In Acute Myocardial Infarction Liver Parameters Are Associated With Stenosis Diameter

Detection of high-risk subjects in acute myocardial infarction (AMI) by noninvasive means would reduce the need for intracardiac catheterization and associated complications. Liver enzymes are associated with cardiovascular disease risk. A potential predictive value for liver serum markers for the severity of stenosis in AMI was analyzed.Patients with AMI undergoing percutaneous coronary intervention (PCI; n = 437) were retrospectively evaluated. Minimal lumen diameter (MLD) and percent stenosis diameter (SD) were determined from quantitative coronary angiography. Patients were classified according to the severity of stenosis (SD ≥ 50%, n = 357; SD < 50%, n = 80). Routine heart and liver parameters were associated with SD using random forests (RF). A prediction model (M10) was developed based on parameter importance analysis in RF.Age, alkaline phosphatase (AP), aspartate aminotransferase (AST), and MLD differed significantly between SD ≥ 50 and SD < 50. Age, AST, alanine aminotransferase (ALT), and troponin correlated significantly with SD, whereas MLD correlated inversely with SD. M10 (age, BMI, AP, AST, ALT, gamma-glutamyltransferase, creatinine, troponin) reached an AUC of 69.7% (CI 63.8–75.5%, P < 0.0001).Routine liver parameters are associated with SD in AMI. A small set of noninvasively determined parameters can identify SD in AMI, and might avoid unnecessary coronary angiography in patients with low risk. The model can be accessed via http://stenosis.heiderlab.de.     

Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest-Pain-Units“

The Chest Pain Unit (CPU) Task Force of the German Cardiac Society has elaborated prerequisites for a CPU certification program. To become a certified CPU, a facility must have 24-h cath lab capabilities, 24-h access to clinical chemistry, at least four intermediate care beds, and the capability for echocardiography, computed tomography (CT), magnetic resonance imaging (MRI) and abdominal ultrasound. The transfer time from the CPU to the cath lab should not exceed 15 minutes. The facility must demonstrate well-defined processes to evaluate moderate- and low-risk patients with chest pain that minimize unnecessary admissions and inappropriate discharges. This means that CPUs must have well-defined pathways when an acute coronary syndrome (ACS) patient arrives at their facility, including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), unstable angina (UA) and low-risk patients. Nurses and doctors in the CPU should have education and training opportunities and undergo practice drills. Doctors should have a sound knowledge of echocardiography and intensive care medicine. The Chest Pain Unit must be headed by a cardiologist.     

Treatment of arteriosclerosis

Summary. Arteriosclerotic disease develops over the course of several decades. Currently, a number of therapies are at hand to effectively stop this process and avoid complications of arteriosclerosis. Among the non-pharmacologic options, a balanced diet and physical activity predominate. A modern dietary plan offers a variety of tasty servings rich in fresh fruit and vegetables, cereals, fish, and poly-unsaturated fatty acids. The value of regular physical activity is demonstrated by the finding that an increase in exercise capacity ("cardiorespiratory fitness") by only one metabolic equivalent already reduces cardiovascular risk by 20-25 %. Regarding pharmacologic therapy, convincing data are available for cholesterol synthase inhibitors ("statins"), some substances which influence the renin-angiotensin system (such as ramipril), and platelet aggregation inhibitors. Statins produce a 20 to 30 % reduction of cardiac death, myocardial infarction, and stroke. In patients with increased cardiovascular risk, the beneficial action of statins is also evident in subjects with low baseline cholesterol values. Apart from the cholesterol-lowering effects, anti-inflammatory and other vasoprotective mechanisms are involved. The angiotensin-converting enzyme inhibitor ramipril has demonstrated that even independent of blood-pressure lowering, cardiovascular events (cardiac death, myocardial infarction, stroke) are substantially reduced in high-risk patients. The effect is in the same order as that of statins. In patients with left-ventricular hypertrophy, the angiotensin-receptor antagonist losartan produces a notable reduction in stroke, independent of its blood-pressure lowering action. Finally, the platelet aggregation inhibitors aspirin and clopidogrel have proven benefit in secondary prevention and, in the case of aspirin, also in primary prevention in cardiovascular high-risk patients. The anti-arteriosclerotic properties of other substances are actively investigated, including calcium channel blockers, betablockers, and novel drug classes. From the medical point of view, a broader use of the well-proven and effective therapies of arteriosclerosis and its complications is clearly warranted.     

