[Prevention of cardiovascular diseases]. / Prävention von Herz-Kreislauf-Erkrankungen.

The incidence of cardiovascular diseases can be reduced by the early detection and targeted treatment of risk factors and subclinical forms of the disease. Primary prevention provides several opportunities for successful interventions. In addition to a drug-based therapy, especially life style-modifying measures, such as physical activity, normalization of body weight, consistent nicotine abstinence and the consideration of psychosocial aspects represent core components of prevention programs. Healthcare data indicate that risk factors still often remain undetected and that the full potential of risk factor management has not yet been fully exploited at a population level. Especially motivation of patients and adherence to therapy represent key elements of successful prevention efforts.

Persistent lipid abnormalities in statin-treated patients with diabetes mellitus in Europe and Canada: results of the Dyslipidaemia International Study.

AIM: To assess the prevalence of persistent lipid abnormalities in statin-treated patients with diabetes with and without the metabolic syndrome. METHODS: This was a cross-sectional study of 22,063 statin-treated outpatients consecutively recruited by clinicians in Canada and 11 European countries. Patient cardiovascular risk factors, risk level, lipid measurements and lipid-modifying medication regimens were recorded. RESULTS: Of the 20,129 subjects who had documented diabetes and/or metabolic syndrome status, 41% had diabetes (of whom 86.8% also had the metabolic syndrome). Of those with diabetes, 48.1% were not at total cholesterol target compared with 58% of those without diabetes. Amongst those with diabetes, 41.6 and 41.3% of those with and without the metabolic syndrome, respectively, were not at their LDL cholesterol goal relative to 54.2% of those with metabolic syndrome and without diabetes, and 52% of those with neither condition. Twenty per cent of people with diabetes but without the metabolic syndrome were not at the optimal HDL cholesterol level compared with 9% of those with neither condition. Of people with diabetes and the metabolic syndrome, 49.9% were not at optimal triglyceride level relative to 13.5% of people with neither diabetes nor the metabolic syndrome. Simvastatin was the most commonly prescribed statin (>45%) and the most common statin potency was 20-40 mg/day (simvastatin equivalent). Approximately 14% of patients were taking ezetimibe alone or in combination with a statin. CONCLUSIONS: Despite evidence supporting the benefits of lipid modification and international guideline recommendations, statin-treated patients with diabetes had a high prevalence of persistent lipid abnormalities. There is frequently room to optimize therapy through statin dose up-titration and/or addition of other lipid-modifying therapies.

[Regional differences in the treatment of dyslipidemia in Germany]. / Regionale Unterschiede in der Behandlung von Fettstoffwechselstörungen innerhalb Deutschlands?

BACKGROUND AND OBJECTIVE: DYSIS (Dyslipidemia International Study) is an international multicenter cross-sectional trial. The objective of the regional analysis was to identify differences in lipid-lowering therapy and attainment of goal/normal lipid levels in Germany. METHODS: 4,260 patients who were at least 45 years of age and receiving regular statin therapy at 748 centers (office practices / outpatient clinics) in Germany were assessed at a routine ambulant appointment. Results from centers in the northern, eastern, southern, and western part of Germany were compared. RESULTS: The mean age of the patients was 66.6 - 67.9 years (p < 0.01, range over the four regions) and the proportion of males was 53 - 60 % (p < 0.01). There were significant regional differences in the number of cardiovascular risk factors and cardiovascular conditions, e. g. arterial hypertension (82 - 88 %), smoking (12 - 17 %), family history of coronary heart disease (CHD) (30 - 42 %), lack of exercise (38 - 48 %), CHD (only in women, 27 - 42 %), peripheral artery vascular disease (11 - 15 %), and heart failure (16 - 20 %). No regional differences were found for body mass index (BMI), waist circumference, metabolic syndrome, or diabetes mellitus. The mean LDL-cholesterol level in the four regions was 107 - 108 mg/dl (p = 0.53), HDL-cholesterol was 50 - 51 mg/dl (p = 0.62), and triglycerides 141 - 148 mg/dl (p = 0.68). The mean simvastatin (or simvastatin-equivalent) dosage was approximately 27 mg/day (p = 0.62). About half of the patients (49 - 53 %, p = 0.11) failed to attain their LDL-cholesterol target despite statin therapy. In addition to elevated LDL-cholesterol, 30 % of the patients had elevated triglycerides and/or low HDL-cholesterol. CONCLUSION: DYSIS showed the existence of significant regional differences in the characteristics of statin-treated patients but not in the type or dosage of statin therapy or in adherence to target/normal lipid levels as per guidelines. In a high proportion of patients the lipid-lowering therapy will need to be reviewed, as guideline target levels have not been attained.

