Ciprofloxacin reduces the risk of hemolytic uremic syndrome in patients with Escherichia coli O104:H4-associated diarrhea.

BACKGROUND: Whether antibiotic treatment in patients with enterohemorrhagic Escherichia coli (EHEC)-associated diarrhea influences the risk of hemolytic uremic syndrome (HUS) has still to be elucidated. PATIENTS AND METHODS: During the EHEC epidemic which occurred in northern Germany in spring 2011, 24 patients with E. coli O104:H4 infection were treated at our hospitals, 19 of whom developed HUS. The use of antibiotics before and after the onset of HUS was documented, and the outcome in patients with and without antibiotic treatment was evaluated. RESULTS: Of the 24 patients with EHEC-associated diarrhea, seven received antibiotics before any signs of HUS were present (ciprofloxacin, cefotaxime, amoxicillin and/or metronidazole). Four of these seven patients (57 %) and 15 of the 17 patients (88 %) who were treated without antibiotics developed HUS (p = 0.12). Microbiological testing showed all E. coli O104:H4 to be extended-spectrum beta lactamase producers and thus susceptible only to fluoroquinolones, aminoglycosides and carbapenems. Two of the five patients (40 %) treated with ciprofloxacin and 17 of the 19 patients (89 %) treated without ciprofloxacin developed HUS (p = 0.043). CONCLUSION: In our E. coli O104:H4-infected patients, treatment of diarrhea with antibiotics did not increase the risk of HUS. Significantly fewer patients treated with ciprofloxacin developed HUS than patients who did not receive ciprofloxacin.

Influence of updated guidelines on short- and long-term mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

AIM: In 2002 the ACC/AHA guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) were updated. We aimed to answer whether the implementation of updated guidelines was capable of influencing short- and long-term mortality in these patients. METHODS: We analyzed data on 812 consecutive patients who were admitted with either UA or NSTEMI between 2001 and 2004. Patients admitted in the two years before the implementation of updated guidelines (UA(01/02) group and NSTEMI(01/02) group) were compared to patients admitted in the two years thereafter (UA(03/04) group and NSTEMI(03/04) group). Yearly follow-up concerning all-cause mortality was obtained up to four years. RESULTS: The rate of revascularizations, the percentage of procedures performed within 48 h of admission, and the administration of clopidogrel increased significantly. However, still many - especially high-risk - patients did not receive revascularization. Patients of both UA groups had an identical in-hospital mortality rate. Differences in mortality between groups gained statistical significance over time (four-year mortality; 15.1% for the UA(03/04) group vs. 26.5% for the UA(01/02) group, p=0.014; HR 0.49 95% CI 0.28-0.87). In patients with NSTEMI in-hospital mortality decreased from 18.4% in the NSTEMI(01/02) group to 9.6% in the NSTEMI(03/04) group (p=0.011; HR 0.47 95% CI 0.26-0.84), and 1-year mortality from 34.7% to 25.1% (p=0.038; HR 0.63 95% CI 0.41-0.98), respectively. Mortality rates beyond one year were still lower in the NSTEMI(03/04) group as compared to the NSTEMI(01/02) group but it did not reach statistical significance. Multivariate Cox-regression analysis revealed furthermore that also patients with higher age and/or renal dysfunction benefit from an early invasive strategy. CONCLUSION: The implementation of updated guidelines for NSTE-ACS had significant impact on short- and long-term mortality. However, an early invasive strategy is still withheld to a significant number of high-risk patients, who would benefit from an invasive treatment.

[Perioperative management of patients with implanted pacemakers or cardioverter/defibrillators. Recommendations of the Austrian Society for Anaesthesiology, Resuscitation and Intensive Care Medicine, the Austrian Society for Cardiology and the Austrian Society for Surgery]. / Perioperatives Management von Patienten mit implantiertem Schrittmacher oder Kardioverter/Defibrillator. Empfehlungen der Osterreichischen Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin, der Osterreichischen Kardiologischen Gesellschaft und der Osterreichischen Gesellschaft für Chirurgie.

