[Use of coronary angiography after acute myocardial infarction in Germany: a comparison of daily clinical practice with international guidelines. MITRA Study]. / Indikationsstellung zur Herzkatheteruntersuchung nach akutem Myokardinfarkt in Deutschland: Klinische Praxis vs. Richtlinien. MITRA-Studie.

OBJECTIVES: Two third of patients with acute myocardial infarction are admitted to hospitals without cardiac catheterization facilities. Whether a postinfarction patient will undergo cardiac catheterization or not is more often decided by general physicians than by cardiologists. The purpose of this presentation is to investigate the determinants for decision making to use cardiac catheterization in patients after myocardial infarction. METHODS: MITRA is a prospective, multicenter registry, which enrolls all consecutive patients with acute Q wave infarction admitted to 54 hospitals in Southwestern Germany. During the pilot phase 949 consecutive survivors of acute myocardial infarction were included, and inhospital outcome as well as therapeutic strategies were registered. RESULTS: Only half of the patients underwent cardiac catheterization regardless of whether a catheterization facility was available or not. In 63% of the patients under 65 years of age coronary angiography was performed; however, every fourth patient with age above 70 years was transferred to an invasive therapeutic strategy. The percentage of male patients was twice a high in the invasive group, whereas patients with prior infarction, clinical signs of congestive heart failure, patients with moderately or severely impaired left ventricular function, and finally patients with a prehospital delay of more than 4 hours were more frequent in the conservative group. The following three parameters were calculated to be independent determinants of an invasive strategy: pathological stress ECG (OR: 2.8; CI: 1.80-4.60), patients < 70 years without stress ECG (OR: 2.18; CI: 1.5-3.18), and male gender (OR: 1.45: CI: 1.10-2.00). Independent factors of a conservative strategy were primary PTCA (OR: 0.2; CI: 0.09-0.46), prehospital delay > 4 hours (OR: 0.71; CI: 0.51-0.97), and the combination of age > 70 years and the absence of a stress ECG (OR: 0.78; CI: 0.55-1.11). CONCLUSIONS: In Germany, patients with acute myocardial infarction are less likely to undergo cardiac catheterization compared to patients in other Western countries (e.g. , the United States). Despite recommended guidelines, invasive strategies are more frequent in low risk groups (younger patients, male gender) than in postinfarction patients at high risk (severely impaired left ventricular function, clinical signs of congestive heart failure, the elderly).

[Early treatment of acute myocardial infarct: implementation of therapy guidelines in routine clinical practice, MITRA pilot phase]. / Frühbehandlung des akuten Myokardinfarktes: Umsetzung von Therapierichtlinien in den klinischen Alltag, MITRA-Pilotphase.

The prognostic value of thrombolytics, aspirin, beta-blockers and ACE-inhibitors has been well documented in large clinical trials, but the application of these drugs in clinical practice is not known. MITRA is a multicenter study of 54 hospitals in a defined region in southwest Germany. The aim is to document actual clinical practice (pilot phase) and to establish an individually optimised prognostic therapy for acute myocardial infarction, considering only the absolute contraindications for each drug. In the pilot phase, 1303 consecutive patients with acute transmural myocardial infarction were enrolled. The median age was 66 years, the prehospital time was 2.7 hours. 47% had an anterior infarction. In the subgroup of patients without absolute contraindications, only 53.4% were treated with thrombolytics, 87.6% with aspirin, 37.1% with beta-blocker, and 17.4% with ACE-inhibitor. Out of these, patients were classified as "optimally treated" if they received thrombolysis, aspirin as well as beta-blocker. Patients were also included if any of these medications was withheld in the presence of absolute contraindications. Treatment was defined suboptimal, if the patients did not receive any of these three medications despite the absence of absolute contraindications. Only 29% (n = 383) received an optimal post-infarction therapy and 71% (n = 775) a suboptimal treatment. The univariate analysis revealed 10 variables influencing optimal therapy. In this subgroup patients were younger, they more often had clear ECG-findings or left bundle branch block, an anterior infarction, acute cardiac failure, AV-block, bradycardia, recent trauma or surgery (less then 2 weeks) and a severe chronic obstructive lung disease. The prehospital time was more often available. Early mortality after 2 days was 5.0% versus 9.3% in the suboptimal treated patients (OR: 0.5, CI: 0.30-0.86) the total inhospital mortality was 10.9% in the optimal versus 17.7% in the suboptimal group (OR: 0.6, CI: 0.38-0.84). In a multivariate analysis the parameter "optimal treatment" was found to be an independent predictor of the early (OR = 0.4; CI: 0.20-0.69) and the inhospital mortality (OR = 0.4; CI: 0.25-0.64). The following in-hospital events occurred: stroke 2.8%, reinfarction 12.9%, cardiac failure 21.5%, cardiogenic shock 10.4% and in-hospital mortality 18.1% (2-days mortality 9.5%). Pharmacological therapy for acute myocardial infarction is inconsistent with the recommendations suggested in recent clinical trials and needs to be individually optimised. Optimal treatment is an independent predictor of early and inhospital mortality.

[A case of chloroquine-resistant tropical malaria from eastern Africa (Kenya)]. / Ein Fall von chloroquinresistenter Malaria tropica aus Ostafrika (Kenia).

