[Suicide attempt by means of phenobarbital overdose. Effective treatment with continuous veno-venous hemodialysis]. / Phenobarbitalintoxikation in suizidaler Absicht. Kontinuierliche venovenöse Hämodialyse als effektive Therapie.

A 68-year-old woman tried to commit suicide using phenobarbital, which was initially prescribed for her dog that suffered from seizures. At admission she was unconscious and ventilated. Five days of intensive care therapy did not improve her state of consciousness. Subsequent continuous veno-venous hemodialysis accelerated the elimination of phenobarbital compared to endogenous elimination by a factor of five. The patient survived without sequelae. Detailed history taking and well-timed indication for dialysis were crucial.

Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis.

OBJECTIVES: This study evaluated the clinical and angiographic six-month follow-up after excimer laser coronary angioplasty (ELCA) for restenosed coronary stents. BACKGROUND: Excimer laser coronary angioplasty has recently been shown to be safe and efficient for the treatment of in-stent restenosis. METHODS: Ninety-six consecutive patients successfully treated with ELCA within 141 stents were included in a six-month clinical and angiographic follow-up. RESULTS: During follow-up there was one sudden death and one patient with documented myocardial infarction. Angina pectoris classified as > or = Canadian Cardiovascular Society II reoccurred in 49 patients. Follow-up angiography was obtained in 89 patients (93%) with 133 stents. Quantitative coronary angiography revealed a mean diameter stenosis of 77 +/- 10% before intervention, 41 +/- 12% after laser treatment and 11% +/- 12% after adjunctive percutaneous transluminal coronary angioplasty (p < 0.001). Six months after ELCA the mean diameter stenosis had increased to 60 +/- 26% (p < 0.001). A > or =50% diameter stenosis was present in 48 patients (54%); in 24 of these patients diameter stenosis was > or =70%. Total occlusions occurred in an additional 10 patients (11%). There was a trend toward an increased recurrent restenosis rate in patients with diabetes mellitus and long lesions or total occlusions (p = 0.059). Forty-eight patients (50%) received medical treatment after six months. Reinterventions were necessary in 30 patients (31%), and coronary artery bypass surgery was performed in 17 patients (18%). Event-free survival was 50%. CONCLUSIONS: Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.

Treatment of in-stent coronary restenosis by excimer laser angioplasty.

We evaluated the efficacy and safety of excimer laser angioplasty (ELCA) with adjunctive balloon angioplasty in patients with restenotic or occluded coronary stents. ELCA was performed in 70 patients (60 +/- 9 years), who had previously been treated with Micro Stents (n = 65), Palmaz-Schatz (n = 38), Wiktor, NIR, Freedom, and Multi-Link stents (n = 1 each). Restenosis (> or =50% diameter stenosis) was documented in 90 stents, another 17 stents were occluded. Laser energy was delivered to the lesions with catheters 1.4, 1.7 (eccentric), and 2.0 mm in diameter. Procedural success was controlled by intravascular ultrasound in a subgroup. Laser catheters crossed all restenotic or occluded stents and decreased diameter stenosis from 80 +/- 13% to 44 +/- 11% (p <0.001). Adjunctive balloon angioplasty further reduced diameter stenosis to 13 +/- 13% (p <0.001). In 13 patients with 21 stents, serial intravascular ultrasound imaging revealed a reduction of plaque area within the stent by 34 +/- 22% (from 4.2 +/- 1.8 mm2 to 2.7 +/- 1.1 mm2) after ELCA and a reduction by 65 +/- 16% (to 1.5 +/- 0.7 mm2) after balloon angioplasty (p <0.01). There were 4 patients with an increase of creatine kinase levels, 8 patients with major dissections (in 7 patients they were related to adjunctive balloon angioplasty), 1 patient with distal embolization, 2 with minor perforations, and 1 patient with stent dislocation. Reintervention during hospitalization was necessary in 3 patients. ELCA is an efficient and safe technique to debulk tissue in restenotic lesions and total occlusions within stents. The incidence of procedure related complications was low.

Antibodies to chlamydial lipopolysaccharides in unstable angina pectoris.

Patients with coronary artery disease frequently have elevated antibody titers against Chlamydia pneumoniae, but whether antichlamydial antibody titers are correlated with prognosis in unstable angina remains unclear. We therefore investigated the sera of 1,096 patients with unstable angina regarding immunoglobulin (Ig) IgG, IgA, and IgM antibody titers against chlamydial lipopolysaccharides (LPS) and the concentrations of C-reactive protein (CRP) and troponin T (TnT). Anti-LPS IgG titers were increased in 45% of patients at enrollment and in 48% of patients at discharge (p <0.0001). Anti-LPS IgA titers were increased in 27% of patients at enrollment and in 33% of patients at discharge (p <0.0001). Patients who subsequently died had significantly lower IgM titers at enrollment than patients without events (p = 0.016). IgG, IgA, or IgM titers did not correlate with concentrations of CRP or TnT. In this large-scale study of patients with unstable angina, we frequently found elevated antichlamydial antibody titers. Patients with low IgM anti-LPS titers were at risk for subsequent death. However, there was no correlation between antichlamydial antibody titers and CRP or TnT.

