Thromboxane A2 and prostacyclin generation in the microvasculature of patients with atherosclerosis--effect of low-dose aspirin.

Generation of thromboxane A2 (TxA2) and prostacyclin (PGI2) at the site of platelet-vessel wall interaction, i.e. in blood emerging from a standardized injury of the microvasculature made to determine skin bleeding time was investigated in 7 patients with atherosclerosis (angiographically verified obstructions of the femoral arteries) and in 7 normal control subjects apparently free of atherosclerotic lesions. Similar amounts of TxA2 (measured as thromboxane B2, TxB2) were generated at the site of plug formation in the patients with peripheral vascular disease (PVD) and in the control subjects. Significantly lower levels of PGI2 (measured as 6-keto-prostaglandin F1 alpha, 6-keto-PGF1 alpha) were found in blood from an injury of the microvasculature in the patients compared with the controls. These data do not suggest a major role of the platelet prostaglandin metabolism in the development of atherosclerosis. However, decreased synthesis of PGI2 by endothelial cells might contribute to the development and/or progression of atherosclerotic lesions. In the patients with PVD, low-dose aspirin (50 mg/day for 7 days) resulted in a greater than 90% inhibition of the TxB2 production at the site of plug formation. Following low-dose aspirin 6-keto-PGF1 alpha levels were below 20 pg/ml (limit of sensitivity of our radioimmunoassay procedure) in the majority of the samples. We therefore conclude that in patients with PVD a decreased synthesis of PGI2 by endothelial cells might contribute to the progression of atherosclerosis. Furthermore, low-dose aspirin treatment results in a similar inhibition of the platelet prostaglandin generation as recently observed in healthy subjects.

A decade of oral anticoagulant treatment to maintain autologous vein grafts for femoropopliteal atherosclerosis.

To determine whether long-term oral anticoagulant treatment was effective in improving graft performance and preventing major amputation following vein bypass surgery for femoropopliteal atherosclerosis, a clinical trial was conducted in one single center and continued during 10 years. After 130 patients had electively received a femoropopliteal vein graft, they were randomly assigned to a therapy group (treatment with phenprocoumon [n = 66]) or to a control group (n = 64) that remained without any anticoagulant treatment. Primary end points of the study were graft reocclusion and limb loss. The median durations of primary patency and limb salvage were significantly longer for treated patients than that for controls. In addition, survival in the therapy group was longer. Following autologous vein bypass surgery in the treated group, the results were superior in terms of graft patency, limb salvage, and survival.

Has total bowel rest a beneficial effect in the treatment of Crohn's disease?

Twenty patients with Crohn's disease were treated with parenteral nutrition (PN). The indication for PN was a bodyweight of less than 80% ideal bodyweight and/or a Crohn's disease activity index (CDAI) above 150 despite conventional therapy. A complete nutrition solution containing per litre 150 g glucose, 50 g sorbitol, 50 g amino acids, 50 g fat, electrolytes, trace elements and vitamins was infused via a central venous catheter to provide 72 kcal per kg bodyweight and day. No other medications were given during the study. The patients were randomized into two groups: both groups received PN in identical fashion. Group 1 was not allowed to eat or drink to reach total bowel rest; Group 2 ate formula diets and low residue diet ad libidum in addition to PN. Criteria for the nutritional status were bodyweight, serum albumin, prealbumin and hemoglobin and for disease activity the CDAI. Mean duration of treatment was 28 days in group 1 and 33.5 days in group 2. At the beginning both groups were comparable with respect to disease activity, nutritional status and extent of Crohn's disease. At the end of the study nutritional status was improved (increase of bodyweight and prealbumin) and disease activity was decreased by therapy in both groups with no significant difference between the two regimens. We conclude that PN improves the nutritional status and reduces the activity of Crohn's disease. The combination of PN and total bowel rest resulted in the same improvement as with PN alone. Total bowel rest is therefore unnecessary, when PN is given in patients with Crohn's disease.

Diminished serum folic acid levels in renal transplant recipients.

Serum folic acid levels were determined by radioimmunoassay in 26 chronic hemodialysis patients, in 52 renal transplant recipients and in 20 healthy controls. In the dialyzed patients, the mean serum folic acid level was 3.37 +/- 1.25 ng/ml and was significantly lower than that of the controls (6.1 +/- 1.38 ng/ml, P less than 0.001). In renal transplant recipients the mean folic acid concentration was 4.09 +/- 1.58 ng/ml and was also significantly decreased (P less than 0.001). 15 (29 per cent) out of 52 renal transplant patients showed serum folic acid concentrations lower than 3.0 ng/ml. Diminished serum folic acid levels were found not only in patients shortly after surgery but also in cases with excellent graft function up to 6 years after transplantation. The highest serum folic acid level was observed in one transplant patient who had taken no azathioprine for 24 months. Macrocytosis was found in 52 per cent of our renal transplant patients. There was no significant difference between the serum folic acid levels of renal transplant recipients with (n = 27) and without (n = 25) macrocytosis; however, serum creatinine levels were significantly lower in cases revealing macrocytosis. Relative folic acid deficiency does not seem to be responsible for macrocytosis after renal transplantation. Macrocytosis was observed only in patients with good graft function treated with azathioprine. Serum vitamin B12 levels were within the normal range in both dialyzed and renal transplant patients.

