Decreasing hospital mortality between 1994 and 1998 in patients with acute myocardial infarction treated with primary angioplasty but not in patients treated with intravenous thrombolysis. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR).

OBJECTIVES: We investigated changes in the clinical outcome of primary angioplasty and thrombolysis for the treatment of acute myocardial infarction (AMI) from 1994 to 1998. BACKGROUND: Primary angioplasty for the treatment of AMI is a sophisticated technical procedure that requires experienced personnel and optimized hospital logistics. Growing experience with primary angioplasty in clinical routine and new adjunctive therapies may have improved the outcome over the years. METHODS: The pooled data of two German AMI registries: the Maximal Individual Therapy in AMI (MITRA) study and the Myocardial Infarction Registry (MIR) were analyzed. RESULTS: Of 10,118 lytic eligible patients with AMI, 1,385 (13.7%) were treated with primary angioplasty, and 8,733 (86.3%) received intravenous thrombolysis. Patients characteristics were quite balanced between the two treatment groups, but there was a higher proportion of patients with a prehospital delay of >6 h in those treated with primary angioplasty. The proportion of an in-hospital delay of more than 90 min significantly decreased in patients treated with primary angioplasty over the years (p for trend = 0.015, multivariate odds ratio [OR] for each year of the observation period = 0.84, 95% confidence interval [CI]: 0.73-0.96) but did not change significantly in patients treated with thrombolysis. Hospital mortality decreased significantly in the primary angioplasty group (p = 0.003 for trend; multivariate OR for each year = 0.73, 95% CI: 0.58-0.93). However, for patients treated with thrombolysis, hospital mortality did not change significantly (p for trend 0.175, multivariate OR for each year: 1.02, 95% CI: 0.94- 1.11). CONCLUSIONS: Compared with thrombolysis the clinical results of primary angioplasty for the treatment of AMI improved from 1994 to 1998. This indicates a beneficial effect of the growing experience and optimized hospital logistics of this technique over the years.

Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry.

OBJECTIVES: We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice. BACKGROUND: In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty. METHODS: The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay of < or =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579). RESULTS: Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p < 0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis. CONCLUSIONS: These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.

Effect of preinfarction angina pectoris on outcome in patients with acute myocardial infarction treated with primary angioplasty (results from the Myocardial Infarction Registry.

Preinfarction angina is associated with better clinical outcome in patients with acute myocardial infarction (AMI) who receive intravenous thrombolysis. This has not been proved in patients with AMI treated with primary angioplasty. We analyzed the data of the prospective multicenter Myocardial Infarction Registry (MIR). Of 14,440 patients with AMI, 774 with a prehospital delay of < or =12 hours were treated with primary angioplasty. Five hundred thirty-two patients (68.7%) had preinfarction angina. Patients with preinfarction angina were slightly older than patients without (63 vs 62 years, p = 0.042), prehospital delay was 1 hour longer (180 vs 120 minutes, p = 0.001), and arterial hypertension was more prevalent (47.6% vs 32.2%, odds ratio [OR] 1.91, 95% confidence intervals [CI] 1.39 to 2.62). There was no significant difference in hospital mortality (5.6% vs 3.3%, OR 1.75, 95% CI 0.79 to 3.87), reinfarction, stroke, or the combined end point of death, reinfarction, or stroke between the 2 groups. Logistic regression analysis showed no association of preinfarction angina with the occurrence of either death (OR 2.21, 95% CI 0.91 to 6.08) or the combined end points (OR 1.10, 95% CI 0.55 to 2.31). There was also no significant difference in mortality (6% vs 5.1%, OR 1.19, 95% CI 0.56 to 2.52), reinfarction, stroke, postinfarction angina, or the combined end points between patients with preinfarction angina within 48 hours compared with patients with preinfarction angina between 49 hours and 4 weeks before the AMI. Thus, the MIR data showed no protective effects of preinfarction angina in patients with AMI treated with primary angioplasty.

