[Computed tomography or cardiovascular magnetic resonance imaging for diagnosis of chronic coronary syndrome?] / Computertomographie oder Magnetresonanztomographie zur Diagnostik des chronischen Koronarsyndroms?

BACKGROUND: Noninvasive imaging modalities are of central importance in the diagnosis of chronic coronary syndrome (CCS) in the current guidelines of the European Society of Cardiology (ESC), while the role of primary invasive coronary angiography in this context is increasingly being questioned. This review provides a summary of the most important diagnostic strategies from the radiology perspective. METHODOLOGICAL ISSUE: The diagnostic algorithm is guided by the pretest probability (PTP) for the presence of CCS, which can be estimated based on age, sex, and symptoms. It is important to note that PTP in the current guidelines has decreased significantly compared to older recommendations and this change has an impact on the selection of the most appropriate imaging technique. STANDARD RADIOLOGICAL METHODS: In patients with low PTP (>5% and <15%) and without prediagnosed coronary artery disease (CAD), CCS can be safely ruled out with inconspicuous computed tomography angiogram (CTA) of the coronary vessels. In patients with increased PTP (>15%) or prediagnosed CAD, noninvasive functional imaging should be primarily used to detect ischemia. PERFORMANCE AND METHODICAL INNOVATIONS: The excellent sensitivity (89%), specificity (87%) and high prognostic relevance make stress perfusion cardiovascular magnetic resonance (CMR) imaging the functional method of first choice. Technical innovations and the use of artificial intelligence-based methods for image analysis could contribute to further improve its accuracy in the future. PRACTICAL RECOMMENDATIONS: Radiologists should be aware of the recommendations of the current guidelines and work towards the establishment of coronary CTA and stress perfusion CMR in clinical routine.

Thalidomide in newly diagnosed multiple myeloma: influence of thalidomide treatment on peripheral blood stem cell collection yield.

In a phase III randomized, multicenter study, the German-speaking Myeloma-Multicenter Group (GMMG) and the Dutch-Belgian Hemato-Oncology Cooperative Group (HOVON) group investigated the influence of thalidomide (Thal) on the outcome of peripheral blood stem cell (PBSC) collection in multiple myeloma (MM) before peripheral autologous blood stem cell transplantation (ABSCT). We analyzed the data of 398 myeloma patients after induction with Thal, doxorubicin and dexamethasone (TAD) in comparison with vincristine, doxorubicin and dexamethasone (VAD) followed by mobilization with cyclophosphamide, doxorubicin, dexamethasone (CAD) and PBSC collection. Within both the study groups, patients treated with TAD showed to collect significantly fewer CD34(+) cells compared with VAD (GMMG, TAD: median 9.8 x 10(6)/kg; range 2.0-33.6; VAD: median 10.9 x 10(6)/kg range 3.0-36.0; P=0.02) (HOVON, TAD: median 7.4 x 10(6)/kg; range 2.0-33.0; VAD: median 9.4 x 10(6)/kg; range 0.0-48.7; P=0.009). However, engraftment after peripheral autologous stem cell transplantation showed no difference between Thal and VAD groups. We conclude that Thal as a part of induction regimen is associated with better response rates (GMMG-HD3: CR/PR 79%, VAD: CR/PR 58%; HOVON-50: TAD: CR/PR 81%, VAD: CR/PR 61%), but significantly affects the yield of PBSC collection. Nevertheless, the number of total CD34(+) cells collected was sufficient for double autologous transplantation in 82% of the Thal patients, with at least 2.5 x 10(6)/kg CD34(+) cells.

Radioimmunotherapy-augmented BEAM chemotherapy vs BEAM alone as the high-dose regimen for autologous stem cell transplantation (ASCT) in relapsed follicular lymphoma (FL): a retrospective study of the EBMT Lymphoma Working Party.