[Sonographic problems in the assessment of abdominal aortic aneurysms]. / Sonographische Probleme bei der Beurteilung von Aneurysmen der Aorta abdominalis.

Ultrasound has taken a solid position in the diagnostic management of aneurysms of the abdominal aorta as it is a non-invasive, simple and quickly practicable method with a low expenditure. After clinical examination ultrasound holds the second place in the sequence of various diagnostic procedures in the case of an aneurysm of abdominal aorta. Diagnostic problems are demonstrated in the sonographic judgement of aortic aneurysms. 42 patients with an abdominal aortic aneurysm have been evaluated in relation to the sonographic features of the aneurysm.

Obliterations of the proximal subclavian artery: to bypass or to anastomose?

A clinical series has been analysed to determine which of two similar, extrathoracic "extraanatomic" methods of treating proximal blocks of the subclavian artery is the superior option. From 1975 until 1988 direct carotid-subclavian anastomosis was used in 32 patients and carotid-subclavian bypass in 19. There were no statistically significant differences for the probability of postoperative survival (p less than 0.877 Breslow; p less than 0.774 Mantel), intraoperative blood loss or the duration of anaesthesia. Those patients who had undergone subclavian artery repair had a significantly longer survival than those following carotid bifurcation endarterectomy (p less than 0.002 Breslow, p less than 0.0002 Mantel). As patients with subclavian lesions have a reasonable life-expectancy, they may possibly experience late complications of their vascular repair. Therefore it seems important to select the most durable operation, and direct carotid subclavian anastomosis has a significantly greater patency rate than bypass (p less than 0.006 Breslow, p less than 0.006 Mantel). Patients with preoperative symptoms of cerebrovascular insufficiency had a lower probability of survival than those with upper extremity claudication, although this did not reach statistical significance (p less than 0.205 Breslow; p less than 0.198 Mantel).

[Prognosis of panmyelopathy: a retrospective study (author's transl)]. / Die Prognose der Panmyelopathie. Eine retrospektive Studie.

45 patients with pancytopenia were admitted and treated at the 1st Department of Medicine, University of Vienna, between 1972 and 1978. Retrospective analysis disclosed a significantly longer survival time in association with a hypercellular bone-marrow smear. These patients showed a higher incidence of remission with cortisone anabolic therapy, but more often developed acute leukaemia as well. The median survival time of patients with pancytopenia and a hypocellular or blank marrow was five months. This group of patients should, therefore, be considered for early bone-marrow transplantation.

[Causal therapeutic management of aplastic anaemia (author's transl)]. / Kausale Therapiemöglichkeiten der aplastischen Anämie.

Aplastic anaemia is characterized by hypoplasia of haemopoietic tissue. The aetiology of aplastic anaemia is multifactorial, the majority of cases being termed "idiopathic" because of lack of discernible noxious agents. Treatment can include stimulation of haemopoietic stem cells or replacement of stem cells by bone marrow transplantation. Some cases show autoimmune-mediated marrow failure and these patients may respond to immunosuppressive therapy. Pathophysiological subclassification of individual cases is necessary to ensure the correct choice of therapy offering the best chance of success, at minimum risk, from amongst a multitude of therapeutic procedures.

[Complications of the central venous feeding of mobilized patients with an all-in-one solution]. / Komplikationen der zentralvenösen Ernährung mobilisierter Patienten mit Gesamtnährlösung.

35 mobilized patients received continuous parenteral nutrition consisting of an all-in-one solution mixed together in this department right before use over a total period of 1155 days (mean per patient 33 days). The primary complication rate was: second puncture in 14%, pneumothorax in 11% and haemothorax in 3% of cases. Secondary complications: catheter-related sepsis was documented in 8.5%. Metabolic complications were not seen. The all-in-one solution is a satisfactory nutrient for long-term, low-risk administration by the route, suitable even in the case of mobilized patients, without the necessity of intensive metabolic monitoring.

[Fungal infections -- always dangerous for immunosuppressed patients (author's transl)]. / Pilzinfektionen -- weiterhin gefährlich für den immunsuppressiv behandelten Patienten.

