[Acute coronary syndrome without ST-elevation (NSTE-ACS)]. / Akutes Koronarsyndrom ohne ST-Hebung (NSTE-ACS).

The timing of an invasive diagnosis and treatment strategy in patients with an acute coronary syndrome without ST-elevation (NSTE-ACS) depends on the patient's risk profile. In addition to the clinical symptoms, ST/T alterations in the resting ECG as well as an increase and kinetics of troponin are of crucial importance in this setting. For the majority of patients the highly sensitive troponin enables a rapid rule in or rule out strategy of a non-ST-segment elevation myocardial infarction (NSTEMI) with a 0/3 h algorithm. An even faster 0/1 h algorithm is increasingly being used; however, troponin only helps to identify patients with NSTEMI. Troponin-negative patients can still suffer from unstable angina pectoris. A dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASS) and an ADP receptor antagonist should be initiated in the acute phase and continued for 12 months, irrespective of the initial treatment strategy, e.g. percutaneous coronary intervention (PCI), bypass surgery or conservative treatment. In patients with a high bleeding risk a duration of 6 months only may be considered, whereas in patients with a high risk of ischemia the DAPT might be prolonged for up to 36 months.

The second step of ATP binding to DnaK induces peptide release.

The interaction of the nucleotide-free molecular chaperone DnaK (Hsp70) from Escherichia coli with nucleotides was studied under equilibrium and transient kinetic conditions. These studies used the intrinsic fluorescence signal of the single tryptophan residue (Trp102) of DnaK, or of novel fluorescent nucleotide analogs of ADP and ATP, N8-(4-N'-methylanthraniloylaminobutyl)-8-aminoadenosine 5'-di- or triphosphate (MABA-ADP and MABA-ATP) as spectroscopic probes. Titration of MABA-ADP with DnaK resulted in a 2.3-fold increase of the fluorescence signal, from which a binding stoichiometry of 1:1, and a dissociation constant (Kd) of 0.09 microM were derived. The intrinsic rate constant of hydrolysis of ATP or MABA-ATP in single turnover experiments was found to be 1.5 x 10(-3) s-1 and 1.6 x 10(-3) s-1, identical with the catalytic rate constant of 1.5(+/- 0.17) x 10(-3) s-1 obtained under steady-state conditions. The dissociation rate constant of ADP was measured to be 35(+/- 7) x 10(-3) s-1 in the absence or 15(+/- 5) x 10(-3) in the presence of 2 mM inorganic phosphate (Pi) and is therefore 10 to 20 times faster than the rate of hydrolysis. These results demonstrated that processes governing ATP hydrolysis are rate-limiting in the DnaK ATPase reaction cycle. The three observed different fluorescent states of the single tryptophan residue were investigated. The binding of ATP gave a decrease of 15% in fluorescence intensity compared with the nucleotide-free state. Subsequent ATP hydrolysis, or the simultaneous addition of ADP and Pi, increased the fluorescence 7% above the fluorescence intensity of the nucleotide-free protein. Changes in the tryptophan fluorescence could not be detected when ADP, Pi or the non-hydrolyzable nucleotide analogs AMPPNP (Kd = 1.62(+/- 0.1) microM) or ATP gamma S (Kd = 0.044(+/- 0.003) microM) were added. These data suggested that DnaK exists in at least three different conformational states, depending on nucleotide site occupancy. The fluorescence increase of DnaK upon ATP binding was resolved into two steps; a rapid first step (Kd 1 = 7.3 microM) is followed by a second slow step (k+2 = 1.5 s-1 and k-2 < or = 1.5 x 10(-3) s-1) that causes the decrease in the tryptophan fluorescence signal. The addition of ATP also resulted in the release of DnaK-bound peptide substrate with koff = 3.8 s-1, comparable with the rate of the second step of nucleotide binding. AMPPNP or ATP gamma S were not able to change the fluorescence signal nor to release the peptide. We therefore conclude that the second step of ATP binding, and not the 1000-fold slower ATP hydrolysis is coupled to peptide release.

Cloning vectors for the production of proteins in Dictyostelium discoideum.

