The Contribution of the Left Phrenic Nerve to Innervation of the Esophagogastric Junction

The contribution of the left phrenic nerve to innervation of the esophagogastric junction. The esophagogastric junction is part of the barrier preventing gastroesophageal reflux. We have investigated the contribution of the phrenic nerves to innervation of the esophagogastric junction in humans and piglets by dissecting 30 embalmed human specimens and 14 piglets. Samples were microdissected and nerves were stained and examined by light and electron microscopy. In 76.6% of the human specimens, the left phrenic nerve participated in the innervation of the esophagogastric junction by forming a neural network together with the celiac plexus (46.6%) or by sending off a distinct phrenic branch, which joined the anterior vagal trunk (20%). Distinct left phrenic branches were always accompanied by small branches of the left inferior phrenic artery. In 10% there were indirect connections with a distinct phrenic nerve branch joining the celiac ganglion, from which celiac plexus branches to the esophagogastric junction emerged. Morphological examination of phrenic branches revealed strong similarities to autonomic celiac plexus branches. There was no contribution of the left phrenic nerve or accompanying arteries from the caudal phrenic artery in any of the piglets. The right phrenic nerve made no contribution in any of the human or piglet samples. We conclude that the left phrenic nerve in humans contributes to the innervation of the esophagogastric junction by providing ancillary autonomic nerve fibers. Experimental studies of the innervation in pigs should consider that neither of the phrenic nerves was found to contribute. Clin. Anat. 33:265-274, 2020. © 2019 Wiley Periodicals, Inc.

[Ultrasound training in the medical curriculum at the Bern University - a pilot project]

Zusammenfassung. Die Sonografie ist ein modernes Bildgebungsverfahren, das im medizinischen Alltag eine breite Anwendung findet. Obwohl die Ultraschallmethode in fast allen medizinischen Fachdisziplinen verwendet wird, ist die Sonografie kein obligates Lernziel im Medizinstudium der Schweiz. Im Artikel wird über eine Initiative an der Medizinischen Fakultät der Universität Bern berichtet, die Studierenden des zweiten Studienjahres einen Kurs «Sonografie des Abdomens» anbietet. Dieser gemeinsam mit Mitgliedern der Schweizerischen Gesellschaft für Ultraschallmedizin (SGUM) durchgeführte Kurs vermittelt theoretisches Wissen zur Ultraschallanatomie und gibt den Studierenden die Möglichkeit, selbst Ultraschalluntersuchungen durchzuführen.

Interprofessional education in anatomy: Learning together in medical and nursing training

Teamwork and the interprofessional collaboration of all health professions are a guarantee of patient safety and highly qualified treatment in patient care. In the daily clinical routine, physicians and nurses must work together, but the education of the different health professions occurs separately in various places, mostly without interrelated contact. Such training abets mutual misunderstanding and cements professional protectionism, which is why interprofessional education can play an important role in dismantling such barriers to future cooperation. In this article, a pilot project in interprofessional education involving both medical and nursing students is presented, and the concept and the course of training are described in detail. The report illustrates how nursing topics and anatomy lectures can be combined for interprofessional learning in an early phase of training. Evaluation of the course showed that the students were highly satisfied with the collaborative training and believed interprofessional education (IPE) to be an important experience for their future profession and understanding of other health professionals. The results show that the IPE teaching concept, which combines anatomy and nursing topics, provides an optimal setting for learning together and helps nurses and doctors in training to gain knowledge about other health professionals' roles, thus evolving mutual understanding.

[Rituximab therapy for relapsing IgG4-autoimmune pancreatitis and cholangitis - a case report]

We report a patient with autoimmune pancreatitis and cholangitis. During a period of 3 years and despite therapy with steroids and immunmodulatory drugs such as azathioprine and mycophenolate mofetil he suffered from multiple relapse episodes including bile duct stenoses requiring endoscopic interventions. After initiation of therapy with the monoclonal CD20 antibody Rituximab, steroids could be stopped completely and the patient remains in remission. Rituximab should be considered in therapy of relapsing autoimmune pancreatitis and cholangitis.

