Clinical and Pathogenetic Significance of Amylase Level and Microtomographic Index of Synovial Fluid in Various Joint Lesions.

The aim of the investigation was to study the level of amylolytic activity and microtomographic index of synovial fluid density as well as to substantiate their clinical and pathogenetic significance by identifying correlations with the known informative indicators reflecting characteristic features of the pathological process in various joint diseases. Materials and Methods: Samples of synovial fluid from 95 patients with various joint pathologies at the stage of the disease progression characterized by copious effusion into articular cavities have been examined. Synovial fluid samples obtained by knee arthrocentesis served as a material for the investigation. Conventional methods were used to determine the concentration of uric acid, inorganic phosphorus, total protein, and amylolytic activity level in the selected samples while X-ray density was identified by computed microtomography. Results: All samples of pathological joint fluid have shown a high level of amylolytic activity as compared to the synovial fluid from healthy joints. The relationship between the level of amylolytic activity in synovia and specific joint pathology has been identified. It has also been found that uric acid values, inorganic phosphorus concentrations, and total protein in various types of joint damage may influence X-ray density of the synovial fluid. Correlations between the studied indices have been established. Conclusion: New data on the level of synovia amylolytic activity has been obtained in one non-inflammatory and six different inflammatory diseases. Pathogenically determined correlation between the microtomographic index of synovial fluid density and concentrations of uric acid, inorganic phosphorus, total protein has been confirmed. Specific indicators of X-ray density of synovia in various joint pathologies as well as unidirectional and multidirectional data in comparison with the norm allow us to consider X-ray microtomography as a method that reveals additional details during investigation of synovial fluid density and brings new surrogate markers for the study of pathogenetic mechanisms of the development, differentiation, and treatment of various joint pathologies.

[Recognizing rare cardiac diseases by electrocardiogram]. / Seltene Herzerkrankungen am Elektrokardiogramm erkennen.

A number of rare cardiac diseases can be recognized by electrocardiogram (ECG). This article illustrates the clinical importance of ECG as a key diagnostic tool to detect Wolff-Parkinson-White syndrome and channelopathies, which are frequently diagnosed late after one or more affected family members have become victims of sudden cardiac death. These channelopathies include long QT syndrome, short QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia. In addition, typical ECG findings are frequently present in patients with idiopathic ventricular tachycardia, arrhythmogenic right ventricular dysplasia, digitalis intoxication, hyperkalemia, acute cor pulmonale due to pulmonary embolism, as well as severe left ventricular hypertrophy as in hypertrophic cardiomyopathy.

[Chronic hypoxia and cardiovascular risk : Clinical significance of different forms of hypoxia]. / Chronische Hypoxie und kardiovaskuläres Risiko : Klinische Bedeutung verschiedener Hypoxieformen.

It is of fundamental importance to differentiate whether chronic hypoxia occurs intermittently or persistently. While chronic intermittent hypoxia (CIH) is found typically in patients with obstructive sleep apnea (OAS), chronic persistent hypoxia (CPH) is typically diagnosed in patients with chronic lung disease. Cardiovascular risk is markedly increased in patients with CIH compared to patients with CPH. The frequent change between oxygen desaturation and reoxygenation in patients with CIH is associated with increased hypoxic stress, increased systemic inflammation, and enhanced adrenergic activation followed by endothelial dysfunction and increased arteriosclerosis. The pathophysiologic consequences of CPH are less well understood. The relationship between CPH and the development of pulmonary hypertension, pulmonary heart disease as well as polycythemia has been established.

[Cheyne-Stokes respiration in patients with chronic heart failure: only a diagnostic marker or also a cardiovascular risk factor?]. / Cheyne-Stokes-Atmung bei Patienten mit chronischer Herzinsuffizienz: nur diagnostischer "Marker" oder auch kardialer Risikofaktor?

Sleep disordered breathing with predominant obstructive or central apnea is an under-recognized but highly prevalent comorbidity in patients with chronic heart failure. As the severity of heart failure increases the prevalence of central sleep apnea (CSA) and Cheyne-Stokes respiration (CSR) is also much more frequent. Cheyne-Stokes respiration is characterized by alternating periods of crescendo and decrescendo respiration followed by central apnea. Present data indicate that CSA-CSR is not only a compensatory response to severe heart failure but also a predictor of worse prognosis. However the results on long-term mortality are not consistent. The prognostic importance of night- and daytime CSR has to be further elucidated. Increased sympathetic nervous activity has been proposed to play a mayor role concerning progression and outcome of chronic heart failure by CSA-CSR.

