[A rare cause of myocarditis in a 30-year-old patient]. / Seltene Ursache einer Myokarditis bei einem 30-jährigen Patienten.

CASE REPORT: A 30-year-old male was admitted to hospital because of chest pain and raised cardiac enzymes. Coronary heart disease was excluded by coronary angiography. Assuming myocarditis serological testing was performed and showed markedly raised antibody titers against Coxiella Burnetii. We treated the patient with doxycycline, 2 times 100 mg daily for 5 months. CONCLUSION: Acute Q-fever should be considered as a possible cause of myocarditis, especially in rural areas.

[Fever, negative blood culture findings and absence of response to antibiotic therapy in a patient after a second aortic valve prosthesis]. / Fieber, negative Blutkulturbefunde und Fehlen des Ansprechens auf Antibiotikatherapie bei einem Patienten nach erneutem Aortenklappenersatz.

HISTORY AND CLINICAL FINDINGS: A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside. INVESTIGATIONS: At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii. DIAGNOSIS, TREATMENT AND COURSE: Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years. CONCLUSION: Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative.

Low-dose iloprost infusions compared to the standard dose in patients with peripheral arterial occlusive disease Fontaine stage IV. DAWID Study Group.

BACKGROUND: Intravenous iloprost, titrated from 0.5 up to 2.0 ng/kg/min has been shown in patients with PAOD III/IV to significantly improve healing of trophic lesions, relief of rest pain, and reduce the rate of major amputation or death at 6 months as compared to placebo. The effect is considered related to improvement of the microcirculation. The aim of the present trial was to identify an optimum dose regarding treatment response and tolerability, by studying 4 doses of 25, 50, 75 and 100 micrograms iloprost daily. PATIENTS AND METHODS: 302 patients with PAOD IV were randomised via a double-blind fashion to one of the 4 doses. The primary endpoint was the responder rate at end of treatment. Responders were defined as patients with very good or good global efficacy, as judged by lesion healing and pain relief. Side effects were documented and a pre-defined benefit/risk index was calculated. RESULTS: No dose-dependency of iloprost regarding primary or secondary endpoints was observed. The rate of responders ranged between 48.7-53.5%. Side effects, mainly related to vasodilation, increased dose-dependently (p < 0.001, chi 2-test), with a significant decrease of the benefit/risk index from 2.19 +/- 1.19 to 1.64 +/- 0.97 (p = 0.012, ANOVA). Responders had a better outcome at 6 months than non-responders (2.6 fold higher rate of major amputation or death; life table analysis). CONCLUSIONS: It is concluded that iloprost should be titrated to the optimum rather than maximum tolerated dose, since a higher incidence of side effects not associated with an increased treatment response was observed at higher doses.

[Right ventricular thrombus after pacemaker implantation in a patient with secondary antiphospholipid syndrome]. / Rechtsventrikulärer Thrombus nach Schrittmacherimplantation bei sekundärem Antiphospholipid-Syndrom.

HISTORY AND ADMISSION FINDINGS: An 85-year-old woman was admitted because of frequent syncopes. She also reported slight weight loss, cough and dyspnoea. Chest auscultation revealed slight stridor and a cardiac arrhythmia, with an irregular ventricular rate between 120 and 140 beats/min. INVESTIGATIONS: She had a thrombocytopenia (96 platelets/nl), and the ECG and long-term monitoring showed a tachyarrhythmia with atrial fibrillation, a bifascicular block (left anterior hemiblock and right bundle branch block), as well typical signs of sick-sinus syndrome with short periods of bradycardic sinus rhythm and pauses of up to 6 s on rhythm change. Echocardiography indicated moderately reduced left ventricular function. Chest radiogram revealed tracheal narrowing by a retrosternal goitre. No evidence of tumour was found on bronchoscopy. DIAGNOSIS, TREATMENT AND COURSE: A VVI pacemaker was implanted. When the platelet count dropped to 30/nl idiopathic thrombocytopenic purpura was suspected, but administration of high doses of corticoids and immunoglobulin was without effect. Another echocardiogram, performed because of chest pain suspicious of pulmonary embolism, revealed a large bowl-shaped right ventricular thrombus with floating parts. Demonstration of anticardiolipin antibodies established the diagnosis of antiphospholipid syndrome (APLS), thought to be secondary to thyroid cancer suspected from the computed tomography. The patient died 2 months later from recurrent pulmonary embolism and progressive liver failure. Autopsy revealed a not previously diagnosed tracheal carcinoma with metastases to the thyroid, as well as haematogenous metastatic foci within the right ventricular thrombus. INTERPRETATION: In case of thrombocytopenia of uncertain aetiology APLS should be included in the differential diagnosis, even in the absence of any early or acute thrombosis. If anticardiolipin antibodies and/or lupus anticoagulant are demonstrated, malignant neoplasm should be considered in addition to autoimmune disease.

