[Treatment of traumatic brain injury in Germany]. / Versorgung Schädel-Hirn-Verletzter in Deutschland.

The relationship between severe, moderate and mild traumatic brain injury (TBI) as well as the course of treatment and quality management, were studied in a 1-year prospective study in regions of Hannover and Münster Germany. A total of 6,783 patients were documented at the initial examination (58.4% male, 28.1% children <16 years old) and 63.5% participated in the follow-up survey 1 year after the accident. Of these TBI patients 5,220 (73%) were admitted to hospital for clinical treatment but only 258 (<4%) received inpatient rehabilitation. The incidence of TBI was 332/100,000 inhabitants and according to the Glasgow Coma Scale (GCS) brain injury was mild in 90.9%, severe in 5.2% and moderate in 3.9%. The main cause of injury was a fall (52.5%) followed by a traffic accident (26.3%). In-hospital mortality was 1%. Only 56% of TBI patients were neurological examined and 63% were examined in hospital within the first hour after the accident. An immediate x-ray of the skull with a doubtful evidential value was made in 82%. Of the participants 35.9% were still receiving medical treatment 1 year after the accident although the majority only suffered mild TBI. An overabundance of severe socioeconomic consequences, e.g. loss of job, accommodation, family, were also found following only mild TBI.

From registry to quality management: the German Cystic Fibrosis Quality Assessment project 1995 2006.

Since 1995, the German Cystic Fibrosis Quality Assessment project has collected demographic data and outcome parameters. It aims to develop tools for quality management. The basic data of 6,835 patients has been collected annually by 93 centres. Weight for height and body mass index (BMI) indicated nutritional status, and forced expiratory volume in one second (FEV(1)) served as the central respiratory parameter. Data on mortality and survival were calculated. The mean age of all patients has increased from 13.9 yrs in 1995 to 17.7 yrs in 2005, and the percentage of adult patients has increased from 28.4 to 43.4%. Benchmarking diagrams and centre reports indicated considerable differences between the centres. The achievement of basic aims at the age of 6, 12 and 18 yrs indicated a positive development in 1995 to 2005. In 2005, median age at death was 23.7 yrs and the median cumulative survival was 37.4 yrs. Mortality correlated with a BMI <19 kg x m(-2) and an FEV(1) <80%. No sex gap in mortality was detected. "Learning from the best" is now possible. Further improvements in the system of cystic fibrosis care are required, such as: defining alarm signals for early treatment; involvement of patients and their families in quality management; auditing; benchmarking; and in-house training.

Intracellular calcium and ventricular function. Effects of nisoldipine on global ischemia in the isovolumic, coronary-perfused heart.

Ischemia-induced ventricular dysfunction has been shown to be associated with increased diastolic and systolic intracellular concentrations of free, ionized calcium ([Ca2+]i). The present study was designed to determine the effects of the Ca2+ antagonist nisoldipine on the relationship between [Ca2+]i and left ventricular contraction and relaxation during ischemia and reperfusion on a beat-to-beat basis. Nine isovolumic coronary-perfused ferret hearts were made globally ischemic for 3 min and reperfused for 10 min. Ischemia and reperfusion were repeated during perfusion with a buffer containing 10(-8) M nisoldipine. From left ventricular developed pressure, time to peak pressure and time to 50% pressure decline were obtained. [Ca2+]i was determined with the bioluminescent protein aequorin. Global ischemia caused a rapid decline in contractile function and a significant increase in diastolic [Ca2+]i, from 0.35 to 0.81 microM, and in systolic [Ca2+]i, from 0.61 to 0.96 microM. During reperfusion, [Ca2+]i returned to baseline while ventricular function was still impaired. Relaxation was more affected than systolic contractile function. Nisoldipine significantly reduced the ischemia-induced rise in diastolic [Ca2+]i to 0.62 microM, and in systolic [Ca2+]i to 0.77 microM, and lessened the decrease in contractile function. Nisoldipine significantly accelerated the decline in [Ca2+]i during reperfusion and improved recovery of contractility and relaxation. These effects were associated with a significant diminution in ischemic lactate production. Taken together, our results provide direct quantitative evidence on a beat-to-beat basis that the calcium antagonist nisoldipine can ameliorate ischemia-induced abnormalities in [Ca2+]i handling, an effect that was associated with improved myocardial function during early reperfusion.

