A Comparative Study of the Flap and Flapless Techniques of Ridge Preservation: A Clinical Double-Blinded Study.

Introduction: Extraction of the tooth often leads to crestal bone loss. It is difficult for clinicians to decide on the technique of extraction. Many studies on flap and flapless have led to confusion. Hence it becomes necessary to conduct this study to show the efficient ridge preservation technique. Materials and Methods: Twenty patients were selected for this study. It was divided into the flap and flapless groups. In group A, the flap was elevated, tooth extraction was undertaken, the socket was cleaned, a graft was placed, a barrier was placed, and a suture was placed. In group B all the procedures were the same but without flap elevation. After surgery, clinical and radiographical parameters were recorded. Result: Flapless technique showed a better result in bone preservation. There was a low vertical bone loss in the flapless technique. Conclusion: Both techniques showed bone loss. But the flapless technique gave better results.

Tricuspid annular plane systolic excursion assessed using MRI for semi-quantification of right ventricular ejection fraction.

OBJECTIVE: Accurate determination of right ventricular volume and ejection fraction (RVEF) is established using MRI. Automatic contour detection of the right ventricular endocardial border is not established in clinical practice, resulting in considerable manual efforts to quantify RVEF. Using transthoracic echocardiography (TTE), the tricuspid annular plane systolic excursion (TAPSE) has proved its worth for quantification of RVEF and risk prediction. Therefore, the aim of this study was to clarify whether TAPSE assessed with MRI as a fast and easily obtainable parameter correlated with volumetric quantification of RVEF. METHODS: Right ventricular volumes and RVEF were measured with the standardised slice-summation method at MRI. MRI-TAPSE was defined as maximum apical excursion of lateral tricuspid annular plane and measured in a four-chamber view using steady-state free precession sequences. Additionally, MRI-TAPSE was compared with TAPSE assessed using TTE. RESULTS: 76 consecutive patients (aged 58±17 years) were examined. At MRI, right end-diastolic volumes were 97±36 ml, right end-systolic volumes were 57±27 ml and the mean RVEF was 42±14%. MRI-TAPSE was determined with 19±6 mm and correlated well at linear regression analysis with volumetric RVEF (r=0.72, p<0.001). Furthermore, MRI-TAPSE discriminated sufficiently between patients with impaired and normal RVEF. Multiplying MRI-TAPSE by 2.5 led to values close to the RVEF by volumetry. Additionally, MRI-TAPSE correlated well with TAPSE determined using TTE. The inter- and intra-observer variabilities of MRI-TAPSE determination were low (3.1% and 1.8%). CONCLUSION: TAPSE assessed with MRI is a fast and easily obtainable parameter which correlates well with volumetric quantification of RVEF.

Clinical applications of cardiac magnetic resonance imaging.

As a direct result of the rapid technical progress which has been realized regarding hardware and software, cardiovascular magnetic resonance imaging (CMR) is increasingly established as an important method in the diagnosis of cardiovascular disease. Numerous clinical and experimental studies have demonstrated the equality or even superiority of CMR compared to other imaging modalities such as nuclear medicine or transthoracic echocardiography. Particular strengths of CMR are the ability to overcome anatomical limitations (such as poor acoustic window), a multimodality approach to comprehensively answer various aspects of cardiac disease, and the absence of ionizing radiation during the exam. Main clinical applications of CMR include assessment of ventricular function, myocardial viability, myocardial perfusion, valvular disease, differential diagnosis of inflammatory heart disease and cardiomyopathies, congenital heart disease and structural abnormalities. In the assessment of coronary artery disease (CAD) by CMR, analysis of global and regional myocardial function is enhanced by examination of myocardial viability and perfusion. This non-invasive diagnostic ''triad'' confers CMR a unique methodological strength for a comprehensive evaluation of CAD within one single exam session. In particular, late gadolinium enhancement scar imaging by CMR is currently the most accurate non-invasive method to examine myocardial viability. In several studies on the prognostic value of CMR in CAD assessment, normal adenosine-stress CMR was highly predictive for a good prognosis, thus able to identify patients in whom invasive coronary angiography can be deferred safely. Regarding myocarditis, CMR is evolving as the most accurate imaging technique. Challenges for future development of the role of CMR in clinical routine will most likely not only include technical improvement, but also a larger CMR scanner availability, optimized cost-efficiency, increased awareness and competence to be achieved by an extended education and training in CMR.