[Could C- and D-network mobile phones endanger patients with pacemakers?]. / Können Mobil-Telefone im C-und D-Netz Herzschrittmacher-Patienten gefährden?

OBJECTIVE: To investigate prospectively the extent of potentially harmful interference of cardiac pacemakers by mobile phones in the C (analog) and D (digital) networks in use in Germany. PATIENTS AND METHODS: 104 patients (54 men, 50 women; mean age 75.8 [40-100] years) with 58 different implanted pacemaker models (43 one-chamber and 15 two-chamber systems) underwent uniform tests at various functional states with three different telephones (D1 portable 8 Watt, D1 Handy model 2 Watt, C Handy model 0.5 Watt). The distances between telephone aerial and pacemaker, as well as reception sensitivity and polarity of the pacemaker were varied. All tests were done during continuous ECG monitoring. RESULTS: 28 different pacemaker types (48.3%) in 43 patients (41.3%) showed interference in the form of pacemaker inhibition and switching to interference frequencies as well as triggering of pacemaker-mediated tachycardias in the DDD mode, as well as in the temperature-regulated frequency-adaptive function. D portables influenced pacemaker function more often and at greater distance than the D Handy model, which was little different from the c network hand phone. Reduction in pacemaker sensitivity as well as switching to bipolar reception only partly eliminated the interference. CONCLUSIONS: Patients with implanted pacemakers should if possible not use mobile phones in the C and D networks. Individual testing with suitable programming of pacemaker sensitivity and polarity can reduce the risk of interference.

[Preclinical resuscitation--which factors influence the long-term course? A 5-year follow-up]. / Präklinische Reanimation--welche Faktoren beeinflussen den Langzeitverlauf? Eine 5-Jahres-Nachbeobachtung.

OBJECTIVE: The factors that influence long-term survival after out-of-hospital resuscitations were investigated. PATIENTS AND METHODS: Between 1985 and 1989, out of a total of 8403 responded emergency calls, 505 resuscitations were undertaken out of hospital by the emergency medical service in Göppingen. All emergency calls were recorded uniformly. Of the 505 resuscitations, 154 were primarily successful (30.5%), and 58 were secondarily successful, i.e. the patients were ultimately discharged from hospital. In 56 of them the further course could be followed at least 5 years after the resuscitation (45 males, 11 females; mean age 57 [10-83] years). The patients' charts were analysed; in 51 cases data could be obtained from the family doctor, from ambulant care or from home visits. RESULTS: 34 patients (60.4%) were still alive 5 years after the resuscitation. The highest death rate (16%) was in the first post-resuscitation year. Prognostically unfavourable factors were: advanced age (P < 0.01), underlying cardiac disease (n = 49; P < 0.025), especially coronary heart disease (n = 34; P < 0.01). Patients with primary ventricular fibrillation and previous myocardial infarction (n = 10) had a poorer prognosis than those with acute infarction (n = 24; P < 0.05). Reduced survival chances occurred in those with impaired left ventricular function, as measured echocardiographically (P < 0.05), or with cardiac arrhythmias, Lown classes III and IV (P < 0.05), as well as in those with severe neurological sequelae (n = 8; P < 0.08). CONCLUSION: Long-term prognosis depends, in the first instance, on the resuscitated patient's basic condition and not so much on the circumstances of the resuscitation.

[Pacemaker therapy for the sick sinus node syndrome. Does the atrially involved pacemaker system lower the frequency of atrial fibrillation and thromboembolic complications as well as mortality?]. / Schrittmachertherapie beim Syndrom des kranken Sinusknotens. Senken vorhofbeteiligte Schrittmachersysteme die Häufigkeit von Vorhofflimmern und thromboembolischen Komplikationen sowie die Mortalität?

Between 1986 and 1992, pacemakers were implanted in 307 patients with symptoms caused by the sick sinus syndrome (SSS). 301 patients were regularly followed up (161 men, 146 women, mean age 72.9 [27-91] years) of whom 180 had a VVI, 65 and AAI and 58 a DDD/DDI pacemaker. Mean follow-up period was 58.3 months for VVI-stimulated patients and 35.6 months for atrial paced patients. The data were analysed retrospectively to ascertain whether a change in pacemaker treatment to a more physiological system produced any lowering in the mortality rate, incidence of permanent atrial fibrillation (AF), and thromboembolic phenomena. The annual mortality rate of the VVI-stimulated patients was 6.9%, that of atrial paced patients 2.8%. Age, abnormal ventricular function, survived resuscitation and diabetes mellitus each correlated with a shortened life expectancy already at the time of implantation, regardless of the pacemaker mode. Permanent AF was more frequent during VVI stimulation (16% vs 7%), especially if it had been preceded by intermittent AF (26% vs 13%). But there was no significant difference with regard to transitory cerebral ischaemic episodes and peripheral arterial emboli (15% vs 10%). Fewer patients with atrial pacing went into heart failure (20% vs 30%). Four patients developed a high-grade atrioventricular (a-v) block on AAI stimulation (annual incidence 2.4%). - These observations suggest that patients with SSS should always have atrial paced pacemaker systems. If a-v conduction is disturbed, a bifocal pacemaker is the system of choice.

