[Inflammatory juvenile conjunctival nevus (IJCN)]. / Inflammatorischer juveniler Bindehautnävus (IJCN).

BACKGROUND: Pathologists may occasionally have difficulties in reliably assessing the dignity of tumour cells in histological sections, especially in nevi with junctional activity. PATIENT HISTORY: This case history of a boy suffering from an inflammatory juvenile conjunctival nevus (IJCN) is reported with a follow-up period of 25 years. Seven years after first surgical treatment of a histologically proven nevus, a recurrent pigmented lesion within the former operation area aroused the suspicion of it being a malignant melanoma. Logically, a second excision was performed followed by cryotherapy with liquid nitrogen (spray freezing). The histological diagnosis performed by a pathologist resulted in a malignant melanoma. A second recurrent pigmented conjunctival tumour developed fourteen years later. This lesion again aroused another strong clinical suspicion of malignant transformation into a melanoma. However, the histological examination of the biopsy at this time only showed benign nevus cells and areas of conjunctival melanosis without atypia. DISCUSSION: Especially in young patients, IJCN must be regarded as an independent type of nevus, which might lead even experts in ophthalmic pathology to over-diagnose this lesion as a malignant melanoma. This could mean that the wrong therapeutic steps were taken with surgical procedures that cause unnecessary mutilation. A reappraisal of the former histological specimens of the first recurrent tumour by other pathologists came to the conclusion that the initial diagnosis of melanoma could not be maintained. Nevertheless, we also strongly recommend follow-up examinations at regular intervals in cases of IJCN since we are aware of the fact that melanocytic tumours of the conjunctiva behave unpredictably.

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.

Clinical profile and management of heart failure: rural community hospital vs. metropolitan heart center.

BACKGROUND: Knowledge on clinical characteristics and prognosis of patients with heart failure originates from studies of selected populations in clinical trials or from epidemiological observations. Reports on the large numbers of patients with heart failure treated in community hospitals are sparse. OBJECTIVE: Are there differences in patient characteristics and heart failure management between a metropolitan heart center (HC) and a rural community hospital (RCH)? PATIENTS AND METHODS: Retrospective analysis of medical charts from all patients admitted for heart failure (ICD 428.x, NYHA II-IV, EF<45%) between May 1997 and April 1998 and discharged alive from a rural community hospital. A similar, but prospective registry was available at the HC. Follow-up information was obtained by request at registration authorities. RESULTS: Patient groups comprised 120 in RCH and 146 in HC. Mean age was 75+/-11 and 66+/-11 years, respectively (P<0.001); 48% (RCH) vs. 74% (HC) of patients were male (P<0.001). On admission the proportion of functional class IV was 69% (RCH) vs. 17% (HC) (P<0.001). At discharge, the rate of ACE-inhibitors was 74% (RCH) vs. 98% (HC); 11% (RCH) vs. 43% (HC) of patients received beta-blocker therapy. Ninety-six percent of patients in HC underwent and 22% in RCH had undergone invasive diagnostics. One-year mortality rate of patients discharged alive was 26% in RCH and 19% in HC (P=n.s. after adjustment for age and gender). CONCLUSION: Heart failure management according to current guidelines, using beta-blockers and ACE inhibitors, and invasive cardiac examination was significantly less performed in the rural community hospital than in the metropolitan heart center. Therefore, strategies to improve heart failure management according to guidelines are urgently needed.

[Current use and outcomes of intraaortic balloon counterpulsation in routine cardiology]. / Aktueller Einsatz und Stellenwert der intraaortalen Ballongegenpulsation in der kardiologischen Routine.

