Impact of Body Composition Indices on Ten-year Mortality After Revascularization of Complex Coronary Artery Disease (From the Syntax Extended Survival Trial).

Numerous studies have demonstrated a paradoxical association between higher baseline body mass index (BMI) and lower long-term mortality risk after coronary revascularization, known as the "obesity paradox", possibly relying on the single use of BMI. The current study is a post-hoc analysis of the SYNTAX Extended Survival (SYNTAXES) trial, which is the extended follow-up of the SYNTAX trial comparing percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in patients with left-main coronary artery disease (LMCAD) or three-vessel disease (3VD). Patients were stratified according to baseline BMI and/or waist circumference (WC). Out of 1,800 patients, 1,799 (99.9%) and 1,587 (88.2%) had available baseline BMI and WC data, respectively. Of those, 1,327 (73.8%) patients had High BMI (≥25 kg/m2), whereas 705 (44.4%) patients had High WC (>102 cm for men or >88 cm for women). When stratified by both BMI and WC, 10-year mortality risk was significantly higher in patients with Low BMI/Low WC (adjusted hazard ratio [HR]: 1.65; 95% confidence interval [CI]: 1.09 to 2.51), Low BMI/ High WC (adjusted HR: 2.74; 95% CI: 1.12 to 6.69), or High BMI/High WC (adjusted HR: 1.59; 95% CI: 1.11 to 2.27) compared to those with High BMI/Low WC. In conclusion, the "obesity paradox" following coronary revascularization would be driven by low long-term mortality risk of the High BMI/Low WC group. Body composition should be assessed by the combination of BMI and WC in the appropriate evaluation of the long-term risk of obesity in patients with LMCAD or 3VD.

Geochemically distinct carbon isotope distributions in Allochromatium vinosum DSM 180T grown photoautotrophically and photoheterotrophically.

Anoxygenic, photosynthetic bacteria are common at redox boundaries. They are of interest in microbial ecology and geosciences through their role in linking the carbon, sulfur, and iron cycles, yet much remains unknown about how their flexible carbon metabolism-permitting either autotrophic or heterotrophic growth-is recorded in the bulk sedimentary and lipid biomarker records. Here, we investigated patterns of carbon isotope fractionation in a model photosynthetic sulfur-oxidizing bacterium, Allochromatium vinosum DSM180T . In one treatment, A. vinosum was grown with CO2 as the sole carbon source, while in a second treatment, it was grown on acetate. Different intracellular isotope patterns were observed for fatty acids, phytol, individual amino acids, intact proteins, and total RNA between the two experiments. Photoautotrophic CO2 fixation yielded typical isotopic ordering for the lipid biomarkers: δ13 C values of phytol > n-alkyl lipids. In contrast, growth on acetate greatly suppressed intracellular isotopic heterogeneity across all molecular classes, except for a marked 13 C-depletion in phytol. This caused isotopic "inversion" in the lipids (δ13 C values of phytol < n-alkyl lipids). The finding suggests that inverse δ13 C patterns of n-alkanes and pristane/phytane in the geologic record may be at least in part a signal for photoheterotrophy. In both experimental scenarios, the relative isotope distributions could be predicted from an isotope flux-balance model, demonstrating that microbial carbon metabolisms can be interrogated by combining compound-specific stable isotope analysis with metabolic modeling. Isotopic differences among molecular classes may be a means of fingerprinting microbial carbon metabolism, both in the modern environment and the geologic record.

Fibrin deposition and removal in disseminated intravascular coagulation induced by endotoxin and saline loading: radioautographic findings in rats.