Long-term prognosis of patients with anginalike chest pain and normal coronary angiographic findings.

OBJECTIVES: This study analyzes the long-term course of patients with typical angina pectoris or anginalike chest pain and normal coronary angiographic findings. BACKGROUND: In previous studies of such patients the rate of occurrence of typical coronary events during follow-up has differed widely, depending on the duration of the study and the number of patients. METHODS: One hundred seventy-six patients (mean age 48.3 years) who underwent coronary and left ventricular angiography for typical angina or anginalike chest pain were followed up for 5.8 to 15.8 years (median 12.4). By definition, all patients had normal findings on coronary and left ventricular angiograms; exercise test results were positive in 31. RESULTS: Fourteen patients (8%) had a coronary event (0.65%/year) after an average of 9.3 years (median 9.2). Two of the 14 died of a coronary event (0.09%/year), 1 of cardiogenic shock during acute myocardial infarction, 1 suddenly; 4 had a nonfatal myocardial infarction at an average of 8.1 years (median 9.1); 8 had severe angina pectoris after an average of 10.3 years (median 11.1), confirmed by a second angiogram, now with positive findings. Two patients died of a noncoronary cardiac event (chronic cor pulmonale due to obstructive lung disease, acute pulmonary embolism), eight of a noncardiac cause, mainly cancer. None of the 31 patients with a positive exercise test result had a coronary event. Patients with a coronary event had significantly more risk factors (hypercholesterolemia, hypertension, cigarette smoking, diabetes type II) than did those without an event (average 2.4/patient vs. 1.3/patient, p < 0.01). Chest pain persisted in 133 (81%) of the 164 survivors and disappeared in 31 (19%). CONCLUSIONS: Patients with typical angina or anginalike chest pain and normal coronary angiograms have a good long-term prognosis despite persistence of pain for many years; coronary morbidity and mortality are similar to those of the overall population. An increased risk for the development of coronary events is present mainly in patients with elevated risk factors.

Lack of prognostic value of syncope in patients with Wolff-Parkinson-White syndrome.

Syncope in patients with Wolff-Parkinson-White syndrome may be considered a premonitory event heralding the future development of sudden death. Therefore, the clinical and electrophysiologic data of 101 patients with Wolff-Parkinson-White syndrome referred for invasive evaluation of known arrhythmias were reviewed to assess the incidence and clinical relevance of syncope. Thirty-six patients reported the occurrence of one or more syncopal episodes (group 1) and 65 patients had no syncope (group 2). These two groups did not differ significantly with regard to age, gender, incidence and characteristics of arrhythmia, clinical history, frequency of arrhythmic events and presence of associated cardiac disease. There were 10 patients in group 1 and 12 in group 2 who had ventricular fibrillation. There were no statistical differences between the two groups with respect to the effective refractory period of the right atrium, atrioventricular node, accessory pathway and right ventricle. Furthermore, no differences between the two groups were noted with respect to cycle length of circus movement tachycardia, mean heart rate during atrial fibrillation, and minimum RR interval during atrial fibrillation. In addition, the accessory pathway location was not significantly different between group 1 and group 2. The occurrence of syncope could not be predicted from any electrophysiologic finding and this symptom had a low sensitivity and specificity for recognition of dangerous rapid heart rates. Furthermore, the prognostic value of syncope was less accurate and predictive than the shortest RR interval during atrial fibrillation and the anterograde effective refractory period of the accessory pathway for aborted sudden death occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of ventricular arrhythmias during transient myocardial ischemia in patients with stable coronary artery disease.

