Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component

Malposition of the acetabular component is a risk factor for post-operative dislocation after total hip replacement (THR). We have investigated the influence of the orientation of the acetabular component on the probability of dislocation. Radiological anteversion and abduction of the component of 127 hips which dislocated post-operatively were measured by Einzel-Bild-Röentgen-Analysis and compared with those in a control group of 342 patients. In the control group, the mean value of anteversion was 15 degrees and of abduction 44 degrees. Patients with anterior dislocation after primary THR showed significant differences in the mean angle of anteversion (17 degrees), and abduction (48 degrees) as did patients with posterior dislocation (anteversion 11 degrees, abduction 42 degrees). After revision patients with posterior dislocation showed significant differences in anteversion (12 degrees) and abduction (40 degrees). Our results demonstrate the importance of accurate positioning of the acetabular component in order to reduce the frequency of subsequent dislocations. Radiological anteversion of 15 degrees and abduction of 45 degrees are the lowest at-risk values for dislocation.

Evaluation of antimitotic activity of Rotula aquatica (Lour): a traditional herb used in treatment of cancer

Rotula aquatica was extensively used by vaidyas (Ayurvedic practioners) in holistic treatment of cancer. In the present study, an attempt has been made to evaluate the antimitotic activity of R. aquatica. Preliminary antimitotic screening was done using Allium cepa root tip assay. The mitotic index of the root tips markedly decreased with increasing concentration of the aqueous extract. The different fractions obtained by successive extraction of R. aquatica using solvents of increasing polarity were also evaluated for their antimitotic activity. Tannins were isolated which showed a better activity than the non-tannin fraction. Experiments were also carried out with incorporation of folic acid in the aqueous extract. Folic acid inhibited the antimitotic activity of aqueous extract of R. aquatica in a dose dependent manner. The results obtained were compared with methotrexate--a known drug available in market as anti-cancer agent. The studies were extended to human cells using 3 pancreatic cancer cell lines, viz: HPAF-II, BxPC-3, and CAPAN-2. Extract of R. aquatica was found to be extremely effective in the prevention of cell proliferation of the pancreatic cancer cell lines. The phytochemical evaluation revealed presence of polyphenols (tannins) and steroids. A HPTLC fingerprinting was developed and studied. Two compounds were isolated and subjected to spectral studies like UV, IR and mass spectrums. The empirical formula was derived by considering this data with elemental analysis of the compounds.

Physical and Physiological Factors Associated with Success in Professional Alpine Skiing

Scientific data on the physiological profile of world class skiers are sparse. During the last decade the Austria Ski Team was the most successful in the world. It was the objective of this study to describe the physical and physiological characteristics of World Cup (WC) skiers. Twenty female and 28 male members of the Austrian WC Ski Team were examined pre- and post-seasonally from 1997 to 2000. Physical parameters such as age, height, body mass, body mass index, percent body fat and thigh circumference were recorded from each athlete. The physiological variables investigated consisted in the aerobic power and in the muscle strength of the lower limbs. Racing performance was defined by the WC ranking position. The athlete's aerobic performance capacity was assessed by maximal exercise testing on a bicycle ergometer, and the isokinetic muscle strength of the knee extensor and flexor muscles by the use of a computer-interfaced dynamometer. From 1997 to 2000 about half (48 %; n = 106) of all alpine WC racing events (n = 221) were won by the athletes investigated. The typical world class skier is in the mid-twenties (25.2 y [female]; 27.6 y [male]). The mean values for height were 1.66 m (female) vs. 1.81 m (male), for body mass 65.1 kg (female) vs. 87 kg (male) and for the percentage of body fat 24.5 % (female) vs. 15.8 % (male). The maximum power output was 4.3 +/- 0.4 (female ) and 4.7 +/- 0.4 W/kg (male), the corresponding values for VO(2)max were 55 +/- 3.5 (female) and 60 +/- 4.7 ml/kg/min (male). The maximal values for peak torque and work for knee extension amounted to 206 +/- 21 (female) and 334 +/- 43 Nm (male), and 2690 +/- 364 (female) and 4414 +/- 629 J (male), respectively. In both sexes there were neither significant laterality nor dysbalance. The hamstring/quadriceps ratios were between 0.57 - 0.60. Among all physical and physiological variables, only the aerobic power in males was found to be strongly correlated (r = 0.947; p = 0.001 for W (max); r = 0.964; p < 0.001 for VO(2)max) to racing performance. The study proves the practical experience that success in professional alpine skiing is not related to single physiological variables. Two main factors, however, are crucial, i. e. high levels of aerobic power and muscle strength.

RES function and liver microcirculation in the early stage of acute experimental pancreatitis

BACKGROUND/AIMS

The reticuloendothelial system and in particular the Kupffer cells in the liver are important for eliminating antigens and toxic substances in many diseases including acute pancreatitis. Optimal Kupffer cell function is believed to depend on numerous factors including intact hepatic blood supply and microcirculation. The aim of the study was to evaluate whether hepatic microcirculation and Kupffer cell function are impaired in acute pancreatitis and whether enhancement of hepatic capillary blood flow leads to improved reticuloendothelial system function.

METHODOLOGY

Acute pancreatitis was induced in rats by intraductal infusion of bile salt followed by i.v. cerulein hyperstimulation. Animals were randomized to receive either a selective endothelin-A receptor antagonist (ET-RA; LU-135252; 50 mg/kg) or saline. Sham-operated animals (intraductal and i.v. saline infusion) treated according to the same protocol served as controls. Liver phagocytic function was evaluated in 6 animals per group 6 and 24 hrs after acute pancreatitis induction and treatment using 99mTc-labeled Nanocoll and a scintillation camera technique. Another 6 animals of each group were used for intravital microscopic determination of hepatic capillary blood flow using fluorescein-labeled erythrocytes.

