[Acute pulmonary embolism: still a diagnostic and therapeutic challenge?] / Akute Lungenembolie: immer noch eine diagnostische und therapeutische Herausforderung?

BACKGROUND: Acute pulmonary embolism (PE) is a cardiovascular emergency with high mortality in which a rapid diagnosis and the early initiation of therapy is vital. In the present study patients with acute PE hospitalized at the Clinic Lippe in Detmold were characterized and their prognosis examined. METHODS: In our department at the hospital Detmold, all patients with acute PE admitted in 2012 and 2013 were documented with respect to the severity of PE, predisposing risk factors and diagnostic and therapeutic steps. RESULTS: A total of 170 patients with acute PE were documented of which 80 patients (47 %) had low, 70 patients an intermediate (41 %) and 20 a high risk (12 %). The main diagnostic tool was thoracic computed tomography (82 %). All patients initially received unfractionated or low-molecular weight heparin; systemic intravenous fibrinolysis was carried out in 3 % of patients (intermediate risk n = 1, high risk n = 4). Nineteen percent (n = 13) of the patients at intermediate and 30 % (n = 6) of patients at high risk received local intrapulmonary fibrinolysis. Overall, the mortality rate in hospital was 10 % (low risk 2.5 %; intermediate risk 7 %; high risk 58 %). All 5 patients who received systemic emergency lysis died. One (5.3 %) of the 19 patients at intermediate risk, undergoing local intrapulmonary fibrinolysis, died. CONCLUSION: In acute PE a rapid diagnosis and the initiation of an adequate therapy remains a big challenge. Further studies are required to evaluate if aggressive treatment options might reduce mortality especially among patients at intermediate or high risk.

Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation : Systematic analysis of a single-center experience.

BACKGROUND: Atrial fibrillation is associated with a high risk for thromboembolic events. Thrombi in the left atrial appendage and spontaneous echo contrast (SEC) correlate positively with this embolic risk. We studied the laboratory, echocardiographic, and epidemiologic parameters that could predict left atrial thrombi and the intensity of the SEC. PATIENTS AND METHODS: Between September 2013 and June 2015 we included 372 patients with atrial fibrillation before planned electrical cardioversion (transesophageal-guided strategy) in this study. After assessing the risk of stroke and bleeding (CHA2DS2-VASc and HAS-BLED scores), we measured the concentration of the D-dimer and B-type natriuretic peptide at the time of the transesophageal echocardiography as well as the left atrial volume and the ejection fraction during transthoracic echocardiography. RESULTS: The ejection fraction and the CHA2DS2-VASc score were identified as independent predictors of both left atrial thrombi and SEC, whereas the left atrial volume could only predict the intensity of SEC. In contrast to the results of other studies, the biomarkers in this study failed to predict the outcome. CONCLUSION: Only the echocardiographic and epidemiologic parameters were predictors of left atrial thrombi and SEC intensity, while the studied biomarkers had no predictive power. Using clinical data and transthoracic echocardiography, we can change the therapeutic strategy in high-risk patients.

[Treatment of coronary three-vessel disease in patients above 75 years]. / Therapie der koronaren Dreigefäßerkrankung bei Patienten über 75 Jahren.

BACKGROUND: Chronic ischemic heart disease take the first place in cause of death in Germany. The proportion of patients aged 75 years or older amounts more than 80 %. Due to their growing part of population the medical care of older patients becomes increasingly important. In this investigation patients aged ≥ 75 years with coronary three-vessel disease were characterized and various treatment strategies were compared. PATIENTS AND METHODS: This analysis was retrospective. The data of patients aged 75 years or older with three-vessel disease diagnosed by coronary angiography at the Klinikum Lippe Detmold between 2005 and 2007 were collected. Depending on the received therapy they were parted in three groups: optimal drug therapy (OMT), interventional - (PCI) and surgical revascularization (CABG). Patient characteristics as well as survival- and MACCE-rates during follow up were ascertained. Subgroup analyzes were performed for acute coronary syndrom (ACS) and stable coronary artery disease( CAD). RESULTS: The data of 434 patients with an average age of 79 years were documented. 139 (32.0 %) were assigned to the OMT- 189 (43.6 %) to the PCI- and 106 (24.4 %) to the CABG-group. Overall there was no significant difference between the three groups regarding mortality. In the subgroup of patients wit ACS (n = 180) mortality significantly increased in the OMT-group compared to the two invasive therapies (PCI (p = 0.029), CABG (p = 0.045)). The subgroup of patients with stable CAD showed no significant differences in mortality between the three types of therapy. CONCLUSIONS: Older patients benefit from an interventional or surgical revascularization in the context of ACS. In contrast, in elderly with stable CAD optimal medical therapy provides a reasonable alternative to invasive therapy without increase in mortality.