To determine the incidence of ventricular arrhythmias related to episodes of transient myocardial ischemia during ambulatory electrocardiographic (ECG) monitoring, 97 patients with stable angina pectoris, angiographically proved coronary artery disease and an abnormal exercise test were studied. A total of 573 episodes with ST segment depression were documented: in 118 episodes (21%) the patients were symptomatic and in 455 (79%) they remained asymptomatic. Ventricular arrhythmias (greater than 5 premature ventricular beats/min, bigeminy, couplets or salvos of premature ventricular beats) occurred during 27 (5%) ischemic episodes in a subset of 10 patients (10%) (group A). The other 87 patients (90%) (group B) showed exclusively ischemic episodes without ventricular arrhythmias. Comparison of patients in group A and group B showed no differences in hemodynamic, angiographic, exercise testing and ambulatory ECG monitoring data. Ischemic episodes with and without ventricular arrhythmias showed a similar duration and amplitude of ST segment depression and a comparable heart rate at the onset of ischemia. Both types of ischemic episodes, with and without arrhythmias, occurred predominantly during the morning hours between 6:00 AM and noon, and both types remained asymptomatic to within similar percentages. The data demonstrate that ventricular arrhythmias are related to transient myocardial ischemia in only a few patients with stable angina pectoris; these arrhythmias are related neither to the degree of ischemia during ambulatory ECG monitoring nor to the occurrence of anginal symptoms.

Population based study on the outcome of small for gestational age newborns.

OBJECTIVE: To explore whether and how population based data from a regional quality control programme can be used to investigate the hypothesis that small for gestational age (SGA) very low birthweight infants (VLBW, <1500 g) are at increased risk of death, severe intraventricular haemorrhage (IVH), and periventricular leucomalacia (PVL), but at decreased risk of respiratory distress syndrome (RDS). METHODS: Analyses of population based perinatal/neonatal data (1991-96) from a quality control programme in Lower Saxony, Germany. After assessment of data validity and representativeness, exclusion criteria were defined: birth weight >90th centile, severe malformations, siblings of multiple births, and gestational age (GA) <25 or >29 weeks. Outcomes of interest were death, severe IVH, PVL, and RDS. Multivariable analyses were performed by Cox proportional hazard and logistic regression models. RESULTS: Within the data validation procedure, an increase in proportions of both VLBW (from 0.95% in 1991 to 1.11% in 1996; +17%) and SGA (from 22.7% to 27.4%; +21%) infants became apparent (p<0.05). The study population consisted of 1623 infants (173 SGA). Mortality was 12.1% (n = 196), with an adjusted hazard ratio for SGA infants of 2.54, 95% confidence interval (CI) 1.70 to 3.79. Both groups were at similar risk of severe IVH (adjusted odds ratio 0.93, 95% CI 0.5 to 1.65) and PVL (1.54, 95% CI 0.78 to 2.87), but SGA infants had less RDS (0.57, 95% CI 0.35 to 0.93). Male sex, multiple birth, hypothermia (<35.5 degrees C), and sepsis were associated with IVH and RDS. Infants admitted to hospitals with <36 VLBW admissions/year had increased mortality (adjusted hazard ratio 1.56, 95% CI 1.12 to 2.18). CONCLUSIONS: SGA VLBW infants are at increased risk of death, but not of IVH and PVL, and at decreased risk of RDS. That mortality is higher in smaller hospitals needs further investigation.

Quality management in traumatic brain injury (TBI) lessons from the prospective study in 6.800 patients after acute TBI in respect of neurorehabilitation.

Preliminary results on epidemiology, acute hospital care, and neurorehabilitation of TBI are presented of the first ever prospective controlled German study to analyse the use of regional structures and quality management as provided by the German social healthcare system. The sum of inhabitants in Hannover and Münster area was 2,114 million. Within an area of 100 kilometres diameter each. 6.783 acute TBI (58% male) were admitted for acute treatment from March 2000 to 2001. Definition of acute TBI was according to the ICD 10 S-02, S-04, S-06, S-07, S-09 in combination with dizziness or vomiting; retrograde or anterograde amnesia, impaired consciousness, skull fracture, and/or focal neurological impairment. The incidence was 321/100.000 population. Cause of TBI was traffic accident in 26%, during leisure time 35%, at home 30% and at work 15%. Initial GCS (emergency room) was only assessed in 3.731 TBI (=55%). Out of those 3.395 = 90,9% were mild, 145 = 3,9% were moderate, and 191 = 5,2% severe TBI. 28% of 6.783 patients were <1 to 15 years, 18% > 65 years of age. The number admitted to hospital treatment is 5.221 = 77%, of whom 72 patients (=1,4%) died caused by TBI. One year follow-up in 4.307 TBI patients (=63.5%) revealed that only 258 patients (=3,8%) received neurorehabilitation (73% male), but 68% within one month of injury. Five percent of these patients were <16 years of age, 25% > 65 years. Early rehabilitation "B" was performed in 100 patients (=39%), 19% within one week following TBI. The management of frequent complications in 148 patients (=57%) and the high number of one or more different consultations (n = 196) confirmed the author's concept for early neurosurgical rehabilitation in TBI when rehabilitation centres were compared regarding GCS and GOS: Early GOS 1 = 4%; GOS 2 = 2,7%, GOS 3 = 37,3%, GOS 4 = 26,7%, GOS 5 = 29,3%, final GOS scores were 1 = 1,2%, 2 = 1,7%, 3 = 21,8%, 4 = 36,2%, and 5 = 39,1% of all patients at the end of rehabilitation. Mean duration for both "B" and "C" was 41 days compared to 80 days for "D" and "E". An assessment of both GCS and GOS was insufficient.