We constructed and tested a series of cloning vectors designed to facilitate protein production and purification in Dictyostelium discoideum (Dd). These vectors carry the origin of replication of the Dd high-copy-number plasmid Ddp2, expression cassettes consisting of the strong, constitutive actin (act15) or the inducible discoidin (disI gamma) promoters, a translational start codon upstream from a multiple cloning site and sequences for the addition of epitope or affinity tags at the N- or C-termini of any protein. The affinity tag used corresponds to 7 (N-terminal fusion) or 8 (C-terminal fusion) His residues. The epitope tags correspond to an 11-amino-acid sequence from human c-myc, recognised by monoclonal antibody (mAb) 9E10, and the Glu-Glu-Phe sequence recognised by mAb YL1/2 to alpha-tubulin. Both these mAb are commercially available. The YL1/2 epitope offers a second affinity tag for the purification of proteins under native conditions. The functional competence of the vectors was tested by determining their ability to promote the expression of various Dd myosin constructs. High synthesis levels were obtained for each vector; up to 1 mg of homogenous, functional protein per g of cells was obtained after purification of the recombinant products.

Echocardiographic control of Swan-Ganz catheters.

In 68 patients, subxiphoidal, percordial, and suprasternal echocardiography was used to trace the Swan-Ganz catheter during its passage to the pulmonary artery and to localize its position. The localization of the catheter could be exactly identified in 62 out of 68 patients in whom we managed to obtain a suprasternal echocardiogram. In one patient, the catheter was found (by chest x-ray film) in the left pulmonary artery (LPA) and was regarded to be in the right pulmonary artery according to suprasternal echocardiography. In two patients, the catheter could not be localized by suprasternal echocardiography although it was positioned in the LPA. In three patients, the catheters could not be advanced to the pulmonary circulation and were visualized within the right ventricular cavity by precordial and subxihpoid echocardiogarphy. Thus, echocardiography, particularly the suprasternal approach, has proven a safe, reliable, and easy way for position control of Swan-Ganz catheters.

AT III in septicemia with DIC.

In the development of sepsis DIC is a common complication. Several studies presented in this paper show a coincidence between the development of DIC and depletion of Antithrombin III, a serine protease inhibitor which inhibits a large scale of activated clotting factors. It seems very probable that substitution therapy should be of benefit in the treatment of sepsis-related DIC and may improve the outcome of septic patients. Physiological and clinical findings are put together to clarify the basic rationale for running clinical trials and future studies.

Transthoracic electrical impedance during extracorporeal hemodialysis in acute respiratory failure ("Shocked Lung syndrome").

The alteration (delta Z0) of transthoracic electrical impedance (TEI) during extracorporeal hemodialysis (EHD) was investigated in two Groups of patients with acute renal and acute respiratory failure, that differed with respect to the severity of respiratory insufficiency. Group I had moderate respiratory failure (FiO2 0.31 +/- 0.10, PaO2 84 +/- 14 mmHg), and Group II had severe respiratory failure (FiO2 0.75 +/- 0.17, PaO2 77 +/- 14 mmHg). There was a significant correlation between increase in TEI (delta Z0) and decrease in body weight (delta BW) in each individual patient, but the slope of regression lines was remarkably flattened in Group II. In Group I, delta TEI was 1.9 +/- 0.9 omega, the calculated TEI for 500 gr decrease in BW (delta Z0-500 gr) was 0.59 +/- 0.21 omega, and a significant correlation existed between pooled data of delta Z0 and delta BW. In Group II TEI increased less significantly, delta TEI was 0.6 +/- 0.3 omega (P less than 0.001), delta Z0-500 gr was 0.26 +/- 0.27 omega (P less than 0.01), and there was no correlation between pooled data of delta Z0 and delta BW. Increase of TEI in Group II could be completely attributed to increase in hematocrit. It is concluded that patients of Group I with acute renal failure and moderate respiratory failure lost intrathoracic fluid during EHD, whereas patients of Group II with severe respiratory failure did not. TEI during EHD may serve as a test for detection of fixed fluid within the pulmonary interstitium indicating a poor prognosis of the acute respiratory failure.

The ability of the Simplified Acute Physiology Score (SAPS II) to predict outcome in coronary care patients.