BACKGROUND: Intraaortic balloon counterpulsation (IABC) is an established technique for temporary support of the left ventricular function. However, less is known about the current use and outcome of IABC in daily clinical practice. PATIENTS AND METHOD: From July 1995 to May 1999 all patients receiving an IABC in the Department of Cardiology of the Heart Center Ludwigshafen were included in a consecutive registry and follow-up data were obtained. RESULTS: Sixty-six patients (mean age 65 years, 64% male) received an IABC during the registration period. In 95% of cases the indication for IABC was the presence of cardiogenic shock. The shock was due to an acute myocardial infarction in 83%, other reasons were less frequent (< or = 5%). Total inhospital mortality was 48%. Patients in shock due to myocardial infarction (53%) showed the highest mortality. During follow-up (median 20 months) another 21% died. Complications occurred in 20% of patients under IABC, including vascular complications in 12%, infections in 5% and major bleedings in 3%. There was no difference between mortality among patients with complications and total mortality. CONCLUSION: Main indication for IABC in daily practice is the presence of cardiogenic shock (95%), dominantly due to myocardial infarction (83%). Despite IABC therapy, half of these patients die during the hospital stay. High mortality of cardiogenic shock in myocardial infarction with pharmacological therapy justifies IABC treatment with regard to a rate of complications of 20%.

Atrial sensing and AV synchrony in single lead VDD pacemakers: a prospective comparison to DDD devices with bipolar atrial leads.

INTRODUCTION: Single lead VDD pacing has offered an alternative to DDD systems in patients with isolated AV block. Up to now, however, the relative performance of these pacemaker systems was not systematically compared. METHODS AND RESULTS: Three hundred sixty patients who received either a VDD pacemaker (n = 180) or a DDD device (n = 180) with a bipolar atrial lead were investigated prospectively for a mean period of 30 +/- 13 months. Pacemaker function was analyzed by telemetry, Holter monitoring, and exercise ECG. Time of implantation and fluoroscopy was significantly lower with VDD devices (44.3 +/- 5.1 min vs 74.4 +/- 13.5 min and 4.6 +/- 2.5 min vs 10.3 +/- 5.6 min in DDD pacemakers, respectively). Intermittent atrial undersensing occurred in 23.3% of patients with a VDD pacemaker and in 9.4% with DDD devices (NS). The incidence of atrial tachyarrhythmias did not differ between the VDD (6.7%) and the DDD group (6.1%). Sinus node dysfunction developed in 1.9% of patients, but the vast majority (85.7%) of patients were asymptomatic. There was a tendency for a higher rate of operative revisions in the DDD group (6.1% vs 3.3% in VDD pacemakers, P = 0.15). Cumulative maintenance of AV-synchronized pacing mode was 94.9% in patients with VDD pacemakers and 92.1% with DDD devices (NS). CONCLUSION: With the benefit of a simpler implant procedure, long-term outcome of single lead VDD pacing is equivalent to DDD pacing in patients with AV block and preoperative normal sinus node function.

[1998 prognosis of left ventricular dysfunction in a maximum care non-university hospital. Analysis of the Ludwigshafen LVD Registry]. / Prognose der linksventrikulären Dysfunktion 1998 in einem nichtuniversitären Krankenhaus der Maximalversorgung. Analyse des Ludwigshafener LVD-Registers.

BACKGROUND: Prognostic data on heart failure rely on epidemiological studies or large clinical trials. These data are not to transfer easily on everyday practice. OBJECTIVE: To assess the prognosis of left ventricular dysfunction under the therapeutic conditions of the 1990s. SETTING: Nonuniversity tertiary care hospital. PATIENTS AND METHODS: Since January 1995 consecutive and complete registry of all inpatients presenting with a left ventricular dysfunction (EF < 45%). No exclusion criteria. RESULTS: n = 512, mean age 64 years, 77% male, mean NYHA class 2.5, left ventricular EF 31%. ETIOLOGY: 58% coronary heart disease, 28% dilated cardiomyopathy. Medical treatment consisting of 91% ACE inhibitors, ACE inhibitor dosage 52% of the recommended dose, 42% beta-blockers, 70% diuretics, and 63% digitalis. Follow-up completeness 95.5%. One-year mortality 64/489 patients (13.9%). Determinants of mortality: NYHA III/IV, EF < 30%, malignant disease, age > 75 years. CONCLUSION: In spite of the aforementioned medical treatment and a proportion of 14.8% implanted defibrillators in 1998, the one-year mortality of ventricular dysfunction is as high as 13.9%. In everyday practice the prognostic effect of ACE inhibition and beta-blockade is not completely utilized.