Circadian distribution of the characteristics of ischemic episodes in patients with stable coronary artery disease.

To determine the circadian distribution of episodes of myocardial ischemia, studies were performed in 111 patients with chronic stable angina pectoris, positive exercise test results and angiographically proven coronary artery disease. During 24 hours of ambulatory electrocardiographic monitoring, 101 symptomatic and 298 asymptomatic ischemic episodes (ST-segment depression greater than 1 mm, duration greater than 1 minute) were observed. The number of ischemic episodes and the cumulative duration of ischemia showed a circadian variation with the highest values between 8 and 10 A.M. and between 4 and 5 P.M. associated with a similar circadian variation of heart rate. Mean duration of ischemic episodes, maximal amplitude of ST-segment depression during ischemic episodes and increase in heart rate before the onset of ischemic episodes showed no significant circadian variation. Heart rate at the onset of ischemic episodes and maximal heart rate during ischemic episodes were lower between midnight and A.M. than during other times of the day. The morning and afternoon increase in ischemic activity is not paralleled by changes reflecting a decrease in myocardial oxygen supply during these periods (heart rate at onset of ischemia, heart rate increase before onset of ischemia), but is paralleled by a similar circadian variation of heart rate. The circadian variation in ischemic activity is predominantly based on a comparable variation in myocardial oxygen requirements.

Anginal symptoms without ischemic electrocardiographic changes during ambulatory monitoring in men with coronary artery disease.

Episodes of angina pectoris without electrocardiographic (ECG) signs of myocardial ischemia during 24-hour ambulatory monitoring were studied in 128 patients with a history of stable angina, angiographically proven coronary artery disease and positive exercise test results. In all, 341 episodes of ischemic ECG changes (ST-segment depression greater than 1 mm for greater than 1 minute) and 190 episodes of angina pectoris were observed: 86 episodes consisted of both ECG changes and angina pectoris, 255 episodes consisted only of ECG changes, and 104 episodes only of angina pectoris. Duration and magnitude of ST-segment deviation and heart rate at the onset of ischemia were similar in the 86 symptomatic and the 255 asymptomatic episodes with ECG changes. The 104 episodes of angina pectoris without ECG changes were detected in 44 patients (34%) (group A); 29 of them had only episodes with angina pectoris and 15 patients had both--episodes of angina pectoris with and without ECG changes. In 84 patients (66%) (group B) angina pectoris without ECG changes was not observed; all episodes were accompanied by ischemic ECG changes in these patients. No differences in the angiographic extent of coronary artery disease and in exercise test data were seen in both groups A and B; however, maximal ST-segment depression during exercise testing was significantly greater in group B than in group A patients (2.4 +/- 0.8 mm vs 1.9 +/- 0.9 mm; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow up of patients with implantable cardioverter-defibrillators and mild, moderate, or severe impairment of left ventricular function.