Four renal transplant recipients, treated with the immunosuppressive combination of azathioprine-prednisolone, developed organ or systemic mycoses caused by Candida albicans and, in one case, additionally by Trichophyton rubrum. Ketoconazole, a new wide-spectrum antimycotic drug, was successfully used in the treatment of the fungal infections in these patients. The oral route of administration, good tolerance and excellent results are good recommendations for this drug.

[Percutaneous transluminal angioplasty (PTA) in peripheral arterial occlusive disease of the lower extremities]. / Perkutane transluminale Angioplastie (PTA) bei peripherer arterieller Verschlusskrankheit der unteren Extremitäten.

The results of 185 percutaneous transluminal angioplasties (PTA) of the iliac (n = 62) and femoropopliteal segment (n = 123) with a double-lumen balloon catheter (Olbert) are presented. The mean age of the 150 patients was 64 years (range 39 to 91). While there were 87% stenoses and only 13% occlusions of the iliac segment, in the femoropopliteal segment the respective ratios were 46% and 54%. 71% of the patients suffered from intermittent claudication and 29% were severely ischaemic cases (Fontaine stages III and IV). Platelet inhibition was induced by means of acetylsalicylic acid 1 g/day prior to and during the procedure, and afterwards heparin was also administered for 4 days. The primary success rate in the iliac segment of 88.7% (of which 12.9% were classified as a partial success) was identical with that in the femoropopliteal region. Stenoses were successfully treated in 94.6% cases (9.9% being partial successes), occlusions in 79.7% (partial success in 16.2% of these cases). Complications occurred in 8.6% of cases, whereby surgical correction was required in half of these. When the procedure was complicated by major embolization into the distal popliteal artery, this was handled successfully by means of local thrombolytic therapy. Over the follow-up period of up to 21 months reocclusion--or high-grade restenosis--occurred in 26 patients. The cumulative patency rate 1 year after PTA was 92% for the iliac and 70% for the femoropopliteal segment.

[Radionuclide studies in chronically hemodialyzed patients. Diagnosis of coronary disease using Tl-201 myocardial scintigraphy after administration of dipyridamole]. / Nuklearmedizinische Untersuchungen bei chronisch hämodialysierten Patienten. Diagnostik der koronaren Herzkrankheit mittels Tl-201-Myokardszintigraphie nach Dipyridamol.

Myocardial perfusion using Tl 201 after dipyridamol was evaluated in 33 patients on maintenance hemodialysis. In addition radionuclide angiography (RNA) was performed following hemodialysis to assess left ventricular function. RNA was done at rest in 31 patients and repeated in 13 after isometric exercise. All patients studied showed no signs of congestive heart failure. 55% of the patients had abnormal Tl 201 scintigrams, whereas coronary artery disease (CAD) was underestimated from clinical symptoms alone (33%). The incidence of an abnormal Tl 201 finding increased with the duration of hemodialysis treatment. However, in the symptomatic patients angina appeared already in the first (45%) or second year of hemodialysis treatment. 39% of patients with abnormal Tl 201 findings died within a year following scintigraphic examination. From 15 patients with normal Tl 201 scans 26% died. Overall mortality rate was above that in asymptomatic or mildly symptomatic patients with CAD, averaging about 7.7% per day. The major causes of death were cardiovascular complications in patients with abnormal Tl 201 findings. In all patients left ventricular ejection fraction (LVEF) was within the normal range following hemodialysis. Thus in our patients LVEF appeared not as an important prognostic characteristic. However, ventricular function can be impaired following exercise. As expected, in 7 patients with CAD (abnormal Tl 201 scan) isometric handgrip induced a mean decrease in LVEF by 11% and abnormalities in regional wall motion. However, also in 4 of 6 patients with normal Tl 201 scintigrams LVEF decreased following isometric exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

[Stenosis of the extracranial carotid artery]. / Stenose der extrakraniellen Arteria carotis.

Magnetic resonance angiography (MRA) as well as intraarterial digital subtraction angiography (DSA) were performed in 45 patients suffering from cerebrovascular disease, both procedures within one week of each other. MRA und DSA were evaluated separately for every patient retrospectively by two experienced radiologists on consensus basis. The results were then compared using catheter angiography as gold standard. Evaluation was confined to the common and internal carotid arteries (CCA, ICA) in the neck subdivided into 5 grades of stenosis. A comparative assessment was impossible in 9% cases due to motion artifacts and patient malposition. Out of 18 verified CCA stenoses 13 were demonstrated by MRA and 39 out of 44 ICA stenoses were assessed by MRA. There was a highly significant correlation between degree of stenosis detected by the two methods. Spearman Rank correlation coefficients of 0.824 and 0.913 were found for CCA and ICA, respectively.

[Ischaemic colitis (author's transl)]. / Ischämische Kolitis.

