Fast-track pulmonary conditioning before urgent cardiac surgery in patients with insufficiently treated chronic obstructive pulmonary disease.

AIM: Chronic obstructive pulmonary disease (COPD) is an important risk factor for perioperative morbidity and mortality in patients undergoing cardiac surgery. Despite high clinical relevance, current guidelines lack clear recommendations on the optimal approach for patients with insufficiently treated COPD and urgent need for cardiac surgery. The aim of the present study was to analyze the efficacy of short-term pulmonary conditioning (PC) in this subset of cardiopulmonary patients. METHODS: Eighteen patients with urgent need for cardiac surgery were treated with 1 mg budenoside twice a day, 1.25 mg salbutamol four times a day and 15 mg ambroxol three times a day. On average, patients received pulmonary conditioning for 5.1 ± 2.1 days. Lung function was assessed before and after treatment. RESULTS: Pulmonary conditioning improved forced expiratory volume in one second (FEV1) by 16% (P<0.001). Predicted FEV1 increased from 48.3 ± 13.6% at baseline to 55.4 ± 16.1% after treatment (P<0.001). Total resistance was reduced from 0.933 ± 0.418 kPa·s/L to 0.631 ± 0.344 kPa·s/L after PC (P=0.004). The percentage of patients in GOLD stages III-IV was reduced from 55.6% at baseline to 27.8% after treatment. After surgery, patients needed mechanical ventilation for 2 ± 3.4 days. One patient (5.6%) received a tracheostomy and four patients (22.2%) developed pneumonia; 30-day mortality was 5.6%. CONCLUSION: Short-term treatment with budenoside, salbutamol and ambroxol significantly improved lung function parameters. If surgery can be delayed for several days, pulmonary conditioning should be considered for patients with insufficiently treated COPD.

[CRT in atrial fibrillation--methodical and apparatus options in decision-making]. / CRT bei Vorhofflimmern. Methodische und apparative Optionen zur Entscheidungsfindung.

Heart failure and atrial fibrillation often coexist, especially with increasing degree of heart failure severity. Under this constellation, the advantage of cardiac resynchronization therapy (CRT) is still under discussion and displayed as an unresolved problem in the guidelines for cardiac stimulation and resynchronization. If ventricular desynchronization can be documented and response to CRT can be expected, the challenge is to interoperatively seek the best left ventricular electrode position and to postoperatively optimize the device in order to achieve the best therapy performance. This situation encourages the development of individualized methods and to utilize innovative apparatus features in order to consolidate individual decisions and to optimize CRT in heart failure with atrial fibrillation.

[Effects of inpatient rehabilitation for patients with back pain]. / Effekte der stationären medizinischen Rehabilitation bei Rückenschmerzpatienten.

BACKGROUND: This prospective, randomised longitudinal study examined the effects of inpatient medical rehabilitation. METHOD: Data was collated on the day of admission (n=261), day of discharge (n=261) and 6 months after discharge (n=243). The length of the rehabilitation measure changed every 3 months from 3 weeks (n=127) to 4 weeks (n=134) and back again. On all three specific days the VAS, the Roland-Morris-Questionnaire (RMQ) and the SF-36 were applied. The distance between fingers and floor and the Schober-sign were measured on the first and second day. The Mainz Pain Staging System (MPSS) was used to classify pain chronicity. RESULTS: On the day of discharge all parameters show an improvement. When the differing rehabilitation times are compared we can see the longer period scores better in VAS and Schober. 6 months after the rehabilitation all parameters show a slight improvement over the first day--except VAS--and a deterioration compared to the second--except RMQ. No significant predominance of the 4 week rehabilitation period is recognizable. CONCLUSION: The length of the rehabilitation measure alone seems to have no real effect on the permanence of the positive treatment of back complaints. It has advantages, though, for the result on the day of discharge.

Predictors of chronotropic incompetence in the pacemaker patient population.

AIMS: We prospectively evaluated results from cardiopulmonary exercise testing for chronotropic incompetence (CI) in a cohort of 292 pacemaker patients. In addition, we evaluated comorbidity and antiarrhythmic patient data as indicators of CI. METHODS AND RESULTS: On the basis of exercise stress testing and application of the definition of CI by Wilkoff, 51% of our cohort was categorized as having CI. Indications for pacemaker implant for this patient group were 42% atrioventricular block, 56% sinus node disease, and 59% atrial fibrillation. Maximum oxygen uptake (VO(2) max) and exercise duration were significantly reduced among CI pacemaker patients, whereas oxygen uptake at the anaerobic threshold remained unchanged. The following clinical characteristics were significant predictors of CI: existence of coronary artery disease (P = 0.038), presence of an acquired valvular heart disease (P = 0.037), and former cardiac surgery (P = 0.041). Age, gender, arterial hypertension, cardiomyopathy, congenital heart disease, left ventricular ejection fraction, and time period between stress-exercise examination and pacemaker implantation were not significant predictors of CI. Chronic antiarrhythmic therapy with digitalis (P = 0.013), beta blockers (P = 0.036), and amiodarone (P = 0.045) were significant predictors of CI. In contrast, medication with class I and IV antiarrhythmics had no significant correlation with CI. CONCLUSION: We found the following characteristics predictive of CI in this pacemaker patient population: VO(2) max, existence of coronary artery disease or acquired valvular heart disease, previous cardiac surgery, as well as medication with digitalis, beta blockers, and amiodarone.