Micronucleated cells during the growth of the Ehrlich ascites tumour on spontaneous and by titanocenedichloride-induced conditions.

The micronucleus assay was used to investigate the activity of the Ehrlich-ascites tumour (EAT) of mice to produce chromosomal aberrations under spontaneous and chemically induced conditions. Titanocene dichloride (TDC), a cytostatic drug similar to cis-platinum, was injected in several dosages into the peritoneal cavity of mice carrying the tumour (40, 60 or 80 mg/kg). Our results show that there exists a constant spontaneous level of micronucleated cells (MNC), and that TDC is a potential dose-related inductor of micronuclei (MN). The highest amounts of MN are registered 48 h after application. We discuss the results in context with basic cytokinetic data of our tumour. This leads to the postulation of a dynamic balance of generating and eliminating factors producing the actual level of MNC.

[Atrial sensing and atrioventricular synchrony in single lead VDD pacemakers. Can the appearance of atrial undersensing be predicted?]. / Atriale Wahrnehmung und AV-Synchronität bei "Single-Lead"-VDD-Schrittmachern. Ist das Auftreten von atrialem Undersensing vorhersabar?

Single-lead VDD-pacing is an alternative to DDD-systems in patients with AV-block and normal sinus node function. Atrial sensing plays a central role in these pacemakers. AV-synchrony, incidence of atrial arrhythmias and the occurrence of sinus node disease were investigated in 108 patients with VDD-pacemakers followed over a mean period of 24.8 months after implantation. Determinants influencing the occurrence of atrial undersensing were especially focused on. Mean atrial potential and sensing threshold were reduced within the first 2 weeks after implantation (p < 0.01). Intermittent atrial undersensing occurred in 25.9% of patients and was observed in 82.1% of these patients within the first 2 weeks after implantation. Positioning the atrial dipole in the low right atrium showed a significantly higher incidence of atrial undersensing (42% in comparison to 24% in the other positions). In a multivariate analysis including intra- and postoperative measurements as well as characteristics of the pacemakers and leads, it was the only parameter significantly (p < 0.02) correlated to the occurrence of atrial undersensing. Atrial fibrillation was observed in 4.6% of patients, a sinus node disease became evident in 2.7% of patients; 92.6% of patients remained in the AV-synchronous mode. Intermittent atrial undersensing is common in single-lead VDD-pacemakers and difficult to provide during implantation. The atrial dipole should not be positioned in the low right atrium and highest atrial sensitivity should generally be programmed. Nevertheless, VDD-pacing achieves an AV-synchrony comparable to DDD-pacemakers.

Electrophysiological characteristics of bipolar membrane carbon leads with and without steroid elution compared with a conventional carbon and a steroid-eluting platinum lead.

In a controlled study, the following four bipolar leads with passive fixation were implanted in 46 patients with the Siemens-Multilog-VVI or Sensolog-VVIR-pacemakers: membrane covered activated porous carbon with steroid elution (Siemens 1402 T, 11 patients) and without (Siemens 1403 T, 15 patients); activated carbon (Siemens 1010 T, 10 patients); and platinum with steroid elution (Medtronic Cap-Sure 5026, 10 patients). Stimulation threshold (STH) (assessed by a vario-test), impedance (IMP), and the intracardial R wave potential (IRW) (both gauged by a telemetric method) were measured 1, 5, and 10 days as well as 3 and 6 months after implantation during unipolar and bipolar stimulation, chronaxie rheobase product (CRP) and energy consumption (EC) were systematically determined. Differing insignificantly at the first day after implantation, STH is significantly lower for the 1402 T and CapSure 5026 leads at the tenth day. However, the 1402 T lead shows a significant increase of STH in the follow-up, in contrast to the other leads. The lowest chronic STH was found in the CapSure 5026 lead (CRP is significantly lower in all other leads, too). IMP is significantly lower in the CapSure 5026 lead compared to 1010 T lead. EC does not differ significantly during chronic stimulation in spite of the best possible programming of pulse amplitude and duration. No significant changes of IRW were observed. Unipolar versus bipolar stimulation shows significantly lower STH, CRP, and IMP, differences of EC and IRW were insignificant. In conclusion, the addition of steroid in membrane covered carbon leads protracts the increase of STH, but does not prevent it. The CapSure 5026 lead shows advantageous stimulation characteristics, but energy consumption is not significantly reduced because of low impedance and impossibility of programming an appropriate low output in Multilog pacemakers.

