Internet use in patients with cardiovascular diseases: Bad Berka Cross-Sectional Study (BABSY).

BACKGROUND: Internet has become a significant resource for dissemination of medical information. We sought to investigate prevalence and usage patterns of Internet access among consecutive patients with cardiovascular diseases. METHODS: A cross-sectional study was performed using a questionnaire as study tool. Among patients with Internet access, the type of health information sought and the impact of these on daily life were assessed. RESULTS: Of 1063 patients invited to the study, 1000 patients [68% male gender, mean age 66 ± 11 years (range 27-83 years)] agreed to complete the questionnaire. 216/1000 (21.6%) used Internet to obtain information related to their disease. The patient education was graded as: low (15%), medium (66%) and high (19%). Reasons for Internet use were as follows: 24-h availability 142/216 (65.7%); free of charge 58/216 (26.9%); and anonymity 50/216 (23.2%). Younger (≤ 66 years) age (35.2% vs. 15.3%; p = 0.0001), male gender (24.6% vs. 15.4%; p = 0.001) and higher education level (49.4% vs. 16.1%; p = 0.001) were significantly associated with Internet use. 30.6% (66/216) of Internet users changed their individual health behaviour attributable to information found on the Internet. However, this was not related to age, gender or level of education (p = 0.5, p = 0.6 and p = 0.4, respectively). Patients without Internet use obtain health information mainly from the pharmacist (62%) or from their treating physician (58%). CONCLUSIONS: A relevant number of patients with cardiovascular disease access the Internet for health information. The impact of such information on health-related behaviour in daily life was low.

Identification of the novel HLA-C*07:315 allele.

The HLA-C*07:315 allele is mostly identical to HLA-C*07:09 but has a non-synonymous substitution of C to G in exon 2.

Hypertrophic cardiomyopathy mimicking acute anterior myocardial infarction associated with sudden cardiac death.

Hypertrophic cardiomyopathy is the most common genetic disease of the heart. We report a rare case of hypertrophic obstructive cardiomyopathy mimicking an acute anterior myocardial infarction associated with sudden cardiac death. The patient presented with acute ST elevation myocardial infarction and significant elevation of cardiac enzymes. Cardiac catheterization showed some atherosclerotic coronary artery disease, without significant stenosis. Echocardiography showed left ventricular hypertrophy with a left ventricular outflow tract obstruction; the pressure gradient at rest was 20 mmHg and became severe with the Valsalva maneuver (100 mmHg). There was no family history of sudden cardiac death. Six days later, the patient suffered a syncope on his way to magnetic resonance imaging. He was successfully resuscitated by ventricular fibrillation.

Hypertrophic obstructive cardiomyopathy masked by tako-tsubo syndrome: a case report.

Introduction. Left ventricular outflow obstruction might be part of the pathophysiological mechanism of Tako-tsubo cardiomyopathy. This obstruction can be masked by Tako-tsubo cardiomyopathy and diagnosed only by followup. Case Presentation. A 70-year-old female presented with Tako-tsubo cardiomyopathy and masked obstructive hypertrophic cardiomyopathy at presentation. Conclusion. Tako-tsubo cardiomyopathy typically presents like an acute MI and is characterized by severe, but transient, regional left ventricular systolic dysfunction. Prompt evaluation of the coronary status is, therefore, mandatory. The prognosis under medical treatment of heart failure symptoms and watchful waiting is favourable. Previous studies showed that LVOT obstruction might be part of the pathophysiological mechanism of TCM. This paper supports this theory. However, TCM may also mask any preexisting LVOT obstruction.

[Prehospital assessment and treatment decisions of a suspected acute coronary syndrome: what are the problems? Results of the "Emergency Doctor and Acute Myocardial Infarction" study (NAAMI)]. / Probleme in der präklinischen Diagnostik des ST-Hebungsinfarktes. Ergebnisse der NAAMI-Untersuchung (NotArzt und Akuter MyokardInfarkt).