[Chronic groin pain in marathon race: bone apposition at insertion of the m. rectus abdominis at ramus superior ossis pubis -- case report]. / Chronischer Leistenschmerz beim Marathonläufer: Knochenapposition am Ansatz des M. rectus abdominis am Ramus superior ossis pubis -- eine Kasuistik.

In this case report we present a 56 years old long standing (20 years) Marathon runner, suffering from chronic groin pain for 1(1/2) year. The great variety of diagnosis, which are subsumed under longstanding groin pain, explain the long time to evaluated the exact diagnosis and to institute a selective therapy. A multidisciplinary investigation was necessary to reveal a bone apposition at insertion of the musculus rectus abdominis in result of a chronic pelvic instability after beginning osteoarthitis and reduced range of rotational motion of the hip. One year after resection the bone apposition the athlete was free of pain, completely resistance in running and whole re-integrated in racing competitions.

Echocardiographic AV-interval optimization in patients with reduced left ventricular function.

BACKGROUND: Ritter's method is a tool used to optimize AV delay in DDD pacemaker patients with normal left ventricular function only. The goal of our study was to evaluate Ritter's method in AV delay-interval optimization in patients with reduced left ventricular function. METHODS: Patients with implanted DDD pacemakers and AVB III degrees were assigned to one of two groups according to ejection fraction (EF): Group 1 (EF > 35%) and Group 2 (EF < 35%). AV delay optimization was performed by means of radionuclide ventriculography (RNV) and application of Ritter's method. RESULTS: For each of the patients examined, we succeeded in defining an optimal AV interval by means of both RNV and Ritter's method. The optimal AV delay determined by RNV correlated well with the delay found by Ritter's method, especially among those patients with reduced EF. The intra-class correlation coefficient was 0.8965 in Group 1 and 0.9228 in Group 2. The optimal AV interval in Group 1 was 190 +/- 28.5 ms, and 180 +/- 35 ms in Group 2. CONCLUSION: Ritter's method is also effective for optimization of AV intervals among patients with reduced left ventricular function (EF < 35%). The results obtained by RNV correlate well with those from Ritter's method. Individual programming of the AV interval is fundamentally essential in all cases.

[Femoral neck fractures in the elderly -- bipolar hemiarthroplasty in total hip replacement]. / Die Schenkelhalsfraktur beim alten Menschen--Bipolare Hemiendoprothese vs. Totalendoprothese.

INTRODUCTION: In this study surgical risk and functional outcome of bipolar hemiarthroplasty and total hip replacement in elderly patients with femoral neck fractures were compared. METHODS: In a prospective study 54 patients with femoral neck fractures (median age: 80.5 years) were treated by implanting a total hip replacement (group I). Group II comprised 52 patients with 55 femoral neck fractures (median age: 81 years) who underwent bipolar hemiarthroplsty. Pre- and postoperative mobility and social history, perioperative parameters such as duration of surgery, blood loss, and number of transfused blood units as well as postoperative complications and mortality were compared. Function was ascertained by a scoring system. RESULTS: Duration of surgery, blood loss, and numbers of transfused blood units were significantly lower in group II, and mortality rate was lower. Postoperative mobility and medium-term functional score were comparable, whereas in the longer-term follow-up after 8 years group I had a significantly better functional score. CONCLUSION: In elderly patients with femoral neck fracture and high comorbidity, we recommend the implantation of hemiarthroplasty and in healthy, active patients with longer life expectancy the total hip replacement.

[Cross-linked hyaluronic acid in the treatment of osteoarthritis of the knee--results of a prospective randomized trial]. / Die Behandlung der Gonarthrose mit hochvernetzter Hyaluronsäure - Ergebnisse einer prospektiven randomisierten Studie.

