Noninvasive techniques for evaluation of heart function and hemodynamics in arterial hypertension. An overview.

Summarizing our experience with noninvasive techniques in arterial hypertension we can establish that a fast development is going on and noninvasive techniques are useful for functional analysis. This holds for older techniques as phonocardiography with estimation of STI and apexcardiography as well as impedance cardiography and radiocardiography. This is valid especially for newer techniques as color coded 2D-Doppler-echocardiography, radionuclideventriculography, thallium scintigraphy and magnetic resonance tomography.

[Planning orthodontic surgery with the Hexapod system]. / Planung orthognather Chirurgie mit dem Hexapod.

Treatment of maxillofacial dysgnathia using a combined surgical/orthodontic approach requires careful orthodontic and orthognathic diagnosis and treatment planning. In the present study, a system enabling on-line presentation of the necessary displacements of the jaw during surgery, while improving the accuracy of the planning, is described. Using the hexapod principle, it is possible to plan operations with six degrees of freedom and to measure the three-dimensional movements of jaws and jaw segments within the planning stage. Routinely prepared casts are employed for simulation of the operation. The displacements of the jaw are presented in a manner familiar to the orthodontic surgeon, namely in a surgical record. The accuracy achieved with the hexapod is superior to that achievable intra-operatively.

[Challenge in diabetes therapy: effects of glitazones beyond blood glucose control]. / Herausforderung Diabetestherapie: Effekte der Glitazone jenseits der Blutzuckerkontrolle.

Not just since the results of ACCORD, ADVANCE and VADT were published, it is clear that lowering blood glucose alone does not reduce the cardiovascular risk of patients with type 2 diabetes. In fact, many studies also indicate that some treatment strategies may even have adverse effects. To treat type 2 diabetes appropriately, the co-morbidities such as diabetic dyslipidaemia, hypertension or nephropathy must also be taken into account. Thiazolidinediones reduce insulin resistance thus allowing to direct the treatment of type 2 diabetes towards its pathophysiologic origin. Due to their mechanism of action, thiazolidinediones not only lower blood glucose but have also beneficial effects on inflammatory and atherogenic parameters, blood pressure and microalbuminuria. Furthermore pioglitazone improves dyslipidaemia and reduces mortality, myocardial infarction and stroke in high risk patients. Effects of rosiglitazone on the cardiovascular risk are yet unclear. Numerous studies document the efficacy and safety of thiazolidinediones and provide a basis for an evidence-based therapeutic approach beyond blood glucose control.

[Acrocephalosyndactyly I (Apert syndrome)]. / Akrozephalosyndaktylie I (Apert-Syndrom).

A fourteen years old girl showed the classic signs of acrocephalosyndactyly I: dysostosis craniofacialis with hypertelorism, exophthalmus, strabism, amblyopia and cleft palate as well as syndactyly of the fingers and toes. The feet showed on both side a 6 cm long horny band. Since the twelfth year of life, she had suffered from papulo-pustular acne with many comedomes. Her menstruation started one year later. Intellectual development was normal. At time of her birth, her father was 54 years old, and her mother 36 years old. Two elder siblings are healthy. The inheritance of acrocephalosyndactyly I is usually autosomal dominant, but sporadic cases are frequent.

[Transesophageal echocardiography in pre- and postoperative diagnosis of heart diseases]. / Transösophageale Echokardiographie in der prä- und postoperativen Diagnostik von Herzerkrankungen.

Transesophageal echocardiography (TEE) represents a substantial methodological extension of the transthoracic approach (TTE). Limitations of TTE can be overcome, furthermore cardiac regions - for instance atrial appendages - can be scanned, which are only difficult to valuate by TTE. The introduction of the endoscope succeed in above 95% of the patients without problems. The transducers work with 30, 48 or 60 single elements and frequencies of 3.5 to 7.5 MHz. The clinical indications for this procedure have included severe cardiac pathology, insufficient TTE, thoracic aortic dissection, prosthetic cardiac valve dysfunction, detection of intracardiac and paracardiac masses, structure lesions and complications of endocarditis, intraoperative monitoring and assessment of critical ill patients in an intensive-care unit. Attending to the prerequisitis and contraindications TEE growth up to an important method for cardiac surgery with regard to prae-, intra- and postoperative diagnostic and evaluation of treatment effectiveness.

Noninvasive investigations of systolic and diastolic heart function in arterial hypertension: from calibrated and differentiated apexcardiography to echocardiography.

In the early stages of arterial hypertension, increased contractility, demonstrated by calibrated and differentiated apexcardiography is present. Already in this early phase of the disease the criteria of diastolic function, as during isovolumetric period (calibrated and differentiated apexcardiography, M-mode echocardiography) and during transmitral flow, are abnormal. These disturbances occur a long time before a reduction of systolic function can be shown. Diastolic dysfunction is more frequent in hypertensives with left ventricular hypertrophy. With noninvasive methods it is possible to show that a primary neurohumoral overstimulation--enhanced contractility, normal systolic function--followed by cardiac remodelling and apoptosis with likewise early but progressive morphological disorders--diastolic dysfunction--are the main pathophysiological processes in hypertensive heart and vessel disease. They are decisive for the prognosis and represent the basis for rational organoprotective and also cardioreparative medical treatment.