The perioperative risk for patients with pacemakers or implanted cardioverter/defibrillators (ICD) is mainly dependent on the underlying disease. However, severe to life-threatening complications of the implanted system can occur due to electromagnetic interference in the environment of the operation. These complications can be prevented or adequately treated by taking special precautions and measures. Even though the currently available data on the optimal perioperative management to pacemakers and ICDs is still unsatisfactory, the increasing clinical relevance of this topic was the reason for the formulation of recommendations by an interdisciplinary working group in Austria.

Design of a village breeding programme for a llama population in the High Andes of Bolivia.

No national breeding programme for llamas is in place in Bolivia. Initiatives for genetic improvement are rarely found and are usually carried out by NGOs working in rural development or improvement of livestock production or research stations. Farmers in the Province of Ayopaya in the District of Cochabamba have formed a breeders' organization with the aim of improving fibre production. In this study, a detailed outline of a breeding programme with a focus on organizational and technical details is described. Facing constraints like illiteracy of farmers, bad infrastructure and lack of finances, a simple breeding programme is set up. The breeding goal is a higher fleece weight while keeping the fleece quality at the current high level. Greasy fleece weight and fibre diameter are identified as main selection criteria. Mass selection of males is carried out. Selected males are either exchanged between farmers and used in the herds or are kept during the mating season in a central mating station owned by the breeders' organization. Model calculations were carried out with the program zplan, which is based on a deterministic approach. zplan evaluates the genetic and economic efficiency of breeding strategies considering one cycle of selection. Scenarios with only intra-herd use, using only the central mating station or combinations of those were compared in terms of expected genetic gain and expected increase of inbreeding. Fastest genetic progress is achieved when the males are kept in a central mating station as the selection intensity is on a high level. Rates of inbreeding vary between 0.08 and 0.32% per generation.

Do conventional cleaning and disinfection techniques avoid the risk of endoscopic Helicobacter pylori transmission?

BACKGROUND AND STUDY AIMS: The aim of the present study was to determine whether endoscopes serve as a reservoir for Helicobacter pylori and whether the disinfection technique currently recommended for manual cleaning and disinfection of the instruments completely removes the risk of H. pylori transmission. PATIENTS AND METHODS: A prospective study was carried out in 400 patients who were undergoing upper gastrointestinal endoscopy for routine clinical indications. The patients' H. pylori status of the patients was identified using a urea detection system (HUT) and culture. H. pylori contamination was assayed by culturing rinsing samples from the endoscopes before and after manual cleaning and disinfection. Gastric biopsies were assayed using rapid urease testing (Helicobacter urease test, HUT) of two antral and gastric body biopsies and cultures. RESULTS: A total of 128 of the 400 patients examined were found to be H. pylori-positive using HUT testing. Endoscopes were contaminated in 54 of the 128 rinsing samples from endoscopes used in H. pylori-positive patients (42 %) before cleaning and disinfection. One of the 128 rinsing samples (0.8 %) was found to be contaminated with H. pylori even after routine manual cleaning and disinfection - indicating that these cleaning and disinfection procedures may be insufficient to eradicate H. pylori from endoscopes completely. No seroconversion was observed during serological follow-up in the patient who had previously been examined with an endoscope contaminated with H. pylori. The patient was still found to be seronegative 5 months after inoculation. CONCLUSIONS: Endoscopes are frequently contaminated with H. pylori immediately after gastroduodenal endoscopy in H. pylori-infected patients. Iatrogenic transmission is possible, as H. pylori can survive manual cleaning and disinfection with 2 % glutaraldehyde, particularly when there is ineffective cleaning before disinfection.

[Implanted rhythm monitoring system--diagnostic and therapeutic options of anti-bradycardic pacemakers]. / Implantiertes Rhythmusmonitoring--diagnostische und therapeutische Optionen antibradykarder Schrittmacher.

Monitoring of pacemaker patients is usually performed by 24 hour-long-term-ECG or event recorder. The newer pacemaker generation offers a variety of diagnostic features such as histograms, event counters of sensed or paced beats, trends of periodically measured lead impedance and amplitudes of sensed beats as well as automatic measurements of ventricular threshold. Predefined episodes of atrial and ventricular tachyarryhthmias can be documented as intracardiac electrogrammes and validated during pacemaker follow-up, thus leading to therapeutic consequences. Patient-triggered episodes can proove or exclude arrhythmogenic events. Special algorithms try to suppress the occurence of paroxysmal atrial fibrillation, newest pacemaker systems are even able to terminate atrial tachyarryhthmias by rapid atrial overdrive stimulation. Diagnostic and therapeutic options of modern antibradycardic pacemakers offer a permanent implanted rhythm-monitoring and try to reduce the incidence of atrial tachyarrhythmias.