BACKGROUND: Interpretation of prehospital 12-lead electrocardiograms (ECG) in acute ST-elevation myocardial infarction (STEMI) remains a diagnostic challenge in many cases. The aim of this study was to determine whether board-certified emergency physicians (BCEP) are able to distinguish STEMI from non-STEMI in a large proportion of cases, thus assuring more precise prehospital triage and treatment. METHODS: Electrocardiograms of eight patients with acute non-traumatic chest pain (with 6 ECGs demonstrating STEMI, one with pericarditis, and one with pulmonary embolism) were assessed in a blinded fashion by 73 BCEP (19 female, mean age 37 +/- 5.3 years). Decisions had to be made by them regarding the diagnosis (STEMI or not) and treatment (immediate reperfusion or transfer to the nearest hospital without facilities for percutaneous coronary intervention). RESULTS: In the ECGs with STEMI 83% of BCEPs made the correct diagnosis without significant differences between the subgroups. But in cases of non-STEMI-ECG only 30% of BECP made the correct diagnosis. The results in interpreting non-STEMI were better in older (> 50 years) BCEPs and in those with a background in internal medicine (p = 0.045, and p = 0.01, respectively). In case of STEMI 75% of BCEPs initiated the correct therapy, without significant differences between the subgroups. In case of non-STEMI ECG only 33% of BECPs made the correct diagnosis. Also, the therapeutic decisions in case of non-STEMI were better in older (> 50 years) BCEPs and in those with a background in internal medicine (p = 0.04, and p = 0.02 respectively). CONCLUSION: In cases of acute non-traumatic chest pain the interpretation of the electrocardiogram by prehospital emergency doctors give to unsatisfactory results. The present study suggests, that additional training in ECG interpretation may be a critical component of the education of physicians who care for patients presenting with acute coronary syndrome.

[Stable tachycardia with wide QRS complex in pre-hospital emergency medicine]. / Stabile Tachykardie mit breitem QRS-Komplex in der prähospitalen Notfallmedizin -- Ergebnisse des NAVT-Trials (NotArzt und Ventrikuläre Tachykardie).

BACKGROUND: Sustained, stable wide QRS-complex tachycardia (WCT) remains a diagnostic challenge, because the treatment of supra-ventricular tachycardia (SVT) with aberrant conduction differs considerably from that of a ventricular tachycardia (VT). A usual recommendation for treating a case of a stable WCT is to manage it as if it were VT, in accordance with the consideration of "first do no harm". The aim of this study was to determine whether Board-certified emergency-physicians are able to differentiate VT from SVT with aberrant conduction in a high percentage of cases (> 90%), thus to assure more precise prehospital treatment." METHODS: Eight electrocardiograms with WCT (four with electrophysiologically proven VT or SVT, respectively) were evaluated in a blinded fashion by 64 Board-certified emergency-physicians (23 female, 41 male, mean age: 37,8 + 5,1 years). Initially, the diagnosis had to be made without any further information. Afterwards the same electrocardiograms were presented again, providing important additional information. RESULTS: 55% of the study population were able to establish the correct diagnosis merely by evaluating the electrocardiogram. Providing the above mentioned additional information, the number of correct diagnoses increased to 61%. These results were roughly similar in all subgroups, only the subgroup of cardiologists showed a trend to better results with correct diagnoses in 68% without and 73 % with additional information. None of the subgroups reached the pre-specified cut-off of > or = 90% correct diagnoses. Specialist status as well as experience in emergency medicine had no significant influence on the results, only the subgroup of emergency physicians with an experience of more than five years showed a trend towards a higher rate of correct diagnosis, compared with the subgroup with less than one year experience in emergency medicine. CONCLUSION: In cases of stable WCT the evaluation of the electrocardiogram without further information in prehospital emergency-medicine leads to unsatisfactory results. The correct diagnosis in WCT can be improved by using additional data but the diagnostic accuracy is still low. Therefore, the differential diagnosis of stable WCT in preclinical emergency-medicine cannot be recommended. Until proven otherwise, any stable WCT should be managed as if it were VT.

[First diagnosis of Fallot tetralogy in a 74-year-old man]. / Erstdiagnose einer Fallot-Tetralogie bei einem 74-jährigen Mann Kasuistik über einen komplexen Fall einer Fallot-Tetralogie bei einem 74-jährigen Erwachsenen, der ohne chirurgische oder medizinische Behandlung überlebte.

