[Physical training as interval or continuous training in chronic heart failure for improving functional capacity, hemodynamics and quality of life--a controlled study]. / Körperliches Training als Intervall oder kontinuierliches Training bei chronischer Herzinsuffizienz zur Verbesserung der funktionellen Leistungskapazität, Hämodynamik und Lebensqualität--eine kontrollierte Studie.

We conducted a three-week randomized trial comparing the improvement of functional capacity by exercise training in chronic heart failure by the steady-state (EF 27.3%, n = 20) and the interval modus (EF 29.3%, n = 20) with a control group (EF = 26.6%, n = 10). Minimal EF was 10%, the lowest maximal oxygen consumption was 9.3 ml/kg/min and the lowest cardiac output was 1.9 l/min; 9 patients had been evaluated for HTX. VO2 at the anaerobic threshold and at maximal exercise increased in the continuous exercise group by 1.4 or 1.6 ml/kg/min, respectively, corresponding to an increase of 13.7% (p < 0.05) and 9.3% (p < 0.05). In the interval training group the increase was 1.3 and 1.5 ml/kg/min corresponding to 14% (p < 0.05) and 8.1% (p < 0.05). Continuous short-term exercise had no impact to central hemodynamics as pulmonary artery pressure (PA), capillary wedge pressure (pc), cardiac index (CI) or stroke volume index (SVI), whereas after interval training a significant increase at maximal exercise could be seen in CI (p < 0.05) and SVI (p < 0.01) with a concomitant drop in systemic peripheral resistance (p < 0.05) compared to the steady-state modus. Interval training was further characterized by a higher short-term but lower mean work load with a significantly smaller increase in lactate. Quality of life was improved according to the SF-36 questionnaire in both training groups but the psychologic sum factor was three times as high, increasing to 24.2% in the steady-state exercise group. It can be concluded that clinically stable patients with heart failure and even those already having been evaluated for cardiac transplantation profit from short-term physical training. Both training modalities seem equally suited to improve functional capacity. However interval training leads to more pronounced improvement in hemodynamics compared to the steady-state exercise, whereas the later had a greater impact on psychological well-being and quality of life. Patients with heart failure and severe peripheral deconditioning tolerate higher workloads with more peripheral stress by an interval training modus. Long-term training modalities need to be established to further improve and stabilize functional status.

Nosocomial outbreak of legionellosis in a rehabilitation center. Demonstration of potable water as a source.

Ten patients from a rehabilitation center were admitted to hospital with serious respiratory infections within ten weeks. An outbreak of Legionnaire's disease was suspected based on the epidemic and atypical manifestation of pneumonia and could be proven microbiologically. Pulmonary and extrapulmonary complications included respiratory failure, lung abscess, transitory renal impairment in five patients and acute renal failure requiring dialysis in one, tetraparesis caused by peripheral neuropathy and acute psychosis. Three patients died despite immediate institution of therapy with erythromycin. Legionella pneumophila serogroup 1 subtype Pontiac was isolated from a bronchial lavage sample of one patient and from the water supply of the rehabilitation center. Monoclonal antibody subtyping and restriction endonuclease analysis were performed on both environmental and patient isolates. Potable water was identified as the source of the outbreak based on identical patterns on restriction endonuclease analysis. Despite thermic and chemical disinfection with chlorination (up to 15 ppm) in the rehabilitation clinic, an eleventh case of Legionnaire's disease was detected 11 months later.

[The therapy of the heparin-induced thrombosis-thrombocytopenia syndrome with immunoglobulins]. / Therapie des Heparin-induzierten Thrombose-Thrombozytopenie-Syndroms mit Immunglobulinen.

A 51-year-old obese woman who had just undergone a second osteotomy for arthrosis of the hip joint was given unfractionated heparin, 7,500 IU subcutaneously three times daily, as thrombosis prophylaxis. Signs of fulminant pulmonary embolism occurred on the 16th postoperative day with a platelet count of 33,000/microliters. Suspected heparin-induced thrombocytopenia and thrombosis (HITT) was confirmed by platelet tests. When heparin had been discontinued immunoglobulin G was administered, seven times 5 g intravenously, in view of the immunological genesis of HITT. In addition thrombolysis treatment with streptokinase combined with phenprocoumon was undertaken, until satisfactory anticoagulation was achieved after 4 days. Platelet count rose to 136,000/microliters within 20 hours of the first immunoglobulin dose. Complete clinical normality was restored, scintigraphy showed no perfusion deficit in the lungs.

[Case study of a Legionella epidemic in a rehabilitation clinic]. / Kasuistik einer Legionellen-Epidemie in einer Rehabilitationsklinik.

A series of nosocomial Legionella infections in a rehabilitation center is reported. In a three months period a total of 10 pneumonias with 3 deaths occurred (8 patients, 1 companion, 1 staff member). Serologic analysis proved additional Legionella infections within the nursing staff. The warm-water system was proved to be the source of infection by isolating Legionella pneumophila serogroup 1 subtype Pontiac both in warm-water and patients samples. The air conditioning system could not be ruled out as another (secondary) route of exposure because of shortcomings in construction. Conclusions about prevention and the course of the disease are discussed and standards for warm-water and air conditioning systems are proposed.

[Spontaneous bacterial peritonitis in a patient with decompensated alcoholic cirrhosis of the liver]. / Spontane bakterielle Peritonitis bei einem Patienten mit dekompensierter alkoholischer Leberzirrhose.

Spontaneous bacterial peritonitis (SBP) constitute a rare complication of cirrhosis of the liver with a high mortality rate. Unspecific sings of decompensation like increasing elaboration of ascites or the development of hepatic encephalopathy are often prevailing. Fever and peripheral blood leukocytosis as well as abdominal sings of peritonitis are not rarely completely missing. There is a strong suspicion of SBP with an ascitic polymorphonuclear count of greater than 500/mm3. Determination of lactate and pH in the ascitic fluid can increase diagnostic sensitivity and specificity if the leukocyte count is dubious. Gram negative rods predominate with over 70% whereas anaerobic organisms appear to be very rare. A 49 year old patient is presented and diagnostic and therapeutic strategies reviewed. In view of the high mortality every clinical deterioration of patients with cirrhosis should alert the physician of the presence of SBP.

[Fulminant venous and arterial thromboses under heparin therapy]. / Fulminante venöse und arterielle Thrombosen unter Heparintherapie.

A deep-vein thrombosis developed in a 71-year-old patient on the eleventh day of heparin treatment (25,000 U intravenously over 24 hours) given because of a nontransmural anterior-wall infarct. Subsequently there occurred a unilateral and then bilateral thrombotic occlusion of the femoral arteries and thrombosis of the infrarenal artery with occlusion of the right renal artery which necessitated operative thrombectomy. Platelet count, initially 370,000/microliters, fell to 34,000/microliters. No source of emboli was found either echocardiographically or by thoracic and abdominal computed tomography. After heparin administration had been discontinued on the 15th day, platelet count quickly returned to normal. Rapidly progressing demarcation necessitated amputation of both legs. The patient died on the 23rd hospital day. The reported findings indicate a heparin-induced thrombosis-thrombocytopenia syndrome.