[Knee-related Pain Problems during Pregnancy Correlate with an Increase in Body Weight. Results of a Prospective Study]. / Knieschmerz im Verlauf der Schwangerschaft in Bezug zum Anstieg des Körpergewichts. Ergebnisse einer prospektiven Studie.

PURPOSE: This study aimed to evaluate the incidence of knee pain or the intensification of knee-related problems during pregnancy. We hypothesised that the occurrence of knee problems correlates with an increase in body weight during pregnancy. METHODS: A total of 326 women (30(th)-40(th) week of pregnancy) were involved in this study. At onset of the pregnancy, the patients were 29.4 [95% CI 28.8-29.9] years of age. We asked all patients retrospectively about their anthropometric data at the beginning of pregnancy. All patients provided information about former knee problems, knee problems occurring after onset of pregnancy or any increase in these problems. These knee patients were re-evaluated 6 weeks after childbirth. At follow-up, the patients were asked about their knee problems and about their body weight. RESULTS: At the beginning of pregnancy, the mean body weight was 68.0 kg (95% CI 64.4-69.6; range 41-117). The mean BMI of all patients was 24.5 kg/m² (25% CI 23.9-25.0; range 17.0-26.0). The absolute body weight increased by 13.8 kg (95% CI 13.2-1.5; range 3-38). A total of 24 patients (7.4%) reported new knee problems during pregnancy. 2 patients reported an increase in knee-related problems during pregnancy (0.6%). The incidence of knee-related problems (new cases and increase of problems n=26) was 26/326 or 7.6/100 pregnancies. In patients without knee problems, the pregnancy-related increase in the BMI (ΔBMI) was 4.8 kg/m² (95% CI 4.6-5.1, range 1.1-14.1). In cases with incident knee problems, the ΔBMI was 5.9 kg/m² (95% CI 4.9-6.9, range 2.1-11.8). The increase in body weight (Δbody weight) in patients without knee problems was 13.5 kg (95% CI 12.9-14.2, range 3-38). Patients with incident knee pain experienced a Δbody weight of 16.8 kg (95% CI 13.9-19.4, range 6-35). The differences in ΔBMI and Δbody weight were significant (p=0.009). A Δbody weight >20 kg was a significant risk factor for pregnancy-related knee pain significant risk factor pregnancy related pain. A total of 23 incident cases (92%) underwent a follow-up interview 6 weeks after parturition. At this time, a total of 6 patients (26.1%) had not experienced further knee problems, whereas persistent knee problems were reported in the remaining patients (73.9%). Patients without any knee complaints [body weight 72.5 kg (CI 95% 60.9-83.9)] tended to have a lower body weight at follow-up than patients with persistent knee pain [85.5 kg (CI 95% 71.8-99.1), p=0.162]. CONCLUSION: There is a body weight-associated increase in the incidence of functional knee pain in pregnant women. In about one-third of the cases, knee problems persist after pregnancy and are associated with a residual increase in body weight. Thus, we conclude that body weight is a potential risk factor for functional knee pain.

[Occlusion of the left main stem after transcatheter aortic valve implantation (TAVI)--a rare complication]. / Verschluss des Hauptstammes der linken Koronararterie nach perkutaner Aortenklappenimplantation (TAVI)--eine seltene Komplikation.

HISTORY: In an 85-year-old woman with severe symptomatic aortic stenosis transcatheter aortic valve implantation (TAVI) was performed via a transfemoral access. A 26 mm Sapien Edwards XTTM prosthesis was implanted. FINDINGS: Shortly after the implantation arterial blood pressure began to drop. Aortic root angiography demonstrated occlusion of the left main stem and the small right coronary artery. TREATMENT: Mechanical resuscitation had to be started, while a 6 French guiding catheter was inserted. A guide wire could be inserted into the left main stem, which resulted in slow antegrade flow (TIMI grade II), with an almost immediate rise in the arterial pressure. Implantation of a bare metal stent into the ostium of the left main stem resulted in a normal flow to the left coronary artery and arterial blood pressure returned to normal. COURSE: Further clinical course was uneventful and the patient could be discharged one week later. Sixteen months after the procedure, she is still well. CONCLUSION: TAVI should be performed by experienced staff with a cardiac surgery unit in stand-by; the compartment should be equipped with all facilities of an interventional catheterization laboratory.