OBJECTIVE: To evaluate the applicability of the Simplified Acute Physiology Score (SAPS II) for coronary care patients. DESIGN: Prospective observational cohort study. SETTING: Medical ICU of a community teaching hospital. PATIENTS: 1587 consecutive patients admitted over a period of 18 months. MEASUREMENTS AND MAIN RESULTS: Patients were divided in two groups according to the primary admission diagnosis: general medical intensive care (ICU) patients and intensive coronary care (CCU) patients. Score prediction was tested using criteria suitable to evaluate the discrimination and calibration properties of SAPS II. Mean SAPS II score was 31.6 (+/- 20.1) in ICU and 28.3 (+/- 15.5) in CCU patients (p = 0.06), mean risk of death 0.206 and 0.134 (p = 0.001), and observed hospital mortality 17.8 vs 10.3%. The area under the receiver operating characteristic curve was 0.888 in ICU and 0.908 in CCU patients (p = 0.5). The correlation between predicted and observed hospital mortality was 0.62 (p = 0.001) in ICU and 0.66 (p = 0.001) in CCU patients. The calibration curves did not differ from each other. The probability of death in survivors and nonsurvivors was equally distributed in ICU and CCU patients (p = 0.5). CONCLUSION: We conclude that SAPS II is applicable to CCU patients in our unit.

Short-term impact of the European Consensus Conference on the use of selective decontamination of the digestive tract with antibiotics in ICU patients.

Because it remained controversial, the use of selective digestive decontamination (SDD) in patients in the intensive care unit (ICU) was chosen as the topic of the first European Consensus Conference in Intensive Care Medicine (ECCICM) in December, 1991. The Consensus Bureau decided to assess the impact of this conference 2 years afterwards. For this purpose, a questionnaire was sent to the members of the European Society of Intensive Care Medicine, the Societé de Réanimation de Langue Française and the Societé Française d'Anesthesie et Réanimation before the conference. The recommendations following the conference discouraged the systematic use of SDD in ventilated patients and urged the monitoring of bacterial resistance and adapting antibiotics to epidemiology of the units. Two years after the conference, the same questionnaire was sent to those physicians who had responded to the first one. Eighteen percent used SDD for all ventilated patients and 17% remain users after 2 years. Among the occasional (32%) or continual (17%) users of SDD, the regimens used were mostly intravenous cefotaxime (60% of systemic antibiotics) and a topical combination of polymixin E, tobramycin, and amphotericin B (62% of overall topical combinations). The antibiotics used were unchanged after 2 years in almost all cases. In conclusion, the short-term impact of the Consensus Conference on SDD in ICU patients has been poor. This may be related to the continuing insufficiency of strong, definite data regarding the impact of this technique upon mortality and the theoretical risk of resistance to antibiotics, thus allowing physicians to stick to their policies until there is new evidence.

Antithrombin III in patients with severe sepsis. A randomized, placebo-controlled, double-blind multicenter trial plus a meta-analysis on all randomized, placebo-controlled, double-blind trials with antithrombin III in severe sepsis.

OBJECTIVES: To evaluate the safety and potential efficacy of antithrombin III (AT III) in reducing mortality in patients with severe sepsis. DESIGN: Prospective, randomized, placebo-controlled, double-blind, phase II, multicenter, multinational clinical trial. SETTING: Seven academic medical center intensive care units (ICU) in Belgium, Denmark, the Netherlands, Norway and Sweden. PATIENTS: 42 patients with severe sepsis who received standard supportive care and antimicrobial therapy, in addition to the administration of AT III or placebo. INTERVENTIONS: Patients received either an intravenous loading dose of 3000 IU AT III followed by a maintenance dose of 1500 IU every 12 h for 5 days or equivalent amounts of placebo. MEASUREMENTS AND RESULTS: All patients were evaluated for safety and for 30-day all-cause mortality. CONCLUSIONS: The administration of AT III was safe and well-tolerated. It was followed by a 39 % reduction in 30-day all-cause mortality (NS). The reduction in mortality was accompanied by a considerably shorter stay in the ICU. Patients treated with AT III exhibited a better performance in overall severity of illness and organ failure scores (Acute Physiology and Chronic Health Evaluation II, multiple organ failure, organ system failure), which was noticeable soon after initiation of treatment. Patients treated with AT III demonstrated a better resolution of pre-existing organ failures and a lower incidence of new organ failures during the observation period. A meta-analysis comprising this and two other double-blind, placebo-controlled trials with AT III with a total of 122 patients suffering from severe sepsis confirms the positive trend. The results of the meta-analysis demonstrate a 22.9 % reduction in 30-day all-cause mortality in patients treated with AT III. Although still too small to be confirmative, the meta-analysis clearly points to the fact that a sufficiently powered phase III trial is warranted to prove whether AT III has a beneficial role in the treatment of severe sepsis.