A novel technique, dynamic intraligamentary stabilization creates optimal conditions for primary ACL healing: a preliminary biomechanical study

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a common lesion. Current treatment emphasizes arthroscopic ACL reconstruction via a graft, although this approach is associated with potential drawbacks. A new method of dynamic intraligamentary stabilization (DIS) was subjected to biomechanical analysis to determine whether it provides the necessary knee stability for optimal ACL healing.

METHODS

Six human knees from cadavers were harvested. The patellar tendon, joint capsule and all muscular attachments to the tibia and femur were removed, leaving the collateral and the cruciate ligaments intact. The knees were stabilized and the ACL kinematics analyzed. Anterior-posterior (AP) stability measurements evaluated the knees in the following conditions: (i) intact ACL, (ii) ACL rupture, (iii) ACL rupture with primary stabilization, (iv) primary stabilization after 50 motion cycles, (v) ACL rupture with DIS, and (vi) DIS after 50 motion cycles.

RESULTS

After primary suture stabilization, average AP laxity was 3.2 mm, which increased to an average of 11.26 mm after 50 movement cycles. With primary ACL stabilization using DIS, however, average laxity values were consistently lower than those of the intact ligament, increasing from an initial AP laxity of 3.00 mm to just 3.2 mm after 50 movement cycles.

CONCLUSIONS

Dynamic intraligamentary stabilization established and maintained close contact between the two ends of the ruptured ACL, thus ensuring optimal conditions for potential healing after primary reconstruction. The present ex vivo findings show that the DIS technique is able to restore AP stability of the knee.

Effects of exogenous surfactant on the non-heart-beating donor lung graft in experimental lung transplantation - a stereological study

The use of non-heart-beating donor (NHBD) lungs may help to overcome the shortage of lung grafts in clinical lung transplantation, but warm ischaemia and ischaemia/reperfusion injury (I/R injury) resulting in primary graft dysfunction represent a considerable threat. Thus, better strategies for optimized preservation of lung grafts are urgently needed. Surfactant dysfunction has been shown to contribute to I/R injury, and surfactant replacement therapy is effective in enhancing lung function and structural integrity in related rat models. In the present study we hypothesize that surfactant replacement therapy reduces oedema formation in a pig model of NHBD lung transplantation. Oedema formation was quantified with (SF) and without (non-SF) surfactant replacement therapy in interstitial and alveolar compartments by means of design-based stereology in NHBD lungs 7 h after cardiac arrest, reperfusion and transplantation. A sham-operated group served as control. In both NHBD groups, nearly all animals died within the first hours after transplantation due to right heart failure. Both SF and non-SF developed an interstitial oedema of similar degree, as shown by an increase in septal wall volume and arithmetic mean thickness as well as an increase in the volume of peribron-chovascular connective tissue. Regarding intra-alveolar oedema, no statistically significant difference could be found between SF and non-SF. In conclusion, surfactant replacement therapy cannot prevent poor outcome after prolonged warm ischaemia of 7 h in this model. While the beneficial effects of surfactant replacement therapy have been observed in several experimental and clinical studies related to heart-beating donor lungs and cold ischaemia, it is unlikely that surfactant replacement therapy will overcome the shortage of organs in the context of prolonged warm ischaemia, for example, 7 h. Moreover, our data demonstrate that right heart function and dysfunctions of the pulmonary vascular bed are limiting factors that need to be addressed in NHBD.

Implementation of a virtual correlative light and transmission electron microscope

In the long run, the widespread use of slide scanners by pathologists requires an adaptation of teaching methods in histology and cytology in order to target these new possibilities of image processing and presentation via the internet. Accordingly, we were looking for a tool with the possibility to teach microscopic anatomy, histology, and cytology of tissue samples which would be able to combine image data from light and electron microscopes independently of microscope suppliers. With the example of a section through the villus of jejunum, we describe here how to process image data from light and electron microscopes in order to get one image-stack which allows a correlation of structures from the microscopic anatomic to the cytological level. With commercially available image-presentation software that we adapted to our needs, we present here a platform which allows for the presentation of this new but also of older material independently of microscope suppliers.