OBJECTIVE: To determine whether patients with life threatening ventricular tachyarrhythmias, impaired left ventricular function, and severe heart failure will benefit from implantable cardioverter-defibrillator (ICD) treatment. DESIGN: 410 patients were followed up after ICD implant. Left ventricular function was assessed by the New York Heart Association (NYHA) functional class of heart failure: 50 patients (12%) were in NYHA I-II, 151 (37%) in NYHA II, 117 (29%) in NYHA II-III, and 92 (22%) in NYHA III. Epicardial ICD implantation was performed in 209 patients (51%) and 201 patients (49%) received non-thoracotomy ICDs. RESULTS: Perioperatively, 12 patients (3%) died, more often after epicardial ICD implant (11/209 patients, 5%) than after transvenous implant (1/201 patients, < 1%) (P < 0.05). During a mean (SD) follow up of 28 (24) months (range < 1 to 114 months), 90 patients (23%) died: nine (2%) died from sudden arrhythmia; five (1%) also died suddenly but probably not from arrhythmic causes; 55 (14%) died from cardiac causes (congestive heart failure, myocardial reinfarction); 21 (5%) died from non-cardiac causes. The three year, five year, and seven year survival was 92-96% for arrhythmic mortality in NYHA class I, II and III, compared to a three year survival of 94% and a five year and seven year survival of 84% for patients in NYHA class II-III. 338 patients (82%) received ICD shocks (21 (SD 43) shocks per patient); patients in NYHA class II (83%), class II-III (84%), and class III (90%) received ICD discharges more often than those in class I-II (64%) (P < 0.05). The mean (SD) time interval between ICD implant and the first ICD shock was shorter in NYHA class II (16 (17) months), class II-III (19 (27) months), and class III (16 (19) months) than in class 0-I (22 (24) months) (P < 0.05). CONCLUSIONS: Patients with mild, moderate, and severe left ventricular dysfunction benefit from ICD treatment and these patients survive for a considerable time after the first shock. Survival is influenced by the degree of left ventricular dysfunction; aggressive treatment of heart failure is necessary as well as ICD therapy.

Surgical therapy for drug-refractory ventricular tachycardia: role of additional aneurysmectomy or bypass grafting.

To assess whether additional aneurysmectomy and/or bypass grafting influence prognosis we studied 97 patients with recurrent sustained monomorphic ventricular tachycardia after an old myocardial infarction. All patients underwent subendocardial resection due to drug-refractory ventricular tachycardia. There were 41 patients who had resection alone, 27 patients had resection and aneurysmectomy, 13 patients had resection and bypass grafting and the remaining 16 patients had resection with both, aneurysmectomy and bypass grafting. During the mean follow-up of 40 +/- 27 months 29 patients died (30%) (total mortality), 7 patients suddenly (7%) and 20 patients from cardiac causes (20%). There were no significant differences in total mortality between patients with resection alone (32%), patients with resection and aneurysmectomy (22%), patients with resection and bypass grafting (31%) and patients who had resection, aneurysmectomy and bypass grafting (38%). In addition, no significant differences were observed in the incidence of sudden death and nonfatal recurrences between patients with resection alone: sudden death 12%, recurrences 7%; patients with resection and aneurysmectomy: sudden death 0%, recurrences 19%; patients with resection and bypass grafting: sudden death 0%, recurrences 8%; and patients with resection, aneurysmectomy and bypass grafting: sudden death 13%, recurrences 0%. Postoperatively, left ventricular function improved in 56% of patients who had resection and aneurysmectomy compared to 17% of patients with resection alone, 31% of patients with resection and bypass grafting and 19% of patients who had resection, aneurysmectomy and bypass grafting. There is a low risk of sudden death and nonfatal recurrences after subendocardial resection. An influence of additional surgical approaches (aneurysmectomy or bypass grafting) on prognosis is not visible.

Circadian variation of myocardial ischemia in patients with stable coronary artery disease.

The circadian variation of myocardial ischemia detected during 24-h ambulatory electrocardiographic monitoring (AEM) was analyzed in 123 patients with stable angina pectoris, positive exercise test, and angiographically proven coronary artery disease. A total of 437 ischemic episodes (ST-segment depression greater than or equal to 1 mm and duration greater than or equal to 1 min) were observed; 333 (76%) episodes remained asymptomatic, and only 104 (24%) episodes were accompanied by anginal pain. Ischemic episodes predominantly occurred during the morning hours, between 6 a.m. and noon, and another smaller peak was observed in the afternoon, between 4 and 5 p.m.; this diurnal pattern was influenced neither by the extent of coronary artery disease nor the degree of left ventricular dysfunction. The circadian variation was restricted to the 345 (78%) ischemic episodes preceded by increases in heart rate; the 92 (22%) episodes without prior heart rate changes occurred randomly throughout the day. The morning peak in ischemic episodes was not associated with less myocardial oxygen supply; in contrast, heart rate profile showed parallel increases during the morning and afternoon hours, indicating elevated myocardial demand during these periods. Ischemia-related ventricular arrhythmias were concentrated during the morning hours, but their overall prevalence was low--28 (6%) of 437 ischemic episodes. These findings may provide further insight into the pathomechanisms of acute clinical events in patients with coronary artery disease, since the circadian variation of myocardial ischemia is very similar to that observed for the onset of myocardial infarction and sudden cardiac death.

