Patient age and patency rate after recanalization of occluded peripheral arteries.

OBJECTIVES: Due to an increase in the percentage of older people in industrialized countries there is an increasing demand for medical care for the elderly. With advancing age, a series of structural, architectural and compositional modifications take place in the vasculature. Therefore, we analyzed the influence of patient age on the reocclusion rate of recanalized peripheral arteries. PATIENTS AND METHODS: 471 patients (mean age +/- SD: 62 +/- 12 years, range: 28-90 years) successfully treated by interventional recanalization were followed up (mean +/- SD: 18 +/- 17 months, range:6-48 months). Reocclusion of the recanalized arterial segment could be proven in 175 patients (37%), whereas octogenarians had the highest patency rate i.e. 68%. Univariate analysis, multivariate logistic regression analysis, and ROC analysis were performed. RESULTS: The univariate analysis showed a significant relation between reocclusion and PAOD stage, hyperlipoproteinemia, and total cholesterol level and erythrocyte sedimentation rate (ESR), respectively. Excluding age-related risk factors, the multivariate logistic regression analysis with backward selection reached a significant level for PAOD stage with p = 0.0012 and an odds ratio of 1.63, and for ESR with a p = 0.0013 and an odds ratio of only 1.02. Age did not reach a significant level with a p value of 0.13 and an odds ratio of 0.98. In the ROC analysis, prognostic relevance could be shown for the combination of PAOD stage and ESR adjusted for age and hyperlipidemia, and for PAOD stage and ESR value as a single prognostic factor, but not for patient age. CONCLUSION: Thus, despite proven and hypothetical differences in the vascular biology of older people compared to younger people, age is not related to middle term patency rates after interventional recanalization of peripheral arterial occlusions.

Lack of neuroprotection by an ACTH (4-9) analogue. A randomized trial in patients treated with vincristine for Hodgkin's or non-Hodgkin's lymphoma.

PURPOSE: This randomized, double-blind, placebo-controlled study evaluates the effect of the corticotropin (4-9) analogue Org 2766 on the neuropathy-free interval in patients receiving vincristine (VCR) containing chemotherapy for Hodgkin's or non-Hodgkin's lymphoma. PATIENTS AND METHODS: In a longitudinal design, 150 patients were evaluated by interview, neurological examination, and neurophysiological techniques. Patients with an expected cumulative VCR dose of at least 8 mg received a single dose of Org 2766 or placebo before and after each intravenous VCR injection and 3-4 weeks after cessation of VCR. The final patient assessment was performed 1 month after discontinuation of study medication. The neuropathy-free interval as the major end point of this study was defined as the first occurrence of bilateral paresthesias and expressed as the administered cumulative VCR dose. This bi-center study represents the largest cohort of patients monitored for the effect of an ACTH-analogue on VCR neurotoxicity. RESULTS: A total of 147 patients were included in the final analysis. No significant differences were observed between the placebo and actively treated group for the major and secondary endpoints. CONCLUSION: Contrary to a single previous pilot study in patients receiving VCR-based chemotherapy, in our study the ACTH (4-9) analogue Org 2766 did not provide protection from VCR-induced neuropathy.

Diagnostic value of high-resolution B-mode and power-mode sonography in the follow-up of thyroid cancer.

OBJECTIVE: Ultrasonography is an established diagnostic modality in the follow-up of thyroid cancer. Color flow Doppler has been proposed by some authors as an additional tool for differentiating benign from malignant cervical lesions in various types of head and neck cancer. Over the last few years, a new generation of high-resolution ultrasound platforms with the "power-mode" feature has become available, that also enables the imaging of small vessel blood flow. The objective of our study was to find ways of optimizing the differentiation of benign and malignant cervical tumors in thyroid cancer follow-up by means of sonography. METHODS: Hundred and twelve cervical lesions in 90 patients with thyroid cancer were evaluated by high-end ultrasonography (Sonoline Elegra, Siemens) using a small-part transducer (7.5 L 40, Siemens). B-mode sonography was performed at a frequency of 8 MHz. The Solbiati index (SI= ratio of largest to smallest diameter), configuration, echogenicity, intranodular structures, and margins were assessed. Perinodular and intranodular blood flow was evaluated by color flow Doppler (PRF 1250 Hz for conventional color flow Doppler, 868 Hz for power-mode Doppler). Possible malignancy was validated by histology, cytology, scintigraphy, and follow-up. Thirty five lesions were benign (diameter 0.4-3.0 cm) and 77 were malignant (0.4-5.4 cm). The patients were randomized into a test group and a learning group to determine the diagnostic value of various ultrasound criteria by means of statistical analysis. In the learning group, decision rules based on the dichotomized criteria were developed using a logistic regression model. Sensitivity and specificity of these decision rules were then evaluated in the test group. RESULTS: The presence of an echocomplex pattern or irregular hyperechoic small intranodular structures (criterion A) and the presence of an irregular diffuse intranodular blood flow (criterion B) are the best indicators of malignancy, whereas an SI >>2 is highly indicative of benign changes. Color flow Doppler is a useful addition to B-mode scanning for distinguishing benign and malignant neoplasms in the follow-up of thyroid cancer. Power-mode Doppler sonography significantly improves imaging of perinodular and intranodular blood flow when compared with conventional color flow Doppler. CONCLUSION: We propose the following decision rules based on a combination of the criteria above: (A) and (B) fulfilled: malignant, if SI< or =4; (B) but not (A) fulfilled: malignant, if SI< or =3; (A) but not (B) fulfilled: malignant, if SI< or =2; neither (A) nor (B) fulfilled: malignant, if SI approximately equal to 1 (sensitivity: 90%; specificity: 82%; accuracy 88%).