Prognostic value of blood lactate in critically ill patients.

Hyperlactatemia is frequently observed in critically ill patients. A correlation of blood lactate concentrations and outcome of patients has been proven in circulatory shock, circulatory arrest, acute myocardial infarction, acute hypnotic drug poisoning and severe pancreatitis. However, the prognostic relevance of hyperlactatemia yields from statistical examinations in larger groups of patients. It should not be misused as a reliable prognostic sign in the individual patient, but is of high value in comparing groups of patients. In individual patients, hyperlactatemia is a useful indicator pointing to the severity of illness and to superimposed complications. Blood lactate is of considerable value for the metabolic monitoring of critically ill patients.

Application of impedance cardiography in critical care medicine.

In spite of good correlations between cardiac output measurements by impedance and established invasive procedures (dye- and thermo-dilution) reported by numerous authors it is doubtful uptil now whether calculations of stroke volume according to the formula of Kubicek et al. (1974) can provide absolutely reliable results. The origin of the dz/dt curve and influencing factors of impedance wave have to be cleared up prior to the total acception of impedance cardiography as a reliable method for determining non-invasive stroke volume. This is true in spite of the agreement of all authors we know, that the reproducibility of the impedance cardiography values is as good as in dye or thermo-dilution measurements. However, for patient monitoring it is sometimes more important to assess the relative changes in stroke volume than to measure its absolute value. For long-term non-invasive monitoring of myocardial contractility in critically ill patients or after pharmacological interventions impedance cardiography may be recommended. Besides systolic time intervals, such as pre-ejection time and ventricular ejection time, three more reliable parameters can be derived from the first derivate of impedance wave. Impedance plethysmography has been shown as a reliable method to diagnose deep vein thrombosis and good correlations between impedance and strain-gauge plethysmography and phlebographic findings are reported. In addition fluid volume changes in the leg, venous capacity, venous outflow and arterial inflow may be determined by impedance plethysmography in a simple way. There is no doubt that alterations in the fluid content of biological tissue may measured by impedance technique. However, correlations between changes in the transthoracic impedance and fluid content of the thorax can be quantified only in a single subject which serves as its own control. Overall standardization is not possible. The reason for interindividual differences in the thoracic impedance at a given reduction of body water are due to anatomical differences, intrapulmonary air volume and pressure, location of the electrodes, electrical conductivity of the tissue and, above all, due to the position of the body. Therefore if transthoracic impedance is determined sequentially measurements must be performed with special attention to the position of the body to get reproducible results. Rapid infusion of colloids or blood transfusion may decrease transthoracic impedance due to intravascular volume expansion even at a net fluid lost during forced furosemide-induced diuresis or extracorporal hemodialysis.(ABSTRACT TRUNCATED AT 400 WORDS)

[Predictive value of score parameters of the Simplified Acute Physiology Score (SAPS)-II for the duration of treatment of intensive care patients]. / Voraussagekraft von Scoreparametern des Simplified Acute Physiology Score (SAPS)-II für die Behandlungsdauer von Intensivpatienten.