Cell-specific expression of human HGF by alveolar type II cells induces remodeling of septal wall tissue in the lung: a morphometric study

Hepatocyte growth factor (HGF) is involved in development and regeneration of the lungs. Human HGF, which was expressed specifically by alveolar epithelial type II cells after gene transfer, attenuated the bleomycin-induced pulmonary fibrosis in an animal model. As there are also regions that appear morphologically unaffected in fibrosis, the effects of this gene transfer to normal lungs is of interest. In vitro studies showed that HGF inhibits the formation of the basal lamina by cultured alveolar epithelial cells. Thus we hypothesized that, in the healthy lung, cell-specific expression of HGF induces a remodeling within septal walls. Electroporation of a plasmid of human HGF gene controlled by the surfactant protein C promoter was applied for targeted gene transfer. Using design-based stereology at light and electron microscopic level, structural alterations were analyzed and compared with a control group. HGF gene transfer increased the volume of distal air spaces, as well as the surface area of the alveolar epithelium. The volume of septal walls, as well as the number of alveoli, was unchanged. Volumes per lung of collagen and elastic fibers were unaltered, but a marked reduction of the volume of residual extracellular matrix (all components other than collagen and elastic fibers) and interstitial cells was found. A correlation between the volumes of residual extracellular matrix and distal air spaces, as well as total surface area of alveolar epithelium, could be established. Cell-specific expression of HGF leads to a remodeling of the connective tissue within the septal walls in the healthy lung, which is associated with more pronounced stretching of distal air spaces at a given hydrostatic pressure during instillation fixation.

Metabolic pathway and distribution of superparamagnetic iron oxide nanoparticles: in vivo study

Background:

Experimental tissue fusion benefits from the selective heating of superparamagnetic iron oxide nanoparticles (SPIONs) under high frequency irradiation. However, the metabolic pathways of SPIONs for tissue fusion remain unknown. Hence, the goal of this in vivo study was to analyze the distribution of SPIONs in different organs by means of magnetic resonance imaging (MRI) and histological analysis after a SPION-containing patch implantation.

Methods:

SPION-containing patches were implanted in rats. Three animal groups were studied histologically over six months. Degradation assessment of the SPION-albumin patch was performed in vivo using MRI for iron content localization and biodistribution.

Results:

No SPION degradation or accumulation into the reticuloendothelial system was detected by MRI, MRI relaxometry, or histology, outside the area of the implantation patch. Concentrations from 0.01 μg/mL to 25 μg/mL were found to be hyperintense in T1-like gradient echo sequences. The best differentiation of concentrations was found in T2 relaxometry, susceptibility-sensitive gradient echo sequences, and in high repetition time T2 images. Qualitative and semiquantitative visualization of small concentrations and accumulation of SPIONs by MRI are feasible. In histological liver samples, Kupffer cells were significantly correlated with postimplantation time, but no differences were observed between sham-treated and induction/no induction groups. Transmission electron microscopy showed local uptake of SPIONs in macrophages and cells of the reticuloendothelial system. Apoptosis staining using caspase showed no increased toxicity compared with sham-treated tissue. Implanted SPION patches were relatively inert with slow, progressive local degradation over the six-month period. No distant structural alterations in the studied tissue could be observed.

Conclusion:

Systemic bioavailability may play a role in specific SPION implant toxicity and therefore the local degradation process is a further aspect to be assessed in future studies.

Clinical value of sentinel node mapping in carcinoma of the colon

AIM

Sentinel lymph node mapping has been used in colon cancer to improve prognosis. This study aimed to determine the accuracy of in vivo SLNM in patients with colon carcinoma undergoing surgery with curative intent.

METHOD

Thirty-one patients operated for colon carcinoma underwent in vivo sentinel lymph node mapping using patent blue dye. Each sentinel lymph node (SLN) was marked intraoperatively, and histological examination was performed after en bloc resection. If no metastasis was found, step sectioning with immunohistochemistry was performed.