CD38 expression is an important prognostic marker in chronic lymphocytic leukaemia.

Employing a multicolour flow cytometry assay, 133 B-chronic lymphocytic leukaemia (B-CLL) cases were analysed for surface expression of CD38. Based on a cut-off value of 20%, CLL patients were categorised into a CD38-positive (> or = 20%, n = 56) and a CD38-negative subgroup (< 20%, n = 77) and separately analysed for clinical and laboratory parameters. Patients in the CD38-positive cohort were characterised by an unfavourable clinical course with a more advanced disease stage, poor responsiveness to chemotherapy, short time to initiation of first treatment and shorter survival. In contrast, the CD38- negative group required minimal or no treatment, remained treatment-free for a longer time period and had prolonged survival (P < 0.05). CD38 expression was a robust marker in the majority of patients in that it was stable over time and not significantly influenced by chemotherapy. In conclusion, our data confirm recent studies suggesting a role of CD38 as a predictor of clinical outcome in patients with B-CLL.

[Sevoflurane augments the degree and speeds the onset of rocuronium evoked neuromuscular blockade in children]. / Sevofluran verstärkt den maximalen Effekt und verkürzt die Anschlagzeit von Rocuronium bei Kindern.

BACKGROUND: In adults, sevoflurane augments the intensity of rocuronium evoked neuromuscular blockade. However, in children effective doses and onset of action of rocuronium have not been reported during sevoflurane anaesthesia. To test in children the hypothesis that sevoflurane speeds the onset and potentiates the degree of rocuronium induced neuromuscular blockade we studied 50 children aged 2 - 7 years following approval by the local ethics committee. METHODS: After induction and maintenance of anaesthesia with either 2 % endtidal sevoflurane in 60 % N(2)O/O(2) (n = 30) or with propofol (3 mg small middle dot kg(-1) and 10 mg small middle dot kg(-1)h(-1), n = 20) and 60 % N(2)O/O(2) for 17 +/- 1 min, we injected either 0.15, 0.22, or 0.3 mg small middle dot kg(-1) rocuronium and quantified by mechanomyography the evoked (0.1 Hz ulnar nerve stimulation) response of the adductor pollicis muscle. Dose-response relationships of rocuronium under both anaesthetic regimes were assessed using a generalised linear model based on the maximum-likelihood-technique. Data were compared by analysis of covariance, F-test, and Mann-Whitney-U-test as indicated, p < 0.05, mean +/- SD, (95% confidence interval). RESULTS: The degree of neuromuscular blockade was greater (p < 0.05) during sevoflurane (estimated ED 50: 0.15 (0.076 - 0.177) mg small middle dot kg(-1)) than propofol (ED 50: 0.25 (0.15 - 0.35) mg small middle dot kg(-1)) anaesthesia. Furthermore, onset time was significantly faster under sevoflurane/N(2)O compared to propofol/N(2)O anaesthesia (110 +/- 31 versus 230 +/- 52 s, p < 0.01, after rocuronium 0.3mg small middle dot kg(-1)). CONCLUSION: In young children during steady state anaesthesia onset of action of rocuronium is halved and the degree of neuromuscular blockade is markedly augmented during sevoflurane/N(2)O anaesthesia compared to propofol.

Probability of acceptable intubation conditions with low dose rocuronium during light sevoflurane anaesthesia in children.