RESULTS

Six hours after acute pancreatitis induction, hepatic capillary blood flow and nanocoll clearance were significantly decreased in saline-treated animals (compared to saline-treated healthy controls). Endothelin-A receptor antagonist significantly improved hepatic capillary blood flow and nanocoll clearance. This beneficial effect was no longer seen after 24 hrs when these parameters had spontaneously returned to values not significantly different from normal.

CONCLUSIONS

Reticuloendothelial system function and hepatic capillary blood flow are impaired (only) in the early stage of this acute pancreatitis model. Endothelin-A receptor antagonist improves hepatic capillary blood flow at this stage. Enhancement of hepatic capillary blood flow is accompanied by normalization of nanocoll clearance, suggesting that hepatic microcirculation influences phagocytic Kupffer cell function early in acute pancreatitis.

[The evaluation of the second-look operation of patients with ovarian carcinoma and tubal carcinoma by means of a retrospective comparison study]

INTRODUCTION

This investigation is a retrospective analysis to evaluate the influence of second-look surgery on the relapse-free and overall survival of patients with ovarian and tubal carcinomas.

METHOD

For 208 patients with and without second-look operation out of 469 of the total collective, a matched analysis and a Cox regression model were established in the framework of a multivariate analysis.

RESULTS

Second-look surgery in patients with ovarian cancer had no significant influence on the relapse-free and overall survival. The 10-year survival was equal in both groups:

CONCLUSION

Second-look surgery cannot be justified on the basis of clinically noninvasive methods such as radiological findings with additional use of tumor markers. It should only be done in control clinical trials to evaluate new means of treatment.

Asymmetric termination of secondarily generalized tonic-clonic seizures in temporal lobe epilepsy

In patients with secondarily generalized tonic-clonic seizures (sGTCS) an asymmetric termination of the clonic phase can be observed. The authors systematically analyzed this phenomenon in patients with temporal lobe epilepsy (TLE). Thirty-nine sGTCS from 29 patients with TLE who underwent successful epilepsy surgery were analyzed, in addition to a prospectively collected group of 28 patients with TLE who had 35 sGTCS. The clonic phase of sGTCS did not end synchronously in 65.7% of all patients and in 59.4% of all seizures. In 79.3% to 80% this was ipsilateral to the hemisphere of seizure onset, and there was excellent interobserver agreement.

Exercise intensity of cycle-touring events

The aim of the study was to analyze the exercise intensity of recreational cyclists participating in a cycling-touring event. In 14 male healthy recreational cyclists heart rate (HR) monitoring was performed during the Otztal Radmarathon 1999 (distance: 230 km; altitude difference: 5500 m) in order to evaluate the HR response and to estimate the cardiopulmonary strains for the less-trained athlete confronted with such a marathon. Four different exercise intensities were defined as percentages of maximal HR (HR(max)) as follows: recovery HR (HR(re)) < 70 % of HR max; moderate aerobic HR (HR(ma)) = 70 - 80 %; intense aerobic HR (HR(ia)) = 80 - 90 %; and anaerobic HR (HR(an)) > 90 %. All athletes finished the competition successfully. The mean racing time was 10 h 14 min, the average speed 22.5 km/h. The mean HR(max) was 188 bpm, the average value of the measured HRs (HR(average)) was 145 bpm resulting in a mean HR(average)/HR(max) ratio of 0.77. Athletes spent 18.5 % (1 h 54 min) of total race time within HR(re), 28 % (2 h 52 min) within HR(ma), 39.5 % (4 h 02 min) within HR(ia), and 14 % (1 h 26 min) within HR(an). The vast majority of exercise was done under "aerobic conditions" (HR(re) + HR(ma) + HR(ia) = 86 % or 8 h 48 min) - confirming the knowledge that the aerobic energy supply is crucial for the performance of long-term exercise. The large amount of high exercise intensities (HR(ia) + HR(an) = 53.5 % or 5 h 30 min), however, features the intense cardiopulmonary strains evoked by such competitions. The HR response was related to the course profile with HRs significantly declining in all subjects to an extent of 10 % during the course of race. Our findings show that the exercise intensity borne by recreational cyclists during a cycle-touring event is high and very similar to that of professionals. With respect to the high cardiovascular strains a thorough medical screening is advisable for any participant of such an event combining both high volume and high intensity loads.

Prevalence of multiple sclerosis in Austria. Results of a nationwide survey

The epidemiology of multiple sclerosis (MS) in Austria is almost unknown. We evaluated the prevalence of MS in Austria using data from questionnaires completed by neurologists, comprising information on a total of 1,006 MS patients who attended 30 out-patient specialized clinics nationwide. Additional data were collected from 2,414 MS patients, who received questionnaires from the Austrian MS Society or their doctor. A novel extrapolation model, based on frequencies of patients visits at MS clinics, was used to estimate the overall prevalence of MS. Considering either disability or the course of the disease, the prevalence of MS patients in Austria was estimated to be 98.5 per 100,000 people. The prevalence of MS in Austria was found to be similar to that of other countries in Central Europe. Epidemiological studies, such as this, provide a unique source of data from which key features of a disease and its impact on patients may be examined.