Tetralogy of Fallot is the most common cyanotic cardiac malformation in late childhood and adult, occurring in approximately 0.25 of 1000 live births. Most patients undergo early surgical correction. Therefore, the natural history of this disease has been evaluated in only a few cases. We report a complex case of a tetralogy of Fallot, who reached the age of 74 years without surgical or medical treatment and who was transferred to our clinic after syncope due to ventricular tachycardia.

Allele-specific quantification of HLA-DQB1 gene expression by real-time reverse transcriptase-polymerase chain reaction.

In addition to coding region polymorphism, allele-specific variation in the upstream regulatory region of the HLA-DQB1 gene has been detected. Reporter gene assays and transfection studies have indicated that HLA-DQB1 promoter polymorphism may be of functional significance. The aim of this study was to utilize real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for allele-specific quantification of HLA-DQB1 expression and to analyze cell-specific HLA-DQB1 expression in vivo. For the allele-specific quantification of DQB1 gene products, a real-time RT-PCR set of primer pairs (n=27) and probes (n=5) targeting exon 2 variability was established. The robustness and integrity of the assay system were confirmed by using recombinant DQB1 exon 2 plasmid clones as active exogenous controls. Sensitivity and reproducibility were assessed by serial dilution and allelic mixing analyses. In application to the study of allele-specific expression of DQB1 gene products during cytokine-driven maturation of monocyte-derived dendritic cells, differential patterns of allelic expression in heterozygous individuals were observed for DQB1*0301, compared to DQB1*0501 and DQB1*0602. At maximum, 1.9-fold (*0301/*0501) and 2.5-fold (*0301/*0602) higher induction was seen for DQB*0301. In conclusion, HLA-DQB1 expression can be analyzed by real-time RT-PCR suitable for cell- and allele-specific detection of HLA-DQB1 transcripts in homo- and heterozygous combinations.

Alterations of myocardial presynaptic sympathetic innervation in patients with multi-vessel coronary artery disease but without history of myocardial infarction.

In patients with myocardial infarction, left ventricular sympathetic denervation exceeds the size of the scar tissue. However, little is known about the regional innervation in patients with coronary artery disease (CAD) but no myocardial infarction. Using positron emission tomography (PET) with N-ammonia and C-hydroxyephedrine (HED), resting perfusion and presynaptic sympathetic innervation were studied in eight patients (seven males, one female; 58+/-9 years) with multi-vessel CAD and no history of myocardial infarction. Using polar map analysis of the PET data, the results were regionally compared with normal databases. The mean HED retention was 8.0%+/-2.0% x min(-1). Myocardial resting perfusion was normal in 23 of 24 vascular territories. Despite normal resting perfusion, significantly reduced HED retention, indicating dysinnervation, was found in 14 of 23 (61%) vascular territories (six of eight patients). Of the dysinnervated territories, 11 (79%) showed angiographically severe stenosis (>or=90% of native vessel/coronary artery bypass graft), eight (57%) showed ischaemia (myocardial perfusion scintigraphy/stress-electrocardiogram) and 12 (86%) had been revascularized. Of the nine segments with normal innervation, two (22%) revealed severe stenosis, two (22%) showed ischaemia and seven (78%) had been revascularized. It can be concluded that, in patients with advanced CAD and normal left ventricular function, dysinnervation can occur in the absence of myocardial infarction. This is consistent with the hypothesis that sympathetic neurones are more susceptible than myocytes to ischaemic damage.

Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance.

BACKGROUND: Recovery of myocardial function after revascularization of acutely occluded coronary arteries may require several days. During this critical time, patients in cardiogenic shock may have low output. A newly developed percutaneous left ventricular assist device (VAD) may offer effective treatment for these patients by providing active circulatory support. METHODS AND RESULTS: Between May 2000 and May 2001, VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction. The device was connected to the patient's circulation by insertion of a 21F venous cannula into the left atrium by transseptal puncture; blood was returned to the iliac artery through an arterial cannula. Mean duration of cardiac assistance was 4+/-3 days. Mean flow of the VAD was 3.2+/-0.6 L/min. Before support, cardiac index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/-0.6 L/min per m(2) (P<0.001). Mean blood pressure increased from 63+/-8 mm Hg to 80+/-9 mm Hg (P<0.001). Pulmonary capillary wedge pressure, central venous pressure, and pulmonary artery pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all P<0.001), respectively. Overall 30-day mortality rate was 44%. CONCLUSIONS: A newly developed VAD can be rapidly deployed in the catheterization laboratory setting. This device provides up to 4.0 L/min of assisted cardiac output, which may aid to revert cardiogenic shock. The left ventricle is unloaded by diverting blood from the left atrium to the systemic circulation, making recovery more likely after an ischemic event. The influence of this device on long-term prognosis warrants further investigation.