Relapse remains the most common cause of treatment failure in patients receiving autologous stem cell transplantation (ASCT) for follicular lymphoma (FL). The aim of this study was to evaluate the effect of adding radioimmunotherapy or rituximab (R) to BEAM (carmustine, etoposide, ara-c, melphalan) high-dose therapy for ASCT in patients with relapsed FL. Using the European Society for Blood and Marrow Transplantation registry, we conducted a cohort comparison of BEAM (n=1973), Zevalin-BEAM (Z-BEAM) (n=207) and R-BEAM (n=179) and also a matched-cohort analysis of BEAM vs Z-BEAM including 282 and 154 patients, respectively. BEAM, Z-BEAM and R-BEAM groups were well balanced for age, time from diagnosis to ASCT and disease status at ASCT. The cumulative incidences of relapse (IR) at 2 years were 34, 34 and 32% for Z-BEAM, R-BEAM and BEAM, respectively. By multivariate analysis, there were no significant differences with Z-BEAM or R-BEAM compared with BEAM for IR, non-relapse mortality, event-free survival or overall survival. With the caveat that the limitations of registry analyses have to be taken into account, this study does not support adding radioimmunotherapy or R to BEAM in ASCT for relapsed FL. However, we cannot rule out the existence a particular subset of patients who could benefit from Z-BEAM conditioning that cannot be identified in our series, and this should be tested in a randomized trial.

[Hemodialysis--the arteriovenous fistula, distal to the wrist joint]. / Hämodialyse--die arterio-venöse Fistel distal des Handgelenkes.

The arterio-venous fistula distal to the proc. styloides radii in the "tabatière" offers a most useful additional and very peripheral vascular access for chronic hemodialysis. It in no way compromises the further construction of arteriovenous anastomoses in be forearm in fistula failure. The results of 26 such fistulas are reported.

[Perinatal risk in significant macrosomia. A study based on the databank of the Professional Society of Swiss Gynecologic Clinics 1983-1992]. / Das perinatale Risiko bei erheblicher Makrosomie. Untersuchung aufgrund der Datenbank der Arbeitsgemeinschaft schweizerischer Frauenkliniken (ASF) 1983-1992.

A comparison of a group of births with severe macrosomia with a group of normal birth weight was made based on the data from the "Arbeitsgemeinschaft schweizerischer Frauenkliniken" (ASF), a work group of Swiss departments of obstetrics and gynaecology. During the period from 1983 to 1992 there were 2911 births of infants weighing more than 4500 g and 222,336 births of infants weighing between 3000 and 4000 g. Overall, the births of the macrosomic infants were more difficult, the rates of secondary Caesarean sections higher and the fetal outcomes poorer. The rates of shoulder dystocia, fracture of clavicle and palsy were higher. Only the last three complications were dependent on the mode of birth. In order to avoid, at least partially, palsy as the most serious of the complications of shoulder dystocia, it has been proposed to perform primary Caesarean section whenever the estimated birth weight is over 4500 g. Indeed, in our study, a part of the palsies had not occurred if all newborn weighing more than 4500 g had been delivered by Caesarean section. However, due to the difficulty in estimating the birth weight in utero, the high occurrence of spontaneous recovery from palsy and the high incidence of palsy in the comparison group, we could not find a clear proof of the necessity to perform primary Caesarean sections of all infants having estimated birth weights of over 4500 g.

[Multifocal atrial tachycardia in the newborn infant--obstetrical implications]. / Die multifokale Vorhoftachykardie beim Neugeborenen--geburtshilfliche Implikationen.

The present discussion deals with the rare multifocal atrial tachycardia in the neonate, initiated by a recent case in our clinic. The difficulties in prenatally diagnosing the disease by cardiotocography are as well discussed as the obstetric management.

[Chorionic villi (placental) biopsy in the 2d and 3d trimester: new perspectives in prenatal diagnosis]. / Die Chorionzotten-(Plazenta-)Biopsie im II. und III. Trimenon: Neue Perspektiven der Pränataldiagnostik.

A report of our first experience in second and third trimester chorionic villus (placental) biopsy is given. In all 16 cases a cytogenetic result could be received within 2 to 5 days. There were 6 normal female and 9 normal male karyotypes. A third trimester CVS showed a mosaicism of a structural aberration of chromosome 9 (46, XX/46, XX, 9p+). Blood cultures of the fetus revealed a normal female karyotype. The following indications of a second and third trimester CVS are discussed: direct or indirect signs of fetal malformations in ultrasound scanning (Oligo- or Anhydramnios with severe intrauterine growth retardation), placental anomalies (exclusion of triploidies), non immunologic hydrops fetalis, low serum alpha FP and failed amniotic fluid culture. We believe that transabdominal CVS in the second and third trimester is a simple and rapid tool to exclude distinctively any chromosomal anomaly and therefore influences further management of pregnancy and parturition.