Primary angioplasty versus no reperfusion therapy in patients with acute myocardial infarction and a pre-hospital delay of > 12-24 hours: results from the pooled data of the maximal individual therapy in acute myocardial infarction (MITRA) registry and the myocardial infarction registry (MIR).

OBJECTIVE: In patients with acute myocardial infarction (AMI), treatment with thrombolysis is superior to no reperfusion therapy only up to 12 hours after the onset of symptoms. There are no data addressing whether this time limit is also justified for treatment with primary angioplasty. DESIGN: The pooled data of two German ST-segment elevation AMI registries, the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) study and the Myocardial Infarction Registry (MIR), were analyzed. PATIENTS: Out of 22,749 patients, eight hundred and forty-eight with a pre-hospital delay of > 12 hours and < or = 24 hours were treated with either primary angioplasty (94/848; 11.1%) or no reperfusion therapy (754/848; 88.9%). RESULTS: Patients treated with primary angioplasty were 10 years younger (59 years versus 69 years; p = 0.001), more often male [72.3% versus 59.9%; odds ratio (OR) = 0.57; 95% confidence interval (CI) = 0.36-0.92] and less likely to be diabetics (17% versus 27.2%; OR = 0.55; 95% CI = 0.31-0.97). Hospital mortality was 8.5% in patients treated with primary angioplasty compared to 17.1% in patients with no reperfusion therapy (OR = 0.45; 95% CI = 0.21-0.95; p = 0.033) and the combined endpoint (death, reinfarction or stroke) occurred significantly less often (11.7% versus 20.3%; OR = 0.52; 95% CI =0.27-1; p = 0.045). However, multiple logistic regression showed only a non-significant trend for lower mortality (OR = 0.54; 95% CI =0.20-1.23) and the combined endpoint (OR = 0.65; 95% CI = 0.29-1.31) in patients treated with primary angioplasty. CONCLUSIONS: These data show the possibility of a benefit of primary angioplasty over conservative treatment in patients with pre-hospital delays of > 12 up to 24 hours, although multiple logistic regression analysis failed to find significant differences between treatments. This might be due to inadequate study power or a selection bias. These findings encourage further investigation of this subject.

Influence of mucolytic therapy on respiratory mechanics in patients with chronic obstructive pulmonary disease.

Mucus hypersecretion is a hallmark of chronic obstructive pulmonary disease (COPD) and is regarded as contributing to airflow limitation in these patients. The value of mucolytic therapy is still a matter for debate. We investigated the short-term influence of an inhalative mucolytic drug mercapto-ethane sulfonate (Mesna) on the lung function, respiratory mechanics and viscous respiratory load in patients with COPD in a randomized, placebo controlled, double-blind, cross-over study in 10 patients with moderate, stable COPD. Resistance, static compliance and frequency dependent dynamic compliance and viscous respiratory work, FVC, FEV(1), PEFR, MEF(75), MEF(50), MEF(25), TLC and RV were measured. These lung function parameters did not show any significant differences between the treatment groups. In conclusion, an inhalative treatment with an active mucolytic drug of patients with mild COPD does not improve respiratory mechanics and respiratory load.

Interstitial lung disease induced by endogenous Candida albicans.

We report on a 64-year old woman with an interstitial lung disease which had characteristics of hypersensitivity pneumonitis. Severe febrile attacks with impairment of ventilation and diffuse poorly defined radiodensities and ground glass opacities on chest x-ray occured repeatedly. Laboratory data showed hypoxemia, leukopenia and circulating Candida albicans (C.a.)-antigen. Bronchoalveolar lavage revealed an increase in neutrophils. Transbronchial biopsies showed lymphocytic alveolitis, bronchiolitis obliterans and epitheloid cell granulomas. IgG and IgA and the lymphocyte proliferation assay were positive with C.a.-antigen. C.a. was detected in the feces. Intradermal skin test with C.a. showed a positive immediate and late phase reaction and inhalative provocation test with C.a.-antigen was positive. After antimycotic treatment the symptoms resolved completely and long-lasting. We conclude that the disease was induced by C.a.-antigen reaching the lungs from the intestinal tract via the bloodstream.