No more tours: how library tours of the past become today's celebrations.

In 1999, Northwestern University's Galter Health Sciences Library redesigned the library orientation program for first-year medical students. Surveys indicated tours were ineffective and students retained little of the information presented. Furthermore, the tour was not related to the student's curriculum and did not reinforce their learning objectives. As a replacement, the library staff developed a self-directed two-hour library open house. Stations throughout the library showcased the library staff, services, and resources, focusing on the first-year student curriculum. A follow-up survey found this redesign more useful and relevant to the students' course work, indicating libraries should be creating more interactive tours for students allowing them to learn actively.

Diagnostic value of intraoperative swabs of heart valves in infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Intraoperative swabs of heart valves are obtained regularly from patients undergoing heart valve surgery for infective endocarditis (IE) in order to confirm the preoperative diagnosis and to adjust the antibiotic regimen. The study aim was to assess the diagnostic value of intraoperative swabs of heart valves in IE. METHODS: A total of 83 patients was referred for surgical treatment of active IE between October 1994 and May 1999. Preoperatively, microorganisms were isolated using a minimum of two positive blood cultures; results were compared with those obtained from intraoperative heart valve swab cultures. RESULTS: Preoperatively, 73 patients (88%) had a positive blood culture, and 10 (12%) had culture-negative endocarditis. The intraoperative swab confirmed the preoperative diagnosis in 31 cases (37%). Bacteria were isolated in three of the ten patients with preoperative culture-negative IE. Despite positive histopathological findings in seven patients, no microorganisms were cultured either pre- or intraoperatively. Among the remaining 42 patients (51%) with active IE, 25 valve cultures were sterile and 17 valve swabs were presumed to be contaminated. CONCLUSION: In patients with active IE in whom the causative agent could be isolated and identified before surgery, intraoperative valve swabs did not contribute further to patient management. In isolating contaminants, the risk of inappropriate modification of the antibiotic regimen is imminent. The diagnostic validity in culture-negative IE appears negligible.

Molecular characterization of co-transcribed genes from Streptomyces tendae Tü901 involved in the biosynthesis of the peptidyl moiety and assembly of the peptidyl nucleoside antibiotic nikkomycin.

Six genes (nikP1, nikP2, nikS, nikT, nikU, and nikV) from Streptomyces tendae Tu901 were identified by analysis of the nucleotide sequence of the nikkomycin gene cluster. These genes, together with the previously described nikQ and nikR, span 9.39 kb and are transcribed as a polycistronic mRNA in a growth-phase-dependent manner. The nikP1 gene encodes a non-ribosomal peptide synthase consisting of an adenylation domain, a thiolation domain, and an N-terminal 70-residue segment of unknown function. The amino acid sequence encoded by the nikP2 gene displays similarity to the sequences of thioesterases, and the nikS product belongs to a superfamily of proteins characterized by a specific ATP-binding fold. The N-terminal 70 amino acids of the predicted nikT gene product show significant sequence similarity to acyl carrier proteins, and the C-terminal 330 amino acids to aminotransferases. The sequences of the deduced proteins NikU and NikV exhibit similarity to components S and E, respectively, of glutamate mutase from Clostridium. Disruption of the nikP1, nikS, nikT, or nikV gene by insertion of a kanamycin resistance cassette abolished formation of nikkomycins I, J, X, and Z, all of which contain hydroxypyridylhomothreonine as the peptidyl moiety. The nikP1 mutants, and the nikS and nikT mutants accumulated the nucleoside moieties nikkomycin Cz, and nikkomycins Cx and Cz, respectively. The nikV mutants formed nikkomycins Ox and Oz, which contain 2-amino-4-hydroxy-4-(3'-hydroxy-6'-pyridyl) butanoic acid as the peptidyl moiety. The nikP2 mutants synthesized nikkomycins I, J, X, and Z, but amounts of nikkomycins I and X, which contain formylimidazolone as the base, were lower. Feeding formylimidazolone to nikP2 mutants restored the ability to form nikkomycins I and X. Our results indicate that nikU and nikV are required for the synthesis of hydroxypyridylhomothreonine, the genes nikP1, nikP2 and nikS are required for the assembly of nikkomycins, and nikT is required for both pathways. The putative activities of each of their products are discussed.