[Prevalence and distribution of knee cartilage lesions in sportspersons and non-sportspersons: results of a retrospective arthroscopic study]. / Häufigkeit und Verteilung von Knorpelschäden des Kniegelenks bei Sportlern und Nicht-Sportlern: Ergebnisse einer retrospektiven arthroskopischen Studie.

AIM: This study was aimed to evaluate the correlation between sports activity and frequency and grad of non-traumatic knee cartilage lesions. METHODS: A total of 868 patients (469 male and 399 female) who were suffering from knee pain (> 3 months) had undergone knee arthroscopy. The mean duration of history was 11.4 ± 11.5 (3 - 48) months. Criteria for exclusion were major knee injuries (e. g., ACL injuries). All cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) guidelines and summarised with the semiquantitative WOAKS (Whole Organ Arthroscopic Knee Score). RESULTS: There was a significant correlation between cartilage degeneration and age. Older female patients (63 to 85 years) demonstrated higher knee degenerations than male patients. The grade cartilage degeneration was higher in non-sportspersons (WOAKS = 13.5 ± 13.8) than in sportspersons (WOAKS = 7.1 ± 5.3), p < 0.001. Only in younger patients (17 to 34 years) was there no difference in the frequency of cartilage lesions in correlation to sports activity. A high-pivoting sport was significantly more frequently associated with cartilage degeneration in comparison to low-pivoting sports. Cartilage lesions most frequently occur within the mean bearing zones of the medial knee compartment. With regard to sports activity, no differences were observed in the distribution of cartilage lesions. CONCLUSIONS: Sportspersons who suffer from knee pain without injury have significantly less cartilage lesions or, respectively, severe cartilage defects. Cartilage lesions mostly occur within the medial knee compartment without correlation to sports activity and sport type. Patients who are performing "high-pivoting" sports more frequently are suffering from severe cartilage lesions than "low-pivoting" sportspersons. For a final epidemiological estimation of any correlations between sports and cartilage damage, longitudinal MRI studies are needed.

[Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part I. General factors]. / Metaanalyse zur Bestimmung von Risikofaktoren für das Karpaltunnelsyndrom (KTS) Teil I. Allgemeine Risikofaktoren.

AIM: The expert committee of the German Ministry for Labour and Social Affairs suggested carpal tunnel syndrome (CTS) as an "occupational disease". This systematic literature review and metaanalysis was aimed at identifying associated and risk factors for CTS. Part I addresses the general factors and possible concurrent factors of CTS. These results may be helpful in later experts' reviews of the "occupational disease CTS". METHODS: A systematic literature review was performed by examining papers in PubMed, Cochrane, EMBASE and Web of Science databases that were published on or before February 15th, 2011. A total of 87 studies (27 longitudinal and 60 cross-sectional) were included in this metaanalysis. The PRISMA (preferred reporting items for systematic reviews and metaanalyses) guidelines for performing a metaanalysis were strictly followed. All of the effect sizes were calculated using a random effects model. RESULTS: The CTS prevalence in all studies independent of study type was 10.6 % (95 % CI 7.8-14.2). The crude incidence calculated from the longitudinal studies was 10.4 (95 % CI 8.9-11.9)/1000 person years. Female patients more frequently suffered from CTS [OR = 1.9 (95 % CI 1.6-2.2), p < 0.001]. The prevalence of CTS was correlated with an increase in age. The highest prevalence was observed in middle-aged patients (40 to 60 years old). Other significant CTS-associated factors were overweight or obesity [OR = 1.4 (95 % CI 1.3-1.6), p < 0.001]. CTS more frequently occurred in the dominant hand [OR = 1.8 (95 % CI 1.4-2.3), p < 0.001] and in persons of "non-white race" [OR = 1.6 (95 % CI 1.2-1.9), p < 0.001]. Furthermore, CTS was often associated with numerous other general diseases. Real risk factors (results from longitudinal studies) were the following: female gender [OR = 3.7 (95 % CI 2.6-5.2), p < 0.001], middle age [OR = 2.2 (95 % CI 0.9-4.9), p < 0.001], overweight or obesity [OR = 1.5 (95 % CI 1.1-1.9), p < 0.001], diabetes mellitus [OR = 5.3 (95 % CI 1.6-16.8), p < 0.001], and excessive alcohol abuse [OR = 2.3 (95 % CI 0.7-2.3), p < 0.001]. CONCLUSION: CTS is an extremely frequent disease. Independent of occupational burden, many patients are suffering from this frequent peripheral nervous compressive syndrome. These data will be essential in later experts' reviews of the "occupational disease CTS".

[Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part II. Occupational risk factors]. / Metaanalyse zur Bestimmung von Risikofaktoren für das Karpaltunnelsyndrom (KTS) Teil II. Berufliche Risikofaktoren.

AIM: The expert committee of the German Ministry for Labour and Social Affairs suggested carpal tunnel syndrome (CTS) as an "occupational disease". This systematic literature review and metaanalysis was aimed at identifying associated and risk factors for CTS. Part II addresses the occupational factors of CTS. MATERIAL AND METHOD: A systematic literature review was performed by examining papers in PubMed, Cochrane, EMBASE and Web of Science databases that were published on or before February 15th, 2011. A total of 87 studies (27 longitudinal and 60 cross-sectional) were included in this metaanalysis. The PRISMA (preferred reporting items for systematic reviews and metaanalyses) guidelines for performing a metaanalysis were strictly followed. All of the effect sizes were calculated using a random-effects model. RESULTS: The prevalence of CTS in working populations [10.9 % (95 % CI 7.9-14 : 9)] was significantly higher than in the general population [8.2 % (95 % CI 2.3-25.1), p < 0.001]. Working people had a CTS incidence of 17.3 (95 % CI 14.5-20.1)/1,000 person years. In contrast, the crude incidence in the general population was 1.8 (95 % CI 1.4-2.2)/1.000 person years (p < 0.001). The heterogeneity of the different study designs made it impossible to detect concrete prevalence or incidence rates for specific job groups. However, "blue-collar work" was a significant risk factor for CTS [OR = 3.1 (95 % CI 1.9-5.3), p < 0.001]. Thus, it makes sense to evaluate concrete hand burdens. In numerous studies, some factors were associated with CTS: repetition [OR = 2.7 (95 % CI 1.8-39), p < 0.001), chronic wrist flexion [OR = 1.7 (95 % CI 1.0-2.6), p = 0.033], powerful grip [OR = 4.4 (95 % CI 1.4-13.6), p = 0.009], and chronic vibration load [OR = 2.6 (95 % CI 1.7-4.0)]. Primarily, combined hand loadings were estimated. For this evaluation, the hand activity level threshold limit values (HAL TLVs®) of the ACGIH (American Conference of Governmental Hygienists) were useful. Manual work in the 4th quartile of this score was significantly associated with the prevalence of CTS [OR = 2.9 (95 % CI 1.5-5.7), p = 0.001]. These score values were identified as a significant risk factor for occupational CTS. CONCLUSION: It was impossible to define exact prevalences or incidences of CTS for specific job titles. However, it was possible to identify manual loadings with a significantly higher risk or association with CTS, including repetition, wrist flexion, powerful grip, and vibration. These loadings are usually combined during occupational work. Subsequent experts' reviews have to respect these complex hand loadings. It may be useful to use instruments, such as HAL TLVs®.

[The prevalence of radiological osteoarthritis in relation to age, gender, birth-year cohort, and ethnic origins]. / Die Prävalenz der radiologischen Gonarthrose in Bezug zu Lebensalter, Geschlecht, Jahrgangskohorte und ethnischer Zugehörigkeit. Eine Metaanalyse.