PURPOSE: The objective of this trial was to compare the effectiveness of intraarticular injection of highly cross-linked hyaluronic acid (HA) with intraarticular injection of gaseous oxygen (O 2 ) in patients with clinical symptoms of cartilage damage in the knee. METHODS: Based on arthroscopically verified diagnosis, 111 patients were randomised and treated prospectively either with HA or O 2. The treatment was completed with an exercise program. The follow up was one year. 109 patients (56 x HA, 53 x O 2 ) were statistically calculated with the Wilcoxon-test according to the results of the Lysholm-score, the Tegner-activity-index, the Womac-score for pain, stiffness, function and the VAS for pain in rest and under strain. RESULTS: Both treatments were able to attain a statistically significant reduction of pain (VAS in rest and under strain, Womac part A), a reduction of joint stiffness (Womac part B) and improvement of joint function (Womac part C, Lysholm-score) during the follow up of one year. The Tegner-activity-index showed no significant change under both treatments. The comparison of both treatments showed differences in VAS under strain (p = 0.001), the Lysholm-score (p = 0.003), Womac part A (p = 0.003) and part C (p = 0.001). As a result HA showed significant better improvements with the VAS and Lysholm-score and oxygen showed significant better changes in the Womac-score part A and C. The results with cartilage damage 2 degrees were the same as in the total (VAS strain: p = 0.029 for O 2, Lysholm-score: p = 0.003 for HA, WOMAC part A: p = 0.009 for HA, Womac part C: p = 0.006 for O 2 ). The results with cartilage damage 3 degrees showed significant differences in reduction of joint stiffness (Womac part B: p = 0.012) for O 2. For cartilage damage 4 degrees HA showed significant reduction of pain (VAS rest: p = 0.001, VAS strain: p = 0.003) and O 2 significant reduction of pain and function (Womac part A: p = 0.004, part C: p = 0.002). CONCLUSION: Both methods are suitable to improve significantly the discomfort due one year to osteoarthritis. The pain relief by HA and the improvement of joint function by O 2 treatment have been shown for higher degrees of cartilage damage.

[Using the Lequesne questionnaires for patients with hip and knee disabilities in daily routine to reflect the quality of outcome in rehabilitation]. / Der routinemässige Einsatz des Lequesne-Index zur Ergebnismessung in der orthopädischen Rehabilitation bei Hüft- und Knieerkrankungen.

AIM: Studies in rehabilitation research put great value on patients' self-assessment. Patients with hip or knee diseases who need an orthopaedic rehabilitation suffer mainly pain, reduction of walking distance and other disabilities that impact on the activities of daily life. The Lequesne scores for the hip and knee are an indicator to show the degree of disabilities. The aim of the study was to prove that the Lequesne indices are reliable instruments for the individual to express the outcome of rehabilitation. We tested the Lequesne indices in daily clinical work, in the handling and in the acceptance. METHOD: Since May 1999 the rehabilitation center Bad Eilsen uses the Lequesne questionnaires as self-report questionnaire instruments for patients with hip and knee disabilities. 145 patients with hip and 122 patients with knee diseases filled in the questionnaires correctly and handed them back. RESULTS: The Lequesne indices are able to show developments in both directions; improvement as well as change for the worse. The Lequesne questionnaires are helpful to complete the common clinical parameters. CONCLUSION: Using the Lequesne questionnaires as a self-report instrument in our daily routine we are able to obtain a good reflection of individual health condition and the quality of outcome in rehabilitation.

Shwartzman phenomenon in a patient with active systemic lupus erythematosus preceding fatal disseminated intravascular coagulation.

The recurrence of widespread and diverse vascular lesions is a hallmark of systemic lupus erythematosus (SLE). Inflammatory and thrombotic mechanisms almost invariably associated with circulating antiphospholipid antibodies play a role in the pathogenesis of SLE-related vascular disease. Both mechanisms can coexist in the same patient. Vasculitis is most commonly induced by the local deposition of immune complexes. However, some SLE patients have an inflammatory complement-mediated vascular injury in the absence of immune complex deposition. We report on a fatal case of disseminated intravascular coagulation (DIC) in a young woman with active SLE. Hemorrhagic lesions due to localized intravascular coagulation (Shwartzman phenomenon) preceded disseminated intravascular coagulation accompanied by disseminated cardiac necrosis. Immune complex 'independent' and other mechanisms of vascular injury and states of hypercoagulability will be discussed.

Transient exit block of a DDD pacemaker with unipolar leads in subcutaneous emphysema following pneumothorax.

This case report describes a transient pacemaker exit block due to subcutaneous emphysema following pneumothorax. Pneumothorax after pacemaker implantation is rare, but development of subcutaneous emphysema under such circumstances is even more uncommon. Exit block develops only with the use of unipolar leads; with implantation of bipolar leads, this complication cannot occur.

Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty.

BACKGROUND: After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus "on-demand" intravenous analgesia to "on-demand" intravenous analgesia alone. METHODS: Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. RESULTS: No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. CONCLUSION: Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.

The influence of sensor orientation on activity-based rate responsive pacing. Sensor Orientation Study Group.