Characterization and analysis of migration patterns of dentospheres derived from periodontal tissue and the palate.

BACKGROUND AND OBJECTIVE: Stem cells derived from periodontal and palatal tissues may be useful for regenerative therapies of periodontal tissues. In addition to the use of single periodontium-derived stem cells (pdSCs) and palatal-derived stem cells (paldSCs), the application of pdSC and paldSC dentospheres, providing a pool of vital stem cells, may be a useful approach. As cell migration is a prerequisite for stem cells to regenerate a three-dimensional tissue environment, we characterized pdSCs and paldSCs and investigated the migratory activity of dentospheres within a three-dimensional environment. We also investigated the capacity of the dentospheres to grow on zirconium dioxide surfaces. MATERIAL AND METHODS: The capacity of pdSCs and paldSCs to differentiate into the neuronal and osteogenic lineages was proved by RT-PCR and immunohistochemistry through the detection of specific lineage markers, such as alkaline phosphatase, glutamate decarboxylase 1 (also known as GAD67, the 67-kDa isoform of glutamate decarboxylase), neurofilament-M and ß-III-tubulin. The expression profile of surface molecules on pdSCs and paldSCs was analyzed by flow cytometry. Adhesion and growth of pdSC/paldSC dentospheres on zirconium dioxide surfaces were determined using confocal laser-scanning microscopy. The migratory behavior of the cells was analyzed using a three-dimensional collagen matrix migration assay. RESULTS: Both pdSCs and paldSCs were positive for epidermal growth factor receptor, CC chemokine receptor 2 and CXC chemokine receptor 4 expression and were able to grow on zirconium dioxide surfaces. Cell-migration experiments revealed that both stem-cell populations responded similarly to epidermal growth factor (EGF), monocyte chemotactic protein 1 (MCP-1) and stromal cell-derived factor 1alpha (SDF-1α). Stimulation with EGF resulted in an increased migratory activity of both stem-cell types, whereas the locomotory behavior of the cells was impaired by both MCP-1 and SDF-1α. CONCLUSION: Dentospheres represent a pool of vital pdSCs/paldSCs. As a result of the migratory activity demonstrated, along with the capacity to grow on zirconium dioxide surfaces, dentospheres may be useful for regenerative purposes in periodontal tissues.

Prophylactic implantable defibrillators in dilated cardiomyopathy.

Arrhythmia risk stratification with regard to prophylactic implantable cardioverter-defibrillator (ICD) therapy was investigated in the Marburg Cardiomyopathy Study, which revealed left ventricular ejection fraction to be the only significant independent arrhythmia risk predictor in a relatively large dilated cardiomyopathy (DCM) patient population. Based of the favorable results of the SCD-HeFT Trial, prophylactic ICD therapy became a class I indication for patients with DCM, NYHA class II or III heart failure and a left ventricular ejection fraction ≤ 35% despite optimized medical therapy. In addition, prophylactic ICD therapy combined with cardiac resynchronization became standard treatment in DCM patients with complete left bundle branch block and an ICD indication according to SCD-HeFT criteria. Unresolved issues of prophylactic ICD therapy in DCM include a high number to treat in order to save one patient from sudden death due to difficult arrhythmia risk stratification which is largely based on reduced left ventricular ejection fraction. Second, optimal timing of prophylactic ICD implant remains difficult, because a significant but unpredictable number of DCM patients show a marked improvement of left ventricular function during follow-up, thus, averting the need prophylactic ICD therapy. Finally, prophylactic ICD therapy is associated with a considerable complication rate with painful inappropriate shocks and lead-related problems being the most frequent complications during long-term follow-up.

[Autonomic dysfunction and cardiac arrhythmia in patients with obstructive and central sleep apnea]. / Autonome Dysregulation und kardiale Arrhythmien bei Patienten mit obstruktiver und zentraler Schlafapnoe.

Obstructive sleep apnea and central sleep apnea with Cheyne-Stokes respiration are associated with an increased risk of cardiac arrhythmia. Apnea- associated arrhythmia may contribute to sudden cardiac death and premature mortality in those patients. Both forms of sleep apnea excert strong modulatory effects on the autonomic system with a special autonomic profile. Profound vagal activity is leading to bradyarrhythmias, and sypathico-excitation to tachyarrhythmias. Atrial fibrillation and ventricular arrhythmias in obstructive and central sleep apnea patients are mainly found in combination with cardiovascular comorbidity (coronary heart disease, hypertensive heart disease, chronic heart failure). Bradyarrhythmias in OSA are induced by a cardioinhibitory vagal reflex due to obstructed airway. CPAP-therapy has been demonstrated to reduce arrhythmias.