[Sub-pectoral implantation of defibrillators: intraoperative data and long-term outcome]. / Subpektorale Implantation von Defibrillatoren: Intraoperative Daten und Langzeitbeobachtung.

UNLABELLED: The present study examined the perioperative mortality and morbidity and lead-related complications in patients who had a defibrillator with a transvenous lead system and subpectoral implantation of the generator. Fifty-four out of 57 consecutive patients (95%) received a transvenous lead system. One patient had an acceptable defibrillation threshold with an additional subcutaneous patch whereas no sufficient defibrillation threshold was found in another 2 patients. Two patients died due to congestive heart failure after implantation. Perioperative complications were observed in 4 patients (7%) including pericardial effusion, pocket hematoma, injury of the plexus brachialis and a pneumothorax. None of these complications required surgical intervention. Fifty-five patients were discharged from the hospital. During 27 +/- 10 months none of these patients died. Lead-related complications were observed in 3 patients (5.5%) including microdislocation in two and a outer conductor fracture in one of the lead. CONCLUSION: Technical advancement such as a non-thoracotomy lead system and smaller devices have made the onc-incision approach and subpectoral implantation of the ICD generator clinical routine. Nevertheless complications related to the lead system can occur. Therefore frequent controls of patients with ICD are necessary.

Present and future role of ambulatory Holter monitoring for arrhythmia risk stratification.

Risk stratification for arrhythmogenic events and sudden death in patients with organic heart disease, particularly those with coronary heart disease and a history of MI, continues to be one of the major tasks of clinical cardiologists, although advanced management strategies including thrombolysis, acute PTCA and surgical intervention dramatically reduced the percentage of sudden deaths following acute MIs, Noninvasive studies like resting and exercise ECG, echocardiography, signal averaging, 24-hour ECG, and radionuclide studies, as well as invasive techniques such as electrophysiologically programmed electrostimulation and coronary angiography, are being used routinely. Ambulatory Holter monitoring is an established noninvasive technique for risk stratification. There is evidence showing that its predictive potential for arrhythmogenic risks is enhanced, if more than one parameter is analyzed. Absence of ST segment changes and a normal HRV are the parameters signaling out low-risk patients. The use of additional parameters which escape electrocardiographic recording, like ventricular function and myocardial ischemia, improve the accuracy of predicting arrhythmogenic events. The most predictive combination of risk parameters is, however, still poorly understood. Future research should define normal ranges of parameters recordable by H-ECG, solve technical problems of recording data and analyzing them. In addition, the accuracy of measuring QT duration and documenting late potentials should be improved by more sophisticated methods. But it is unrealistic to expect that the QT interval will become amenable to automatic analysis in all patients. A fully automatic QT analysis without visually checking the measuring points at the tip and the end of the T wave for their consistency is hardly conceivable. The documentation of late potentials, in turn, is limited by artefacts caused by muscle contraction during physical activity. Clinical aspects, e.g., the predictability of arrhythmogenic events in patients with cardiomyopathies and valvular disease should be addressed. This will require studies combining the predictive potentials of rhythmologic and hemodynamic data.

[Does thermotherapy of prostatic hypertrophy interfere with pacemaker function? - First results of a pilot-study]. / Beeinflusst die Thermotherapie der Prostatahypertrophie die Schrittmacherfunktion? : Erste Ergebnisse einer Pilotstudie.

In 8 patients with implanted pacemaker (3 unipolar, 5 bipolar systems) the risk of interference of a regular pacemaker function and an energy source with a capacity of 110 Watt and a frequency of 434 MHz was investigated. The results show that thermotherapy in patients with prostatic hypertrophy can be used without the risk of interference with regular pacemaker function.

Cardioverter discharges following sensing of electrical artifact due to fluid penetration in the connector port.