Attention must be drawn to the fact that especially in elderly patients with acute onset of abdominal pain concomitant with haemorrhagic, mucous diarrhoea, ischaemic colitis must be considered in the differential diagnosis. Ischaemic colitis arises as a consequence of insufficient blood flow through the peripheral branches of the middle colic artery and inferior mesenteric artery and mostly strikes the left colonic flexure, the colon descendens or sigmoid. Because of the segmental involvement and the macroscopic appearance on X-ray and endoscopy the disease is sometimes indistinguishable from Crohn's disease or ulcerative colitis. In every day clinical life ischaemic colitis is a relatively rare phenomenon, in spite of the high incidence of arterial occlusive disease in the patients treated at this unit. The increasing frequency of ulcerative colitis in elderly patients, as reported in the literature, may be partly associated with unidentified cases of ischaemic colitis and this possibility is discussed.

[Radionuclide studies in chronically hemodialyzed patients. Bone scintigraphy for the evaluation and control of renal osteopathy]. / Nuklearmedizinische Untersuchungen bei chronisch hämodialysierten Patienten. Skelettszintigraphie zur Beurteilung und Uberwachung der renalen Osteopathie.

The clinical applicability of bone scintigraphy (Tc99m MDP) was evaluated in 42 patients on maintenance hemodialysis. Typical scintigraphic findings are shown which were related to hormonal and biochemical parameters of calcium and phosphate metabolism. Visual grading of representative regions for metabolic bone disease in bone scans was compared to scintimetry which applies a bone to soft tissue ratio to grade osseous abnormalities. It could be shown that visual interpretation and grading of the findings according to a score is sufficient to assess the degree and extent of renal bone disease. Semiquantitative analysis of bone scintigrams by scintimetry did not improve the diagnostic information.

Early postoperative changes after desobliteration of the carotid artery. Subsequent diagnostic control using a high resolution ultrasonic-real-time-duplex-scanner.

The ultrasonic morphology of the carotid artery following 55 endarterectomies in 50 patients (36 males, 14 females, mean age 68 (53-83) years) was studied using a high resolution ultrasound duplex system (HUDS). The examinations were done 1-3 days before as well as 2-4 days and 1, 2, 4 and 8 weeks after surgery, respectively. The following typical appearance after carotid endarterectomy was found: At the site of endarterectomy the new vessel wall showed the following details: lack of the "sonographic tunica intima" the thickness of the vessel wall was reduced with less pronounced ultrasonic structure compared with healthy subjects the surface toward the lumen was less smooth "ultrasonic soft" thrombotic layers with irregular surface, individual distribution (sometimes only spots) and thickness (0.5 to 4.0 mm) were seen in the majority of patients. The edge of the tunica intima was always visible in the common carotid (edge of endarterectomy) whereas in the internal carotid artery there was often an interference of the jaw. The change of caliber at the site of the edge of the tunica intima was dependent on the thickness of the "sonographic intima" as well as on the layer of the vessel wall in which endarterectomy was done. At the site of arterial clamping, intramural hematomas, lesions of the tunica intima with thrombotic layers causing some stenosis were observed after 9 of 55 procedures. Vascular sutures were always visible as bright spots. A "normalization" of local flow patterns could be seen in dependence on the morphological "normalization".(ABSTRACT TRUNCATED AT 250 WORDS)

[Ischemia syndrome of the upper extremities not due to cardiac causes. Proximal arterial stenosis with embolization into the periphery]. / Ischämiesydrome der oberen Extremität aus nicht kardialer Ursache. Proximale Arterienstenose mit Embolisierung in die Peripherie.

Five cases are reported with the pathological entity of proximal arterial stenosis and embolization into the peripheral vascular bed. Therapeutic management, e.g. diagnostic work-up, eradication of the embolic source and embolectomy of the peripheral arterial tree - if technically feasible - seems beyond any doubt. Sometimes the diagnosis is difficult to obtain, since in the upper extremity microembolic seeds occur, posing a differential diagnosis problem. Once a partial sternotomy and in situ removal of the lesion was employed, in the remaining cases extrathoracic repair was done. In the left subclavian artery using a carotid-subclavian-anastomosis, we obtained satisfactory results, in the right subclavian and end-to-end-anastomosis was performed after resection of the diseased arterial segment.

[Rare cause of ureteral obstruction following renal transplantation]. / Seltene Ursache einer Ureterobstruktion nach Nierentransplantation.

The case of a 22-year-old man with an urinary tract obstruction which developed 4 weeks after renal transplantation is reported. Ureteral obstruction was caused by the ductus deferens, a very rare cause of ureteral obstruction. The importance of ultrasound examination as a very convenient, noninvasive method in the differential diagnosis of possible complications after renal transplantation is stressed.