Should patients with implantable cardioverter-defibrillators be allowed to drive? Observations in 291 patients from a single center over an 11-year period.

Motor-vehicle driving restrictions for patients with implantable cardioverter-defibrillators (ICDs) vary widely throughout the world because safety concerns have never been adequately resolved in this patient population. To address this issue, we examined the driving behavior of 291 ICD patients to correlate the frequency of device therapy during driving, the occurrence of syncopal symptoms, and the incidence of traffic accidents. Fifty of the 291 patients had never driven. Of the remaining 241 patients, 171 (59%) continued driving postimplant and 70 (24%) elected to stop prior to (n = 30) or at the time of ICD implantation (n = 40). Patients were followed for a mean of 38 +/- 26 months (range < 1-124). During this period, no patients died while driving. Of 11 accidents involving 11 driving patients (6%), only 1 was caused by the driver, and none was related to syncopal symptoms or ICD therapy. Although 2 accidents (8%) occurred within 12 months postimplant, the majority (50%) took place after more than 36 months. ICD therapy was delivered in 8 patients (5%) while driving: 13% (1 episode) of the discharges occurred within the first year postimplant, 13% (1 episode) occurred between 1-2 years, and 74% (6 episodes) occurred > 2 years. None of these patients experienced syncope before or during these episodes. A multivariate analysis was unable to identify any variables that might predict increased risk of ICD therapy (with or without sudden death) while driving and consequent motor vehicle accidents. Our data suggest that such events occur only rarely.

[Problems and complications after implantation of automatic defibrillators]. / Probleme und Komplikationen nach Implantation automatischer Defibrillatoren.

Until now there are only few reports about problems and complications associated with the automatic implantable cardioverter-defibrillator (ICD). Therefore, we studied the follow-up of 295 patients, who underwent ICD therapy. Epicardial ICD implantation was performed in 206 patients (71%) and 89 patients (29%) received transvenous ICD systems. Infections or seroma of the pulse generator and/or lead systems were observed in 18 patients (6%), in nine patients after first ICD implant and in nine patients after generator replacement. General signs of inflammation were present in eleven patients, whereas local signs with seroma of the pocket were observed in seven patients. Explantation of the entire ICD hardware was performed in eleven patients and seven patients underwent partial removal of the ICD system. Lead complications occurred in 15 patients (5%), in eleven patients with epicardial and in four with transvenous ICD systems. All patients had inappropriate ICD shocks and had to undergo lead replacement. Inappropriate ICD shocks due to supraventricular tachyarrhythmias occurred in 24 patients (8%). Other complications (apoplexia, hematoma, pneumothorax) were observed in 15 patients (5%). Our data show that complications associated with the ICD are low. However, these complications can cause big problems and need appropriate diagnosis and treatment.

[Results and experiences of transvenous endocardial defibrillator therapy]. / Ergebnisse und Erfahrungen der transvenösen endokardialen Defibrillatortherapie.