[Sepsis-like disease in an immunocompromised patient with a travel history to Mallorca]. / Sepsisähnliches Krankheitsbild bei Immunsuppression nach früherem Mallorcaurlaub.

In immunosuppressed patients, a high rate of complications due to opportunistic infection is known. We report the case of a 36 year old patient with ulcerative colitis and a septic complication with ongoing pancytopenia. Due to colonic perforation, colectomy had to be performed. Despite this intervention, the septic constellation persisted. The pancytopenia in peripheral blood counts also persisted with the necessity of repetitive transfusions. A bone marrow biopsy showed an infiltration with Leishmania bodies in macrophages. Tissue culture allowed for typing of the parasites as belonging to the L. donovani/infantum complex, DNA sequencing confirmed infection with L. infantum. This infection must have been contracted during a vacation on Mallorca about 1.5 years earlier. Administration of liposomal amphotericin B cured the patient. Surprisingly, histological examination of the resected colon reveiled the presence of an immunoblastic B-cell lymphoma. In this case, immunosuppression was a prerequisite for the manifestation of leishmaniosis.

[Clinical pathway "Acute Coronary Syndrome"]. / Behandlungspfad ,,Akutes Koronarsyndrom"

The clinical pathway "acute coronary syndrome" of the university hospital Marburg describes the guideline-conform and consented management of patients with ST-segment elevation infarct (STEMI), non-ST-segment elevation infarct (NSTEMI) and Troponin negative unstable angina. A 12-lead ECG recording is made and read in all patients within 10 minutes. All patients with STEMI undergo immediate revascularisation using primary percutanuous catheter intervention (PCI) after administration of basic medical therapy. Primary PCI is also used in all patients with NSTEMI, persistent chest pain, rhythm or hemodynamic instability. Patients with unstable angina, who became free of symptoms after application of basic medication, but who have additional risk factors undergo cardiac catheterisation within 48 hours. Acute myocardial infarction can be ruled out in patients with twofold negative cardiac troponin levels during 6-12 hours. In the absence of further symptoms, these patiens undergo differential diagnostic evaluation of cardiac and extracardiac causes of chest pain. The introduction of this clinical pathway 2 years ago, which was consented before by the hospital board and the clinical directors, has lead to a remarkable improvement in the clinical decision-making at the emergency room of the hospital and reduced the door to intervention time considerably.

[Significance of aldosterone antagonist therapy]. / Stellenwert der aldosteronantagonistischen Therapie.

Since the introduction of ACE-inhibitors into clinical practice, the diuretic treatment with the classical aldosterone antagonist spironolactone has disappeared. It was generally believed that chronic treatment with ACE-inhibitors significantly reduces aldosterone secretion via reduction of angiotensin II-dependent aldosterone formation. However, aldosterone "escape" occurs: Even during chronic treatment with ACE-inhibitors, plasma levels of aldosterone rise again, which is associated with increased cardiovascular risk. Furthermore, extrarenal actions of aldosterone have been demonstrated, which detrimentally affect coagulation, autonomic activity, inflammatory signalling, hemodynamics, and fibrosis, subsequently leading to cardiovascular damage. Recently published studies (RALES, EPHESUS) convincingly support the concept of detrimental cardiovascular aldosterone actions even during chronic ACE-inhibition. In addition to those cardiovascular effects, aldosterone antagonism has beneficial impacts on ascites, chronic renal disease, renal volume regulation, and hypokalemia induced by diuretics. Of note, aldosterone dependent mechanisms are believed to be even involved in essential hypertension, and the value of aldosterone antagonism is currently tested in those patients. In conclusion, an old-fashioned, previously abandoned treatment strategy is currently celebrating its revival.

[Helicobacter pylori infection in children and juveniles: an epidemiological study on prevalence, socio-economic factors and symptoms]. / Helicobacter pylori-Infektion bei Kindern und Jugendlichen. Eine epidemiologische Untersuchung zu Prävalenz, sozioökonomischen Faktoren und Beschwerdebild.