In rats a single injection of endotoxin followed by an infusion of normal saline induced the generalized Shwartzman reaction. The presence of disseminated intravascular coagulation (DIC) was demonstrated by measuring plasma fibrinogen, platelet counts, schistocytes, plasma haemoglobin, fibrin(ogen) degradation products, and fibrin thrombi in the glomerular capillaries, 125I-fibrinogen was given after triggering DIC in order to examine the fibrinogen turnover in plasma and the kinetics of fibrin deposition and removal in kidney, liver, and spleen. 125I-fibrinogen turnover was found to be highly accelerated. Early deposition and removal were observed in the kidneys, while a later peak with a more delayed fall of radioactivity was noted in liver and spleen. On histological examination fibrin could be seen only in the glomerular capillaries and only in the early phase of DIC. In radioautographs radioactive material was localized in the glomerular capillaries, the Kupffer' cells of the liver, and in the perifollicular macrophages of the spleen. Comparing the results obtained by scintillation counting to those obtained by light microscopy it can be assumed that radioactivity in kidneys is correlated to fibrin deposition in glomerular capillaries and to an accumulation on fibrin(ogen) degradation products in liver and spleen.

Glomus tumor with diffuse infiltration of the quadriceps muscle: a case report.

A case of a diffuse growing glomus tumor with interstitial infiltration of the musculus vastus medialis and intermedius (quadriceps muscle) in a 21-year-old woman is reported. The tumor was diagnosed by needle biopsy and then removed with wide margins. The typical histological appearance and the immunohistochemical findings in the resected specimen confirmed the diagnosis. Histogenesis and the biological behavior of glomus tumors are discussed.

The body reaction to carbon fibre particles implanted into the medullary space of rabbits.

It is thought that abrasion particles can produce a tissue reaction when alloplastic material is used for prosthetic devices. Therefore it is important to examine the reaction of the tissues and the body to microparticles before introducing a new material. Carbon reinforced carbon is a new material which is suitable for artificial joints because of its physical properties (strength and elasticity). Carbon fibre fragments with a diameter of 7 microns and a length between 20-100 microns were injected in the medullary canal of 16 rabbits, and evaluated after periods of 2 and 12 weeks. Phagocytosis of small carbon fibre fragments by macrophages occurs, but only a minimal foreign body reaction to the intramedullary carbon fibre fragments. There is a small amount of fibrosis around some carbon fibres and a small amount of new bone formation with inclusion of carbon. Only a few carbon fragments are transported to the parenchymal organs. There is no foreign body reaction.

Cartilage choristoma of the eye.

A young girl had a rigid, white tumor that penetrated the sclera. It was partially resected, and histopathologic study demonstrated choristoma of elastic cartilage.

Entamoeba histolytica infections in flight personnel of an international airline.

A cohort of 99 subjects, members of the flight staff of Lufthansa German airlines, all infected with Entamoeba histolytica, were followed over a period of 2.5 years to monitor their clinical and parasitological status. All but 4 of the subjects were infected with non-pathogenic zymodemes of E. histolytica and had negative amoebic serology, and most were clinically well. One male heterosexual carrying a pathogenic zymodeme was found, despite massive treatment regimes, to carry the infection persistently for 12 months. Most non-pathogenic infections were left untreated.

Effect of piroxicam on structure and function of joint cartilage.

In vitro experiments were performed on isolated articular chondrocytes under the influence of piroxicam. It was demonstrated that this non-steroidal anti-inflammatory agent affected neither cell proliferation nor the incorporation of 35SO4 into matrix macromolecules. Dogs were treated with piroxicam for 8 weeks. Morphological studies were performed on the tissues of the knee joints. Macroscopic and light microscopic investigations revealed no structural differences between the tissues (synovial membrane and articular cartilage) of control and treated dogs. Even at the ultrastructural level no alterations in the cartilage were observed. The capacity of chondrocytes to incorporate 35SO4 under in vitro conditions was identical in control and experimental animals. It is concluded that piroxicam has no adverse effect on chondrocytes under in vitro conditions or on articular cartilage structure in the in vivo model.

Fibroelastosis of the right ventricle in two brothers of triplets.

We present an autopsy report of endocardial fibroelastosis of the right heart in two brothers of triplets. Beside this anomaly no other macroscopical malformations in the hearts were found. Morphologically an unusual hypertrophy of the subendocardial myocardiocytes in the right heart was observed. A history of tocolysis (sympathomimetic drugs for treatment of premature labour) was the main reason for publishing this case report. We could not answer the question if the drug was causative or only coincident with the observed lesions.