Short-term effects of prolonged strenuous endurance exercise on the level of haematocrit in amateur cyclists

Knowledge is sparse about the extent of potential dehydration due to prolonged strenuous cycling and its haematological acute effects on the haematocrit (Hct) in study populations credibly not taking any kind of doping. With increasing training load levels of Hct and haemoglobin (Hb) decrease in both amateurs and professionals as a long-term consequence due to expanded plasma volume (PV). On a short-term basis, however, counteracting dehydration potentially brought about by endurance exercise may cause a rise in Hct bringing competitive cyclists into conflict with the current condition regulations and Hct cut-off of 50 % set by the International Cycling Union (UCI) in its fight against erythropoietin (rhEPO) doping. On the other hand adequate and sufficient fluid substitution being substantial for a successful endurance performance should prevent any pronounced Hct rises. To study the haematological acute effects of prolonged strenuous cycling we measured Hct, Hb, red blood cell (RBC) count and plasma protein in a reliably 'clean' population of 38 well-trained male amateur cyclists before, immediately after and one day after an extraordinary ultramarathon. The pre-race levels of Hct, Hb and RBC count were placed in the lower range of normal distribution and well below the Hct cut-off limit of the UCI. Immediately post-exercise the mean levels of Hct, Hb, RBC count and protein remained unchanged. One day after race, however, all four parameters significantly dropped by 3 %, 6.7 %, 6.5 %, 9.9 % respectively (p < 0.001), indicating marked post-exercise PV expansion. The calculated percentage increase in PV was 11.9 %. No evidence for coexisting exercise-induced haemolysis was found. Our study shows that in "clean, rhEPO-free" amateur cyclists who involve in strenuous marathon cycling the haematological short-term effects of extraordinary marathon cycling consist in considerable PV expansion making Hct values fall on the following day. The findings - gained from amateurs though - suggest that despite all its disadvantages the UCI Hct cut-off represents an appropriate means to discourage from excessive rhEPO doping at least as long as the available direct methods for detecting this kind of misuse are not yet applied by the international sports federations.

Persistent multiple organ microcirculatory disorders in severe acute pancreatitis: experimental findings and clinical implications

This study characterizes microcirculatory changes (capillary blood flow, capillary permeability, and leukocyte rolling) in the pancreas, colon, liver, and lungs at different stages of severe acute pancreatitis (AP) in a well-established rat model using intravital microscopy and computerized image analysis. The results demonstrate that microcirculatory disorders in severe AP are not confined to the pancreas but can also be found in the colon, liver, and lungs; that they extend beyond the early stage of AP and persist for 48 hr (and longer); and that they not only affect capillary blood flow but also involve prolonged changes of capillary permeability and leukocyte endothelial interaction. These findings may explain previous observations that therapeutic strategies aimed at enhancing microcirculation improve outcome in AP even if therapy is delayed and pancreatic necrosis can no longer be influenced. Since these systemic microcirculatory disturbances may contribute to AP-associated multiple organ dysfunction syndrome, further studies are warranted to evaluate whether improvement of microcirculation stabilizes organ function in AP and how long this may be effective after disease onset.

Persistent multiple organ microcirculatory disorders in severe acute pancreatitis: experimental findings and clinical implications

This study characterizes microcirculatory changes (capillary blood flow, capillary permeability, and leukocyte rolling) in the pancreas, colon, liver, and lungs at different stages of severe acute pancreatitis (AP) in a well-established rat model using intravital microscopy and computerized image analysis. The results demonstrate that microcirculatory disorders in severe AP are not confined to the pancreas but can also be found in the colon, liver, and lungs; that they extend beyond the early stage of AP and persist for 48 hr (and longer); and that they not only affect capillary blood flow but also involve prolonged changes of capillary permeability and leukocyte endothelial interaction. These findings may explain previous observations that therapeutic strategies aimed at enhancing microcirculation improve outcome in AP even if therapy is delayed and pancreatic necrosis can no longer be influenced. Since these systemic microcirculatory disturbances may contribute to AP-associated multiple organ dysfunction syndrome, further studies are warranted to evaluate whether improvement of microcirculation stabilizes organ function in AP and how long this may be effective after disease onset.

High expression of the chemokine receptor CXCR4 predicts extramedullary organ infiltration in childhood acute lymphoblastic leukaemia

Childhood acute lymphoblastic leukaemia (ALL) is a malignancy with the potential to infiltrate the liver, spleen, lymph nodes and brain. Such extramedullary presentation is important for understanding the biology of childhood ALL and also for developing new prognostic parameters. A potential mechanism in the trafficking of leukaemia cells is the interaction of the chemokine receptor CXCR4, which is expressed on ALL cells, and its ligand stromal cell-derived factor-1 (SDF-1), produced by stromal cells in bone marrow and extramedullary organs. Functionality of CXCR4 was demonstrated by a high correlation between cell surface density of CXCR4 and transendothelial migration of leukaemia blasts towards a gradient of SDF-1 (r = 0.73, P = 0.001). Inhibition of SDF-1-induced migration by an anti-CXCR4 monoclonal antibody (78.33 +/- 23.86% inhibition) evidenced the specificity of CXCR4 to SDF-1. In order to evaluate clinical significance of CXCR4 expression, lymphoblasts from the bone marrow of 73 patients with and without extramedullary organ infiltration were compared. Multiparameter flow cytometry revealed that lymphoblasts from patients with high extramedullary organ infiltration, defined as ultrasonographically measured enlargement of liver or spleen, expressed the CXCR4 receptor at higher fluorescence intensity (median 66.12 +/- 66.17) than patients without extramedullary organ infiltration (median 17.56 +/- 19.29; P < 0.001). Consequently, high expression of CXCR4 was strongly predictive for extramedullary organ involvement, independently of the peripheral lymphoblast count. Highest CXCR4 expression was seen in mature B ALL (median 102.74 +/- 92.13; P < 0.003), a disease characterized by a high incidence of extramedullary bulky disease. As high expression of the chemokine receptor CXCR4 predicts extramedullary organ infiltration in childhood ALL, we suggest that CXCR4 and its ligand play an essential role in extramedullary invasion.