BACKGROUND: To define the rocuronium doses which would provide 50%, 90%, and 95% probability of 'acceptable' intubation conditions during light sevoflurane anaesthesia, we studied 60 children aged 2-7 years in a prospective, randomised, assessor blinded study. METHODS: After mask ventilation with 1 MAC sevoflurane/N2O for 17+/-1 (x+/-SD) min we administered rocuronium (either 0.15, 0.22, 0.3, 0.5, or 1.0 mg. kg(-1)) or placebo, and quantified the evoked force of the adductor pollicis muscle. Intubation conditions were assessed before and 2 min after injection of the test drug. RESULTS: Intubation conditions were improved significantly with rocuronium and scored 'acceptable' in 70%, 90%, and 100% of the children after injection of rocuronium 0.15, 0.22, and 0.3 mg x kg(-1), respectively. In parallel, twitch tension decreased to 53% (6-100), 26% (11-100), and 11% (0-19) of baseline (median (range)). Recovery of train-of-four ratio to 0.8 was achieved 13 (7-19), 16 (8-28), and 27 (23-44) min after injection of the respective rocuronium doses. Higher rocuronium doses did not further improve intubation conditions but only prolonged time of neuromuscular recovery. Logistic regression analysis revealed that rocuronium 0.11 (CI 0.05-0.16), 0.21 (0.14-0.28), and 0.25 (0.15-0.34) mg x kg(-1) provides a 50%, 90%, and 95% probability of 'acceptable' intubation conditions in children during 1 MAC sevoflurane/N2O anaesthesia, respectively. Furthermore, we calculated that force depression of adductor pollicis muscle to 81% (CI 72-90), 58% (42-74), and 50% (29-71) of baseline is associated with 50%, 90%, and 95% probability of 'acceptable' intubation conditions. CONCLUSIONS: Submaximal depression of muscle force with low dose rocuronium improves intubation conditions in children during light sevoflurane anaesthesia while allowing rapid recovery of neuromuscular function. However, when using low dose rocuronium neuromuscular monitoring may be helpful to detect children with inadequate response to the relaxant so as to avoid an unsuccessful intubation attempt.

Adenoviral infection after allogeneic stem cell transplantation (SCT): report on 130 patients from a single SCT unit involved in a prospective multi center surveillance study.

The incidence of adenovirus (AV) infections following SCT was determined in a prospective multicenter trial. Over 1 year, 130 consecutive patients undergoing allogeneic SCT at Essen University Hospital were included and followed for 6 months. Source of stem cells was blood in 68 cases. Fifty-eight patients had HLA-identical sibling donors. Throat swabs, urine and stool samples were screened weekly for AV antigen and DNA by ELISA and nested PCR, respectively. In 35 cases adenovirus infection was detected. There was no seasonal variation. Throat swabs were positive in 24, urine in 12, and stool in 11 cases, resulting in a cumulative risk of infection of 29%. The incidences of AV infection of the respiratory, gastrointestinal and urinary tract were 19%, 10%, and 9%, respectively, and infections were diagnosed after a median (range) interval of 44 (-2-179), 37 (-2-168), and 53 (17-153) days after transplantation. On multivariate analysis, presence of AV antibody in the donor and acute graft-versus-host disease grade IV were found to be independent risk factors for AV infection. Eleven patients had AV isolated from more than one site and five patients had probable AV disease. We were not able to identify patients in whom AV infection was the leading cause of death. The majority of patients infected with AV suffered from severe acute graft-versus-host disease often accompanied by other opportunistic infections, such as aspergillosis or CMV reactivation. Nineteen out of 36 patients who died during the observation period had AV infection. In summary, AV infection after allogeneic SCT was observed in a substantial number of patients. In addition to well-known risk factors for viral infection after SCT we were able to demonstrate that a positive AV antibody test in the donor is an important risk factor for AV infection. Further studies are needed, however, before final conclusions on the clinical sequelae of AV infection can be made and the role of preventive and therapeutic strategies toward AV infection after allogeneic SCT can be defined.

Somatic comorbidity of addicts: does hospitalization yield relevant findings?