We studied the follow-up of 72 patients who underwent implantation of a transvenous defibrillation lead system (ELS) (Endotak, CPI). All patients had ventricular tachycardia (VT) or fibrillation (VF) refractory to antiarrhythmic drug therapy. There were 51 patients with coronary disease and 21 patients had non-ischemic VT/VF. ELS was combined with a subcutaneous patch in 52 patients and implanted alone ("single lead only") in 20 patients. 40 patients received the ELS combined with antitachycardia pacing devices (Ventak PRx, CPI; Cadence, Ventritex) and 32 patients with the Ventak P 1600 or P2, CPI. Implantation of the ELS was attempted in 80 patients and performed in 72 patients (90%): Intraoperatively, the mean defibrillation threshold (DTF) was > 25 Joule (J) in five patients and no reliable ELS position was possible to achieve in three patients. These eight patients underwent thoracotomy with epicardial patch implantation. The mean DFT was < or = 20 J in all 72 patients with a mean DFT of 14 +/- 8 J in VT patients and 17 +/- 10 J in VF patients. Two of 80 patients (3%) died: one patient died intraoperatively and one during the mean follow-up of 6 +/- 2 (< 1 to 18) months. Complications occurred in three patients (4%): Dislocation of the Endotak electrode was observed in two patients (3%) and one patient developed pneumothorax postoperatively. Our data show that the ELS is most suitable in the majority of patients with VT/VF and is the approach of first choice for cardioverter defibrillator implantation at the present time. However, despite a relatively low intra- and perioperative complication rate, this approach should not be performed in institutions without cardiac surgery.

[The importance of the underlying disease for outcome of patients with implanted automatic defibrillators]. / Die Bedeutung der Grunderkrankung für den Krankheitsverlauf bei Patienten mit implantiertem automatischen Defibrillator.

It is unclear whether the outcome of patients with implanted cardioverter defibrillator (ICD) is influenced by the underlying etiology or not. Therefore, we studied the follow-up of 271 patients who underwent ICD implantation for life-threatening ventricular tachyarrhythmias. Coronary artery disease was present in 203 patients (75%) (G1), dilated cardiomyopathy in 36 patients (18%) (G2), while 32 patients (12%) (G3) had an "arrhythmogenic" ventricle (dysplasia, valvular disease, idiopathic arrhythmias). Mean left ventricular ejection fraction was 30 +/- 11% in G1, 33 +/- 13% in G2 and 48 +/- 13% in G3. Perioperatively, 12/271 patients (4%) died. During the mean follow-up of 21 +/- 17 (< 1 to 99) months, 52/259 patients (20%) died: 31% (11/36 patients) in G2, 19% (36/193 patients) in G1 and 17% (5/39 patients) in G3. There was a low incidence of sudden death (SD) (4%, 2% per year) without significant differences between G1 (3%), G2 (8%) and G3 (3%). In addition, no significant differences were observed in cardiac mortality (CD) between G1 (10%), G2 (14%) and G3 (3%) (p = n.s.). ICD discharges occurred in 188 patients (69%); ICD discharges occurred in G1 in 138 patients (68%), in G2 in 27 patients (75%) and in G3 in 23 patients (72%). The mean incidence of ICD discharges per patient was 16 +/- 10 shocks in G1, 24 +/- 8 shocks in G2 and 18 +/- 8 shocks in G3. After ICD implant, complications occurred in 67 patients (23%). Our data show that the ICD is highly effective in preventing sudden death independent on the underlying etiology.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow-up of anti-tachycardia surgery in patients with ventricular tachycardia]. / Langzeitverlauf nach antitachykarder Operation bei Patienten mit Kammertachykardien.

From March 1980 to May 1992 mapping guided surgery was performed in 132 patients with drug-refractory recurrent ventricular tachycardia. There were 121 patients (group I) with coronary disease and 11 patients (group II) had noncoronary ventricular tachycardia. Patients in group I underwent subendocardial resection and cryoablation was performed in group II patients. Perioperative mortality (< 30 days after surgery) was 8% (10/132 patients). During the mean follow-up of 41 +/- 24 months, 37/122 patients (30%) died, 35/111 patients in group I (32%) and 2/11 patients in group II (18%) (p = 0.29). In group I, sudden death occurred in 8/111 patients (7%) and cardiac death in 23/111 patients (21%); in group II, 1/11 patients (9%) died from sudden and 1/11 patients (9%) from cardiac death. Nonfatal recurrences occurred significantly more frequently in group II (6/11 patients, 55%) than in group I (16/111 patients, 14%) (p < 0.01). During the follow-up functional class of heart failure improved in 69 patients (57%), remained constant in 27 patients (22%) and decreased in the remaining 26 patients (21%). The surgical approach to control ventricular tachycardia has low rates of sudden death and nonfatal recurrences in patients with drug-refractory ischemic ventricular tachycardia. Patients with noncoronary disease had a high incidence of nonfatal ventricular tachycardia after surgery and should be considered for other therapeutic approaches in the future.