Mycobacterium tuberculosis gene-amplification in breath condensate of patients with lung tuberculosis.

The applicability of Mycobacterium tuberculosis-gene-amplification test (NAT) in breath condensate (BC) was examined in lung tuberculosis (TB). Ten patients with bacteriologically confirmed lung TB have been examined by ligase chain reaction (LCx). In BC the NAT were negative in all patients as well as the examination of acid fast smears and of solid phase or liquid media cultures were. This indicates that the use of NAT in BC can not replace or complement sputum or materials obtained invasively in patients with lung TB.

[Incidence of severe local complications in ulcerative colitis and Crohn disease]. / Untersuchungen zur Häufigkeit schwerwiegender lokaler Komplikationen bei Colitis ulcerosa und Morbus Crohn.

At the example of the severe and foudroyant courses of the ulcerous colitis in patients who died or underwent a resection (n = 93) the severe local complications are demonstrated. 70 patients with resection of the intestine, 21 patients with diagnostic laparotomy as well as 32 deceased patients with Crohn's disease were compared with them. Transmigration peritonitides (3.3% of 458 patients with ulcerous colitis except haemorrhagic proctitis), perforation peritonitides (2.0%) as well as the toxic megacolon (3.3%) alone or in combination are the most frequent severe complications. Therapy-resistant intestinal haemorrhages (1.1%) are infrequent. In 0.9% of the cases colorectal carcinomata appear. The acute or chronic mechanical ileus is the most frequent complication in Crohn's disease (21.1% of 171 patients altogether). Intraabdominal abscesses are found in 11.7%. In participation of the colon fistulae are nearly twice as frequent as in localisation of the small intestine. Free perforations of the small intestine (3.8%) are more frequently observed than perforations of the colon (2.2%).

Influence of oxygen concentration on argon plasma coagulation-induced tissue damage in isolated pig tracheas.

BACKGROUND: Argon plasma coagulation (APC) is used during bronchoscopy to restore passage of central airways. Concern has been raised about the possibility that elevated oxygen concentration may increase the tissue damage by APC. OBJECTIVE: to examine the extent of tissue damage at different concentrations of oxygen in isolated pig tracheas. METHODS: The APC-induced tissue damage was investigated macroscopically and microscopically in isolated and artificially ventilated pig tracheas at oxygen concentrations of 21, 50, 75 and 100%. RESULTS: There was deep coagulation of all tissue layers reaching the adventitia independent of the oxygen concentration up to 75% O(2). With 100% O(2), only tissue damage increased and combustion occurred. CONCLUSIONS: APC-induced tissue damage in ex vivo pig tracheas was independent of the oxygen concentration relevant for clinical practice.

Serum concentration of D-dimers as a marker of the activation of the fibrinolytic system in patients undergoing bronchoscopic and thoracoscopic investigations.

BACKGROUND: Hypercoagulability is common even after minimally invasive surgical techniques and is pathogenetically linked to postoperative thrombotic and cardiac complications. The activation of the coagulation and fibrinolytic systems after bronchoscopic and thoracoscopic investigations has not yet been elucidated. OBJECTIVE: The aim of our study was to evaluate whether bronchoscopic and thoracoscopic investigations activate the fibrinolytic system. METHODS: This study assessed cross-linked fibrinogen degradation products (D-dimer) in 120 patients after bronchoscopy with and without biopsies and/or bronchoalveolar lavage and after thoracoscopy with biopsies of the parietal pleura. RESULTS: Both bronchoscopy and thoracoscopy induced a minor but significant increase in D-dimers in most patients, reversible mostly within 24 h. In rare cases, distinct increases lasting at least 24 h occurred. CONCLUSIONS: The slight and temporary increase in serum D-dimers induced by bronchoscopy and thoracoscopy is nonsignificant in most patients; however, in some cases, the coagulation/fibrinolytic systems may become markedly activated.