Length of intensive care therapy and the total length of stay in hospital are important determinants of hospital costs. We therefore analysed the correlation between score parameters of SAPS-II with the time spent in the intensive care unit (ICU), and also in the hospital, for 604 general medical intensive care patients (ICU group) and 510 coronary care patients (CCU group). The mean stay in the ICU was 3.68 days for ICU patients and 2.67 days for CCU patients. The total stay in hospital was 13.5 days vs 16.1 days with a mortality of 18% (risk of death 0.21) in ICU and 10% (risk of death 0.13) in CCU patients. In patients who died, duration of therapy in the ICU was significantly longer than in surviving patients (5.88 vs 3.20 days in the ICU group and 3.65 vs 2.56 days in the CCU group). In contrast, total hospital stay was significantly shorter in patients who died (8.6 vs 14.5 days in the ICU group and 8.8 vs 16.9 days in the CCU group) (p = 0.001). The risk of death calculated from SAPS II was significantly correlated with the duration of intensive care. There was a significant indirect correlation between risk of death and the total hospital stay. In ICU patients duration of intensive treatment and hospital stay correlated with age, heart rate, maximum systolic blood pressure, body temperature, BUN, serum bilirubin, and sodium (all signs of systemic inflammatory reaction and organ dysfunction); in CCU patients length of intensive treatment and hospital stay correlated with body temperature, diuresis, BUN, bicarbonate, minimum systolic blood pressure (as signs of organ perfusion). A low Glasgow Coma Score was correlated with prolonged intensive care in all patients. In conclusion, score data, appear a suitable tool to predict the duration of intensive care treatment and length of hospitalization, in addition to outcome, and thus serve as gauge of efficiency.

[Outcome of intensive care]. / Outcome nach Intensivtherapie.

BACKGROUND: The mean hospital mortality of patients after intensive therapy in Germany is about 15%, the mortality within the intensive care unit about 8%. Short-term prognosis is mainly determined by severity of disease, type of disease and patient age. FACTORS IN INTENSIVE CARE: The impact of disease severity is measured by acute physiology score systems. The significance of disease categories becomes apparent in disease states with a continuing high mortality. Age is an independent risk factor. The higher risk of older patients cannot be explained by different diagnosis, and it is not secondary to a less aggressive therapy. The same factors mainly determine long-term prognosis. The 5-year-survival rate after intensive therapy is around 60%, a 3-fold increase as compared to the general population. Dependent upon the disease category, survival curves of intensive care patients parallel survival curves of the general population 2 years after admission. Analysis of quality of life is based upon objective measurement and subjective estimation of health-related life quality in the physical, psychological, and social life domain. Patients after intensive therapy experience a moderate but significant decrease in quality of life. This is the case in global estimations of quality of life as well as in investigations of different life domains. CONCLUSION: The remaining quality of life is tolerable. This is in accordance with the positive overall judgement of intensive care by patients themselves. The chief problem of intensive care remain diseases with continuing high mortality.

[Atrial fibrillation in patients of a medical clinic--a marker for multi-morbidity and unfavorable prognosis]. / Vorhofflimmern bei Patienten einer Medizinischen Klinik--ein Marker für Multimorbidität und ungünstige Prognose.

Out of 724 patients admitted to the medical department of a community teaching hospital during three months 110 (14.5%) had electrocardiographically documented atrial fibrillation (AF). 56% had chronic and 44% intermittent AF. Only 66% of patients with AF suffered from diseases generally accepted as cause of AF, 29% had cardiovascular and pulmonary risk factors, 5% had lone AF. AF was already known in 66% of patients, in 21% AF was documented at the first time, only 14% were admitted because of AF, although AF was clearly the cause of symptoms in an additional 11%. The mean age of patients with AF (72 years) was higher than that of patients without AF. 95% of patients with AF suffered from more than one cardiovascular or pulmonary disease or risk factor (mean index of diseases of 3.2). Hospital mortality of patients with AF was much higher than mean total hospital mortality (19 vs 7.7) except in patients with lone AF. We conclude that AF is a marker of multimorbidity and bad prognosis in patients of general internal medicine.

[Analysis of outcome quality control in intensive care medicine using the Simplified Acute Physiology Score II]. / Analyse einer Ergebnisqualitätskontrolle in der Intensivmedizin mittels des Simplified Acute Physiology Score II.