[Federal admission criteria for levels of perinatal care: definition, interpretation and first conclusions]. / Aufnahmekriterien nach dem G-BA-Beschluss: definition, interpretation und erste schlussfolgerungen.

BACKGROUND: The outcome of high risk pregnancies is better in tertiary hospitals. The German government introduced levels of perinatal care only in 2006. The aim of this study was to investigate how many children are to be expected for each level, taking the possible width of interpretation of the admission criteria into account. MATERIALS AND METHODS: Perinatal quality assurance data from four German states (2005) were available. Based on the admission criteria used for level definitions, children were categorised into four different levels of care. To illustrate the possible width of interpretation of these admission criteria three analytical strategies were used. In addition, the distribution of children on different types of hospitals prior to the introduction of levels of care was analysed. RESULTS: Most deliveries (86-93 %) correspond to the lowest level, and only 1-5 % to the highest. Up to 15 % of children who should have been cared for in the highest level were born in hospitals with less than 500 annual deliveries. Among the neonates with risk profiles corresponding to the admission criteria for the two highest levels, up to 30 % were born in delivery units without NICUs. The majority (83 %) of attached NICUs had low caseloads (< 50 neonates < 1500 g / year). CONCLUSION: Most children fulfil the admission criteria for the lowest level of care whereas the need for specialised centres is rather low. Optimising the place of birth appropriately remains a challenge. Definition of levels of care based on admission criteria are difficult to implement due to a broad variety of interpretations.

[Pregnancies without prenatal care--which women are potentially affected, what are the inherent fetal risks?]. / Schwangerschaften ohne Vorsorgeuntersuchung--welche Frauen sind potenziell betroffen, welche Risiken ergeben sich für das Kind?

BACKGROUND: In the past decades prenatal care has lead to a reduction in maternal and fetal-neonatal morbidity and mortality. However, the number of examinations that should be recommended - especially in low-risk pregnancies - is still unclear. OBJECTIVE: Women not taking part in prenatal care resemble a subgroup of pregnant women at risk. The objective of this study was to define characteristic parameters based on patient's history and clinical outcome and which maternal and fetal-neonatal morbidity has to be taken into account. PATIENTS AND METHODS: From 913 255 data sets of the Perinatal Registry Lower Saxony, Germany, between 1987 and 1999 n = 2 208 pregnancies (0.24 %) were documented as 'not taken part in prenatal care', while n = 163 143 pregnancies were identified as having undergone optimal prenatal care according to the recommendations. Both groups were compared regarding pregnancy associated and obstetrical parameters. Data are given as odds ratio (OR) and 95 % confidence interval (CI) for pregnancies without any prenatal care vs. pregnancies with standard prenatal care. RESULTS: History of still birth: OR 1.750 (1.175 - 2.609), p < 0.05; mother single: 7.271 (6.603 - 8.006), p < 0.01; maternal age < 18 yrs: 9.904 (7.771 - 12.624), p < 0.01; maternal age > 40 yrs: 3.781 (2.900 - 4.907), p < 0.01; German vs. other origin: 0.214 (0.196 - 0.234), p < 0.01; preterm birth: 2.667 (2.380 - 2.989), p < 0.01; cesarean section: 0.728 (0.644 - 0.823), p < 0.05; birth weight < 5 %: 2.552 (2.140 - 2.943), p < 0.01; APGAR at 1 min < 3: 5.463 (4.521 - 6.602), p < 0.01; umbilical artery pH < 7.0: 2.941 (1.753 - 4.932), p < 0.01; neonatal intubation: 3.945 (3.244 - 4.797), p > 0.01; still birth: 6.089 (4.731 - 7.838), p < 0.01; death post partum: 4.444 (3.008 - 6.567), p < 0.01. CONCLUSION: Pregnant women not taking part in prenatal care are younger or older, more frequently foreigners, and present characteristics of a lower socioeconomic status. These pregnancies are associated with a very high potential of neonatal morbidity. From a both medical and economic point of view, it appears to be reasonable to specifically look after those women before or during pregnancy.