Distribution pattern of neuropeptide Y in the brain, pituitary and olfactory system during the larval development of the toad Rhinella arenarum (Amphibia: Anura).

The first NPY-immunoreactivity (ir) in the central nervous system of Rhinella arenarum was obtained just after hatching in the pre-optic area, ventral thalamus and rostral rhombencephalon. During pre-metamorphosis, new NPY-ir cells were observed in other brain areas such as pallium, septum and striatum, infundibulum and pars intermedia of the pituitary. Further maturation continued through pro-metamorphosis with the appearance of cell groups in the diagonal band, amygdala, pre-optic nucleus, dorsal nucleus of the habenula, anterior ventral and dorsal thalamus, suprachiasmatic nucleus, tuberculum posterior, tectum, torus semicircularis, inter-peduncular nucleus and median eminence. During the metamorphic climax and soon after, the relative abundance of NPY-ir fibres decreased in all hypothalamic areas and the staining intensity and number of NPY-ir cells in the pallium also decreased, whereas no cells were found in the striatum, dorsal nucleus of the habenula and tectum. In the olfactory epithelium, nerve or bulb, neither cells nor NPY-ir fibres were found during the stages of development analysed. The ontogeny pattern of the NPY-ir neuronal system in the brain of Rh. arenarum is more similar to the spatiotemporal appearance reported for Rana esculenta than to that reported for Xenopus laevis. Many NPY-ir fibres were found in the median eminence and in the pars intermedia of the pituitary, supporting the idea that this neuropeptide may play a role in the modulation of hypophyseal secretion during development.

Galanin: presence and distribution in the brain and pituitary of Rhinella arenarum (Amphibia: Anura) during development.

The immunohistochemical distribution of galanin (Gal) in the brain and pituitary of Rhinella arenarum was studied during development. Gal-immunoreactivity was first observed in the brain just after hatching in anterior preoptic area, infundibular area, median eminence and pars distalis of the pituitary as well as in the olfactory epithelium. At the beginning of prometamorphosis new Gal-immunoreactive (ir) cells were observed in the olfactory nerve and bulb. Later in prometamorphosis new Gal-ir cells were observed in the telencephalon, suprachiasmatic nucleus, rostral rhombencephalon and in the pars nervosa of the pituitary. The most numerous accumulations of Gal-ir neurons throughout the larval development were observed in the ventral hyphothalamus where numerous Gal-ir cells of cerebrospinal fluid-contacting type were found. During metamorphic climax and soon after we did not detect Gal-ir neurons in the pallium, medial or pretectal dorsal thalamus. In the median eminence and pars distalis of the pituitary many Gal-ir fibers were found during development indicating that Gal may play a role in the modulation of hypophyseal secretion. Furthermore, the distribution of Gal-ir elements observed throughout larvae development indicates that galaninergic system maturation continues until sexual maturity.

[Acute myocardial infarction after discontinuing aspirin two years after implantation of a drug-eluting coronary stent]. / Akuter Herzinfarkt nach Absetzen von Acetylsalicylsäure 2 Jahre nach Implantation eines Medikamenten-freisetzenden Stents.

HISTORY AND ADMISSION FINDINGS: A 48-year-old man was admitted to our cardiac catheterization unit with severe chest pain 75 minutes after onset of symptoms. Two years before he had undergone percutaneous coronary intervention (PCI) for stable angina pectoris with implantation of a drug-eluting stent (TAXUS) into the proximal left anterior descending artery. Antiplatelet therapy with 75 mg clopidogrel was given for one year, together with 100 mg aspirin. Subsequently he was put on low-dose aspirin monotherapy. Eight days before admission aspirin was discontinued because a tooth extraction was planned. DIAGNOSTIC PROCEDURES: The ECG showed significant ST-segment elevation in the precordial leads V1-5. TREATMENT AND OUTCOME: 90 minutes after onset of symptoms coronary angiography was performed and an in-stent thrombosis of the proximal left coronary artery was diagnosed. A successful PCI was performed and abiximab given. The creatine kinase concentration increased to a maximum of 3170 U/l. The pre-discharge echocardiogram showed a slightly reduced left ventricular ejection fraction. After the procedure the patient was stable and free of chest pain and he was discharged from the hospital after one week. CONCLUSION: Discontinuing antiplatelet therapy, even years after implantation of a drug-eluting coronary stent, increases the risk of a late stent thrombosis. This should be taken into account especially before any procedure, even with a low bleeding risk such as tooth extractions. Antiplatelet treatment should be continued, even if there is a risk increasing minor bleeding complications, so that any life-threatening complication of an acute myocardial infarction is avoided.