[Percutaneous myocardial laser revascularization (PMR), a new therapeutic procedure for patients with refractory angina pectoris]. / Perkutane myokardiale Laserrevaskularisation (PMR), ein neues Therapieverfahren für Patienten mit therapierefraktärer Angina pectoris.

In patients with severe angina pectoris due to coronary artery disease, who are not candidates for either percutaneous coronary angioplasty or coronary artery bypass surgery, transmyocardial laser revascularization (TMR) often leads to improvement of clinical symptoms and increased exercise capacity. One drawback of TMR is the need for surgical thoracotomy in order to gain access to the epicardial surface of the heart. Therefore, a catheter-based system has been developed, which allows creation of laser channels into the myocardium from the left ventricular cavity. Between January 1997 and November 1999, this "percutaneous myocardial laser-revascularization" (PMR) was performed in 85 patients at the Herzzentrum Leipzig. In 43 patients, only one region of the heart (anterior, lateral, inferior or septal) was treated with PMR; in 42 patients two or three regions were treated in one session. 12.3 +/- 4.3 (range 4-22) channels/region were created into the myocardium. Six months after PMR, the majority of patients reported significant improvement of clinical symptoms (CCS class at baseline: 3.3 +/- 0.4; after 6 months: 1.6 +/- 0.9) (p < 0.001) and an increased exercise capacity (baseline: 349 +/- 138 s; after 6 months: 470 +/- 193 s) (p < 0.05); however, thallium scintigraphy failed to show increased perfusion in the PMR treated regions. PMR seems to be a safe and feasible new therapeutic option for patients with refractory angina pectoris due to end-stage coronary artery disease. The first results indicate improvement of clinical symptoms and increased exercise capacity; evidence of increased perfusion in the laser-treated regions is still lacking.

[Percutaneous myocardial laser revascularization (PMR)]. / Die perkutane myokardiale Laserrevaskularisation (PMR).

In patients with severe angina pectoris due to coronary artery disease, who are not candidates for either percutaneous coronary angioplasty or coronary artery bypass surgery, transmyocardial laser revascularization (TMR) often leads to improvement of clinical symptoms and increased exercise capacity. One drawback of TMR is the need for surgical thoracotomy in order to gain access to the epicardial surface of the heart. Therefore, a catheter-based system has been developed, which allows creation of laser channels into the myocardium from the left ventricular cavity. Between January 1997 and November 1999, this "percutaneous myocardial laser revascularization" (PMR) has been performed in 101 patients at the Herzzentrum Leipzig. In 63 patients, only 1 region of the heart (anterior, lateral, inferior or septal) was treated with PMR, in 38 patients 2 or 3 regions were treated in 1 session. There were 12.3 +/- 4.5 (range 4 to 22) channels/region created into the myocardium. After 3 months, the majority of patients reported significant improvement of clinical symptoms (CCS class at baseline: 3.3 +/- 0.4, after 6 months: 1.6 +/- 0.8) (p < 0.001) and an increased exercise capacity (baseline: 397 +/- 125 s, after 6 months: 540 +/- 190 s) (p < 0.05). After 2 years, the majority of patients had experienced sustained clinical benefit after PMR, the CCS class after 2 years was 1.3 +/- 0.7, exercise capacity was 500 +/- 193 s. However, thallium scintigraphy failed to show increased perfusion in the PMR treated regions. The pathophysiologic mechanisms of myocardial laser revascularization is not yet understood. Most of the laser channels are found occluded after various time intervals after intervention. Other possible mechanisms include myocardial denervation or angioneogenesis after laser revascularization, however, unequivocal evidence for these theories is not yet available. In conclusion, PMR seems to be a safe and feasible new therapeutic option for patients with refractory angina pectoris due to end-stage coronary artery disease. The first results indicate improvement of clinical symptoms and increased exercise capacity, whereas evidence of increased perfusion after laser revascularization in the laser-treated regions is still lacking.