A case of chloroquine-resistant falciparum malaria in a non-immune Swiss tourist is described. The infection was acquired in Kenya in spite of regular chloroquine prophylaxis with therapeutic serum levels. The isolated plasmodia showed marked in vitro resistance to chloroquine and sensitivity to mefloquine and pyrimethamine.

[Premedication of esophago-gastro-duodenoscopy with a neuroleptanalgesic drug and a tranquillizer--a controlled clinical study (author's transl)]. / Neuroleptanalgesie und Tranquilizer als Prämedikation bei der Osophago-Gastro-Duodenoskopie--Eine kontrollierte klinische Studie.

In a controlled double-blind randomized study Thalamonal and Valium were compared in 498 esophago-gastro-duodenoscopies. Both drugs were injected intravenously immediately before the procedure. Satisfactory sedation which made additional injection of the drug during the endoscopy superfluous could be achieved in 66% of the patients with Thalamonal and in 52% with Valium respectively. The difference between the two preparations is statistically significant (p less than 0,005). In 95 patients catamnestic studies were performed in order to evaluate second episodes of fatigue after the endoscopy. A good effect of the preparation during endoscopy and a lack of second attacks of sedation following discharge was observed only in 23% of the patients after Thalamonal and in 21% of the patients after Valium injection, respectively. Therfore a good premedication was achieved in only one fifth of the patients receiving one of the two drugs.

Topical anesthesia in preendoscopic medication: spray versus lozenges.

Patients' acceptance of upper fiberpanendoscopy was significantly (p less than 0.001) better when topical anesthesia with oxybuprocaine was performed with a spray than with a lozenge.

[Fiber endoscopy and radiology in stomach ulcer, stomach neoplasms and hiatal hernia: questions, timing and value]. / Fiberendoskopie und Radiologie bei Ulcus ventriculi, Magenkarzinom und Hiatushernie: Fragestellung, Zeitpunkt und Aussagekraft.

In 306 patients, fiberpanendoscopy and radiology were performed within a time interval of 7 days or less. In 196 cases, radiology was performed before endoscopy and in 110 cases after endoscopy. In cases with histologically unproven divergent findings, follow-up studies were performed. In the diagnosis of gastric ulcer and gastric cancer, endoscopy with biopsy was more accurate than radiology. In the diagnosis of hiatal hernia, radiology was more accurate. Important additional findings difficult or impossible to observe with endoscopy were present in 36% of the radiological examinations. Thus, the first examination should be endoscopy when ulcer or carcinoma is suspected. In patients with uncharacteristic epigastric symptoms, radiology should be performed first.

Haemolytic activity in gastric and duodenal juice.

Gastric juice was aspirated during upper endoscopy in 141 patients. In 48 patients duodenal juice was also aspirated. pH, bilirubin concentration, and haemolytic activity were measured in each sample. Patients with atrophic gastritis and subtotal gastrectomy (Billroth II) showed the highest concentrations of haemolytic activity and bilirubin in their gastric juice. Gastric juice of patients with gastric and duodenal ulcer, with gastric erosions, and with antral gastritis was not statistically different from the control group in which 22 of 32 persons had a positive haemolytic activity. The ratio of bilirubin and haemolytic activity concentration was significantly higher in duodenal than in gastric juice. The reason for this phenomenon remains unknown. It is concluded that for practical purposes bile staining more than haemolytic activity of gastric contents is a quite sensitive, though unspecific, sign of abnormal duodenogastric reflux.

[Benign spontaneous pneumothorax: possibilities and prognosis of conservative therapy]. / Benigner Spontanpneumothorax: Möglichkeiten und Prognose konservativer Therapie.

There is much divergence of opinion as to how spontaneous pneumothorax should be treated or even whether it should be treated at all. Nowadays this benign pulmonary disease is primarily treated surgically, although conservative management of spontaneous pneumothorax seems to provide equally good results, as already indicated in 1932 by KJAERGAARD. Histories and clinical findings for 87 patients who were initially treated for spontaneous pneumothorax were reviewed and the factors responsible for the choice of treatment established. The mean age of the patients was 34 years, and 60% of the patients were below 30. Males predominated over females by 8:1. No coexisting pulmonary diseases were found in 80% of the patients. 54 patients were treated conservatively (no treatment except antitussives or analgesics). 46 conservatively treated patients had pneumothorax for the first time; 4 patients each had pneumothorax for the second or third time or more. 46 of 66 patients with idiopathic pneumothorax received no treatment, whereas 12 of 20 patients who had coexisting pulmonary diseases were treated surgically. The pneumothorax did not recur in 30 of 37 patients treated conservatively and observed for 1--15 years. These data suggest that conservative management is as effective as surgical treatment in uncomplicated spontaneous pneumothorax.

[The value of endoscopic retrograde cholangiopancreatography in negative or undetermined cholecystocholangiography]. / Wert der endoskopischen retrograden Cholangiopankreatographie bei negativem oder nicht aussagekräftigem Cholezystocholangiogramm

In 299 patients with negative cholecystocholangiogram, endoscopic retrograde cholangio-pancreatography (ERCP) was performed. In obstructive jaundice ERCP is the method of choice, while in cholestasis it is indicated if the intravenous cholecystocholangiogram is insufficient. In unclear abdominal conditions and in "postcholecystectomy syndrome" ERCP may be carried out after other abdominal diseases have been ruled out.