AIM: This metaanalysis was performed to evaluate the prevalence of the radiological assessed knee osteoarthritis in the whole community. MATERIALS AND METHODS: Medical databases (Medline, EMBASE, Cochrane) were searched for the strategy: ["Osteoarthritis" and "Knee" and "Prevalence"]. The deadline for the search was 31.12.2009. Two investigators (first and senior author) independently made the selection from 17 studies (from a total of 1428) according to the inclusion criteria: a cross-sectional study of the whole community, radiological investigation and definition of knee ROA by an established radiological score. Only studies in English or German language were evaluated. Effect sizes (event rate, odds ratio [OR] and confidence interval [CI]) were calculated by the software "Comprehensive Metaanalysis V2". Study heterogeneity (I2) was determined accordingly to Higgins. RESULTS: The kappa index for interobserver validity was k = 0.948. All studies judged the grade of osteoarthritis according to the Kellgren-Lawrence (KL) score. For calculation of knee ROA KL grades 2+ were estimated only. The total prevalence of knee ROA was 24.3 % (CI 23.4-25.2 %). The whole prevalence in male patients was 24.3 % (CI 23.4-25.2 %); I2 = 59.4 (p = 0.002) and in female patients 32.6 % (CI 31.8-33.4 %); I2 = 49,1 (p < 0.001). Younger male patients (age 50-) had a prevalence of 5.6 (CI 4.5-6.8). In older patients (80+) the male prevalence was 44.5 % (CI 39.6-49.5 %). In this age group female patients had a prevalence of 71.6 % (CI 67.6-75.3 %). The higher prevalence of knee ROA in female patients was significant (OR = 1.8 [1.7-1.9]; I2 = 46.0 [p < 0.001]). The prevalence of knee ROA was higher in male Asians compared with male Caucasians (OR = 1.1, CI 0.9-1.2; p = 0.080) in tendency. This difference was significant in female patients (OR = 2.2; CI 2.0-2.4; p < 0.001). Furthermore another trend was evaluated. Female patients (70-79 years) from the birth-year cohort 1920- had a prevalence of 37.8 % (CI 35.9-39.7)%. In contrast female patients from the birth-year cohort 1920 had a prevalence of 62.8 % (CI 60.8-64.8 %) at 70-79 years. This difference was significant (OR = 2.8; CI 2.5-3.1; p < 0.001). CONCLUSIONS: This investigation confirms the high prevalence of knee ROA. The evaluated data may serve as a reference for medical or scientific investigations in the future.

[Transcatheter aortic valve implantation (TAVI)TAVI): A new therapeutic option for patients with severe symptomatic aortic stenosis who are not suitable or at high risk for surgical valve replacement]. / Perkutane Aortenklappenimplantation (TAVI): Neue Therapieoption für inoperable oder Hochrisikopatienten mit symptomatischer Aortenklappenstenose.

BACKGROUND: Percutaneous transcatheter aortic valve implantation (TAVI) is a new therapeutic method for patients with severe symptomatic aortic stenosis who are at very high surgical risk or in whom there are contraindications to surgical valve replacement. PATIENTS AND METHODS: Between August 2008 and December 2009, sixty such patients underwent TAVI at our hospital. RESULTS: The mean age of the patients was 82 +/- 6.1 years, 25 of them were men. The mean "European system for cardiac operative risk" (EuroSCORE) was 25.8 +/- 17.0%. A very high surgical risk was the indication for TAVI in 51 patients. The mean aortic valve orifice area was 0.6 +/- 0.1cm(2) and the mean transvalvular gradient 48.2 +/- 14.4 mm Hg before the intervention. The mean duration of the intervention was 62.6 +/- 19.9 minutes and the screening time 11.8 +/- 5.1 minutes. The procedure was technically successful in all but one patient. The post-interventional mean transvalvular gradient was 2.87.0 mm Hg. Significant residual aortic regurgitation (more than grade 3) was present in six patients but was reduced by the catheter-based "snare" technique in most cases. Mean hospital stay was 15.4 +/- 18.9 days. A permanent pacemaker was implanted in 22 of the patients. Eight patients died during the hospital stay, most of them for reasons not directly related to the intervention. CONCLUSIONS: TAVI is becoming a new therapeutic method for elderly patients with severe co-morbidities and severe symptomatic aortic stenosis. Complications of TAVI are not trivial and their management by catheter techniques is challenging. In consequence the selection of patients and of suitably experienced hospitals is crucial for the further development of this promising new technique.

[Knee cartilage lesions and occupational load. Results of an arthroscopic study]. / Knorpelschaden des Kniegelenks und berufliche Belastung. Ergebnisse einer arthroskopischen Studie.