AIM: the main aim of the study was to assess the applicability of the Simplified Acute Physiology Score II (SAPS II) to the evaluation of outcome quality within the framework of quality assurance in patients in a medical intensive care unit. The outcome parameter employed was hospital mortality, measured as mortality index (hospital mortality actually observed/predicted mortality), the predicted mortality being derived from the individual mortality risk calculated for each patient in accordance with SAPS II. METHOD: For the period of one year, the SAPS II score, the individual mortality risk, the mean scores, mortality risk, intensive care and hospital mortality, and the mortality index (99% confidence interval) were calculated with the aid of a specially developed program for all 1,114 patients kept under observation or treated for longer than 4 hours in the intensive care unit. The entries (data) were monitored by random checks for the correctness of the individual entries and overall completeness of patient inclusion. The applicability of the SAPS II for our own patient material was checked with the aid of Receiver Operating Characteristic curves. In compliance with the original SAPS II to include patients of a coronary care unit but not to evaluate them, only the 604 patients with the diseases of medical intensive care were taken into account for quality control. High-risk groups (patients older than 76, critically ill patients with a mortality risk of more than 0,5, patients receiving respiratory support) and individual diagnostic categories were considered separately as subgroups. RESULTS: In the entire group, the mean mortality risk was 21,1% the observed intensive care mortality 11,2%, the hospital mortality 18,0%, and the mortality index 0,86 (0,75 to 1,00). The mortality actually observed, therefore, corresponded to that predicted on the basis of the SAPS prognostic system. Also in the subgroups of elderly patients, and individual diagnostic categories (cerebral, bronchopulmonary cardiovascular, gastrointestinal diseases), the mortality index did not differ significantly from 1,0. A mortality index significantly less than 1,0 (observed mortality significantly lower than predicted mortality) was found in the sub-groups of the seriously ill, of patients receiving respiratory support, and in the diagnostic category of intoxications. The monthly analysis showed fluctuating mortality indices which, however, never differed significantly from 1,0. The surface under the ROC curve for the entire group was 0,89, and 0.81-0.99 for the various diagnostic categories. CONCLUSIONS: The prognostic system SAPS II can be employed to evaluate the quality of outcome measured by hospital mortality in patients of a medical intensive care unit, provided that the applicability of the score is demonstrated for the patient material involved, the outcome of the overall group and of the high-risk groups is referred to the accuracy and completeness of the entered data is checked, and the scoring systems accepted as quality standard.

[Incidence of intravenous thrombolytic therapy and fatalities in patients with acute transmural myocardial infarct (Q infarct). A study of observations from 1984 to 1987]. / Häufigkeit der intravenösen Thrombolysetherapie und Letalität bei Patienten mit akutem transmuralen Myokardinfarkt (Q-Infarkt). Eine Beobachtungsstudie von 1984 bis 1987.

All patients admitted to the ICU with acute myocardial infarction (MI) were treated by the same protocol since 1984. We report the results in Q-wave-MI of 1987 compared to 1984. Age (67.2 +/- 12.4 vs. 66.8 +/- 11.4 years), sex distribution (70.1% vs. 71.9% male), time elapse between begin of symptoms and admittance to the hospital (15.5 +/- 27.0 vs. 15.0 +/- 32.5 hours) were similar in both years, but the total number of definite Q-MI decreased by 22% from 135 (1984) to 105 (1987). Inhospital mortality (20% vs. 23%) and ICU mortality (14% vs. 20%) tended to decrease, although differences did not reach statistical significance. This was paralleled by an increase in the rate of i.v. thrombolytic therapy from 17% (1984) to 28% (1987) of all patients with Q-MI. The percentage of patients who definitely received i.v. thrombolysis when all indication criteria were present and all contraindicatory factors excluded increased from 47% (1984) to 97% (1987). We conclude, that the performance of i.v. thrombolysis in all patients, who fulfill the general accepted criteria for thrombolysis may improve clinical course and outcome in a given population of patients with acute Q-wave-infarction.

[Predictive value of a combined physiologic-therapeutic oriented score system in patients of intensive internal medicine]. / Aussagefähigkeit eines kombinierten physiologisch-therapeutisch orientierten Score-Systems (KOPT) bei Patienten der internen Intensivmedizin.

171 consecutive patients of a medical intensive care unit (age 18 to 81 years, mortality 24.6%) who were treated in the ICU for at least 72 hours were investigated in order to test the hypothesis, that the combination of therapeutic scoring (TISS) and physiologic scoring (APS) may improve the prognostic significance of score systems and/or the severity of disease classification in critically ill patients. Discrimination of survivors and non-survivors of the combined score was comparable to the results of isolated scores. A higher weighting of the physiology parameters in the combined score did not improve its prognostic significance. On the other hand, only the combined score implicated a linear increase of mortality with increasing score point values. - We conclude, that the combined score system improves the severity of disease classification in critically ill medical patients.