Peroxisome proliferator-activated receptor gamma induces pancreatic cancer cell apoptosis

Peroxisome proliferator-activated receptor gamma (PPAR-gamma) decreases the growth of certain cancer cells. In the present study, we found that six different human pancreatic cancer cell lines (AsPC-1, BxPC-3, Capan-2, HPAF-II, MIA PaCa-2, and PANC-1) expressed PPAR-gamma m-RNA and synthesized the protein. The endogenous and exogenous PPAR-gamma ligands 15-deoxy-d12,14-prostaglandin J(2) (15-PGJ(2)) and ciglitazone decreased cell number, cell viability, and increased floating/attached ratio, in a time- and dose-dependent fashion. 15-PGJ(2) increased intracellular nucleosome concentration after 6 h, but did not increase caspase-3 activity even after 96 h. Combined treatment with both 15-PGJ(2) and the caspase-3 inhibitor DEVD-CHO had no effect on cell viability, but the general caspase inhibitor ZVAD-FMK reduced 15-PGJ(2)-induced apoptosis. We concluded that the six human pancreatic cancer cells tested all expressed PPAR-gamma receptor, and treatment with PPAR-gamma agonists decreased cell viability and growth in a time- and dose-dependent manner. These effects were partially mediated by induction of caspase-3 independent apoptosis.

Contrast-enhanced transrectal color doppler ultrasonography (TRCDUS) for assessment of angiogenesis in prostate cancer

BACKGROUND

The clinical relevance of tumor angiogenesis has been investigated in several human tumors, including prostate carcinoma (PC). Previously, we found angiogenesis, measured as microvessel density (MVD), to be an independent prognostic factor in PC. Therefore, we evaluated contrast-enhanced Transrectal Color Doppler Ultrasonography (TRCDUS) for assessment of angiogenesis in PC.

MATERIALS AND METHODS

We investigated 15 patients with PC before radical prostatectomy (RP) and 3 control patients before radical cystoprostatectomy. TRCDUS was performed using a micro-bubble-based ultrasound enhancer Levovist for identifying hypervascularized areas within the prostate. Computer-assisted quantification of color pixel intensity (PI) was used to evaluate objectively the hypervascularized areas; resistive index (RI) measurements were also obtained in these areas. After histopathological examination of the entire prostate gland for tumor confirmation, immunohistochemical evaluation of MVD using a polyclonal antibody against factor VIII was performed as described by Weidner et al. (N Engl J Med 324: 1-8, 1991). TRCDUS findings were correlated with the immunohistochemical data.

RESULTS

All patients showed hypervascularized areas (range: 1-9) on contrast-enhanced TRCDUS. Hypervascularized areas showed a sensitivity of 50.8% and a specificity of 95.2% for detecting PC. Analysis of TRCDUS data and immunohistochemistry revealed a significant correlation between PI and MVD in PC specimens, demonstrating a correlation coefficient of r2 = 0.977 (p<0.001). RI did not correlate with MVD.

CONCLUSION

Contrast-enhanced TRCDUS showed a high specificity in identifying PC. PI correlated significantly with MVD. Therefore, quantification of color Doppler signals seems to be helpful for assessment of angiogenesis in PC.

Radiographic abnormalities in the thoracolumbar spine of young elite skiers

An increased frequency of radiologic abnormalities in the thoracolumbar spine has been reported among young athletes in various sports, but there are no data concerning ski sports. To evaluate the incidence of these abnormalities in young elite skiers, we compared 120 skiers younger than 17 years old (alpine skiers, ski jumpers, and Nordic cross-country skiers) with a random sample of 39 control subjects of the same age who had no history of high-performance sports participation. Standardized anteroposterior and lateral radiographs of the entire lumbar spine, the lower thoracic spine, and the upper part of the sacrum were obtained from each athlete and each control subject. Radiographs were evaluated by two independent observers for the presence and size of anterior and posterior endplate lesions and Schmorl's nodes. The elite alpine skiers and ski jumpers demonstrated a significantly higher rate of anterior endplate lesions than did the control subjects. This finding might be attributable to excessive loading and repetitive trauma of the immature spine under high velocity, especially in the forward bent posture.

Prolonged iron depletion after allogeneic 2-unit RBC apheresis

BACKGROUND

Allogeneic 2-unit RBC apheresis is a safe procedure offering many advantages for donors and blood banks. A controlled study was performed to determine whether the recommended minimum interval of 4 months between 2-unit RBC apheresis donations is appropriate in terms of the recovery of RBCs and the regeneration of iron stores.

STUDY DESIGN AND METHODS

Twenty male subjects each donated 2 units of RBCs by apheresis. The RBC count, reticulocyte count, EPO, and measures of iron status were analyzed before and during the 4 months after donation.

RESULTS

A significant decrease in Hb (15.89 +/- 0.82 [mean +/- SD] vs. 14.08 +/- 0.97 mg/dL, baseline vs. Day 7; p<0.001) was equalized within 2 months. In contrast, ferritin values declined significantly from 54.2 +/- 33.7 to 23.42 +/- 21.94 microg per L (predonation vs. Day 30) and remained significantly below predonation values, but within the normal range, until the end of the study period.

CONCLUSION

A donation interval of 4 months is appropriate in terms of RBC recovery, but may not be appropriate in terms of iron store regeneration. The tendency to shorten the donation interval should be reconsidered in light of the measurements of iron storage. The use of ferritin levels is recommended as a preselection criterion for allogeneic 2-unit RBC apheresis.