[Acute hepatic failure after ingestion of mushrooms]. / Akutes Leberversagen nach Pilzingestion.

This report is about a married couple who were admitted to hospital suffering from gastrointestinal complaints after eating mushrooms. With the suspicion of poisoning with Amanita phalloides treatment started with elimination of the toxins, symptomatic therapy and specific therapy with silibinin. After quantitative determination of the Amanita toxins the patients were immediately transferred to a university hospital.Poisoning by the death cap mushroom is responsible for acute hepatic and often also renal failure and is accompanied by a high mortality. Clinical symptoms follow a three-phase course with gastrointestinal complaints, an asymptomatic interval and finally the hepatorenal phase. Even in suspected cases of intoxication, treatment should be started by antidote therapy with silibinin.

[A 70-year-old man with multiple injuries after a road accident: syncope with large right atrial tumour]. / 70-jähriger Patient mit Polytrauma nach Verkehrsunfall: Synkope bei grossem Tumor im rechten Vorhof.

ANAMNESIS: A 70-year old man caused a road accident without evidence for outer influence. He suffered from multiple injuries. An unstable chest required long-term mechanical ventilation. Recurrent depression of circulation and right heart failure complicated the course. Syncope could not be excluded as trigger of the accident. EXAMINATIONS: There were all criteria of right heart failure. A stable circulation could only be established at high values of central venous pressure. The reason was a large right atrial myxoma, which nearly filled the whole right atrium and partially occluded the tricuspid valve. Coronary angiography demonstrated neovascularizations which arose from the left circumflex artery. THERAPY AND COURSE: Immediate cardiac surgery was not possible because of the patient's bad general condition after the accident. The course was repeatedly complicated by hypotension and tachycardia. Only highly-normal central venous pressure values allowed stable circulation. Further complications were bilateral pleural effusion and small pulmonary embolism. As soon as possible the patient was referred to cooperating cardiac surgery for definite therapy. A tumor of 40 g, which inserted in the interatrial septum was removed. Histologic examination revealed myxoma. CONCLUSION: In unclear syncope and suspicion of cardiac cause echocardiography should be performed. In the case of myxoma often the transthoracic view provides diagnosis. Hemodynamic problems in great myxoma make close-meshed monitoring of central venous pressure, systemic blood pressure and heart rate necessary. Soon cardiac surgery is recommended.

Between realism and nominalism: learning to think about names and words.

Some of the factors that influence our understanding of the nature of names and words were investigated. Participants (from kindergarten, 2nd, 4th, and 6th grades, and a university undergraduate class) were told a series of brief narratives thematizing the relation between objects and names, after which they were asked questions about the origins and changeability of names and words. Responses were coded as either realist (i.e., viewing names as intrinsic properties of objects) or nominalist (i.e., understanding names and words as arbitrary social conventions). By Grade 2, the children showed a significant increase in nominalist thinking, but this was not a universal development among the participants. Many adults expressed views that did not reflect a strictly nominalist understanding of words and names. Furthermore, the use of nominalist and realist models was influenced by various social-discursive factors including the type of object being named, the type of name being asked about, and the participant's prior experience with the name. It is argued that linguistic (especially literate) experiences play a crucial role in developing a nominalist understanding of names and words.

[Acute myocardial infarction in patients with angiographically normal coronary arteries: clinical features and medium term follow-up]. / Akuter Myokardinfarkt bei Patienten mit angiographisch unauffälligen Koronararterien: Klinische Charakterisierung und Verlaufsbeobachtung.