Relations between various DNA-parameters and degree of malignancy in endometrial carcinoma.

120 imprint-cytology specimens obtained from standardized areas of 20 endometrial carcinomas were investigated by use of a computed-controlled image analysis system to determine special quantitative DNA-parameters. The stem line ploidy, the 2c deviation index (2cDI), the DNA-associated graduation of malignancy (DNA-MG) as well as the 5c exceeding rate (5cER) were calculated for each preparation. 85% of the imprint-cytology preparations had diploid stem lines, and aneuploidy was found in 15%. There were statistically significant correlations between the DNA-MG, the 5cER and the stem line ploidy as well as between the DNA-MG and the 5cER. The sensitivity of the 5cER was 76.6% in our study and so we cannot regard this parameter as prouding accurate information about tumor malignancy in endometrial carcinoma. Special DNA-parameters defined mathematically should be utilized for objective grading of tumor malignancy.

Adverse pacemaker hemodynamics evaluated by pulmonary venous flow monitoring.

The pacemaker syndrome refers to symptoms and signs in the pacemaker patient caused by an inadequate timing of atrial and ventricular contractions. The lack of normal atrioventricular synchrony may result in a decreased cardiac output and venous cannon A waves. The objective of this study was to define the left atrial and pulmonary venous flow response to ventricular pacing in a group of 14 unselected consecutive patients with total heart block and sinus rhythm. Pulmonary venous flow was assessed by transesophageal pulsed Doppler echocardiography in the VVI and DDD pacing modes. An inappropriate atrial timing caused a marked augmentation of the normally small pulmonary venous z wave in all patients ("negative atrial kick," peak z wave in DDD pacing 14.5 +/- 4.6 cm/s, VVI pacing 51.8 +/- 15.0 cm/s). Restoration of AV synchrony (DDD pacing, AV interval 100 ms) abolished these "cannon z waves" in all patients, and a normal pattern of pulmonary venous flow was achieved. Abnormal pulmonary venous flow characteristics were observed in 2 of 14 patients during DDD pacing with short AV intervals (100 ms). The Doppler pattern was similar to the findings seen in VVI pacing. Assessment of pulmonary venous flow by transesophageal pulsed Doppler echocardiography may provide a simple, sensitive, and relatively noninvasive technique to evaluate patients with suspected pacing induced adverse hemodynamics.

[Variability of quantitative DNA parameters in endometrial carcinoma]. / Untersuchungen zur Variabilität von quantitativen DNA-Parametern in Endometriumkarzinomen.

We performed image analysis examinations of 20 cases of endometrial carcinoma and the compared quantitative DNA parameters within each carcinoma. Specimens were taken from each carcinoma, at standardised, pre-defined sites. Six smear preparations were made from each case and DNA parameters were determined after Feulgen staining. 17 of the 20 cases of endometrial carcinoma (85%) showed in all the examined preparations a uniform diploid or aneuploid (n = 1) DNA distribution. Only 3 carcinomas showed diploid as well as non-diploid DNA distributions. For each carcinoma the mean values of DNA-MG were found to be between 0.37 +/- 0.12 and 2.16 +/- 0.11 and those of the 5cER between 0.91 +/- 0.78 and 15.37 +/- 4.17. Relationships were shown between DNA distribution, DNA-MG, 5cER and morphological prognostic factors while a reliable diagnostic of dignity based on DNA distribution and 5cER as a marker of single cell ploidy seems not possible. With an increase in DNA-MG, the coefficient of variation of this parameter decreased within the individual cases. Concluding, quantitative DNA parameters, owing to their relatively small variability within specific cases of endometrial carcinomas seem to be suitable objective indicators of prognosis to plan a risk-adapted therapy.