Inappropriate detection of supraventricular arrhythmias by implantable dual chamber defibrillators: a comparison of four different algorithms

Inappropriate therapy of supraventricular tachyarrhythmias by an ICD is still a common problem. Dual chamber (DDD) ICDs provide additional atrial sensing and should result in higher specificity for detection of supraventricular tachyarrhythmias. However, a direct comparison of different dual chamber algorithms has not been reported. The detection algorithms of four different DDD ICDs were tested: Phylax AV, Defender IV, Ventak AV III DR, and Gem DR 7271. Based on arrhythmias recorded from patients undergoing invasive electrophysiological studies and in many cases of catheter ablation at our institution, a library consisting of 71 supraventricular and 15 ventricular tachyarrhythmias was created. The library consists of episodes of atrial fibrillation, atrial flutter with different AV conduction, typical and atypical AV nodal reentrant tachycardia, AV reentrant tachycardia, sinus tachycardia, and ventricular tachycardia with and without ventriculoatrial conduction. Atrial fibrillation was appropriately classified by all four algorithms. However, the specificity for detection of other supraventricular tachyarrhythmias achieved by the Biotronik (12%) and the Guidant (11%) devices was significantly lower compared to the specificity of the ELA (28%) and the Medtronic DDD ICD (20%). This is due to the fact that the Biotronik and the Guidant algorithm classified all supraventricular tachyarrhythmias resulting in a stable ventricular rate as ventricular tachycardia, whereas the ELA and Medtronic algorithms performed a more detailed analysis by assessment of PR association, atrial onset, or timing of the atrial event relative to the ventricular event, respectively. Atrial fibrillation, the most common supraventricular tachyarrhythmia in patients with ICD, was detected by all devices.

[Influence of reflex zone therapy of the feet on intestinal blood flow measured by color Doppler sonography]

OBJECTIVE

An influence on organ-associated blood flow is considered as a possible mechanism of action of reflex zone massage of the feet (FRZM) therapy. In the present study we investigated whether changes in intestinal blood flow can be achieved by FRZM.

MATERIAL AND METHODS

32 healthy adults (19 women and 13 men) were randomly assigned to the treatment or the placebo group. Subjects of the treatment group received foot massage on the zones assigned to the intestines and those of the placebo group received massage on zones unrelated to the intestines. Before, during and after FRZM, the blood flow velocity, the peak systolic and the end diastolic velocities in the superior mesenteric artery as well as the resistive index as a parameter of vascular resistance were calculated.

RESULTS

During FRZM, in the subjects of the treatment group there was a significant reduction in the resistive index (p = 0.021), suggesting an increase in the blood flow in the superior mesenteric artery and the subordinate vascular system. In contrast, there were no significant changes in the resistive index in the subjects of the placebo group.

CONCLUSION

The reduction in the resistive index observed in the treatment group supports the assumption that FRZM improves blood flow in the organs considered to be associated with the specific foot zones, at least during the therapy process.

Plasma levels of cardiac troponin I after prolonged strenuous endurance exercise

This study provides biochemical evidence that ultraendurance exercise may cause subclinical myocardial damage, even in well-trained cyclists. The cellular nature of this damage and its clinical relevance remain unknown at present.

Comparison of score evaluations and instrumented measurement after anterior cruciate ligament reconstruction

Forty-four patients who had undergone unilateral anterior cruciate ligament reconstructions were evaluated retrospectively with seven different scoring systems (International Knee Documentation Committee, Orthopadische Arbeitsgruppe Knie, Lysholm, Feagin and Blake, Zarins and Rowe, Cincinnati, and Marshall scores). The results varied between systems and therefore lacked reliability. Of the 44 patients, 32 were rated as excellent according to the Cincinnati score while only 3 patients were rated as normal according to the International Knee Documentation Committee form. Good and excellent results were found twice as frequently with the Cincinnati and Lysholm scores compared with the scores of Zarins and Rowe or the International Knee Documentation Committee form. Statistical analysis confirmed this observation and revealed significant differences between the scoring systems. Side-to-side differences using the manual maximum displacement test with the KT-1000 arthrometer revealed good correlation with the International Knee Documentation Committee and the Orthopadische Arbeitsgruppe Knie questionnaires. None of the other scoring systems, which do not measure anterior laxity, produced reasonable correlation with instrumented measurements. We found that certain population-specific factors as well as the distribution of single findings can distort the results of scoring systems. To avoid these interference factors, the patient sample should be homogeneous and selected prospectively and there should be agreement about the value of single findings.

Effect of fluid resuscitation with and without endothelin A receptor blockade on hemoconcentration and organ function in experimental pancreatitis

BACKGROUND

Intravascular fluid loss contributes to pancreatitis-associated multiple organ dysfunction and is thus a major target for therapy in this life-threatening disease.

AIM

To evaluate intravascular fluid loss and extravascular fluid sequestration together with cardiorespiratory and renal function in a well-established rat model of severe acute pancreatitis (AP) and to investigate the effect of fluid resuscitation with and without endothelin receptor A blockade on these parameters.

METHOD

Induction of AP in rats by a standardized bile salt infusion into the pancreatic duct and intravenous cerulein hyperstimulation. Six hours after AP induction, animals were randomized into 4 groups to receive (1) no therapy; (2) 4 ml/kg/h Ringer's lactate (RL) i.v.; (3) 8 ml/kg/h RL i.v., or (4) 4 ml/kg/h RL plus an endothelin receptor antagonist. Target parameters measured before and after AP induction and during the 24-hour observation period included: mean arterial blood pressure, heart rate, hematocrit, arterial blood gases, urine production, ascites and pleural effusions.

RESULTS

After 6 h, all animals presented with severe hemoconcentration (hematocrit >57%) and oliguria (<0.5 ml/6 h). Cardiorespiratory parameters were within the normal range. Up to 12 h after AP induction, animals without therapy had an increased hematocrit and oliguria and developed metabolic acidosis. Animals receiving fluid resuscitation had a significant drop in hematocrit and maintained compensated blood gas values. A significant increase in urine production was only observed in animals given 8 mg/kg/h RL. Between 12 and 24 h, urine production significantly increased with fluid resuscitation and respiratory parameters stabilized except for animals treated with 8 ml/kg/h RL which developed arterial hypoxia and hypercapnia.