We report a unique case of fluid penetration, 3 months after implantation, in the connector port of an automatic implantable cardioverter defibrillator (ICD) with transvenous subcutaneous lead system. The patient had coronary artery disease and recurrent episodes of ventricular fibrillation, the fluid caused electrical signals interpreted as ventricular fibrillation by the device, which triggered shock delivery.

[Efficacy of the implantable cardioverter-defibrillator in patients on the waiting list for heart transplantation]. / Effizienz des implantierbaren Cardioverter-Defibrillators bei Patienten auf der Warteliste zur Herztransplantation.

8 of 122 patients receiving an implantable cardioverter defibrillator (ICD) in our department since 1985 for the treatment of ventricular tachyarrhythmias were considered candidates for cardiac transplantation. In 6 of 8 patients, at least one successful ICD discharge (range 1-378 discharges) was documented in the follow up time until transplantation. These therapies included cardioversions/defibrillations as well as overdrive stimulation in sustained monomorphic ventricular tachycardia. 1 patient died shortly before receiving a compatible organ. The remaining 7 patients survived successful heart transplantation undertaken 7-34 months after implantation of the cardioverter defibrillator. Cardiac transplantation was not complicated in any of these patients by the previous ICD management. Our results show the high efficacy of ICD as "bridge to transplant" therapy unit cardiac transplantation.

[The value of tilt-table examination in diagnosis of syncope: studies of 24 patients]. / Der Stellenwert der Kipptischuntersuchung in der Synkopendiagnostik: Untersuchungen an 24 Patienten.

Sudden hypotension, alone or combined with bradycardia is a major cause of syncope. 24 consecutive patients with a history of > 1 syncope of unknown aetiology were exposed to vagal provocation by the head-up tilt test. The clinical symptoms were reproduced in 11 patients under the given protocol, representing a sensitivity of 46%. The patients were followed up for 13.2 +/- 5.3 months. 7 of the 11 patients (64%) with a positive result on tilting versus 2 of the 13 patients (15%) with a negative result had a relapse of syncope. There was no statistical difference between the groups with regard to the number of syncopal episodes before patients were included in the study. Syncope in the head-up tilt test is, thus, a pointer towards identifying with a higher incidence of syncope on follow-up.

[Complications in transvenous and transvenous-subcutaneous implantable defibrillator systems]. / Komplikationen bei transvenös bzw. transvenös-subkutan implantierbaren Defibrillatorsystemen.

Due to technical improvement using the transvenous-subcutaneous approach for lead fixation for cardioverter-defibrillator implantation, the incidence of device implantation has extended enormously. While a significant lower perioperative mortality in transvenously implanted systems compared to epicardially fixed implantable cardioverter-defibrillator (ICD) has been proven, perioperative as well as complications during follow-up are not analyzed systematically. In 59 patients, in whom transvenous-subcutaneous ICDs had been implanted, 3 patients showed bleeding complications in the subcutaneous patch area, 1 patient showed a bleeding in the device pocket, and in 1 patient a seroma in the subcutaneous patch region was observed necessitating surgical revisions. During follow-up of 10 +/- 7 months, lead dislocations were observed in 6 patients, in another 6 patients patch crinkling was observed. There was 1 patient with a lead fracture as well as 1 patient with a bleeding in the subcutaneous patch region. Despite the high efficacy of this therapy used in patients with life-threatening ventricular arrhythmias, these potential complications have to be considered.

Hemodynamics during ventricular tachyarrhythmias.

The hemodynamic consequences of ventricular tachycardias are caused by cardiac and peripheral reactions. As a result, cardiac output and arterial pressure decrease. Even if the decrease is related to the tachycardia rate and left ventricular function, clinical symptoms do not in each case correlate with the degree of hemodynamic compromise. The explanation for this phenomenon is the different cardiac and peripheral reaction of patients to an immediate rise in heart rate. In this regard, it is questionable if pressure monitoring is superior to heart rate monitoring as a sensor for implantable antitachycardia devices.

[Therapy monitoring in cardiac arrhythmias: guidelines for evaluation of anti-arrhythmia effects]. / Therapiekontrolle bei Herzrhythmusstörungen: Richtlinien zur Prüfung antiarrhythmischer Wirkungen.