Beneficial effects of abciximab in patients with primary percutaneous intervention for acute ST segment elevation myocardial infarction in clinical practice.

OBJECTIVES: To assess the safety and effectiveness of abciximab in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in clinical practice. METHODS: Data were analysed of 2184 consecutive patients treated with primary PCI for acute STEMI and either concomitant abciximab or no glycoprotein IIb/IIIa inhibitor (control group), who were prospectively enrolled in the Acute Coronary Syndromes (ACOS) registry between July 2000 and November 2002. RESULTS: Patients who were treated with abciximab were younger than the control group, and fewer of them had a history of stroke/transient ischaemic attack and systemic hypertension, but more of them had three-vessel coronary artery disease and cardiogenic shock. Cumulated mid-term survival for patients treated with abciximab was significantly higher than in the control group (91% v 79%, log rank p < 0.05, median observational time 375 days, range 12-34 months). The Cox proportional hazards model of mid-term mortality after admission with adjustment for baseline characteristics showed that mortality was significantly lower in the abciximab group than in the control group (hazard ratio 0.68, 95% confidence interval 0.49 to 0.95). Whereas overall there was no difference in bleeding complications, patients older than 75 years had more major bleeding events with abciximab (12.5% v 3.4%, p = 0.03). CONCLUSION: In clinical practice adjunctive treatment with abciximab in patients with primary PCI for acute STEMI was associated with a reduction in mid-term mortality. The subgroup of patients older than 75 years who were treated with abciximab had more major bleeding complications.

[Use of heparin in acute myocardial infarction in routine clinical practice in Germany. Results of the MITRA and MIR registries]. / Stellenwert des Heparins in der aktuellen Therapie des akuten Myokardinfarktes in Deutschland--Ergebnisse der MITRA- und MIR-Register.

OBJECTIVE: Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today. METHODS: MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22,697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy. RESULTS: 21,004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p = ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p < 0.001). CONCLUSIONS: Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only slightly higher than reported in randomized trials.

[Long-term follow-up of patients with acute myocardial infarction treated with primary angioplasty or thrombolysis. Results of the MITRA trial]. / Langzeitverlauf bei Patienten mit akutem Myokardinfarkt, die mittels Primär-Dilatation oder Thrombolyse behandelt wurden. Ergebnisse der MITRA-Studie.

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.

[Not Available]. / Stellenwert des Heparins in der aktuellen Therapie des akuten Myokardinfarktes in Deutschland - Ergebnisse der MITRA- und MIR-Register.

Objective Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today. Methods MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy. Results 21004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p=ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p<0.001). Conclusions Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only sightly higher than reported in randomized trials.

[Current prescription practice of CSE inhibitors at clinic discharge after acute myocardial infarct]. / Aktuelle Verordnungspraxis von CSE-Hemmern bei Entlassung aus der Klinik nach akutem Myokardinfarkt.