CONCLUSIONS

Intravascular fluid loss and extravascular fluid sequestration together with decreased urine production characterize the early phase of this model of severe AP. Massive fluid resuscitation necessary for increasing urine output may lead to respiratory distress. Reduction of intravascular fluid loss by endothelin receptor blockade is associated with improved renal and respiratory function.

Endothelin receptor blockade in severe acute pancreatitis leads to systemic enhancement of microcirculation, stabilization of capillary permeability, and improved survival rates

BACKGROUND

We previously demonstrated that therapy with a new endothelin A receptor antagonist (ET-RA) significantly reduced mortality rates in severe acute pancreatitis (AP) in the rat without attenuating local signs of disease severity (intrapancreatic protease activation, acinar cell necrosis). This raised the question as to why ET-RA was so effective. The purpose of this study was to assess the effect of ET-RA on microcirculation (particularly capillary permeability) within and outside of the pancreas on intravascular fluid loss and extravascular fluid sequestration and on distant organ function.

METHODS

Severe AP was induced in rats by standardized intraductal bile acid infusion and cerulein hyper-stimulation. Starting 6 hours (n = 24 rats) and 12 hours (n = 30 rats) after the onset of AP, animals randomly received either the ET-RA (LU-135252) or saline solution with fluid resuscitation (6 mL/kg/h Ringer's lactate). At 24 hours, animals were relaparotomized for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Further monitoring included cardiorespiratory and renal parameters, hematocrit levels and quantification of ascites and pleural effusions, and acinar cell necrosis at autopsy. Groups of sham-operated healthy animals (n = 6 animals each) that had been treated according to the same protocol served as control animals.

RESULTS

ET-RA treatment that was started 6 hours after AP-induction significantly decreased hematocrit levels (38% +/- 1% vs 45% +/- 2% with saline solution treatment), reduced ascites and pleural effusions (6.7 +/- 1.3 mL vs 11.9 +/- 1.3 mL), and improved urine production (4.8 +/- 0.5 mL vs 2.9 +/- 0.6 mL) and respiratory parameters. Moreover, all microcirculatory parameters were improved; in particular, capillary permeability was stabilized (158% +/- 9% vs 248% +/- 8% in the colon). These beneficial effects were also seen when therapy was delayed until 12 hours after AP induction. Pancreatic necrosis was not significantly reduced. The overall mortality rate was 12% in ET-RA-treated animals and 42% in saline solution-treated control animals (P <.05). In healthy animals ET-RA did not significantly alter the target parameters, except for a reduction of capillary permeability in the pancreas.

CONCLUSIONS

Improved microcirculation and stabilized capillary permeability in ET-RA-treated animals together with reduced intravascular fluid loss and extravascular fluid sequestration and improved renal and pulmonary function (1) may explain improved survival in this model, (2) support the hypothesis that systemic disease sequelae significantly contribute to outcome in AP, and (3) suggest that ET-RA may be a promising therapeutic tool in AP because it counteracts microcirculatory disorders that contribute to pancreatitis-associated organ dysfunction even when therapy is delayed to a point at which pancreatic injury may no longer be influenced.

Experimental models of acute pancreatitis: are they suitable for evaluating therapy?

Since randomized controlled studies of severe acute human pancreatitis can be performed only with restrictions, at least some aspects of innovative therapy concepts should first be clarified in animal experiments. In vitro trials are inadequate for this purpose since they cannot simulate the complex course of severe acute pancreatitis. Animal test results can be transferred to clinical practice if the results are based on trials with established models, standardized methods, and a study design imitating the clinical situation. This contribution discusses the demands on such an animal model of acute pancreatitis and a corresponding study protocol and presents models and protocols which meet these requirements. Concrete examples are presented to show that animal experiments are of great value under these conditions, especially in acute necrotizing pancreatitis. Further standardization of models, protocols, and monitoring should further improve future animal therapy studies at least to the extent that it is possible to select particularly promising substances, which should then be tested in randomized controlled trials.

Therapy for microcirculatory disorders in severe acute pancreatitis: comparison of delayed therapy with ICAM-1 antibodies and a specific endothelin A receptor antagonist

Many of the complications in severe acute pancreatitis result from the amplifying effects of microcirculatory disruption. The pathogenesis of these microcirculatory disorders is multifactorial and involves various vasoactive mediators. Thus questions arise as to which vasoactive mediators are most important and how long after the onset of disease vasoactive mediator blockade may be effective. The present study compares the effect of delayed therapy with two vasoactive mediator antagonists, previously tested with promising results in other studies in a well-established rodent model of severe acute pancreatitis. Twelve hours after induction of acute pancreatitis, rats were randomized to therapy with intracellular adhesion molecule-1 (ICAM-1) antibody (2 mg/kg IA-29), endothelin A receptor antagonist (ET-RA) (40 mg/kg LU 135252), or saline solution (volume equivalent). After 12 hours of fluid resuscitation, animals underwent repeat laparotomy for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Other measurements included cardiorespiratory parameters, hematocrit, pleural effusions, ascites, urine production, and survival. Compared to saline treatment, both ICAM antibody and ET-RA significantly enhanced capillary blood flow in the pancreas and colon, reduced leukocyte rolling, and stabilized capillary permeability. These beneficial effects on microcirculation were associated with decreased fluid loss into the third space and improved renal function and survival. Although both antagonists likewise enhanced capillary blood flow and reduced leukocyte rolling, ET-RA was significantly more effective than ICAM antibody in counteracting capillary leakage, thereby further reducing fluid sequestration. The present study confirms the beneficial effects of endothelin and ICAM antagonists in severe acute pancreatitis, even with delayed therapy, suggesting that both compounds are candidates for further clinical testing. Selective endothelin A receptor blockade appears to be especially attractive for clinical use not only because it was superior to ICAM antibody in the present study but also because of its favorable pharmacologic properties and (preliminary) positive results in clinical phase 2 studies currently underway for other diseases.