Absolute bioavailability of pirenzepine in intensive care patients.

The absolute bioavailability (f) of pirenzepine was determined in 27 intensive care patients receiving the drug for prophylaxis and therapy of upper gastrointestinal tract bleeding. A multiple oral and intravenous dosage regimen and the times of blood sampling were adapted to individual conditions and treatment. Mean f in the patients was 0.28, which was significantly higher than in 12 normal subjects (0.14). It showed no dependence on age (range 20-82 y), nor on the risk factors cardiac insufficiency, renal and hepatic dysfunction, gastrectomy (Billroth II) and bleeding gastrointestinal ulcers, nor on concomitant administration of metoclopramide or antacids. Due to the wide therapeutic index of pirenzepine, it is concluded that individualization of therapy is not necessary for patients in intensive care.

[Correlation between endoscopic biopsy findings and sonograms of the abdomen in stomach cancer]. / Beziehungen zwischen endoskopisch-bioptischem Befund und Sonogramm des Abdomens beim Magenkarzinom.

35 out of 57 patients with gastric carcinoma presented with a so called "target" pattern. In cases with distal cancer the more advanced cases with endoscopic types Borrmann III/IV showed this sign more frequently than less advanced forms, i.e. suspected early cancer, Borrmann I or Borrmann II. On the other hand in endoscopically advanced cancers Borrmann III/IV a thickening of the gastric wall was more frequent in distal than in proximal localization of carcinoma. The presence of target sign in abdominal ultrasound did, statistically, not influence gastric resection. Other findings, which were observed exclusively in gastric cancer type Borrmann III/IV, like infiltration to the surrounding (pancreas, liver), liver metastasis, and/or ascites, were decisive. Additional sonography of the abdomen is, therefore, a valuable preoperative diagnostic procedure in gastric cancer beside upper GI endoscopy and biopsy.

Correlated inhibition of ribosomal RNA synthesis and silver staining by actinomycin D.

Preferential inhibition of the synthesis of ribosomal RNA by low doses of actinomycin D was used to investigate the quantitative relationship between the intensity of silver staining of nucleoli and the rate of RNA-synthesis. The two parameters were found to be strongly correlated in human diploid fibroblasts.

Pattern of activity of nucleolus organizers during spermatogenesis in mammals as analyzed by silver-staining.

Silver-staining in the nuclei and chromosomes of spermatogenesis of four species of mammals (Man, Mus musculus, Rattus norvegicus, and Cavia cobaya) was investigated qualitatively and quantitatively. These species show a very similar pattern of activity of the nucleolus organizer regions (NORs) during the various stages of spermatogenesis. Silver precipitates are detectable in growing spermatogonia and up until the pachytene stage of meiotic prophase. During the meiotic metaphases I and II and during interkinesis silver-stainability disappears completely. A resumpton of silver-stainability occurs in round spermatids indicating a postmeiotic reactivation of NORs. This process does not persist beyond the early elongation phase. The quantitative determination of the silver-covered areas in relation to the total nuclear areas reveals minor differences between the species investigated with regard to the times and extents of maximum activation. The known localizations of the NORs in the karyotypes of the species investigated was confirmed using metaphase-preparations derived from somatic tissues.

Evidence for postmeiotic expression of ribosomal RNA genes during male gametogenesis.

Pre- and postmeiotic stages of male gametogenesis of 10 different vertebrate species belonging to mammals, birds, amphibians, and fishes were subjected to the Ag-AS staining technique (Goodpasture and Bloom, 1975). A uniform pattern of silver-staining is observable during spermatogenesis of the different vertebrate species. Silver-staining is present in spermatogonia and during the whole period of meiotic prophase, but totally absent during diakinesis and metaphase II of meiosis. In early spermatids silver-staining reappears and only disappears around the beginning of elongation of the spermatid nucleus. Since the Ag-AS technique is believed to stain only transcriptionally active nucleolus organizer regions, our findings indicate that ribosomal RNA genes become reactivated in the haploid spermatid.