We investigated the use of statins in clinical practice in patients with acute myocardial infarction in Germany in 17,732 consecutively included patients of the registries MIR-1 and MITRA-1. A clinical follow-up has been performed in the MITRA-1 study after a mean period of 18 months. In total 30% of all patients with acute myocardial infarction received statins at discharge. From 1994 to 1998 the use of statins increased from 6% to 44%; however in 1998 still less than half of the patients with acute myocardial infarction received statins at discharge. In a logistic regression model, concomittant diseases as renal failure (OR 0.7), heart failure (OR 0.7) and diabetes mellitus (OR 0.9) were associated with a lower use of statins. Age > 70 years (OR 0.5) was also associated with a lower use of statins at hospital discharge. Patients with statins at discharge had a lower long-term mortality of 5.8% versus 12.9% in patients without statins. After adjustment to age and comorbidity, use of statins at discharge was associated with a borderline significant reduction of long-term mortality (multivariate OR 0.7, 95% CI 0.4-1.0). In a subgroup analysis of therapeutic benefit, measured by the "number needed to treat" (NNT), the number of patients to treat with statins to save one life, patients with cardiovascular risk factors, as heart failure (NNT 7.5), diabetes mellitus (NNT 7.8) and age > 70 years (NNT 13.8) had a larger therapeutic benefit as patients without these risk factors (NNT 345). However, these high-risk patients received less often statins than patients without risk factors (use of statins 11.8% versus 19.8%).

[Quality assurance in acute myocardial infarct]. / Qualitätssicherung beim akuten Myokardinfarkt.

The Ludwigshafen myocardial infarction project has demonstrated, that an intense public media campaign can reduce prehospital delays in acute myocardial infarction. With an additional intrahospital improvement, this can lead to a better and more frequent use of recanalization (thrombolysis or percutaneous transluminal coronary angioplasty [PTCA]). Several large multicentric registries (60 minutes myocardial infarction project, MIR, MITRA) with a total of about 40,000 patients at over 300 hospitals in Germany showed, that intrahospital improvement of infarction therapy can also be achieved in other hospitals. Voluntary participation in an infarction registry leads to quality control and improvement. Two factors are especially important: (1) documentation of every infarction patient, and (2) documentation of the reasons why therapy was given or withheld in every single patient. The improvement in early therapy is associated with a 20% reduction of hospital mortality (MITRA-1). The media campaign in Ludwigshafen to reduce pre-hospital patient delay, however, could not yet be carried out in other areas effectively and intensely enough.

Incidence, risk factors, and clinical outcome of stroke after acute myocardial infarction in clinical practice. MIR and MITRA Study Groups. Myocardial Infarction Registry. Maximal Individual Therapy in Acute Myocardial Infarction .

In this analysis of ischemic and hemorrhagic strokes after acute myocardial infarction (AMI) in 21,330 consecutively included patients with AMI, we found an incidence of stroke after AMI of 1.2% and a very poor prognosis. Previous stroke, atrial fibrillation, and older age were the strongest predictors of stroke after AMI; thrombolysis was a borderline risk factor and early therapy with aspirin was associated with a reduction in stroke after AMI.

Transfer of patients with acute myocardial infarction for primary or acute angioplasty from hospitals without the facilities to perform angioplasty. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR).

In patients with acute myocardial infarction (AMI) admitted at hospitals without angioplasty facilities there are some subgroups of patients which seem to profit from a transfer to primary or acute angioplasty. However, current clinical practice at such hospitals is unknown. We analyzed the pooled data of the German acute myocardial infarction registries MITRA and the MIR. Angioplasty was not available at 221/271 hospitals (81.5%). Out of 14,487 patients with acute myocardial infarction admitted to these hospitals, 50.1% (7,259/14,487) received thrombolysis at the initial hospital and 3.6% (523/14,487) were transferred. Out of the transferred patients, 55.3% (289/523) were treated with primary angioplasty and 44.7% (234/523) received a combination of thrombolysis and angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998 (p for trend = 0.001). One hundred and four hospitals (47.1%) never transferred patients. Patients transferred for primary angioplasty (289 patients) were compared to patients treated with thrombolysis at the initial hospitals (7,259 patients). Multivariate analysis showed the following independent predictors for transfer of patients for primary angioplasty: contraindications for thrombolysis (OR = 17.9), a non-diagnostic first ECG (OR = 4.0), pre-hospital delay > 6 hours (OR = 2.5), unknown symptom onset of the acute myocardial infarction (OR = 2.0) and anterior wall acute myocardial infarction (OR = 1.6). Heart failure at admission was the only independent predictor not to transfer patients (OR = 0.40). In Germany only 47.1% of hospitals without angioplasty facilities transfer patients with acute myocardial infarction to primary or acute angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998. Contraindications for thrombolysis were the strongest predictor to transfer patients to primary angioplasty.