[Mortality of patients who are older than 75 years after ST elevation myocardial infarction in clinical practice]. / Sterblichkeit bei über 75-jährigen Patienten mit akutem ST-Hebungsmyokardinfarkt im klinischen Alltag.

BACKGROUND: Patients who are older than 75 years are often excluded in clinical trials evaluating therapies for ST elevation myocardial infarction. Therefore there is a lack of prospective data for this steadily increasing number of elderly patients. PATIENTS AND METHODS: Between 07/2000 and 11/2002 a total of 16 823 patients with acute coronary syndromes in 154 hospitals were enrolled in the ACOS registry, with 8309 having a STEMI. Baseline characteristics, therapies during the hospital course and at discharge, hospital-mortality and 1-year mortality were prospectively collected. In this study we analysed the outcome of patients older than 75 years with STEMI of less than 24 duration. RESULTS: A total of 2045 patients > 75 years (median age 80.1 years, 53.9 % women) were included. Of the latter 51 % were treated conservatively, 19 % with fibrinolysis and 30 % with primary PCI. In-hospital mortality in the three groups was 23.4 %, 25.4 % und 10.2 %, while total mortality after one year was 52.4 %, 41.3 % und 19.3 %, respectively. In the multivariate analysis both primary PCI (odds ratio 0.36, 95 % CI 0.25 - 0.52) and fibrinolysis (odds ratio 0.65, 95 % CI 0.44 - 0.97) where associated with a lower mortality after discharge. CONCLUSION: Hospital- as well as 1-year mortality in patients with STEMI who are older than 75 years are high. Primary PCI is associated with a decrease of in-hospital and 1-year mortality, while fibrinolysis improves mortality after discharge. Therefore early reperfusion therapy, preferably with primary PCI should be considered in elderly patients, after taking in count biological age and major comorbidities.

[Prescribing behavior of primary care physicians in diabetes therapy: effect of drug budgeting]. / Primärärztliches Verordnungsverhalten bei der Diabetestherapie: Einfluss der Arzneimittelbudgetierung.

BACKGROUND AND OBJECTIVE: In spite of the great importance of diabetes in Germany, little is known about the medical treatment of diabetic patients by primary health care practices and the effects of the drug budget, introduced by the German Health Care Structure Reform Act (GSG) from 1993. PATIENTS AND METHODS: Computerized data (MediPlus, IMS HEALTH) on prescriptions of the most important drugs were analysed in 2892 diabetic patients of 362 primary care physicians for the period of July 1992 to December 1994. RESULTS: There was an initial decrease in prescriptions per treated patient of antidiabetic drugs and antihypertensive drugs according to the GSG, which was not maintained during the study period. Nevertheless, a cost saving per treated patient with respect to beta-blocker and ACE inhibitors was observed, mainly as a result of a change of preparations and a drop in drug company sales prices. When beginning of a new therapy with oral antidiabetics, the physicians increasingly used acarbose rather than less expensive sulphonylureas. A previous trend of increased use of ACE inhibitors and diuretics for antihypertensive treatment was maintained. In 1993 and 1994, the number of prescriptions and the prescription costs for lipid lowering drugs decreased compared to the values of the last six months of 1992. A global decrease in prescription use of drugs without proven efficacy observed in the first six months of 1993, did not persist. CONCLUSION: The data show, that the drug budget had no relevant long term impact on drug prescribing by internists and general practitioners for diabetic patients.

Attenuation control of ilvBNC in Corynebacterium glutamicum: evidence of leader peptide formation without the presence of a ribosome binding site.