Effect of endothelin and endothelin receptor blockade on capillary permeability in experimental pancreatitis

BACKGROUND

Capillary leakage with fluid loss into the third space contributes to many of the early systemic complications in severe acute pancreatitis. There has been increasing interest in endothelin as one of the factors affecting capillary permeability.

AIM

To elucidate further the role of endothelin in the development of capillary leakage in acute pancreatitis by investigating the effect of exogenous endothelin administration and endothelin receptor blockade in sham operated animals and two models of acute pancreatitis.

METHODS

Determination of capillary permeability in the pancreas and colonic mucosa by quantifying extravasation of fluorescein labelled dextran using a novel computer assisted video image analysis system.

RESULTS

Pancreatic and colonic capillary permeability increased stepwise from mild to severe acute pancreatitis. Endothelin increased pancreatic and colonic capillary permeability in healthy animals and animals with mild acute pancreatitis but had no additional adverse effect in severe acute pancreatitis. Endothelin receptor blockade decreased pancreatic capillary permeability in sham operated rats but had no effect on the colon. In mild and severe acute pancreatitis, endothelin receptor blockade stabilised increased capillary permeability in both the pancreas and colon.

CONCLUSIONS

Endothelin plays an important role in mediating capillary permeability in the pancreas. In severe pancreatitis, it increases capillary permeability even outside the pancreas, thereby contributing to capillary leakage. Endothelin receptor blockade significantly reduces capillary permeability in acute pancreatitis both in and outside the pancreas, suggesting a therapeutic approach to counteract capillary leakage in severe acute pancreatitis.

Does glutamine reduce bacterial translocation? A study in two animal models with impaired gut barrier

Failure of intestinal barrier function and subsequent translocation of bacteria from the gut are believed to play a decisive role in the development of systemic septic complications, for example, following major trauma or major abdominal surgery. This study evaluated: (a) the effect of glutamine on colonic microcirculation and electrophysiological parameters reflecting gut barrier function, (b) the translocation of live bacteria to extraintestinal organs, and (c) disease outcome in two animal models with impaired gut barrier function. Severe acute pancreatitis or colitis was induced in rats randomized for therapy with or without glutamine (0.5 g/kg daily). After 48 h one animal group was prepared for intravital microscopy of colonic capillary blood flow and electrophysiological measurement of gut permeability; another was killed after 96 h for histological and microbiological examination. In animals with pancreatitis, glutamine (Gln) supplementation significantly improved gut permeability, i.e., Gln increased colonic transmucosal resistance from 67+/-7 to 92+/-3 Omega/cm(2) and decreased mannitol flux through the epithelium by 53%. Capillary blood flow in the colonic mucosa was improved by 25%. The prevalence of pancreatic infections was reduced from 86% in animals on standard parenteral nutrition to 33% in animals given the Gln-enriched diet (P<0.05); mortality decreased by 32%. In colitis, Gln had no significant effect on these parameters except for improving colonic capillary blood flow in colon segments not adjacent to the major injury site. Glutamine supplementation improves colonic capillary blood flow, stabilizes gut permeability, and reduces secondary pancreatic infections and mortality in severe rodent pancreatitis, but it is not helpful in colitis. This confirms previous reports that glutamine stabilizes gut barrier function only in certain diseases. Our experimental data strongly suggest that acute pancreatitis (rather than colitis) is one of the diseases with gut barrier dysfunction in which glutamine substitution may be helpful to reduce bacterial translocation and should therefore be tested in a controlled clinical trial.

Increased frequency of thorax injuries with ACD-CPR

A prospective, randomised out-of-hospital study in a two-tiered system with active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) versus standard (STD) CPR in patients following non-traumatic cardiac arrest was planned to test the hypothesis that ACD-CPR by the first tier may increase the occurrence of ventricular fibrillation as compared with STD-CPR. Furthermore, in a later phase of the study, sternal and rib fractures induced by both CPR methods were determined by extensive autopsy. After enrolling 90 patients the study was terminated because of a high frequency of chest injuries found at autopsy. Forty-two patients received STD-CPR from the first tier and ACD-CPR from the second tier. Thirty-three patients received ACD-CPR only by the first and the second tier, while 15 patients received STD-CPR only from the first and second tiers. In order to obtain a sufficiently large control group for autopsy findings after STD-CPR, STD-CPR was performed in an additional 33 patients within a second period of 4 months. There was no improvement in the number of patients found in ventricular fibrillation after ACD-CPR as compared to STD-CPR performed by the first tier. In patients undergoing autopsy (n = 35) there were significantly more sternal fractures with ACD-CPR versus STD-CPR (14/15 vs. 6/20; P <0.005) and rib fractures (13/15 vs. 11/20; P < 0.05) In conclusion, ACD-CPR appears to cause more CPR-related injuries than does standard CPR, but as a result of a number of limitations on this study, this fact cannot be proven beyond doubt.

