3.0) (6.0 +/- 2.5 vs. 9.0 +/- 2.5 mg/kg/min, P = 0.021). Univariate linear regression demonstrated a strong correlation between CFR and M-value (r = 0.76, P < 0.001). In multiple regression analysis, the significant association of CFR with M-value was independent of potential confounders (sex, age, BMI, LDL-cholesterol and plaque burden on intravascular ultrasound). Bootstrap analysis corroborated this finding. CONCLUSIONS: Whole-body insulin sensitivity relates to coronary vasoreactivity. Across a wide range of both insulin sensitivity and coronary flow reserve from markedly abnormal to normal values, an increase in insulin sensitivity appears to be associated with an increase in coronary flow reserve. Insulin resistance is therefore associated with coronary microvasculature abnormalities in nondiabetics.

Acute and long-term outcome after coronary artery perforation during percutaneous coronary interventions.

BACKGROUND: Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions (PCI). METHODS: We reviewed our database for cases of overt coronary perforation during PCI procedures. Hospital charts, procedural reports, and coronary angiograms of these patients were reviewed, with particular emphasis on mechanisms of perforation, management of the complication, and clinical outcome. RESULTS: Between 01/1998 and 12/2003, a total of 19 cases (mean age: 66+/-8 years, 13 male) of coronary perforation occurred during 6433 PCI procedures performed within this period (incidence: 0.3%). In 12/19 (63%) cases, perforation occurred during recanalisation procedures of chronic total occlusions of coronary arteries. In all but one patient, non-surgical management was attempted: 2 out of 19 (11%) patients were treated conservatively by reversal of heparin anticoagulation. Prolonged balloon inflation at the perforation site was applied in 10/19 (53%) patients. Six (32%) patients received stents (5 of them received covered stentgrafts), 3 (16%) patients developed cardiac tamponade requiring percardiocentesis, and only 2 (11%) patients underwent bailout surgical repair. There were 2 (11%) deaths early after the procedure. CONCLUSION: Coronary perforation during PCI is a rare complication, but is associated with significant morbidity and mortality. In the majority of patients, non-surgical management is both feasible and associated with a high success-rate.

[Minimally invasive quantitation of myocardial microvascular function using computed tomography: the blood volume-to-flow relationship]. / Minimal-invasive Quantifizierung der myokardialen Mikrozirkulationsfunktion mittels Computertomographie. Die Blutvolumen-Fluss-Beziehung.

The intramyocardial coronary microvasculature has an important role in regulating regional myocardial perfusion. Pathologic alterations of microvascular function may be present in early stages of coronary artery disease, myocardial hypertrophy, cardiomyopathy or systemic diseases such as arterial hypertension and diabetes mellitus. Fast computed tomography permits noninvasive simultaneous quantitation of regional intramyocardial blood volume and myocardial perfusion using indicator dilution principles. Our data indicate that especially the blood volume-to-flow relationship is sensitive enough to characterize and quantitate the functional impact of different pathologies along the coronary tree on microvascular function. This could be demonstrated for 1) acute impairment of microvascular function following coronary microembolization, 2) endothelial dysfunction induced by chronic hypercholesterolemia, 3) chronic epicardial non-significant stenoses, 4) physiologic maturation of the normal microvasculature and 5) quantification of heterogeneity of microvascular function. These findings, the methodological background and the concept itself are presented in this article. Application of the blood volume-to-flow relationship is not limited to fast-CT but may be used in any cross sectional imaging technique, such as MRI or echocardiography, as long as intramyocardial blood volume and perfusion can be quantitated simultaneously. This new noninvasive approach to the quantification of intramyocardial microvascular function may prove a useful adjunct to those imaging techniques that are used to noninvasively quantitate epicardial stenoses or regional wall motion abnormalities.

Genetic variation of the platelet- surface integrin GPIIb-IIIa (PIA1/A2-SNP) shows a high association with Type 2 diabetes mellitus.