[Porphyria cutanea tarda-like skin changes in chronic hemodialysis patients]. / Porphyria-cutanea-tarda-artige Hautveränderungen bei chronischen Hämodialysepatienten.

Porphyria cutanea tarda-like changes of the skin are described in two male patients undergoing chronic haemodialysis. The protoporphyrin values of the erythrocytes were somewhat higher than normal. Despite the same conditions of dialysis and the same medication in the subsequent two years of control no recidivations could be registered. The etiopathogenesis is not clarified.

[Porphyria cutanea tarda following treatment with depot estrogens in patients with prostate cancer]. / Porphyria cutanea tarda nach Behandlung mit Depot-Ostrogenen bei Patienten mit Prostatakarzinom.

In 3 out of 133 patients suffering from prostatic cancer and treated with depot estrogens a porphyria cutanea tarda was found after a follow-up ranging from few months to 10 years. Therefore, a defect of the uroporphyrinogen decarboxylase has been postulated. The therapy could be continued under small doses of chlorochin diphosphate.

[Basic program for the diagnosis of arterial hypertension]. / Basisprogramm für die Diagnostik der arteriellen Hypertonie.

The diagnostic step-program in arterial hypertension can be divided in a so called basic program and in special differential-diagnostic programs. The basic evaluation for every hypertensive subject contains family and personal history, clinical investigation, blood pressure measurement, electrocardiogram, chest X-ray, blood tests (creatinine and potassium) and urine analysis. The extended basic program enables the evaluation of global cardiovascular risk. Furthermore other blood and urine examinations (including vanilmandelic acid), fundoscopy, echocardiography and sonography of the kidneys are of particular value for determining severity and etiology of the disease. After this program an extension of diagnostics can be renounced in about 90% of hypertensives.

[New viewpoints on the pathophysiology and pathogenesis of arterial hypertension]. / Neuere Gesichtspunkte der Pathophysiologie und Pathogenese der arteriellen Hypertonie.

The pathophysiology and pathogenesis of the arterial hypertension can be explained from disturbances in the meshed regulating circle. Newer knowledge concerns the noradrenergic transformation of the excitation at the synapse. Concerning the humoral pressor systems we refer to the tonin-angiotensin-system, it is furthermore emphasized the disturbance in the sodium-potassium-transport on the membrane. The depressor systems -- prostaglandins, kallikrein-kinin-system -- will in future certainly bring newer knowledge concerning their participation in the pathogenesis of arterial hypertension. The practical importance of such findings should be taken into consideration in the formation of the long-term therapy of arterial hypertension.

[New aspects of the pathophysiology and pathogenesis of arterial hypertension--a review of the literature]. / Neue Aspekte zur Pathophysiologie und Pathogenese der arteriellen Hypertonie--eine Literaturübersicht.

The literature review reflects new aspects of pathophysiology and pathogenesis of arterial hypertension with special regard to the role of tissue renin-angiotensin-systems, endothelial and growth factors. The arteriolar wall as well as different organs produce angiotensin, which is of higher regulatory capability than the circulating angiotensin. Natriuretic hormones, endogenous opioids, neuropeptide Y and other vasoactive peptides are accepted as new humoral factors and neuromediators with different influence on the blood volume and the peripheral resistance. The vessel endothelium produces potent vasoconstricting (e.g. endothelin and vasodilating (e.g. EDRF) factors. Finally, growth factors with their potential role in vessel wall and myocardial hyperplasia/hypertrophy are analyzed. Tissue systems, endothelial and growth factors as new elements of arterial hypertension pathogenesis may influence the further development of new antihypertensive drugs.

[Necrobiosis lipoidica diabetricorum and serum lipids]. / Necrobiosis lipoidica diabeticorum und Serumlipide

Necrobiosis lipoidica diabeticorum is briefly described. Its high coincidence with hyperlipoproteinaemia in casuistic reports from the literature as well as in about half of the 22 cases observed in our clinic can be taken in favour of possible relations between these conditions. Disturbances of fat metabolism may even be considered important for pathogenesis of necrobiosis in general, the more as at least no optimally regulated fat and carbohydrate metabolism can be achieved by best therapeutic control of carbohydrate parameters in juvenile diabetics. Microangiopathia diabetica seems to exist from the very beginning of diabetes mellitus and may ne a basic etiologic prerequisite for the development of necrobiosis. Topical conditions of certain body regions are said to take part in final precipitation of necrobiotic spots.

[Value of diagnostic procedures in heart failure]. / Stellenwert diagnostischer Verfahren bei Herzinsuffizienz.