The aim of this prospective study was to examine the severity and character of somatic comorbidity when addicted patients were admitted to hospital for detoxification. The study was conducted at a university-based psychiatric clinic. Somatic comorbidity was registered by laboratory, radiological and electrocardiographic parameters and by the amount of non-psychiatric consultations. Besides the number of patients with dual diagnosis interpreted as combination of addictive and psychiatric diseases was registered. A total of 111 consecutive patients (32 women) was divided into patients with alcohol dependence and patients with other addictive diseases including polydrug abuse and opiate dependence. Patients with alcohol dependence were characterized by an elevated heart rate and higher values for gamma-glutamyltransferase. No significant differences between groups could be found for the rate corrected QT interval and cardiothoracic ratio. Although viral liver disease was diagnosed in both groups patients with a history of injecting drug use were at greatest risk for hepatitis C. About one-third of all patients required consultant non-psychiatric treatment. Concomitant heart and pulmonary diseases were more pronounced in the alcohol dependence group. The findings emphasize that hospitalization of addicted patients yields relevant somatic morbidity which has an impact on cost and requires medically supervised detoxification programs.

[Effectiveness of an improved antiseptic in treatment of contaminated soft tissue wounds]. / Wirksamkeit eines neuartigen Antisepticum in der Behandlung kontaminierter Weichteilwunden.

A novel antiseptic biguanide has been shown to be more bactericidal and tissue compatible in vitro than other antiseptics. In our controlled, prospective and randomized double-blind study on patients with bacteria-contaminated wound types 2-4, one group (n = 45) was treated with humid cotton swab dressings of 0.2% Lavasept solution compared with Ringer solution (n = 35). No deterioration of wound healing was observed in either group. Lavasept treatment resulted in faster and significant reduction of gram-positive germs. The tissue compatibility of Lavasept was evaluated as significantly better than Ringer solution.

Segmental manifestation of peripheral atherosclerosis and its association to risk factors.

BACKGROUND: To prove whether the aortoiliac, femoropopliteal or crural segments of the peripheral arteries might have a different sensitivity to a risk profile we did a statistical analysis of segmental peripheral atherosclerosis and risk factors. PATIENTS AND METHODS: In 132 patients (mean age 61 +/- 13 years) with peripheral arterial occlusions the arterial segments with occlusion or stenosis were angiographically documented: 17 had occluded or stenosed aortoiliac, 45 femoropopliteal and 25 crural arteries and 45 patients had multiple manifestations. Analysis of total cholesterol, HDL- and LDL-cholesterol, triglyceride, lipoprotein a, fibrinogen, uric acid, homocysteine, hematocrit, erythrocyte sedimentation rate, HBA1, IgG- and IgM-antibodies versus Cytomegalovirus, Herpes simplex-virus, Chlamydia pneumoniae and Helicobacter pylori were done and nicotine abuse, arterial hypertension and obesity were evaluated. RESULTS: Age of the patients had the strongest correlation with isolated segmental manifestation (p < 0.0001). Patients with isolated aortoiliac manifestation were younger than patients without this manifestation (54 +/- 9 years versus 62 +/- 13 years). Patients with isolated femoropopliteal manifestation were older than patients without this manifestation (66 +/- 11 years versus 58 +/- 13 years). None of the investigated risk factors showed a correlation with these age related differences. Independent from the age related differences for the nicotine abuse a p-value of 0.08 was estimated, but in smokers a diffuse manifestation was most frequent. CONCLUSION: There are age dependent differences of the prevalence of isolated aortoiliac or femoropopliteal atherosclerotic occlusions or stenosis. An association of these differences to a specific risk profile was not found.

Risk factors in young patients with peripheral atherosclerosis.

BACKGROUND: Risk factors and especially the combination of multiple risk factors are associated with the development of atherosclerosis. Therefore, patients with an early manifestation of atherosclerotic disease are likely to show an extraordinary risk profile. We analysed the frequencies and severity of risk factors in young patients with manifest peripheral arterial occlusive disease as compared to old patients. METHODS: We analysed the risk profiles in 303 patients who were sent for interventional treatment of a symptomatic peripheral arterial occlusive disease. The risk profiles were described for different age groups (54 patients under 50 years of age, 194 patients from 51 to 74 years, 55 patients over 75 years). Multiple linear regression analysis and analysis of variance were performed to look for age-dependent effects. RESULTS: Elevated total cholesterol, and triglyceride levels and nicotine abuse were more frequent in patients younger than 50 years. Diabetes mellitus and hypertension were more frequent in patients older than 75 years. The different frequencies for smoking, diabetes mellitus and hypertension were age-related (p<0.05). Concerning laboratory parameters such as HDL- and LDL-cholesterol, fibrinogen, lipoprotein(a) and homocysteine there were no relevant age-related differences in frequency nor in absolute values with the exception of the hematocrit and uric acid. The coincidence with clinically manifest myocardial infarction was 11.15% in the patients under 50 years compared to 20.6% in those aged 51-74 years and 16.4% in those over 75 years, for cerebral stroke it was 5.6%, 17.5% and 14.5%, respectively. Patients under 50 years with peripheral arterial occlusive disease and a history of myocardial infarction were characterised by high levels of total cholesterol, triglyceride and lipoprotein(a). Excluding patients with prior myocardial infarction patients did not show any difference in risk profile between the three age groups. CONCLUSIONS: In a population suffering from manifest peripheral arterial occlusive disease the risk profile in patients under 50 years is not different from that in older patients. In contrast an additional myocardial infarction in such a population is associated with pathological lipid profiles.