[Scintigraphic findings in amoebic abscess of the liver (author's transl)]. / Szintigraphische Befunde bei Amöbenabszessen der Leber

The accuracy, size, localization and course of liver scans of solitary or multiple amoebic liver abscesses was evaluated in 52 patients. The scintigraphic data were correlated with the clinical symptoms. In 47 of the 52 patients it was possible to demonstrate the liver abscess on the scintigram; the right lobe of the liver was involved more frequently than would have been expected simply on the basis of its volume. In most of the patients investigated the abscesses were solitary and in only 28% was it posssible to recognise two or three abscesses occurring simultaneously. Follow-up examinations showed rapid diminution in the size of the abscess furing medical treatment but complete return to normal during the first six months occurred in only 17% of cases. The results are discussed.

[Spiral computerized tomography of the breast]. / Spiral-Computertomographie der Mamma.

AIM: To evaluate the use of spiral CT in the diagnosis of breast lesions. MATERIAL AND METHODS: 93 female patients with suspicious or uncertain mammographic findings were examined by CT before and after contrast enhancement according to the following practical method: table movement, 6 mm/s, slice thickness 6 mm, increment 4 mm, contrast 200 ml, injection rate 3 ml/s, scan start 50 s after the beginning of the injection. Histological confirmation was present in 85 patients. RESULTS: All 44 invasive carcinomas were recognised. They were characterised by intensive focal contrast uptake. Only 2 out of 7 intraductal carcinomas were not shown by CT. 36 out of 38 benign lesions were correctly diagnosed. 2 out of 11 fibroadenomas showed strong enhancement and were incorrectly diagnosed. The examinations provided valuable additional information compared to mammography and sonography. CONCLUSION: Spiral CT is very useful for elucidating problems in the diagnosis of breast lesions. Its advantages consist in the speed of the method, comfort for the patient, absence of movement artifacts, easy standardisation and wide applicability.

[Evaluation of percutaneous vertebroplasty in osteoporotic vertebral fractures using a combination of CT fluoroscopy and conventional lateral fluoroscopy]. / Perkutane Vertebroplastie osteoporosebedingter Wirbelkörperfrakturen: Erfahrungen mit der CT-Fluoroskopie.

PURPOSE: Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures. MATERIALS AND METHODS: Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions. RESULTS: A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case. CONCLUSION: Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

Perigraft-reaction after implantation of vascular prostheses. Pathogenesis, clinical picture and treatment.

This report is based on 18 perigraft reactions in 2237 implanted vascular prostheses (1970-1985). The incidence of this complication is 6.8-9.5/1000 both for Dacron-double-velour and expanded PTFE-prostheses. The clinical picture is characterized by localized or extended fluid accumulation around the artificial graft (perigraft cysts or "swimming prosthesis"). Including 271 reports from the literature, 75% of vascular prostheses in extraanatomical positions were affected. The time interval between vascular substitution and clinical manifestation is on average 23.5 months. The pathogenesis of this aseptic late complication is still unclear. Several disposing factors are under discussion: (a) physico-chemical irritation of the surrounding tissue by the fabric itself (release of monomers, emulgators etc.), (b) mechanical trauma (continuous movement of the graft in the tissue bed, i.e. insufficient tissue fixation resulting in gaps and exudation of fluid round the prosthesis), (c) latent or manifest renal insufficiency. The partial or total removal of the affected prosthesis and its substitution by another type of vascular prosthesis offers the best chance of definitive cure. Repeated puncture of perigraft cysts produces frequent recurrencies and the danger of secondary infections. Therefore only an exchange of the graft can be recommended.

Diagnosis and management of laryngeal obstruction in childhood pachyonychia congenita.

Pachyonychia congenita is a genetic syndrome of epithelial dysplasia. In infants and young children, laryngeal involvement can present a life threatening complication: obstruction of the patient's airway due to leukokeratosis can lead to severe respiratory distress. This report concentrates on the diagnosis and successful microsurgical management of laryngeal obstruction in the first female case, a 19-month-old girl with pachyonychia congenita.

[Pannus development in adjuvant arthritis of the rat - an autoradiographic study (author's transl)]. / Autoradiographische Untersuchungen zur Pannusentwicklung bei der Adjuvansarthritis der Ratte.