RESULTS

The SLN was successfully identified in 28 (90%) of 31 patients. The false-negative rate to identify stage III disease was 66% (eight of 12), the negative predictive value was 46% (19 of 27) and the accuracy was 14% (four of 28). One patient negative on routine histopathology had micrometastasis on step sectioning of the SLN.

CONCLUSION

Sentinel lymph node mapping in colon carcinoma cannot accurately predict nodal status.

Aortic arch morphometry in living humans

Anatomical features of the aortic arch such as its steepness, the take-off angles and the distances between its supra-aortic branches can influence the feasibility and difficulty of interventional and/or surgical maneuvers. These anatomical characteristics were assessed by means of 3D multiplanar reconstruction of thoracic angio-computed tomography scans of 92 living patients (79 males, 13 females, mean age 69.4 ± 9.9 years) carried out for various indications (gross pathology of the thoracic aorta excluded). There was a significant variation of all measured parameters between the subjects - a standard aortic arch (i.e. with all measured parameters within 2 SD) does not seem to exist. There were no significant differences between genders but some of the parameters correlated significantly to age.

Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go?

BACKGROUND

Paravertebral regional anaesthesia is used to treat pain after several surgical procedures. This study aimed to improve on our first published ultrasound-guided approach to the paravertebral space (PVS) and to investigate a possible discrepancy between the needle, catheter, and contrast dye position.

METHODS

In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches combined with loss of resistance (LOR) and after an interim analysis performed 36 novel, pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was controlled by a first computed tomography (CT) scan. After placement of the catheters, the tips were assessed by a second CT and the spread of injected contrast dye was assessed by further CT scans. The part of the PVS near the intervertebral foramen was defined as the primary target to reach.

RESULTS

The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34 (94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed: three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected in the epidural space. In two cases, insertion of the catheter was not possible. In cases with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (sd)] vertebral segments.

CONCLUSIONS

Our new PUSG technique has a high success rate for paravertebral needle placement. Although needles were correctly positioned, catheters were usually found distant from the needle-tip position.

Sonographic transvaginal bladder wall thickness: does the measurement discriminate between urodynamic diagnoses?

INTRODUCTION

Measurement of bladder wall thickness (BWT) using transvaginal ultrasound has previously been shown to discriminate between women with confirmed detrusor overactivity and those with urodynamic stress incontinence. Aim of the current study was to determine if vaginally measured BWT correlates with urodynamic diagnoses in a female population.

PATIENTS AND METHODS

Between December 2008 and February 2010, adult female consecutive patients undergoing urogynaecologic investigation for lower urinary symptoms were approached to participate in this study. Ethical consent for the current study was obtained. Patients underwent multichannel urodynamics and transvaginal ultrasound measuring the bladder in three location with an emptied bladder.

RESULTS

123 patients were included in the study with a median age of 69 years (range 40-93), median parity of 2 (range 0-3) and a median body mass index of 29.5 kg/m(2) (range 23-38). Urodynamic stress incontinence was diagnosed in 59 patients, DO in 40 and obstruction in 24 cases. Bladder wall thickness was significantly higher in DO patients and in obstruction than in urodynamic stress incontinence. Detrusor pressure at maximum flow rate (pdet/Q(max) ) correlated significantly with BWT.

CONCLUSION

Bladder wall thickness shows a significantly positive correlation to pdet/Q(max) and to urodynamic diagnoses of stress incontinence, DO and obstruction.

Demonstration of pelvic anatomy by modified midline transection that maintains intact internal pelvic organs

Gross dissection for demonstrating anatomy of the human pelvis has traditionally involved one of two approaches, each with advantages and disadvantages. Classic hemisection in the median plane through the pelvic ring transects the visceral organs but maintains two symmetric pelvic halves. An alternative paramedial transection compromises one side of the bony pelvis but leaves the internal organs intact. The authors propose a modified technique that combines advantages of both classical dissections. This novel approach involves dividing the pubic symphysis and sacrum in the median plane after shifting all internal organs to one side. The hemipelvis without internal organs is immediately available for further dissection of the lower limb. The hemipelvis with intact internal organs is ideal for showing the complex spatial relationships of the pelvic organs and vessels relative to the intact pelvic floor.