AIM: Numerous epidemiological studies have suggested a relationship between knee osteoarthritis and occupational load or, respectively, a kneeling or squatting position at work. Cartilage breakdown was clearly identified as the main mechanism of the osteoarthritic process. This arthroscopic study was aimed to evaluate the relationship between frequency and grade of knee cartilage damage compared with occupational load. It was hypothesised that heavy work conditions cause higher cartilage degeneration in diverse age groups. Furthermore, it was suggested that kneeling or squatting work positions (analogous to the BK 2112) produce more severe cartilage damage or other distributions thereof compared with patients in low knee-loading professions. METHODS: A total of 1199 patients with knee pain (history of 3 months or more) underwent arthroscopic operations. Cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) protocol. The grading of joint degeneration was quantified by using the WOAKS (whole organ arthroscopic knee score). Patients were divided into 5 age groups (24-39-51-64-75 years) by analysis of cluster centres. RESULTS: In 80.6% (n = 1086) the preoperative radiography suggested signs of a knee osteoarthritis. There was a range from grade I to grade III osteoarthritis according to the Kellgren-Lawrence score. Older female patients had knee osteoarthritis significantly (p = 0.027) more frequently. The grade of osteoarthritis correlated significantly with the patients' age (p > 0.001). The mean WOAKS was 16.6 +/- 13.7 points. There was a continuous increase of WOAKS from 8.2 +/- 5.1 in 24-year-old patients to 24.2 +/- 16.3 points in 75-year-old patients (p < 0.001). In about half of the cases cartilage lesions within the patella and trochlea were evaluated. Most frequently we recorded cartilage lesions within the mean bearing zone of the medial femoral condyle (96.2%) and the medial tibia (57.7)%. Only about a third of our patients suffered from cartilage lesions within the mean bearing zone of the lateral condyle and tibia. The frequency of cartilage lesions and the severity of the lesions grade was significantly less within the non-loaded margin of the surfaces. In 45 knees (3.8%) we found intraarticular osteophytes located: medial (n = 9) and lateral (n = 3) patella margin, intracondylar notch (n = 12), medial tibia (n = 9) and lateral margin of the lateral tibia (n = 4), lateral femoral condyle at the intersection to the lateral trochlea margin (n = 3). The occurrence of osteophytes correlated with the patients' age and the radiological grade of the osteoarthritis. There were no differences with respect to the profession within the age groups. In the non-adjusted WOAKS, patients with hard knee-loading work had a WOAKS of 16.8 +/- 13.9 points and patients with soft work a score of 17.2 +/- 14.3 points (p = 0.583). Differences in the frequency of cartilage distributions within the judged regions of the knee with respect to professional burden were also not evaluated. The same held for the frequency of intraarticular osteophytes. CONCLUSION: Despite there is a known relation between occupational load and knee osteoarthritis no relation to cartilage degeneration was found in our arthroscopic investigation. For better understanding of work-related knee osteoarthritis prospective studies are needed urgently.

[Is there a link between the mercury release of amalgam fillings and the results of psychological questionnaires?]. / Gibt es Zusammenhänge zwischen der Quecksilberbelastung durch Amalgamfüllungen und Ergebnissen testpsychoIogischer Fragebogen-Untersuchungen?

Amalgam as a dental filling material shows excellent material property. It is fast, easy and economical to implement. Evidence for the release of mercury (Hg) from amalgam fillings was given in a number of studies. Mercury release from amalgam dental fillings is often claimed to be a possible cause of unspecific chronic symptoms such as chronic fatigue, headache and migraine. The present study explored relationships between the mercury release from amalgam fillings and the results of psychological questionnaires. The urine of 126 men and women in the age range of 16 to 76 years was examined. 45 participants did not present any amalgam restorations. The mercury released into the urine was measured by using cold-vapour AAS. The results of the study show that chronic mercury exposure, in the low concentration range, is not linked with chronic subjective symptoms.

[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.

[Prevalence of functional pain of the back, the hip and the knee in adolescents. Results of a cross-sectional study]. / Prävalenz funktioneller Beschwerden des Rückens und der Hüft- und Kniegelenke bei Adoleszenten. Ergebnisse einer Querschnittuntersuchung.