AIMS/HYPOTHESIS: The gene encoding the beta(3)-subunit (GPIIIa) of the platelet alpha(2)beta(3)-integrin (fibrinogen receptor) shows a polymorphism PlA1/A2 with the A2 allele putatively associated with an increased risk of acute ischaemic events. This study investigated whether Type 2 diabetes as a particular macrovascular risk factor associates with the thrombogenic PIA2 genotype. METHODS: The PlA genotype was determined in 112 consecutive Type 2 diabetic patients additionally classified according to the presence of macrovascular disease. Forty-four non-diabetic patients with angiografically documented cardiovascular disease (CAD/ AMI) and a further 59 non-diabetic subjects with no angiografical signs of CAD were investigated as genomic background control (n=103). PIA-genotyping was carried out by standard restriction fragment length analysis (RFLA) of PCR amplified lymphocyte template DNA. RESULTS: The overall allelic PlA2- prevalence accounted to 34.8% (39/112) in diabetic patients as compared to 14.6% (15/103) in non-diabetic patients [OR 3.1 (1.6-6.1), p<0.01]. This odds ratio increased to 7.0 (2.5-19.7), (p<0.01) in subjects free of criteria of macrovascular disease. In non-diabetic control subjects without CAD there was an allelic PIA2 frequency of 10.2% (6/59) as compared to 20.5% (9/44) in patients with CAD and a history of AMI being less than either diabetes subgroup. The PIA2 prevalence in the subgroup of diabetes patients with macrovascular complications did not differ from the respective value in patients without macrovascular disease. [29.0% (20/69) vs. 44.2% (19/43)]. CONCLUSION/INTERPRETATION: This study confirms a trendwise association of PlA2 with severe coronary artery disease, but rather suggests an even stronger, highly significant association with the metabolic condition of Type 2 diabetes mellitus. This justifies the speculation that pathways dependent on the platelet alpha(2)beta(3) integrin physiology could be implicated in the pathogenesis of Type 2 diabetes which lends further support to the "common soil" hypothesis of diabetes and vascular disease.

Hormonal, morphological, and physiological responses of yellow perch (Perca flavescens) to chronic environmental metal exposures.

The effects of a chronic environmental exposure to metals on the hormonal, physiological, and reproductive status were assessed in yellow perch (Perca flavescens) sampled in six lakes situated along a contamination gradient of Cd, Zn, Cu, Pb, and Ni in the mining region of Rouyn-Noranda, Québec. Fish were captured in the summer and fall, and sampled before or after a confinement of one hour. Metal concentrations in the kidneys and the interrenal tissues (homologous to mammalian adrenals) were measured to compare tissue-specific metal accumulation. An exposure-related decrease of condition factor, gonadosomatic index (GSI), branchial Na+/K(+)-ATPase activity, plasma thyroxine (T4), triiodothyronine (T3), and 17 beta-estradiol and an impaired capacity to enhance cortisol levels after confinement were observed. Fish from the metal-contaminated lakes possessed gonads at less mature stages and exhibited structural alterations of their gills, interrenal cells, and thyroid follicle epithelium. A comparison of the morphological, biochemical, and physiological endpoints measured in the present study revealed that plasma concentrations of hormones and parameters of gill function were the most affected by metal contamination. The results of this study indicate that lifelong exposures to sublethal concentrations of metals alter the physiological functions of fish and delay reproduction.

[Brachytherapy after coronary interventions: current state and future perspectives]. / Brachytherapie nach koronaren Interventionen: aktueller Stand und Zukunftsperspektiven.

Intracoronary brachytherapy is a novel, meanwhile established therapy. It is currently the only interventional procedure which has proven to effectively reduce the restenosis rates after intervention of long and diffuse in-stent restenosis. For this indication, brachytherapy can be regarded as the current treatment of choice. Randomized studies yield promising results for bypass interventions or interventions in small vessels or diabetic patients. These findings may encourage the decision to perform a percutaneous, transluminal intervention in such high-risk patients. In clinical practice, implantation of new stents in combination with brachytherapy procedures should be avoided as far as possible. In any case, the combined antiaggregatory therapy should be conducted sufficiently long to minimize the danger of late stent thrombosis. Under this treatment, the expected thrombosis rates ar within the range of placebo-treated patients. The length of the radiation source should be sufficient to cover the entire interventional injury length to avoid recurrent edge stenosis. De novo lesions are currently not a routine indication for intracoronary brachytherapy. Although intracoronary brachytherapy may effectively reduce restenosis rates in sufficiently irradiated de novo lesion segments, de novo lesions should be treated only within the set-up of controlled studies. The current available data with a follow-up period of up to 5 years show that intracoronary brachytherapy is also in the mid-term a safe and effective therapy for the reduction of restenosis after coronary interventions.