[Cardioversion in atrial fibrillation. Results and complications in 1,152 prospective patients. Study Group of the Working Society of Leading Cardiologic Hospital Physicians]. / Kardioversion bei Vorhofflimmern. Ergebnisse und Komplikationen bei 1152 prospektiv erfassten Patienten. Studiengruppe der Arbeitsgemeinschaft leitender kardiologischer Krankenhausärzte (ALKK).

BACKGROUND: Pharmacological and direct-current cardioversion of atrial fibrillation are often performed interventions. Little is known about results and complications of cardioversion in daily practise. PATIENTS AND METHODS: Demographic, procedural and outcome data from patients with cardioversion of atrial fibrillation were collected in a prospective, multicenter registry of 61 hospitals. RESULTS: Between July 1994 and December 1994 1152 patients with a mean age of 64 +/- 11 years were registered on an intention-to-treat basis. 62% were male. The most prevalent underlying disorders were coronary artery disease (34.7%), valvular heart disease (18.1%), and cardiomyopathy (6.9%). 16.4% of patients had lone atrial fibrillation. New onset atrial fibrillation was reported in 21%, paroxysmal in 32% and chronic in 47% of patients. The mean duration of atrial fibrillation was 7 +/- 26 weeks (range 1 day to 7 years, median 5 days). In 3.8% of patients no cardioversion attempt was made and follow-up was not possible in another 5.5%. 19.2% of patients cardioverted spontaneously. Direct current cardioversion was attempted in 39.7% and pharmacological cardioversion in 31.8% of patients. Cardioversion was successful (sinus rhythm at discharge) in 96.4% of spontaneous cardioversion, in 73.1% of direct current cardioversion and in 84.4% of pharmacological cardioversion. Success of cardioversion was significantly related to duration of atrial fibrillation, NYHA functional class and left atrial diameter (p < 0.001). In 55 (4.8%) cases complications were reported of which 14 were fatal. Five cases of sudden death occurred, all of which were related to quinidine therapy for pharmacological cardioversion. Five cases of embolism were reported. Two were not associated with cardioversion attempts and 3 occurred within 24 hours after successful direct current cardioversion. Two of these patients were effectively anticoagulated at the time of cardioversion. A total of only 62% of patients with atrial fibrillation of more than 48 hours duration were anticoagulated for cardioversion with coumadine or i.v. heparin. CONCLUSIONS: The main risks of cardioversion are fatal proarrhythmic events in pharmacological attempts to restore sinus rhythm. The risk of embolism is despite low rates of effective anticoagulation low.

[Diarrhea, coli infection, septic encephalopathy: escalation of a seemingly banal symptom]. / Diarrhöe, Kolisepsis, septische Enzephalopathie: Eskalation eines scheinbar banalen Symptoms.

Septic encephalopathy is an early manifestation of sepsis. Changes in consciousness, focal or generalized seizures, multifocal myoclonus and/or varying hemiparesis are common clinical findings. All of these symptoms are reversible when sepsis has been successfully treated. Because there are no generally accepted criteria for the diagnosis of septic encephalopathy, it is a diagnosis of exclusion. We report the case of a 68-year-old patient who developed septic encephalopathy secondary to diarrhea and E. coli sepsis. In this case, symptoms of septic encephalopathy were fully reversed after the patient's E. coli sepsis had been adequately treated.

[Ethanol ingestion following Antabus overdose: acetaldehyde-induced cardiological emergency]. / Ethanolaufnahme nach Antabus-Uberdosierung: Acetaldehyd-induzierter kardiologischer Notfall.

The differential diagnosis of chest pain is challenging, when the clinical presentation appears pathognomonic, yet conventional diagnostic tests fail to reveal the suspected cause. We report the case of a 38-year-old patient who had an acetaldehyde intoxication (antabuse syndrome) in the setting of disulfiram overdose and ethanol ingestion. The patient presented with severe angina pectoris. Coronary artery disease was suspected, because the patient had risk factors and electrocardiographic repolarization changes were present. During the further investigation it became evident that symptoms were solely caused by acetaldehyde intoxication following disulfiram and alcohol ingestion. Toxic levels of acetaldehyde were found in the patient's serum. Coronary artery disease was ruled out by cardiac catheterization.