Therapy for microcirculatory disorders in severe acute pancreatitis: effectiveness of platelet-activating factor receptor blockade vs. endothelin receptor blockade

Many of the complications of severe acute pancreatitis are the result of the amplifying effects of microcirculatory disruption. The factors causing microcirculatory disorders in acute pancreatitis involve vasoactive mediators such as platelet-activating factor (PAF) and endothelin-1 (ET) activated during the inflammatory response to pancreatic injury. To further evaluate the potential therapeutic role of specific receptor antagonists (RA) to these mediators, the present study compares the effect of PAF and ET receptor blockade on microcirculation and organ function in a well-established rodent model of severe acute pancreatitis. Six hours after acute pancreatitis induction, rats were randomized to therapy with ET-RA (50 mg/kg LU-135252), PAF-RA (82 microg/kg WEB-2170), or NaCl 0.9% (volume equivalent). After 18 hours of fluid resuscitation, animals were relaparotomized for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Other measurements included cardiorespiratory parameters, hematocrit, pleural effusions, ascites, urine production, and survival. Compared to saline treatment both ET-RA and PAF-RA significantly improved capillary blood flow in the pancreas and colon, reduced leukocyte rolling, and stabilized capillary permeability. The beneficial effects of receptor antagonist treatment on microcirculation were associated with decreased fluid loss into the third space, improved renal and respiratory function, and survival. Although both receptor antagonists likewise improved capillary blood flow, ET-RA was significantly more effective in counteracting leukocyte rolling and capillary leakage, thereby further reducing fluid sequestration. The present study confirms the beneficial effects of PAf and ET receptor blockade on microcirculation inside and outside the pancreas, organ function, and survival when given at the early stage of severe pancreatitis. Because ET-RA was more effective in stabilizing capillary permeability and avoiding subsequent fluid loss into the third space, we propose that ET-RA should be tested in a clinical trial (either in comparison or in addition to PAF-RA).

[Endoscopic cholecystectomy as cost assessment--still a learning intervention?]

Economic considerations are putting increasing pressure on surgical departments to avoid intra- and postoperative complications and thus additional costs. Under this aspect, it was investigated whether laparoscopic cholecystectomy is a suitable training intervention for young prospective surgeons. These physicians in advanced training did not have a higher intra- or postoperative complication rate in a preselected patient population than senior physicians or specialists. The additional costs per surgical intervention due to longer operation times required by young physicians were acceptable so that laparoscopic cholecystectomy as a training intervention for young colleagues can be justified.

[Value of magnetic resonance tomography in preoperative staging of stomach carcinoma]

The value of MRI as a preoperative staging procedure in stomach carcinomas compared to CT and endosonography was examined in a prospective study and correlated with the pathohistological results. MRI showed better correlation with the pathohistological evaluation at the T3, T4, N and M stage than the other two test procedures. MRI is thus a suitable staging procedure for stomach carcinomas.

[Monstrous pseudocyst of the adrenal gland]

We report on a 64-year-old patient with a huge adrenal pseudocyst. These are rare cystic lesions of the adrenal gland with an unclear etiology. Recent studies suggest that the majority of adrenal pseudocysts are of vascular origin. All cystic masses in the epigastric region have to be considered in the differential diagnosis. The treatment of choice is surgical removal.

[Endothelin receptor block in acute pancreatitis--improvement of microcirculation and decrease of capillary permeability also distant from the pancreas]

We have previously demonstrated that therapy with a new specific endothelin-1 receptor antagonist (ET-RA) significantly reduced mortality in acute necrotizing pancreatitis (ANP) in the rat. Improved survival was not associated with decreased intrapancreatic trypsinogen activation or parenchymal necrosis but with reduced fluid sequestation into the third space suggesting that ET-RA counteracts systemic rather than local sequelae of severe pancreatitis. The present study further tests this hypothesis by evaluating the effect of the specific ET-1 antagonist LU-135252 on capillary blood flow, capillary density, and capillary permeability not only in the pancreas but also in the colon, and monitoring fluid losses and renal and respiratory function. The experiments demonstrate that therapy with the specific ET-RA started 6 hours after disease onset stabilizes increased capillary permeability in ANP not only in the pancreas but also in the colon. This is associated with reduced ascites and improved renal and respiratory function. Furthermore, ET-RA enhances decreased capillary blood flow and capillary density in the pancreas and colon. The present results are consistent with our previous observation that ET-RA improves outcome in ANP by counteracting systemic microcirculatory disorders (particularly capillary leakage) which are believed to contribute to organ failure in early pancreatitis in this model as well as in severe human pancreatitis.

[The effect of the lactation period on the cell content of sheep milk]

Milk samples of 201 ewes were examined in 6 week intervals during a complete lactation period. Those samples were analyzed for the presence of pathogenic bacteria and the somatic cell count was determined. Besides, the California Mastitis Test (CMT) was performed and the udder was clinically examined. The cell counts were found to depend on the lactation period. During 6 weeks following parturition the cell count was 63,000 cells/ml. This number decreased towards the 24th week of lactation to 32,000 cells/ml. At the end of lactation this value increased again to 425,000 cells/ml. The median value of ewes with normal udder health was 56,000 cells/ml milk. For samples from which pathogenic bacteria were isolated this value was 159,000 cells/ml. The most frequent pathogens isolated from the milk samples were coagulase-negative cocci (59.6% of bacteriologically positive samples), the median number being 88,000 somatic cells/ml in these sheep. Coagulase-positive cocci were isolated in 25.3% of the samples, the median value of the cell count was 295,000 cells/ml. In 12.1% of the samples streptococci were found. The median value was 167,000 cells/ml. From the remaining 3.0% of bacteriologically positive samples Pasteurellae, E. coli and Actinomycetae were isolated. The median value of the somatic cell count was 184,000 cells/ml. We consider coagulase-positive cocci therefore as the most pathogenic bacteria for the ovine udder.

[Ten years of emergency medical service in Munich. Experiences and results]

The emergency ambulances of the emergency medical service in Munich have been called out on 89,748 occasions. From the point of view of the specialties involved, internist emergencies were the most frequent with more than half the calls. One fifth of the emergencies were street accidents, occupational and domestic accidents. Genuine saving of life was possible in 1.3% of the cases. Vital functions were disturbed in 10% of all emergencies. With increasing popularity, the emergency ambulance is called to every urgent medical case, because it appears for every patient with unsurpassed reliability and speed. Herein lies the dangers of misuse and decreasing efficiency of an organization originally conceived only for victims of street accidents.