Changes in the epidemiology of hepatitis C infection in Germany: shift in the predominance of hepatitis C subtypes.

Hepatitis C virus (HCV) subtype distribution was studied in 395 chronically infected patients from Germany. HCV genotype 1 was most frequent (80.5%). One hundred forty-three individuals (36.2%) were infected with subtype 1a and 175 (44.3%) were suffering from subtype 1b infection, respectively. HCV subtype 3a was found in 53 (13.42%) persons. Subtypes 2a, 2b, and 2c have been detected in 5 (1.27%), 10 (2.53%), and 4 (1.01%) individuals. Genotypes 4 and 5a accounted for HCV infections in 4 (1.01%) and 1 (0.25%) subjects. There was a notable variation in the distribution of the prevalent subtypes 1a and 1b in different age groups. Subtype 1a was detected in 53.3% and 68.0% of patients aged 1-10 and 11-20 years, whereas subtype 1b in the same groups was present only in 33.3% and 28.0% of patients, respectively. In contrast, in individuals older than 50 years subtype 1b was most frequent. Thus, subtype 1b has been gradually substituted for subtype 1a during the last 20 years. Logistic regression analysis with adjustment for sex and different modes of HCV acquisition demonstrated that age of the infected subjects was a direct explanatory variable for subtype 1a and 1b distribution. Therefore, the observed shift in HCV subtype prevalence could not be attributed to changes in the epidemiological relevance of different known risk factors of HCV transmission, as had been assumed in previous studies. The altered subtype pattern reported here may have a profound influence on the future epidemiology of HCV infection.

Electrocardiographic abnormalities during recovery from ultra-short opiate detoxification.

The aim of this study was to detect electrocardiographic abnormalities during recovery from ultra-short opiate detoxification, using a retrospective study design conducted at a university hospital. Twenty-two consecutive patients (mean±SD, age 30.0±6.3 years) receiving daily oral methadone underwent ultrashort opiate detoxification under general anaesthesia. In the post-anaesthetic stages they received oral clonidine and naltrexone, and in some cases trimipramine was dispensed. Heart rate, rate-corrected QT interval (msec) and repolarization abnormalities of 12-lead electrocardiographic recordings before and after detoxification were examined. The serum electrolyte concentrations (mmol/l) including Na⁺, K⁺ and Ca2⁺ were assessed. Eighty-one ECGs were evaluated in total. Compared to the initial values, heart rate was significantly lowered in the first two tracings after detoxification (median values 60.0/min. vs. 52,5/min; p=0.0006). The lowest heart rate measured after detoxification was 44/min. The cQT interval was significantly lengthened (median value 420 msec vs. 453 msec after detoxification). In 16 tracings (20%) taken from 10 patients (45%) cQT rose above 460 msec and in two tracings (2%) it topped 500 msec. Modest hypokalaemia (2.9-3.5 mmol/l) was linked to cQT prolongation (460 msec) in 10 ECG tracings. Spearman's correlation coefficient indicated that prolonged cQT intervals correlated with decreased potassium values. Twelve tracings (15%) taken from 10 patients (45%) after detoxification showed T-wave inversion and in two cases sinus rhythm was turned into a rhythm arising from the atrioventricular node. Serum potassium was significantly lowered (median values 4.3 v.s 3.8 mmol/l, p=0.0001). The Ca2⁺ concentration fell significantly (2.4 vs. 2.2 mmol/l, p=0.0001) but not below the normal range. It was concluded that ultra-short opiate detoxification carries the risk of QT prolongation and bradycardia. These side effects are reversible and can be explained by hypokalaemia and clonidine medication, the effects of which might reinforce each other. To avoid arrhythmic complications, ECG tracings should be carried out regularly during recovery, i.e. at least daily, for a span of 3 days after discharge from the intensive care unit.