The effect of immune mediators (cytokines) on the release of endothelium-derived relaxing factor (EDRF) and of prostacyclin by freshly harvested endothelial cells.

The effect of recombinant tumor necrosis factor and other cytokines stimulated by LPS (lipopolysaccharide), on the release of endothelial-derived relaxing factor and of prostacyclin was investigated using freshly harvested endothelial cells attached to plastic microcarrier beads. The results show that the cytokines failed to interfere with the release of EDRF and prostacyclin under the conditions of these experiments.

The production of coronary vasoconstrictor substances by freshly harvested endothelial cells.

The effects of cell free superfusates from freshly harvested bovine endothelial cells attached to microcarrier beads on the isolated rabbit and rat heart and on superfused rabbit jugular veins were observed. Cell free conditioned filtrates from freshly harvested cells caused marked diminution in coronary flow and cardiac output in the isolated rabbit heart; in the perfused rat heart an increase in coronary perfusion pressure and a decline in left ventricular systolic tension and maximal left ventricular contractility (dP/dt) were recorded. Marked differences were found between changes induced by conditioned filtrate as compared to synthetic endothelin. Endothelin as present in conditioned filtrate could not account for the pronounced effect on coronary perfusion pressure, dp/dt and cardiac output induced by conditioned filtrate; more than one hundred times that of synthetic endothelin was needed to achieve comparable cardiodynamic effects. This suggested that additional non-prostanoid vasoconstrictor substance or substances are produced by freshly harvested endothelial cells. This conclusion was supported by the observation that BQ-123, a specific inhibitor of endothelin A (ETA) receptor significantly prevented contractions by endothelin, while failing to inhibit those induced by freshly harvested endothelial cells. These constrictor substances may be leukotrienes.

Cytokine production from freshly harvested human mononuclear cells attached to plastic beads.

The release of tumor necrosis factor (TNF), interleukin-1 beta (IL-1) and granulocyte-macrophage colony-stimulating factor (GM-CSF) from freshly harvested monocytes and lymphocytes attached to plastic beads was investigated. Previous studies had shown that freshly harvested endothelial cells attached to microcarrier beads release an endothelium-derived relaxing factor. Attachment of freshly harvested lymphocytes and monocytes to plastic beads created a dense network, consisting of 25% monocytes and 75% lymphocytes as shown by flow cytometry. Viability of cells was 90%. Monocytes were characterized by phagocytosis and non-specific esterase stain. Freshly harvested cells stimulated with lipoprotein lipase (LPS) released TNF and IL-1. Non-stimulated cells also produced GM-CSF five hours after collection of blood.

Disseminated aspergillosis attributable to Aspergillus deflectus in a springer spaniel.

Disseminated aspergillosis attributable to Aspergillus deflectus was diagnosed in a Springer Spaniel with lethargy, lameness, anorexia, weight loss, pyrexia, lymphadenopathy, hematuria, and urinary incontinence. Necropsy revealed granulomatous inflammation and numerous fungal hyphae in many organs. The conidial heads of the fungus have a characteristic briar-pipe appearance in culture.

[Diagnosis and therapy of infectious endocarditis. What measures are required?]. / Diagnostik und Therapie der infektiösen Endokarditis. Welche Massnahmen sind erforderlich?

Infectious endocarditis remains a potentially life-threatening disease, the outcome of which can be substantially influenced by rapid diagnosis and initiation of suitable treatment. Leading clinical features are fever, a new sound suggestive of valvular insufficiency and, when the course is subacute, anemia. The main diagnostic procedures are transthoracic and transesophageal echocardiography that reliably identify vegetation, valvular insufficiency and abscess. Of decisive importance for treatment and prognosis is the rapid identification of the pathogen by means of blood culture and, if necessary, serologic and molecular-biologic measures. Antimicrobial treatment is applied in accordance with the recommendations of the American Heart Association. Surgical treatment is indicated in the event of refractory infection, severe valvular insufficiency with heart failure, valve avulsion, recurrent emboli or large floating vegetation with an elevated risk of embolism.

[Near fatal intoxication with the novel psychoactive substance 25C-NBOMe]. / Lebensgefährliche Intoxikation mit der neuen psychoaktiven Substanz 25C-NBOMe.

BACKGROUND: Effects of overdosing 2-(4-chloro-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine (25C-NBOMe) have not been previously described. Currently the drug is legal in most parts of the world. CASE REPORT: The case of a 19-year-old man who had nasally administered 2 mg of 25C-NBOMe, a novel psychoactive drug, within 1 h is described. Two hours later, he experienced a generalized seizure. Due to loss of consciousness and low oxygen saturation, he required mechanical ventilation. On day 2, he could be extubated without need for supplemental oxygen and appeared to recover quickly. On day 3, he developed acute kidney failure requiring hemofiltration. His condition continued to deteriorate with development of acute lung failure on day 4. He again required non-invasive and subsequently invasive ventilation with high demands for oxygen and high supporting pressure. On days 7 and 8 his condition became life threatening due to difficulties to achieve sufficient oxygenation even with a FIO2 of 80 %. After 13 days in the intensive care unit, he finally recovered without sequelae. CONCLUSION: In summary, 2 mg of 25C-NBOMe placed a young healthy man in a critical situation both acutely a few hours after ingestion due to a generalized seizure and during the subsequent days due to multiple organ failure.