OBJECTIVE: To determine the prevalence of functional back, hip and knee pain in adolescents. Risk factors which are associated with these complaints also should be detected. METHODS: A total of 2368 adolescents were included (1137 male, 1231 female, age 14.5 +/- 0.7 years). The persons were interviewed in a self-reported questionnaire about episodes of back, hip and knee pain, furthermore sociodemographic information, activity in sports and consumption of legal drugs (tobacco and alcoholic beverages). All adolescents were examined by school doctors to determine back, hip and knee pathologies. RESULTS: A total of 62.4 % of the adolescents were suffering from musculo-skeletal pain (back 45.4 %, hip 6.4 % and knee 33.6 %). The prevalence of pathological findings was: back 18.0 %, hip 2.7 % and knee 28.5 %. Summarized the prevalence of functional pain was 34.5 % for back pain, 5.7 % for hip pain and 28.5 % for knee pain. There were significantly with functional pain associated factors. Male sex was significantly associated with functional back and hip pain. Knee pain was associated with sports activity. Adolescents who were visiting a high school and adolescents who were smoker had a significant higher prevalence of functional pain. CONCLUSION: The majority of functional back, hip and knee pain in adolescents must be classified as functional complaints. There is a significant association with female sex, visiting a high school and the consumption of legal drugs.

[The prevalence of pain and deformities in the feet of adolescents. Results of a cross-sectional study]. / Die Prävalenz von Beschwerden und Deformierungen des Fusses bei Adoleszenten -- Ergebnisse einer Querschnittuntersuchung.

AIM: The purpose of the study was to evaluate the prevalence of foot pain and foot deformities in adolescents. It was aimed to obtain information on the association between foot pain and foot deformities. METHOD: A total of 2 368 adolescents (age 14.5 +/- 0.7 years) were evaluated. The frequency of foot pain was probed by using a self-reporting questionnaire. The foot deformities were evaluated during clinical examinations by school doctors. RESULTS: The prevalence of foot pain was 14.0 % and the prevalence of foot deformities was 13.7 %. The prevalence of pain was significantly higher in adolescents with foot deformity (17.8 %) than in persons without deformity (13.4 %), p < 0.05. The prevalence of a flexible flat foot was 6.2 % and the prevalence of a rigid flat foot was 0.5 %. Other deformities registered were splay foot (2.3 %) and flexible splay-flat foot (2.0). The prevalence of hallux-valgus deformity was 3.5 %. A total of 3.5 % patients were suffering from a plantar hyperkeratosis. This was significantly correlated to a high pain prevalence (the hyperkeratosis was significantly associated with a high prevalence of pain). Significant factors which were significantly associated with foot pain were foot deformity (1.4 fold) and hyperkeratosis (75 fold). Foot pain was 1.4 fold higher in children with foot deformity and 75 fold higher in feet with hyperkeratosis. CONCLUSION: The prevalence of foot pain and foot deformity in adolescent is high. Mild deformities (flexible flat foot and splay foot) are physiological variations without any association to foot pain. Pathological conditions that are associated with foot pain are the rigid flat foot, the hallux valgus and the cavus deformity. Plantar hyperkeratosis is an indicator of foot pathology.

[Prehospital delay-not just a question of patient knowledge]. / Prähospitalzeit-Patientenwissen allein reicht nicht aus.

Patients with acute myocardial infarction reaching the hospital within the first hour after symptom onset preserve their chances for an optimal treatment. But only about one fifth of them actually reach the hospital within this "golden hour". Information of the public to reduce time from symptom onset to medical service call have shown success only during the time the continuous publicity was maintained. Soon after the end of such activities the prehospital delay again reached the initial duration. Because of restricted resources, prehospital thrombolysis as another means of reducing time to treatment is as yet only used for a very small proportion of patients. Reduction of door-to-balloon and -treatment time seems to have reached its limit in recent years. In patients with delayed hospital admission, the use of PTCA interventions seems to result in better outcome data compared to thrombolysis.

Comparison of different cardiac markers in monitoring percutaneous coronary interventions with frequent use of stents and gpIIbIIIa-antagonists.

Studies from the early 1990s found elevations of creatine kinase (CK) and its isoform CK-MB in 5-30% of patients after PCI, indicating minor myocardial damage. Less is known about the influence of modern improved PCI-techniques on the frequency of elevated cardiac markers and the correlation between different commonly used markers, especially cardiac troponins. From 1997 to 2001, 1486 patients undergoing PCI during the regular working hours were included in the prospective "Ludwigshafen Infarctlet Registry". Myocardial infarction in the past 48 hours was an exclusion criterion. Clinical and procedural data were documented. Follow-up data were obtained from discharge up to one year. PCI-related elevations of troponin T were found in 18%, of total-CK in 11%, of CK-MB in 33% and of myoglobin in 23% of cases. The correlation between the different markers was poor. Compared with troponin T, other markers showed low sensitivity (total-CK 58%, CK-MB 27%, myoglobin 22%) and, especially total-CK, low specificity. Stenting, side branch occlusion or major dissection, complex lesion morphology, gpIIbIIIa-antagonist application, proximal stenosis and unstable angina were independent predictors of an elevated troponin T in multivariate analysis. Due to this weak correlation between more specific and sensitive troponins and the other markers, troponins are preferred in monitoring after PCI. In addition to lesion characteristics, particularly stenting is associated with an increased rate of elevated troponin.