Strategy for the diagnosis of heart insufficiency is directed to the accomplishment of distinct therapeutic aims. Main factors for diagnostic approaches are pathophysiology and progression of qualitatively and quantitatively different disturbances in cardiac performance. Anamnesis and clinical investigations are irremissible for the evaluation of congestive heart failure. For the detection of noncongestive cardiac insufficiency investigations during exercise are often necessary. Ventriculography ist the standard reference technique for measurement of the systolic and diastolic ventricular functions. For exercise and follow-up investigations non-invasive methods are widely used. Accepted methods are two dimensional and Doppler-echocardiography, quantitative radiocardiography with single-pass bolus technique, and radionuclid-ventriculography. We found a good correlation for the measurement of stroke volume when comparing impedance cardiography with uniplane ventriculography at rest. M-mode echocardiography did not yield sufficiently reliable volumetric data. The new imaging methods, positron emission tomography, magnetic resonance technique, and cine computed tomography are future tools for cardiac output measurements.

[Coronary reserve determination by intracoronary papaverine: effects of various doses on coronary circulation and hemodynamics]. / Bestimmung der Koronarreserve durch intrakoronare Papaverinapplikation: Auswirkungen unterschiedlicher Dosen auf Koronarfluss and Hämodynamik.

In 40 male coronary patients during heart catheterization the coronary flow reserve was investigated by continuous thermodilution in the coronary sinus after intracoronary papaverine application. Simultaneously a number of heart function parameters were recorded. Already the lowest dosage of papaverine (5 mg) was able to induce a maximal flow acceleration. Higher dosages were accompanied with haemodynamic side effects (increase of heart rate and left ventricular end-diastolic pressure, decrease of left ventricular systolic pressure, appearance of myocardial ischemia) without further increase of coronary flow. After at most 5 minutes time the papaverine effects completely disappeared. In conclusion, a safe, short-lasting and repeatable determination of the coronary flow reserve (for instance during PTCA) proved to be possible after intracoronary papaverine injection in low dosages (5 mg).

Comparative estimation of central haemodynamics during dynamic load by impedance cardiography and radiocardiography.

77 unselected patients were examined simultaneously by impedance cardiography and radiocardiography in the recumbent position during dynamic exercise (bicycle ergometry). In all cases evaluable impedance curves were registered till the 100 W load. Stroke volume, estimated by impedance cardiography, is at rest and during exercise by about 30% lower compared to its value determined by radiocardiography. However, the percent increase during exercise is not significantly different with the use of either method. The stroke volumes estimated by both methods correlate significantly at rest and during exercise. This fact shows the usefulness of impedance cardiography for estimating central haemodynamics during dynamic exercise.

[The measurement of airway resistance during exercise by body plethysmography before and after application of asthma-protective drugs (author's transl)]. / Die ganzkörperplethysmographische Messung des Atemwegswiderstances unter physischer Belastung vor und nach Gabe asthmaprotektiver Pharmaka.

The behaviour of airway resistance under and after physical exercise up to 75 watt was investigated in 70 persons. In this test the airway resistance of subjects with healthy lungs and patient suffering from bronchial hyperreactivity does not show any significant changes. Patients with manifest obstructive ventilation disorders may be divided into two groups: in the major group (preponderant patients with a chronic bronchitis) the airway resistance decreases under exercise and reaches not the starting level up to the 8th minute after finishing exercise. In the minor group with the clinical picture of asthma the airway resistance increases during and after exercise and reaches it maximum in the 4th minute of recreation. In the same group the oxygen partial pressure decreases under exercise but on the average remains within the age-dependent reference-range. With the drugs disodium cromoglycate ("Intal"), Ketotifen ("Zaditen") and ipratropium bromide ("Atrovent") it's possibly to reduce the exercise induced increase of airway resistance; in comparison ipratropium bromide has the best effect.

[Leishmaniasis of the lips mimicking a mycotic infection]. / Leishmaniose der Lippen unter dem klinischen Bild einer Mykose.

A 24-year old German man was complaining of painful ulcers with infiltration of the lips without alteration of the oral mucosa and swelling of the regional lymph nodes. Three months earlier he had visited Israel, Italy, Romania and Bulgaria. He was treated with penicillin, doxycyclin, ciprofloxacin, itraconazole and prednisolone after detection of Candida spec. and staphylococci in another town without any effect. The smear and biopsy were sent to the Robert Koch Institute Berlin. Giemsa stain by phase contrast light microscopy with oil immersion showed extracellular amastigote leishmaniae with clearly stained kinetoplasts. Leishmania major could be detected by PCR investigation. The IgE was elevated, other investigations of the blood and from the lips were inconspicuous. The ulcers healed promptly under the treatment with Pentostam (antimony derivative) 0,1 ml/kg body weight i.m. for 12 days and 15% Paromomycin ointment.

[Determination of central hemodynamics in dynamic stress using impedance cardiography in comparison to radiocardiography]. / Die Bestimmung der zentralen Hämodynamik unter dynamischer Belastung mittels Impedanzkardiographie im Vergleich zur Radiokardiographie.

77 unselected patients were examined synchronously by impedance and radiocardiography in recumbent position during dynamic exercise. In all cases the load of evaluable impedance curves was possible till 100 watts. Stroke volume, estimated by impedance cardiography, is lower about 30% at rest and during exercise compared to its estimation by radiocardiography. But the percentual increase during exercise is not significantly different between the methods. The stroke volumes, estimated by both methods, correlate significantly at rest and during exercise. This fact shows the usefulness of impedance cardiography for estimating central haemodynamics during dynamic exercise.