[Primary pulmonary manifestation of extramedullary acute myelocytic leukemia]. / Primär pulmonale Manifestation einer extramedullären akuten myeloischen Leukämie.

We report on a 49 year old female with primary extra-medullary manifestation of a acute myeloid leukemia in the lungs without leukemic signs. The disease was diagnosed by detection of leukemic blast cells in bronchoalveolar lavage. Chemotherapy with the TAD-VP-scheme resulted in partial remission. The patient died in systemic early relapse. To our knowledge this is the first description of primary isolated extra-medullary manifestation of a acute myeloid leukemia in the lungs.

[Obturating endobronchial lipoma--bronchoscopic therapy]. / Obturierendes endobronchiales Lipom--bronchoskopische Therapie.

We report on the case of a 77-year old man in whom a lipoma caused occlusion of the lingular bronchus with consecutive dystelectasis. The lipoma was resected via the bronchoscope with a hot snare. The incidence, clinical characteristics and treatment of endobronchial lipomas are described.

[Multifocal malignant transformation of extreme fibromatosis with pulmonary involvement]. / Multifokale Malignisierung einer extremen Neurofibromatose mit pulmonaler Beteiligung.

We report on the case of a 40-year old patient with extreme neurofibromatosis with severe kyphoskoliosis and deformation of the thorax. The patient died from malignant transformation which occurred multifocally with extensive pulmonary metastases. The well-known thoracic manifestations of neurofibromatosis are reviewed.

Hypersensitivity alveolitis induced by endogenous candida species

We report the case of a 64-year old woman with severe attacks of allergic alveolitis occurring frequently independent of a concrete place. These attacks were regularely preceded by diarrhoe. Laboratory data showed marked leukopenia and circulating Candida albicans (C.a.)-antigen. Bronchoalveolar lavage revealed an increase in neutrophils (13%). Transbronchial biopsies showed focal alveolitis and focal septal fibrosis with bronchiolitis obliterans and an epitheloid cell granuloma. Immunohistochemical examination revealed C.a.-antigen in alveolar macrophages. In the faeces a high amount of C.a. and C. glabrata was detected. In serum IgG and IgA were positive against C.a., IgE against C.a. was negative. Lymphocyte proliferation assay with C.a.-antigen was positive. Intradermal skin test with C.a. showed positive immediate and late phase reaction. Furthermore inhalation challenge with C.a.-antigen was positive. A febrile reaction with chills, dyspnea and hypoxemia and leukocytosis in peripheral blood occured after 6 hours. Lung function showed a predominantly obstructive impairment of ventilation. An extensive search for other IgG- or IgE-mediated allergies (other fungi, environmental or food allergens) was completely negative. Investigation of the gastrointestinal tract did not show any abnormality exept the detection of lactose intolerance. There was no fungal growth in the patients flat. After initiation of antimycotic treatment the symptoms resolved completely. - We conclude that the disease was induced by C.a.-antigen reaching the lungs from the intestinal tract via the bloodstream. It is still a matter of debate whether an additional factor is necessary for the antigen to penetrate the intestinal mucosa.

[Non-tubercular mycobacterial infection of the lungs due to Mycobacterium smegmatis]. / Nichttuberkulöse Mykobakteriose der Lungen durch Mycobacterium smegmatis.