BACKGROUND AND OBJECTIVE: In view of numerous sequelae of a Helicobacter pylori (H.p.) infection and sparse epidemiological data on the infectious status of children and juveniles, a cross-sectional study was undertaken in schools of the Aschaffenburg area. Data were recorded on the number of H.p. infections in pupils aged 14-20 years, the possible influence of various socio-economic factors, and a possible association of the infection with upper abdominal symptoms. SUBJECTS AND METHODS: In 540 pupils of grade 2 (aged 7-9 years: primary school, n = 183) grade 7 (aged 11-15: primary and secondary schools, n = 177) and grade 12 (aged 16-20 years: vocational or grammar school: n = 180), the presence of H.p. was elucidated with the 13C-urea breath test. An anonymous questionnaire was used to ascertain socio-economic status and any symptoms. RESULTS: In 51 of the 540 pupils (9.4%) the test for H.p. was positive. The infectious state increased with age, but there was no significant difference between the various age groups. Ethnically German pupils were less often infected (7.1%) than those of foreign origin (28.2%). The number of persons in a household correlated with the H.p. status. Upper abdominal symptoms were more frequently reported by infected children and juveniles and were an independent risk factor for H.p. infection. CONCLUSION: This study highlights the importance of socio-economic factors and the possible association of upper abdominal pain with H.p infection.

[Continously increasing sensitivity in thyroid cancer aftercare in the course of three generations of thyroglobulin IMAs]. / [Kontinuierliche Sensitivitatssteigerung in der Schilddrusenkarzinom-Nachsorge im Verlauf dreier Thyreoglobulin-IMA-Generationen]

UNLABELLED: Aim of our study was to evaluate the increasing sensitivity within three generations of thyroglobulin (Tg) assays, which were available during the past decade, and its clinical impact for patients with differentiated thyroid carcinoma. METHODS: Determination of Tg using the IRMA introduced in 1989 (Dynotest Tg, Henning Berlin, Berlin; assay A) and 1994 (Selco Tg, Medipan Diagnostica, Selchow; assay B), as well as the IEMA available recently (Medizym Tg Rem, Medipan Diagnostica, Selchow; assay C). RESULTS: We found a close correlation between the measurable Tg values of assay A and B (r=0.985; p<0.001) as well as assay B and C (r=0.978; p<0.001). Assay B (lowest detection limit: 0.3 ng/ml) was more than twice as sensitive as assay A and did not show quite as many disturbances of recovery (in 0.5% versus 4% of our patients). Due to its strict calibration to the European reference preparation CRM 457, Tg values determined by assay C were in the mean 1.9-fold higher than by assay B. Thus, with its functional sensitivity of 0.03 ng/ml assay C is nearly 20-fold more sensitive than assay B. Whereas the proportion of measurable Tg values was only 22% in a selected group of patients (criterion of inclusion: Tg in assay B< or =1 ng/ml with TSH-suppressive conditions; n=317 serum samples from 103 patients), it was 68% in assay C, with good intraindividual reproducibility of these values in the course. CONCLUSION: The ultrasensitive assay C is especially suitable for the follow-up of treated thyroid cancer patients being considered as cured, and may shorten the time interval until the detection of a recurrence markedly: the gain of time calculated from the Tg courses in patients with a gradually progressive tumor relapse ranged from 5 to 15 months.

[Amiodarone induced pulmonary toxicity]. / Amiodaron-induzierte Pneumonitis bei dilatativer Kardiomyopathie.

BACKGROUND: Antiarrhythmic therapy with class III drug amiodarone (Cordarex(R)) for supraventricular and ventricular tachycardia is commonly used because of its high efficacy and absent negative inotropy. Pulmonary toxicity of amiodarone possibly leading to lung fibrosis is a rare, but severe side effect of chronic therapy. In contrast to patients with coronary artery disease, there are only a few data about pulmonary toxicity in patients with dilated cardiomyopathy. CASE REPORT: We report on two patients with dilated cardiomyopathy who received amiodarone because of symptomatic non-sustained or sustained ventricular tachycardia. After 6 weeks resp. 8 months of treatment with amiodarone both patients developed pulmonary toxicity. Other causes of pulmonary toxicity were ruled out by bronchoscopy, bronchoalveolar lavage and biopsy. Pulmonary function improved in both patients within some weeks after discontinuation of amiodarone. CONCLUSIONS: This report deals with two cases of amiodarone induced pulmonary toxicity in dilated cardiomyopathy leading to respiratory insufficiency. Pulmonary toxicity is a rare, but potentially lethal side effect of amiodarone. Reversibility of pulmonary changes in case of an early drug discontinuation is shown. Because of severe reduced left ventricular function in dilated cardiomyopathy, heart failure symptoms could conceal clinical signs of pulmonary amiodarone toxicity. Therefore, pulmonary function should be controlled periodically during amiodarone therapy including bronchoscopy, bronchoalveolar lavage, biopsy and measurement of diffusion capacity.