[Value of cytometric parameters the planning of therapy of urothelial carcinoma]. / Die Bedeutung zytometrischer Parameter bei der Therapieplanung von Urothelkarzinomen.

The prognostic value of cytometric DNA parameters and their possible influence on the planning of treatment were investigated in 44 patients with transitional carcinoma of the urinary bladder (17 G1 tumours, 15 G2 tumours, 12 G3 tumours) as compared with normal urothelium of 7 patients. The nuclear DNA content was measured by scanning cytophotometry in Feulgen stained cytological smears. A statistically significant correlation was found to exist between the combination of the DNA parameters stem line quotient, 5c exceeding rate and DNA malignancy grade and the appearance of recurrences. A discrimination of a low grade and a high grade tumour group was based on this result within the G1 and the G2 transitional carcinomas as well. All patients with a carcinoma classified as low grade were recurrence-free within an observation period of more than 10 years. Further studies should clarify if this group can be treated without a topic chemotherapy after transurethral electroresection in contrast to the high grade group in which a topic chemotherapy is necessary.

A new simulation approach for the determination of the error of parameters of biological importance describing the growth of the Ehrlich ascites tumor of the mouse.

Some aspects of the growth of the Ehrlich ascites tumor of the mouse can be described by the logistic function. The parameters used are fitted to the experimental data in a nonlinear way. It is important to determine the error of these parameters of biological importance in order to discriminate between different consequences induced by various experimental situations by means of statistics. But often there is a gap between the data that are available and the stronger assumptions necessary for statistics. We propose a simulation approach which also works in a much larger range of similar situations to close this gap.

The relation between the results of cytophotometric examination of endometrial carcinoma and clinical course of these disease.

We made a prospective cytophotometric study of 48 cases of endometrial carcinoma. Thirty-two (66.7%) of the cases had diploid DNA content and the proportion of non-diploid tumors increased with the staging of tumors, lack of differentiation and depth of myometrial invasion. DNA content (AE), DNA malignancy grade (DNA-MG) and 5c exceeding rate were statistically significant in relation to the clinical course of the disease and the histological grade of differentiation. DNA parameters appear to be especially suitable for the objective assessment of malignancy.

[Pacemaker syndrome with AV-synchronized stimulation of the heart]. / Schrittmachersyndrom bei AV-synchronisierter Stimulation des Herzens.

Characteristic signs of the pacemaker syndrome occurred in a 69-year-old woman with intermittent 3 degrees atrioventricular (AV) block after implantation of a dual-chamber AV-synchronized pacemaker. Cannon beats due to inappropriate atrial timing were the main haemodynamic finding. Their development and size depended on the programmed AV interval and AV-synchronized mode of stimulation. Very long AV intervals in the DDD mode at a heart rate of 100/min caused very unpleasant palpitations and pulsations in the upper thorax. The symptoms due to the cannon beats were avoided by changing to a short AV interval. The clinical and haemodynamic events were thus the consequence of preserved sinus node function with subsequent atrial triggering.

[Cytophotometric studies for evaluating the prognosis in endometrial cancer]. / Zytophotometrische Untersuchungen zur Prognosebeurteilung bei Endometriumkarzinomen.