Angina intensity is not different in diabetic and non-diabetic patients with acute myocardial infarction.

BACKGROUND: Diabetic patients with acute myocardial infarction (AMI) may have diminished pain or a higher frequency of asymptomatic infarctions. This appears to be a common clinical perception. METHODS: Data from two registries of AMI patients presenting in hospital (MITRA PLUS with 18786 patients; North German Registry, NGR, 1042 patients with detailed symptom interviews) were analyzed concerning symptoms of acute myocardial infarction in patients with diabetes mellitus (DM) and without diabetes (non-DM). RESULTS: DM patients were significantly older and more often female than non-DM. There were no differences in the frequency of pre-infarction angina between DM and non-DM (Mitra Plus). In NGR, severe angina during AMI occurred in 49.8% of DM and 46.3% of non-DM (n. s.). No chest pain was reported in 16.9% of DM and 15.0% of non-DM (n. s.). Extra-thoracic pain, dizziness, nausea, sweating, palpitations, radiation of angina and localization of radiating pain was not different between DM and non-DM patients. Severe dyspnea occurred in 29.5% of DM and 19.5% of non-DM patients (p = 0.003). CONCLUSIONS: Apart from a higher frequency of severe dyspnea in diabetics, there appears to be no difference in the clinical symptoms of AMI patients with and without diabetes mellitus. AMI with little or no angina was also frequently found in non-diabetics. In the hospital, diabetics with suspected AMI do not appear to need a special judgement of symptoms. This could accelerate access of diabetics to standard therapeutic procedures.

Small differences in non-fatal in-hospital reinfarctions complicating acute myocardial infarction as observed in current randomised controlled trials will not essentially influence long-term mortality. Results from the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry.

BACKGROUND: Recent randomized controlled trials (RCT) comparing different nonmechanical reperfusion strategies in patients with acute ST elevation myocardial infarction (AMI) (The GUSTO V, the ASSENT 3 and the HERO 2 trials) reported no differences in mortality, but lower nonfatal reinfarction rates in each best treatment arm during the hospital stay. METHODS: We analyzed the prospective observational Maximal Individual The rapy in Acute Myocardial Infarction (MITRA) data base selecting AMI patients similar to the RCT patients, to determine whether the observed differences in reinfarction rates will have an influence on longterm mortality. RESULTS: Out of 6737 patients included in MITRA between 1994 and 2000, 2109 (31%) fulfilled the selection criteria simulating the RCTs and were followed up for a median of 18 (quartiles: 16/22) months. Mortality at 1-year after discharge was 6.8% (95%CI: 2.3-11.3%) in patients with versus 4.4% (95%CI: 3.5-5.3%) in patients without a non-fatal reinfarction (absolute difference 2.4%, p = 0.04 by log rank test). Transferred to the results of the RCTs, this difference would require more than 1 million patients in each treatment arm of the RCTs to show significant differences in long-term mortality. CONCLUSION: Non-fatal in-hospital reinfarctions were associated with a higher mortality during the 18 month follow-up in MITRA. However, because the observed differences in the rates of non-fatal in hospital reinfarctions between the treatment arms in the GUSTO V, the ASSENT 3 and the HERO 2 trials were very small, our data make it very improbable that they will result in lower 1-year mortality rates.

[Symptomatic pericardial effusion as initial manifestation of gastric signet ring cell carcinoma]. / Symptomatischer Perikardergussals Erstmanifestation eines Siegelringzell-Magenkarzinoms.