BACKGROUND: Acute myocardial infarction (MI) in patients with normal coronary arteries has been recognized for several years. In most cases its etiology is unknown. The objective of the present study was to describe clinical features and medium term follow-up of those patients. PATIENTS AND METHODS: Between April 1991 and December 1996, 9860 coronary angiographies were performed in our hospital. During this period 17 patients with documented myocardial infarction and completely normal coronary arteries were identified. Acute myocardial infarction was defined as the clinical event with acute angina pectoris, ST-elevation typical for myocardial infarction, and an increase in serum creatinine phosphokinase (CPK) above 125 U/l. RESULTS: The mean peak CPK was 675 U/l (range: 129-1760 U/l). All 17 patients revealed significant ST-segment elevation. According to the ECG criteria there was no predilection for a specific location of MI (9 anterior MIs and 8 inferior MIs). Thrombolytic therapy was performed in 9 patients. In 12 patients areas of localized hypo- or akinesia were shown on left ventricular cineangiography. The mean ejection fraction was 61.5+/-10.3%. The age and sex distribution revealed a bimodel character: there was a younger age group of 9 patients, all men with a mean age of 35.9 years (31-43) and all strong cigarette smokers (mean 28 cigarettes/day) and there was an older group of 7 patients (1 man, 6 women) with a mean age of 56,4 years (47-68) and no significant association with cigarette smoking. During a mean follow-up period of 48.6 months (31-85 months) no patient died and no patient suffered from recurrent chest pain and used nitroglycerin occasionally. CONCLUSION: Patients with acute MI and angiographically normal coronary arteries show a bimodal sex and age distribution: a younger age group, all men and uniformly strong cigarette smokers and an older group predominantly women with no significant association with cigarette smoking. Both groups seem to have a favorable prognosis.

Resolution of ST-segment elevation in acute myocardial infarction--early prognostic significance after thrombolytic therapy. Results from the COBALT trial.

In acute myocardial infarction, early identification of patients at a high mortality risk is important for planning further therapeutic strategies. Previous studies have demonstrated that the extent of early resolution of ST-segment elevation may represent a simple, quick and noninvasive assessment to identify high risk groups of patients. In a subgroup of the COBALT Study population (Continuous Infusion vs Double Bolus Administration of Alteplase), ST-segment elevation was measured before and 90 to 120 minutes after treatment with alteplase. The subgroup of n = 1,760 patients was not different from the total COBALT population of n = 7169 patients regarding most clinical parameters except Killip Class before treatment. However, the overall 30-day mortality differed significantly between the main study and the substudy (7.76% vs 3.52%; p < 0.001). Three groups of ST-segment resolution were defined: 1. complete resolution (resolution > or = 70%; 762 patients), 2. partial resolution (< 70% and > 30%; 491 patients), 3. no resolution (< 30%; 507 patients). Mortality rate at 30 days for complete, partial and no resolution of ST-segment elevation was 1.31%, 4.28% and 6.11%, respectively (p < 0.001). While this significant correlation between the extent of ST-segment resolution and mortality could be observed for inferior acute myocardial infarction, it could not be found in patients with anterior acute myocardial infarction. This in part may be due to a selection bias that leads to an extremely divergent mortality rate of anterior acute myocardial infarction in the main study and the substudy (10.1% vs 3.94%; p < 0.0001). Despite this limitation, resolution of ST-segment elevation in acute myocardial infarction after thrombolytic therapy allows to identify patients at a high mortality risk and may help to select patients for early invasive procedures such as PTCA. Patients with complete ST-segment resolution showed a particularly low mortality rate, irrespective of the alteplase regimen used (front-loaded alteplase vs double bolus alteplase).

Inhibition rather than enhancement of hemostatic system activation during initiation of oral anticoagulant treatment.

Coumarin-induced skin necrosis is believed to be due to a transient hypercoagulable state resulting from a more rapid decline of the protein C activity relative to that of coagulation factors (F) II, IX and X during initiation of oral anticoagulant therapy. We studied hemostatic system activation during early oral anticoagulant treatment with a technique that investigates coagulation activation in the microcirculation. We determined in 10 healthy volunteers the concentrations of prothrombin fragment F1 + 2 (f1.2) and thrombin-antithrombin complex (TAT) in blood emerging from an injury of the microvasculature (bleeding time incision) before and after initiation of both high-intensity and low-intensity coumarin therapy. In addition, f1.2, TAT, activated F VII (F VIIa) and the activities of F II, F VII, F X and protein C were measured in venous blood. A rapid decline of F VII and protein C was observed in venous blood with activities at 24 h of 7 +/- 1% and 43 +/- 2%, respectively, during the high-intensity regimen. A 20 to 30% reduction of f1.2 and TAT was seen in venous blood at 72 h with no major difference between the high- and the low-intensity regimen. F VIIa levels were substantially affected by anticoagulation with a > 90% reduction at 48 h during the high-intensity regimen. Following high-intensity coumarin, a > 50% decrease in the f1.2 and TAT levels was found in shed blood at 48 h suggesting substantial inhibition of thrombin generation during early oral anticoagulation. An increase in the f1.2 and TAT levels was seen neither in shed blood nor in venous blood. Our data do not support the concept of a transient imbalance between generation and inhibition of thrombin as the underlying pathomechanism of coumarin-induced skin nekrosis.