The ilvBNC operon of Corynebacterium glutamicum encodes acetohydroxy acid synthase and isomero-reductase, which are key enzymes of L-isoleucine, L-valine and L-leucine syntheses. In this study we identified the transcript initiation site of ilvBNC operon 292 nucleotides in front of the first structural gene, and detected the formation of a short transcript from the leader region in addition to the full-length transcript of the operon. This identifies the control of ilvBNC transcription by an attenuation mechanism involving antitermination. Mutations in the leader region were made and their effect on the operon expression in ilvB'lacZ fusions was quantified. Although a presumed leader-peptide-coding region is only one nucleotide away from the transcript initiation site determined, there is clear evidence to support the formation of this leader peptide: (i) the substitution of initiation codon ATG of the peptide by AGG reduced lacZ expression of the appropriate fusion construct to 19%; (ii) the replacement of three subsequent Val codons by Ala codons resulted in the loss of Val-dependent expression; and (iii) a leader peptide LacZ fusion resulted in active beta-galactosidase. Based on these results, it is concluded that transcription of ilvBNC is controlled by a translational-coupled attenuation mechanism. The absence of a ribosome binding site for leader peptide formation means that additional mechanisms may contribute to the transcription control at the decoding initiation step in the leader peptide formation.

[Drug prescribing in primary health care for diabetic and non-diabetic patients: effect of therapeutic drug budgeting]. / Primärärztliche Arzneimittelverordnungen bei Diabetikern und Nichtdiabetikern: Einfluss der Arzneimittelbudgetierung.

With computerised data on drug prescriptions, which were collected among a sample of 362 internist, general and medical practitioners throughout Germany, the effects of the drug budget, based on the German Health Care Structure Reform Act (GSG), on diabetic patients were analysed. The data of 3053 diabetic patients (10% random sample) were compared with the same number of nondiabetic patients for the period of July 1992 to December 1994. The frequency of consultations per patient increased in both groups during the study period (p < 0.01). Diabetic patients had more contacts with the physicians than nondiabetic subjects (p < 0.01). The prescriptions and costs among the patients with diabetes decreased in the first six month of 1993 (-10%/ -16%). In the following time costs increased and exceeded the values of 1992 by about 13%. The costs per prescription decreased during the study period about 10%. The data show that costs as well as prescriptions per consultation between diabetic and nondiabetic patients remained in the same ratio. The proportion of consultations with > or = 1 prescription increased in diabetic patients after the GSG. A refusal to prescribe drugs in primary health care practices among diabetic patients was not observed. There was also no restriction on prescription drug use among diabetic patients compared with nondiabetics.

[Initial experiences with a computer program for diagnostic localization of visual field deficits]. / Erste Erfahrungen mit einem Computerprogramm zur lokalisatorischen Diagnose eines Gesichtsfeldausfalles.

A computer program for localizing visual field defects is presented. It is based on a decision tree which has been converted into a program written in Turbo-Pascal and can be run on any IBM-compatible computer. A question-and-answer routine guides the examiner to the localization of the defect.

[Why perform Doppler sonography before every biopsy of the temporal artery?]. / Warum eine Dopplersonographie vor jeder Biopsie der A. temporalis?

The authors present three cases of AION with suspected temporal arteritis to show why a Doppler sonographic examination should be performed prior to a biopsy of the temporal artery. In Case 1, with stenosis of the internal carotid artery, the cerebral perfusion depended, entirely on collateral circulation, the nutritive vessel of which was the temporal artery. Cases 2 and 3 illustrate a proximal stenosis of the ophthalmic artery. In these two cases the temporal artery maintained the blood supply to the eye. All these findings were obtained by Doppler sonographic examinations. Biopsy of the temporal artery, which could otherwise have caused sudden death in Case 1, or blindness in Cases 2 or 3, was therefore dispensed with.

[Recurrent oculomotor paralysis: a case of ophthalmoplegic migraine?]. / Rezidivierende Okulomotoriuslähmungen: Ein Fall von ophthalmoplegischer Migräne?

A total of ten transient oculomotor palsies of varying severity were observed in a 12-year-old boy from the age of ten months onward, accompanied by migraine-like headaches and vomiting. Damage to the oculomotor nerve due to swelling of the internal carotid artery (or an abnormal vessel) in the cavernous sinus was suspected as the cause.