The incidence of avoidable or unavoidable, cardial and extracardial side effects is a risk in the drug treatment of supraventricular and ventricular tachyarrhythmias. Therefore the indication of antiarrhythmic drug therapy has to be considered critically. The patient has to be controlled close-meshed, especially at the beginning of the drug treatment. In patients with life threatening ventricular tachyarrhythmias, which can not be suppressed by drug therapy, nonpharmacological therapy--implantable cardioverter/defibrillator, catheterablation and heart-transplantation--has to be discussed.

Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias.

BACKGROUND: Torsade de pointes is characterized not only by its particular ECG pattern but by its context of congenital or acquired long QT syndrome and the long coupling interval of the initial premature beat. METHODS AND RESULTS: We observed 14 patients aged 34.6 +/- 10 years (mean +/- SD) with no structural heart disease who presented with syncope related to a typical ECG aspect of torsade de pointes. However, there was no evidence of long QT syndrome, and the torsade had the unusual particularity of an extremely short coupling interval of the first beat or of the isolated premature beats (245 +/- 28 milliseconds). In 10 cases they deteriorated into ventricular fibrillation. Four patients had a familial history of sudden death. Only 2 patients had a tachyarrhythmia inducible by programmed stimulation. At Holter recordings the heart rate variability was globally and significantly depressed, the vagal limb of the autonomic nervous system being predominantly affected. During a mean follow-up of 7 years there were 5 deaths (4 sudden). Nine patients are alive, 3 with implanted defibrillators and 6 treated with verapamil alone. Unlike the other types of antiarrhythmic agents including beta-blockers and amiodarone, verapamil is in our experience the only drug apparently active on the arrhythmias; however, it does not prevent sudden death. CONCLUSIONS: The short-coupled variant of torsade de pointes should be identified because of their ECG pattern and the risk of sudden death in young adults with no structural heart disease.

[Electrocardiography and electrophysiologic findings in patients with myotonic muscular dystrophy]. / Elektrokardiographische und elektrophysiologische Befunde bei Patienten mit myotoner Muskeldystrophie.

Myotonic dystrophy is associated with diffuse cardiac conduction disturbances. Seven consecutive patients, all asymptomatic with respect to cardiac abnormalities, were investigated by means of ECG, Holter monitoring, and invasive electrophysiologic studies (EPS). During Holter monitoring, no abnormalities were found in any patient, except for one patient who showed single monomorphic VEBs. During EPS three patients showed conduction disturbances in the AV-node (AVN) as well as in the His-Purkinje-system (HPS) in another three patients. Except for two patients ventricular vulnerability was normal during programmed ventricular stimulation. A considerable number of asymptomatic patients with myotonic dystrophy reveals AVN- and HPS-conduction disturbances as shown during EPS.

[Torsades de pointes with short coupling interval]. / Les torsades de pointes à couplage court.

The authors describe a ventricular arrhythmia observed in 14 patients between 1972 and 1991, and 9 cases in the literature. The patients were hospitalised for investigations of syncope related to torsades de pointes. They were characterised by the very short coupling interval to the initiating extrasystole (average: 245 ms), by the young age of the patients (average: 34.6 years) and by the absence of overt cardiac disease. The resting electrocardiogrammes were normal, especially ventricular repolarisation. Some recordings showed isolated ventricular extrasystoles with short coupling intervals. Quite often, a family history of sudden death was obtained. These episodes of ventricular arrhythmia may degenerate to ventricular fibrillation. Pharmacological and electrophysiological investigations did not show any consistent characteristic electrophysiological behaviour. Investigations of autonomic nervous system function showed a decrease in global sinus rhythm variability and an increased sympathetic over parasympathetic activity. The clinical outcome of these patients is unpredictable with present methods. From a therapeutic point of view, Class I antiarrhythmics, betablockers and amiodarone were ineffective. Verapamil showed an electrocardiographic improvement by increasing the coupling interval of the extrasystoles and decreasing or even suppressing some repetitive forms, but without preventing recurrences. The indications for an implantable automatic defibrillator should be considered in this group of patients. These patients have clinical and electrocardiographic abnormalities which are sufficiently coherent for them to constitute a new pathological entity which the authors suggest calling "torsades de pointes with a short coupling interval".