Piezoelectric activity-based rate responsive pacemakers are commonly implanted with the sensor facing inward. This study was conducted to assess the safe and effective rate response of an activity-based rate responsive pacemaker implanted with the sensor facing outward. A comparison were made to a previously studied patient group with sensor facing inward. Patient and pacemaker data was collected at predischarge and 2-month follow-up. Two-minute hall walks in conjunction with programmer-assisted rate response assessment were utilized to standardize initial rate response parameter settings for both patient groups. At 2-month follow-up, sensor rate response to a stage 3 limited CAEP protocol was recorded. Adequate sensor rate response was achieved for both patient groups. No difference was noted in reported patient complications for both groups. A statistically significant difference in programmed rate response curve setting and activity threshold for the two groups was noted at 2-month follow-up. Adequate sensor rate response was achieved for a patient population implanted with an activity-based rate responsive pacemaker with sensor facing outward. In this orientation, one higher rate response curve setting and an activity threshold one value more sensitive were required on average when compared to the normal sensor orientation group.

Fibrinogen breakdown, long-lasting systemic fibrinolysis, and procoagulant activation during alteplase double-bolus regimen in acute myocardial infarction.

Recent clinical studies comparing accelerated versus bolus administration of alteplase tissue plasminogen activator (t-PA) suggest similar thrombolytic efficacy, but reveal higher bleeding complications among older patients during the double-bolus regimen. The objective of the present study was to characterize the hemostatic profile of t-PA administered as double-bolus doses of 50 mg, at intervals of 30 minutes. Among 50 patients with acute myocardial infarction treated by double-bolus t-PA thrombolysis, coagulation and fibrinolysis parameters, as well as t-PA levels, were monitored. Monitored t-PA levels peaked at 5 and 35 minutes and were detectable within the therapeutic range even after 90 minutes. Marked systemic fibrinolytic activation was indicated by 75% depletion of both plasminogen and fibrinogen, as well as by 19-fold and 300-fold increases of fibrin degradation and fibrinogen degradation products. Plasminogen-activator inhibitor activity was completely suppressed. Pronounced procoagulant activation was reflected by a 3.4-fold increase of both factor XIIa and prothrombin fragment 1+2, and by a threefold increase of thrombin-antithrombin complex. Independent of t-PA weight dosage, fibrinolytic activation was more pronounced among older patients (> or = 63 years). We conclude that t-PA after bolus administration has a long half-life. Double-bolus regimen leads to a long-lasting systemic fibrinolytic state, which is even more remarkable among older patients--a fact that may explain the higher bleeding complications reported for this age group.

[Initial results of the evaluation study of ultrasound hip screening in Germany]. / Erste Ergebnisse aus der Evaluationsstudie des sonographischen Hüftscreenings in der Bundesrepublik Deutschland.

AIM OF STUDY: To assess the effectiveness of a universal sonographic screening of developmental dysplasia of the hip (DDH) established in Germany since 1996. METHODS: Currently a national survey is being performed in Germany to identify infants and young children who receive inpatient treatment for DDH. Between May, 1997 and October, 1997 monthly questionnaires were sent to all pediatric orthopaedic surgeons (active surveillance) and they were asked to report all inpatient cases between 10 weeks of age and 5 years with current closed or open reduction and/or osteotomies due to DDH. Information on time and results of previous ultrasound screening as well as treatment modalities was obtained in reported cases. RESULTS: 129 children (mean age at hospital admission 15.9 months, range 1.1 to 57.1 months) underwent closed reduction (n = 51), open reduction (n = 40) and osteotomies of the hip (n = 38) in the 6-month study period. Ultrasound screening has been performed too late and not at all in 45 children (35.1%). While in 18 cases (13.7%) no information could be obtained on screening results, the majority of children (n = 66, 51.2%) had completed DDH screening prior to the sixth week of life as recommended. Preliminary calculation of the unadjusted incidence of inpatient treatment for DDH in Germany was 0.33 per 1000 livebirths. CONCLUSION: DDH cases are still identified after introduction of an universal ultrasound hip screening in Germany. Continued evaluation must show, whether the incidence will decrease throughout the next few years.

["Primary" shoulder stiffness: illness duration and therapeutic comparison]. / Die "primäre" Schultersteife: Krankheitsdauer und Therapievergleich.

AIMS: Etiology, natural history and therapy of the frozen shoulder still remains obscure. Therefore observation of natural history is of interest. METHOD: In a retrospective study 140 patients with different therapies were followed-up. RESULTS: 28 (20%) patients were not considered as healed because of persisting complaints during the whole follow-up period with an average duration of 49 months. Mobilisation under anaesthesia (27 patients) showed an less improval in range of motion with a shortening of complaint period. CONCLUSION: The existence of a subgroup of patients with no response on regular therapy is assumed.