This paper deals with a prospective cytophotometric study of specimens from 48 cases of primary endometrial carcinoma. The tumor material was obtained from the region of tumor invasion immediately after an operation and in 8 cases by fractional curettage after ultrasonographic localisation of the tumor. The specimens were air-dried and Feulgen stained. The cytophotometric examinations were performed with a scanning cytophotometer. A computer-assisted data registration and processing was carried out. The histological diagnosis of the tissue specimen and curettage specimen was established according to standardized criteria. 32 out of the 48 investigated cases of endometrial carcinoma were diploid. Observations conducted over a period of 12 months showed a partially significant correlation (u-test according to Mann and Whitney) between DNA-content and stage of the tumor (FIGO), histological grade of the tumor, relative depth of myometrial invasion as well as the clinical course. A differentiation based on the ploidy and the average relative DNA content (AE) in relation with typing is not possible. It was not possible to state the difference between average nuclear surface (F) and individual morphological variables. The average extinction, as a measure of the chromatin density, was determined for each specimen. A significant increase of the average extinction was established for carcinomas which infiltrated more than 2/3 of the uterine wall. Ploidy, average relative DNA content and average extinction provide an invaluable additional parameter in the assessment of the prognosis, post-operative therapy and aftercare of patients with endometrial carcinoma.

Histological examination of blood vessels in peripheral gangrene among patients with sporadic outbreak of ergotism.

During the academic year 1985-1986 at Gondar College of Medical Sciences Hospital gangrenous ergotism was clinically diagnosed in seven patients (5 males, 2 females) ranging in age from 20 to 45 years. Amputation and subsequent histological examination of the blood vessels revealed occluded tibial arteries by acute thrombosis without cellular reaction or inflammatory lesion of the arterial wall in 3 patients. Endangitis with organized arterial thrombosis and focal recanalization of the vessels was noted in the remaining four patients. The smaller arterial branches including the dorsal pedal artery appeared to be contracted with knobby projections into the lumen. The latter was occluded by chronic, organized thrombosis in all patients. The present finding indicates that thrombosis and its organization could be another pathogenic factor in the development of gangrene due to ergotism, which is a histological picture similar to that of thrombangitis obliterans.

[DNA distribution and mitotic index in Ehrlich ascites tumor after colchicine administration]. / DNA-Verteilung und Mitosehäufigkeit beim Ehrlich-Aszites-Tumor nach Colchicin.

Additional information like the type of growth is efficient for the interpretation of single parameter DNA distribution curves of tumors. The consideration of mitotic indices leads to further insights. The different growth phases of the Ehrlich ascites tumor are characterized by reproducible DNA histograms. The mitotic index and the frequency of the four mitotic phases turn out to be independent of the growth phase. Colchicine exerts an obvious effect on the prophases and metaphases. In the histogram an accumulation of cells in the G2M phase is evident, also on a higher ploidy level. Nearly identical DNA histograms result in different growth phases. The mitotic index of prophases and metaphases is found to be nearly twice at the 11th and 15th day of growth in comparison with the 8th day. This indicates a higher sensitivity of the Ehrlich ascites tumor to colchicine in steady state which is not expressed in the histogram.

[Proliferation kinetics of Ehrlich ascites tumors during cisplatin administration]. / Proliferationskinetik des Ehrlich-Aszites-Tumors unter cis-Platin.

In order to study the relationship between numerical growth and DNA-frequency distribution of tumor cells model experiments were made on the Ehrlich ascites tumor of mice after a single doses of the cytostatic cis-Platin. In 84 mice the tumor growth was measured by cell counting and the DNA-histogram by flow-cytometry. With exception of the controls 4, 8, 16 mg cis-Pt/kg were applied i.p. at the 5th day of tumor growth. An inhibition or a retardation of tumor growth is always observed. The 4 mg doses leads to a G2-blockade resulting in an increase of the G2-peak in the DNA-histogram after 2 days (7th day of growth). After 7 days of tumor growth) the effect has been mainly subsided. The effect of 16 mg/kg is a blockade of G2- and S-phase as well, connected with a complete inhibition of tumor growth. Therefore after two days (7th day of growth) this DNA-histogram is very similar to that of the control. Later on a recovery of DNA-synthesis occurs while the G2-blockade is still existing. Therefore the G2-peak is very marked 7 days after application (12th day of growth). All doses result in a disturbance of higher ploid cycles with an increase of hyper-8c-nuclei.