Hydrodissection for subperichondrial septoplasty - an experimental anatomical study

OBJECTIVES

The effect of hydrostatic infiltrations for subperichondrial dissection is controversial. Classical textbooks promote it as the "key step in elevating the flaps" or consider its practicability "a mere fable". Moreover, case reports describe fatal side effects. Up to now, experimental tests are missing.

DESIGN

Experimental study.

MATERIALS AND METHODS

Three surgeons simulated subperichondrial hydrodissection with 20 mineral salt fixed human cadaver heads. One ml lidocaine 5% with 1:105 adrenaline and India ink was infiltrated. Each septum was examined histologically using serial 3 microm sections in 150 microm intervals. Tissue cleavage containing the ink deposits with minimal distance to the proposed subperichondrial zone, intravasal spread and tissue deposition were analyzed.

RESULTS

Every injection produced a physical dissection (n = 20). However, dissected planes were localized mostly in the supra-perichondrial connective tissue (n = 8) or within the perichondrium (n = 4). Only five cases showed the propagated correct dissection in a subperichondrial zone. Three anomalous septa were excluded from quantitative analysis. Infiltrated matter did not only accumulate within the dissection plane but also penetrated the surrounding vessels of the septal intumescentia (n = 8).

CONCLUSION

Hydrostatic infiltrations represent an unreliable surgical technique for dissection of an anatomical correct subperichondrial plane but can be useful for anesthesia and hemostasis, however, using high pressure and high volume infiltrations might foster serious side effects.

Nitric oxide synthase protein levels, not the mRNA, are downregulated in olfactory bulb interneurons of reeler mice

Homozygous mutations in the Reelin gene result in severe disruption of brain development. The histogenesis of layered regions, like the neocortex, hippocampus and the cerebellum, is most notably affected in mouse reeler mutants and similar traits are also present in mice lacking molecular components of the Reelin signalling pathway. Moreover, there is evidence for an additional role of Reelin in sustaining synaptic plasticity in adult networks. Nitric oxide is an important gaseous messenger that can modulate neuronal plasticity both in developing and mature synaptic networks and has been shown to facilitate synaptic changes in the hippocampus, cerebellum and olfactory bulb. We studied the distribution and content of neuronal nitric oxide synthase in the olfactory bulbs of reeler and wildtype mice. Immunocytochemistry reveals that Reelin and neuronal nitric oxide synthase containing interneurons are two distinct, non overlapping cell populations of the olfactory bulb. We show by in situ hybridization that both nitrergic and Reelin expressing cells represent only a subset of olfactory bulb GABAergic neurons. Immunoblots show that neuronal nitric oxide synthase protein content is decreased by two thirds in reeler mice causing a detectable loss of immunolabelled cells throughout the olfactory bulb of this strain. However, neuronal nitric oxide synthase mRNA levels, essayed by quantitative real-time RT-PCR, are unaffected in the reeler olfactory bulb. Thus, disruption of the Reelin signalling pathway may modify the turnover of neuronal nitric oxide synthase in the olfactory bulb and possibly affects nitric oxide functions in reeler mice.

Relationship between therapeutic time intervals and intermediate term left ventricular systolic function in patients treated with facilitated percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

The concept of initiating fibrinolytic therapy in patients who cannot undergo immediate percutaneous coronary intervention (PCI) in the setting of acute ST-segment-elevation myocardial infarction (STEMI) has been proposed as a strategy to improve outcomes. However, evidence supporting the use of this strategy is not conclusive, and the results of recent randomized controlled trials are apparently contradictory. Probably, the time points of administration of the adjunctive thrombolytics and antiplatelet agents and the time loss until coronary intervention have a major influence on the discrepancy of outcomes in different trials. Therefore, the relationship between therapeutic time intervals and outcome in patients treated with facilitated PCI has been analyzed.