HISTORY: A 78-year-old woman presented at our hospital with palpitation, tachycardia and progressive dyspnea. The health history included the diagnosis of diabetes mellitus and chronic obstructive pulmonary disease. INVESTIGATIONS: The ECG showed atrial fibrillation, later changing with sinus rhythm and low voltage. The echocardiography revealed pericardial effusion. The cytology showed signet ring cells from the stomach. Endoscopic study revealed a 3 cm tumor in the posterior wall of the upper part of the body. The histopathological examination diagnosed cancer of diffuse type according to Lauren, with signet-ring cells. TREATMENT AND CLINICAL COURSE: After treating the atrial fibrillation a pericardial drainage was performed. The pericardiocentesis yielded 500 ml of serous fluid. In an echocardiogram after pericardial drainage, pericardial effusion was no longer present. During the clinical course the patient suffered a stroke and the chemotherapy could not be initiated. The patient died 2 months after diagnosis. CONCLUSION: Cardiac involvement with clinical manifestations and pericardial effusion may be associated with a malignant neoplasm. Echocardiography and pericardiocentesis are helpful for the diagnosis of cardiac metastases.

Prognostic value of non-sustained ventricular tachycardias after acute myocardial infarction in the thrombolytic era: importance of combination with frequent ventricular premature beats.

PURPOSE: of this study was to re-evaluate the association between ventricular arrhythmias and long-term mortality after acute myocardial infarction (AMI) in the thrombolytic era. METHODS: MITRA (maximal individual therapy in patients with AMI) is a multicenter registry of 54 hospitals in Germany investigating patients with AMI. RESULTS: 2420 patients received Holter ECG. Positive Holter ECG was defined: > or =10 ventricular premature beats (VPB)/h, or > or =4 couplets/d, or > or =1 non-sustained ventricular tachycardia (nsusVT)/d, or their combination. Mortality rates (median 17 months) were 6.5% without ventricular arrhythmias, with > or =10 VPB/h 15.2% and with the combination of > or =10 VPB/h plus either > or =4 couplets/d or > or =1 nsusVT/d 23.4%. In multivariate analysis, none of the ventricular arrhythmias alone correlated with mortality. There was a significant association between mortality and the combination of > or =10 VPB/h plus > or =4 couplets/d (OR 2.3) or > or =10 VPB/h plus > or =1 nsusVT/d (OR 2.8). CONCLUSION: Non-sustained VTs are only associated with poor prognosis if combined with frequent VPBs.

Intensive treatment of coronary artery disease in diabetic patients in clinical practice: results of the MITRA study.

Patients with diabetes are at high risk for the development of coronary artery disease and have a significantly impaired prognosis after ST-elevation myocardial infarction (STEMI) as compared with non-diabetic patients. The beneficial effect of pharmaceutical treatment for secondary prevention after STEMI is proven also for diabetics, but little is known about its use in clinical practice. Between June 1994 and December 2000, consecutive patients with STEMI, admitted to hospital within 24 h of symptoms onset, were enrolled into the multicenter MITRA registry in 61 hospitals in Germany. We examined whether there were differences in the frequencies of pharmaceutical secondary prevention after STEMI and in long-term outcomes between diabetics and nondiabetics in 8206 patients who had been discharged alive and followed for a mean period of 17 months. The prevalence of diabetes in 8206 patients discharged alive after acute STEMI was 18%. Diabetics were older and more often female, and more often already had prior myocardial infarction (MI) and stroke than non-diabetics. As chronic discharge medication, diabetics received aspirin and betablockers less often, but more often ACE inhibitors than non-diabetics. The mortality rate 17 months after STEMI was nearly twice as high in diabetics than in non-diabetics (19.1% vs. 10.4%, p<0.01 at univariate analysis; OR=1.50 and 95% CI 1.27-1.77 at multivariate analysis). The combined endpoint of death, MI and stroke occurred in 25.8% of diabetics, but only in 15.8% of non-diabetics ( p<0.01). Long-term treatment with aspirin, betablockers and ACE inhibitors in diabetics was associated with a significant reduction of mortality. Diabetics received intensive pharmaceutical therapy for secondary prevention significantly less often than non-diabetics, although the beneficial effects of this treatment were similar or even more pronounced as compared with non-diabetics. Diabetes was an independent predictor of increased mortality in follow-up after acute STEMI. Intensifying secondary prevention by a more frequent use of established pharmaceutical regimes might improve the prognosis of diabetics after STEMI and prevent cardiovascular and cerebrovascular events.