After the injection of complete adjuvant, rats develop arthritis with increased proliferation of synovial tissue cells at the attachment of the synovial membrane to cartilage and bone. From this synovial tissue a connective tissue pannus develops which covers the cartilage surface as a monocellular or multicellular layer of proliferating cells. Areas with cartilage destruction are usually characterized by a great number of proliferating connective tissue cells. Cartilage destruction is not restricted to the superficial pannus, since granulation tissue of the subchondral bone may also participate in cartilage resorption. The quantitative determination of 3H-thymidine labelled chondrocytes excludes participation of these cells in pannus formation.

[Paraganglioma of the glomus caroticum--a frequently misdiagnosed disease picture]. / Paragangliome des Glomus caroticum--ein oft verkanntes Krankheitsbild.

24 carotid body tumors in 21 patients (1970-1990) have been analysed retrospectively. These well vascularized tumors are growing slowly in the carotid bifurcation and often cause failures in diagnostic and therapeutical approach. 66% (14) have been operated on partially 2-3 times with wrong diagnosis (cervical gland, lateral cervical cyst a.o.) in other hospitals. It is important to come to an early diagnosis by the typical trias according to Fontaine and Kocher, by CT-scan and arteriography. The best method of operation is the so-called technique of transsection, which is also applicable in advanced tumor stage (type II-III acc. to Linder). In tumors, which are beyond radical operability, good cosmetic and functional results can be achieved by partial resection.

[Aneurysm of the descending thoracic aorta in tertiary syphilis]. / Aneurysma der Aorta thoracalis descendens bei tertiärer Syphilis.

A 53-year-old female presented with septicaemia caused by left ureteric obstruction due to ureterolithiasis. Further diagnostic work-up for left mediastinal widening revealed an asymptomatic aneurysm of the descending aorta. Serologic tests for syphilis were highly positive (TPHA 1:10240, 19s-IgM-FTA-Abs 1:20, Cardiolipin KBR 1:72 IU/ml). After a three weeks course of Penicillin G, 19s-IgM-FTA-Abs was negative. A successful tube resection of the aneurysm was performed. The diagnosis of luetic aneurysm of the descending aorta was confirmed histologically. Although rare today, tertiary syphilis should be considered in the differential diagnosis of thoracic aneurysm in middle-aged patients lacking classical risk factors for atherosclerosis. The immune pathogenesis of cardiovascular syphilis still remains subject of controversy.

Discovering a dialectic of care.

Using data from a recent study on the outcomes of child psychiatric hospitalization, the author presents a critique of the intervention-outcome movement that dominates the health care agenda. Employing an exploratory descriptive study design and Denzin's interpretive interactionism method, she presents data that illustrate how interventions can become distorted by contextual factors, conflicting ideologies, agendas, and failure to thoughtfully consider patient needs. She posits that research agendas are heavily tilted toward outcomes research that often discount the nature of structure and process. The marketplace emphasis of health care may result in environments in which a structure and process of caring is replaced by a focus of profits over patients. The value of focusing on interventions and outcomes in research without addressing broader ecosystem variables that influence practice is questioned in view of in-depth data that emerge from practice settings.

Rethinking professional attitudes in mental health settings.

Given that the psychiatric nursing standards developed by the American Nurses Association strongly advocate the inclusion of families in treatment settings, the study discussed in this article sought to determine how families were actually experiencing care in mental health settings for children and adolescents. The aim was to elicit the perspectives of parents whose children were hospitalized in psychiatric hospitals and to examine those experiences against the ideal rhetoric set forth by the standards of care. Results of in-depth interviews with a purposeful sample of parents demonstrate that there is a significant gap between standards and practice.

Dirty hands: the underside of marketplace health care.

The ethos of the corporation and the urgency for profit maximization place pressures on health care corporations to act in a way that may be incompatible with ethical practice. Profit-driven incentives often result in corporate deviance and criminal behavior. Nurses may be pressured to go along with schemes that may be unethical or illegal and because of shaky job markets may be unable to adhere to professional ethical guidelines. Recent events in health care are drawn on to argue that ethical theory and research must begin to consider the issue of moral compromise of professionals as a result of deviant organizational environments.