[The postpartum course of the HCG titer of maternal blood and its clinical relevance]. / Der postpartale HCG-Titer-Verlauf im mütterlichen Blut und seine klinische Relevanz.

In 62 postpartum patients serial beta-HCG-measurements were performed. These tests show that beta-HCG should disappear entirely during the third week postpartum. Significant titers beyond this time are seen when placental tissue remains in utero. This condition may lead to late postpartum hemorrhage which is best treated by curettage. If there is only mild bleeding and beta-HCG-titers are negative, a hormonal curettage with subsequent estrogen administration (3 weeks) can be performed. In doing so, unnecessary and potentially harmful intrauterine manipulations can be avoided.

[Routine measurement of the biggest amniotic fluid pocket in the 3d trimester: prognostic significance?]. / Routinemässige Messung des grössten Fruchtwasserdepots im 3. Trimenon: Prognostische Bedeutung?

The largest pocket of amniotic fluid was measured routinely during the last trimester of pregnancy in 577 patients representing risk and nonrisk cases. The measurements were performed at two clinics between 26 and 42 weeks of gestational age. A statistically significant relationship between a value of less than 30 mm and the following perinatal parameters was found: 5-min Apgar score less than 7, umbilical cord blood pH values less than 7.15, severe neonatal complications, intrauterine growth retardation, perinatal mortality. The good predictive value of decreased amniotic fluid measured by the largest pocket, and the simple practicability of the method raise the question whether the largest pocket of amniotic fluid should not be assessed routinely at each ultrasound examination during the last trimester. The consequences of a decreased value are discussed.

[Acute intermittent porphyria in pregnancy: glucose or hematin therapy?]. / Akute intermittierende Porphyrie in der Schwangerschaft: Therapie mit Glukose oder Hämatin?

The symptoms and management of acute intermittent porphyria (AIP) during pregnancy and delivery are presented on the basis of three case reports. Two patients became asymptomatic after infusion of a concentrated glucose solution (600 ml 50% glucose = 300 g glucose per day), while the third patient needed treatment with hematin (1 mg/kg body weight, 6 infusions at intervals of 12 hours) because of deterioration of psychic state in spite of glucose infusion. Whenever an attack of AIP occurs, concentrated glucose solution should be administrated as a first measure accompanied by an analgesic and possibly a neuroleptic agent after elimination of precipitating factors. However, if symptoms persist for 48-96 hours or the psychic and/or neurological state of the patient further deteriorates, administration of 1-3 mg hematin per kg body weight can be recommended.

[Iodine supply at various periods in life and ultrasonographic thyroid volume in school children in a region of Switzerland]. / Jodversorgung in verschiedenen Lebensphasen und sonographische Schilddrüsenvolumina bei Schulkindern in einer Gegend der Schweiz.

In Switzerland the previous severe iodine deficiency has been corrected by iodization of salt. Changing food habits make it mandatory to periodically monitor iodine intake. In 1994 we therefore measured thyroid volume by sonography in 217 schoolchildren, and iodine, creatinine and sodium in casual urine samples of 214 schoolchildren, 40 pregnant women and 30 breast-fed newborns. Iodine was also measured in 30 breast milk samples. In schoolchildren, goiters of WHO grades Ia/Ib/II were found by palpation in 10.6/2.3/ 0.9%. By contrast, only two of the children had a sonographic thyroid volume exceeding the 97 percentile of the WHO, which underlines the difficulty of estimating the size of small goiters by palpation. Mean thyroid volume at 6/7/9/ 10/11 years of age was 2.1/2.2/3.3/3.3/3.1 ml, which is well within the normal range suggested by the WHO. Mean urinary iodine in schoolchildren (118 +/- 49 micrograms per gram creatinine) and in pregnant women (193 +/- 113 micrograms per gram creatinine) is within required limits, albeit with a decrease since 1988. In breast milk (7.8 +/- 5.9 micrograms/dl) and in urine of newborns (6.6 +/- 3.3 micrograms/dl) iodine values are below the Swedish reference values but well above values found in iodine deficient areas. We conclude that the iodine supply in schoolchildren and pregnant women is just sufficient and in newborns slightly below recently recommended limits. Compared to 1988 the iodine supply to schoolchildren is diminishing. The discrepancy between the rather low iodine content in breast milk despite a normal iodine supply during pregnancy remains to be explained.