Pharmacodynamic studies in suicidal digoxin poisoning (author's transl)

In two patients with suicidal digoxin poisoning the correlations between serum digoxin concentration and changes in the duration of QTc and the flattening of the T-waves were studied. The digoxin serum half-life following suicidal digoxin poisoning was in the first patient (10 mg beta-acetyl derivative of digoxin) 77 h, prolonged cause of renal insufficiency, and in the second patient 39.6 h. (20 mg beta-acetyl derivative of digoxin). In both patients the digoxin induced flattening of the T-wave reached a plateau of maximum efficacy at a serum level of 2-3 ng/ml with no further change up to a serum level of 13.2 ng/ml and 9.6 ng/ml respectively. A linear correlation, however, was found between the digoxin serum concentration and the digoxin induced shortening of QTc, r = 0.88 and r = 0.92 respectively. A plateau maximum efficacy was not found. The regression equations were y = -12.0 chi + 430.8 and y = -8.0 chi + 391.9 respectively. The shortening of QTc is therefore an important parameter for the diagnosis of digoxin poisoning. It can be determined very quick with no methodical problems.     

Bimanual Recoupling by Visual Cueing in Callosal Disconnection

Abstract

The cerebral control of bimanual movements is not completely understood. We investigated a 59-year-old, right-handed man who presented with an acute bimanual coordination deficit. Magnetic resonance imaging showed a lesion involving the entire corpus callosum, which was found on stereotactic biopsy to be an ischemic infarct. Paired-pulse transcranial magnetic stimulation indicated that the patient had a lack of interhemispheric inhibition, while intracortical inhibition in motor cortex of either side was normal. Functional magnetic resonance imaging showed activation of the left SMA, the bilateral motor cortex and anterior cerebellum during spontaneous bimanual thumb-index oppositions, which were uncoupled as evident from simultaneous electromyographic recordings. In contrast, when the bimanual thumb-index oppositions were cued by a visual stimulus, the movements of both hands were tightly correlated. This synchronized activity was accompanied by additional activations bilateral in lateral occipital cortex, dorsal premotor cortex and cerebellum. The data suggest that the visually cued movements of both hands were recoupled by action of a bihemispheric motor network.     

Influence of resection extent on morbidity in surgery for squamous cell cancer at the pharyngoesophageal junction

Purpose

Squamous cell cancer (SCC) of the pharyngoesophageal junction area has a poor prognosis mainly due to late symptom manifestation and diagnosis. Treatment of choice is still pharyngolaryngoesophagectomy, substantially affecting quality of life. Limited surgical procedures have been adopted as well. The aim of this retrospective study was to evaluate whether the extent of resection influences postoperative safety and mortality.

Methods

From 1984 to 2006, 66 patients were operated at a single tertiary referral center. Nineteen patients (28.8 %) had SCC of the hypopharynx and 47 patients (71.2 %) had SCC of the cervical and cervicothoracic esophagus. Thirty-five patients (53.0 %) underwent cervical esophageal resection (CE) and 31 underwent total esophagectomy (TE). In 39 patients (59.1 %), the larynx was preserved. Thirteen patients (19.7 %) underwent multimodal treatment.

Results

Overall postoperative morbidity was 69.7 % and reoperation rate reached 28.8 %. TE (P?=?0.03) and larynx preservation (P?=?0.02) were followed by a higher rate of non-lung infections compared with CE and pharyngolaryngectomy, respectively. Pulmonary complications have been observed more frequently after larynx preservation (P?=?0.02). Hospital mortality was 9.1 %. Four patients died after TE (12.9 %) and two patients died after CE (5.7 %). In all of them, the larynx had been preserved (15.4 %). Overall, 53 patients (80.3 %) died until follow-up. One-year and 5-year survival in patients with the major tumor burden at the cervicothoracic site was 35.7 and 0 %.

Conclusions

CE can be recommended as long as R0 resection is warranted. The advantage of larynx preservation is gained by higher morbidity and mortality rates and may not be recommended as standard procedure. Surgery may not be appropriate for advanced SCC in the cervicothoracic region.