[Transient global amnesia and Tako-Tsubo cardiomyopathy--coincidence or corollary?]. / Transiente globale Amnesie und Tako-Tsubo-Kardiomyopathie - Zufall oder logische Folge?

HISTORY: A 69-year-old female patient who had been physically and mentally healthy was admitted to our emergency department because of acute onset of amnesia. INVESTIGATIONS: Inconspicuous diagnostic findings led to the diagnosis of transient global amnesia (TGA). Furthermore bradycardia and elevated troponins were detected. Because of these findings a cardiologic workup was performed resulting in the diagnosis of Tako-Tsubo cardiomyopathy. TREATMENT AND COURSE: The patient recovered completely from TGA as well as from the slight reduction of the left-ventricular ejection fraction as part of the Tako-Tsubo cardiomyopathy. CONCLUSION: There are similarities of the two diseases Tako-Tsubo cardiomyopathy and TGA concerning triggers as well as reversibility. Patients presenting with symptoms suggestive for TGA should be considered to undergo additional cardiologic evaluation.

[Perioperative pharmacological myocardial protection. Systematic literature-based process optimization]. / Perioperative medikamentöse Kardioprotektion. Systematische Literaturübersicht als rationale Grundlage zur Prozessoptimierung.

Patients with major cardiac risk factors have been suggested to benefit from perioperative beta-blockade. However, the scientific literature on perioperative beta-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative beta-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative beta-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of beta-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative beta-blockade is lacking. This article offers a simple clinical concept for this purpose.

A site visitor's first year.

CHAP--The Community Health Accreditation Program--is a wholly owned subsidiary of NLN. In this regular column, employees and associates of CHAP, and representatives of CHAP-accredited agencies will introduce readers to various aspects of accreditation of home and community health care organizations. Here, Jim Kahler, who is involved in many facets of community health care in Hawaii talks about his impressions after a year as a part-time CHAP site visitor.

A survey of students' attitudes toward medical school and factors motivating them to become physicians.

During the 1981-1982 academic year a study was undertaken to assess medical students' opinions on various occupational/personal/demographic issues. Results demonstrated that a typical USD School of Medicine student was family medicine oriented, wanted to enter private practice, and viewed his/her calling into medicine as primarily altruistic in nature.

[Concerning the casuistics by aspiration of waste oil sediments (author's transl)]. / Zur Kasuistik der Olschlammaspiration

When cleaning an underground waste oil dump, an 18 year old worker suffered loss of consciousness by inhaling vapours of trichloroethylene and then suffocated by aspiration of waste oil sediments. Histological examination of the lungs proved the copious presence of partly granulous darkish-brown and of rather light coloured crystalloid foreign substances up to the multiple size of erythrocytes. "Chemical examination of blood, brain and urine showed the presence of trichloroethylene and its metabolites, respectively. The trichloroethylene concentration has been determined in the brain."

Membrane-covered stents: a new treatment strategy for saphenous vein graft lesions.

The restenosis rate after stenting of lesions in aortocoronary venous bypass grafts still has to be considered unsatisfactorily high. We investigated a new stent design characterized by an expandable polytetrafluorethylene (PTFE) membrane in between two layers of struts. Five consecutive male patients (age 70 +/- 6 years) were followed prospectively who presented with at least two de novo lesions in different grafts 13 +/- 3 years after bypass surgery. A total of 11 lesions were treated located in grafts anastomosed to the circumflex (n = 3), to the LAD (n = 7), and to the right coronary artery (n = 1). Within the same procedure, every patient received membrane-covered stents (n = 6) and conventional stents (n = 5) in either of their lesions. All patients underwent successful interventions. The minimal luminal diameter increased from 1.0 +/- 0.5 to 2.9 +/- 0.6 mm in lesions treated by the membrane-covered stents and from 0.8 +/- 0.4 to 2.4 +/- 0.7 mm in the lesions treated by conventional stents. During follow-up, four out of five patients required angioplasty for in-stent restenosis of lesions covered by a conventional stent, whereas no patient underwent revascularization for a lesion treated by a membrane-covered device. The mean minimal luminal diameter of lesions covered by a conventional stent decreased by 42% to 1.4 +/- 0.6 mm; the mean minimal luminal diameter of the lesions treated by a stent graft declined by 9% to 2.8 +/- 0.6 mm (P < 0.05). This series of intraindividual comparisons suggests that membrane-covered stents may have the power to reduce in-stent restenosis in obstructed aortocoronary venous bypass grafts.