Nontuberculous mycobacteriosis due to M. smegmatis is a rarity. We report on the case of a 51 year old male HIV-seronegative patient without predisposing bronchopulmonary disease, but with a state after gastrectomy and splenectomy who developed unproductive cough, night sweat and weight loss. The chest radiograph and thoracic CT showed wide-spread bilateral patchy infiltrations. Histological examination of transbronchial biopsies revealed chronic carnificating pneumonia. A perhoracic fine-needle biopsy showed caseating epitheloid cell granulomas with acid fast bacilli. These were identified as M. smegmatis by PCR with subsequent sequencing. Acid fast bacilli could not be detected microscopically neither in sputum nor in bronchial secretions, however M. smegmatis has been repeatedly detected by culture in these materials. In neither material tubercle bacilli have been detected by nucleic acid amplification (NAT) or culture. Immunologic investigations revealed a reduced number of CD4+ lymphocytes and a reduction of interferon alpha- and -gamma-synthesis by peripheral blood mononuclear cells. Treatment with Rifabutin, Ethambutol, Clarithromycin and Ofloxacin resulted in complete clinical and roentgenological resolution.

Impact of prehospital delay on mortality in patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis.

BACKGROUND: In patients with acute myocardial infarction treated with thrombolysis, longer times to treatment are associated with increasingly worse clinical outcome. This relation may be different for treatment with primary angioplasty. METHODS: We analyzed the pooled data of the German acute myocardial infarction registries Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) and Myocardial Infarction Registry (MIR) to determine the influence of prehospital delays on hospital mortality rates. Primary angioplasty was performed in 1063 patients and thrombolysis in 7552 patients. RESULTS: In patients treated with thrombolysis, in-hospital time to treatment was constantly 30 minutes median. In patients treated with primary angioplasty, in-hospital time to treatment increased from 60 minutes median up to 87 minutes median with increasing prehospital delay. Hospital mortality rates slightly decreased with increasing prehospital delays in patients treated with primary angioplasty (P for trend =.02). However, in patients treated with thrombolysis, mortality rate was nonsignificantly increased (P for trend =.11). Logistic regression analysis showed no significant difference in mortality rates between primary angioplasty and thrombolysis for prehospital delays of <3 hours. However, when prehospital delay was >3 hours, thrombolysis was independently associated with a higher mortality rate compared with primary angioplasty. CONCLUSIONS: Compared with thrombolysis, primary angioplasty is independently associated with a lower mortality rate in prehospital delays of >3 hours. The reason for this may be a time-dependent loss of efficacy to achieve reperfusion for thrombolysis but not for primary angioplasty.

Differences in treatment and outcome of patients with acute myocardial infarction admitted to hospitals with compared to without departments of cardiology; results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA 1+2) Registries and the Myocardial Infarction Registry (MIR).

AIMS: The specialty of the admitting physician may influence treatment and outcome in patients with acute myocardial infarction. METHODS AND RESULTS: The pooled data of three German acute myocardial infarction registries: the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) 1+2 studies and the Myocardial Infarction Registry (MIR) were analysed. Patients admitted to hospitals with departments of cardiology were compared to hospitals without such departments. A total of 24 814 acute myocardial infarction patients were included, 9020 (36%) patients at 91 (29.8%) hospitals with departments of cardiology and 15 794 (64%) at 214 (70.2%) hospitals without cardiology departments. There were only minor differences in patient characteristics and prevalence of concomitant diseases between the two types of hospital. The first electrocardiogram was more often diagnostic at hospitals with cardiology departments (71.8% vs 66.5%, P<0.001). Reperfusion therapy and adjunctive medical therapy, such as aspirin, beta-blockers and ACE-inhibitors were used more often at cardiology departments (all P -values <0.001), even after adjustment for confounding parameters. Treatment improved at both types of hospital over time. Admission to a hospital with a department of cardiology was independently associated with a lower hospital mortality (14.2% vs 15.4%, adjusted OR=0.91; 95%CI: 0.83-0.99). Additional logistic regression models showed that the higher use of reperfusion therapy and recommended concomitant medical therapy was responsible for most of the survival benefit at such hospitals. CONCLUSION: Treatment of acute myocardial infarction patients at hospitals with departments of cardiology was independently associated with a higher use of recommended therapy and a lower hospital mortality compared to hospitals without such departments.