METHODS

In this single center retrospective study, 131 patients with STEMI were treated with a combined pharmaco-mechanical reperfusion strategy using half-dose r-tPA combined with a glycoprotein (GP) IIb/IIIa antagonist prior to PCI. Specific time points were recorded for each patient, including the time of symptom onset, the time of first medical contact, the start of intravenous thrombolysis, the time of administration of the GP IIb/IIIa antagonist and the start of coronary intervention. We then examined the relationship between the time delay from symptom onset to the initiation of various steps of treatment and the residual myocardial damage as expressed by the severity of both global and regional myocardial dysfunction calculated from a left ventriculography study performed 3 months later.

RESULTS

The median time from symptom onset to the first medical contact, with 25th and 75th percentiles in parentheses, was 1.25 h (0.75, 3), from symptom onset to initiation of thrombolytic therapy 2.25 h (1.25, 3), to initiation of GP IIb/ IIIa inhibitor therapy 3.5 h (2, 5.69), and to the start of coronary intervention 4.81 h (2.85, 7.91). The time between symptom onset and initiation of both thrombolytic therapy and coronary intervention was significantly related to the global ejection fraction and to the extent of regional hypokinesia at the 3-month follow-up (p<0.05). The time to the initiation of GP IIb/IIIa inhibitors was only significantly related to the global ejection fraction (p<0.05), while the time to the first medical contact did not show a similar relationship (p>0.05). Furthermore, we observed a significant relationship between the infarct-related artery (IRA) patency at the initial angiogram and the residual regional myocardial damage at follow-up; normokinesia at follow-up was found in 61.3% of patients with an initially patent IRA and in 41.2% of patients with an initially occluded IRA, whereas severe hypokinesia was found in 13.8% and 37.3%, respectively (p<0.05).

CONCLUSION

In patients with STEMI treated with a facilitated PCI strategy using half dose r-tPA in combination with a glycoprotein IIb/IIIa receptor blocker, the 3-month global and regional residual myocardial dysfunction is significantly related to the time elapsed between the onset of symptoms and the start of both fibrinolytic therapy and coronary intervention.

Acetic acid-guided biopsies after magnifying endoscopy compared with random biopsies in the detection of Barrett's esophagus: a prospective randomized trial with crossover design

BACKGROUND

In contrast to standard video endoscopy, magnifying endoscopy after local acetic acid application enables recognition of mucosal surface architecture.

OBJECTIVE

To investigate the diagnostic yield of magnifying endoscopy with acetic acid-targeted biopsies compared to random, 4-quadrant biopsies.

DESIGN

Prospective randomized trial (ratio 1:1) with crossover design.

SETTING

Two referral hospitals in Germany.

PATIENTS

Thirty-one patients with Barrett's esophagus or visible columnar-lined lower esophagus.

INTERVENTIONS

Patients were randomized to undergo either standard video endoscopy with 4-quadrant biopsies or magnifying endoscopy in conjunction with acetic acid application. All patients were re-examined 14 days after the initial endoscopy with the corresponding procedure.

MAIN OUTCOME MEASUREMENTS

Primary outcome analysis (per protocol and per biopsy) was the histological proof of Barrett's epithelium. Secondary outcome analysis was the correlation between the surface architecture and the presence of Barrett's epithelium and the needed number of biopsies to confirm Barrett's epithelium for the 2 different procedures.

RESULTS

Magnifying endoscopy enabled the prediction of Barrett's epithelium with a sensitivity of 100% and a specificity of 66%, respectively (accuracy 83.8%). Acetic acid-guided biopsies obtained a significantly higher percentage of tissues containing SCE (78%; 188/241) compared to random biopsies (57%; 159/280).

LIMITATIONS

No data on the diagnosis of Barrett's dysplasia.

CONCLUSION

Magnifying endoscopy with acetic acid-guided biopsies is superior to standard video endoscopy with random biopsies, and the number of biopsies needed to confirm Barrett's epithelium is half as much when compared to random biopsies.

Effect of an exercise training program on endothelial dysfunction in diabetic and non-diabetic patients with severe chronic heart failure

BACKGROUND

Endothelial dysfunction is found both in patients with chronic heart failure and in patients with insulin-treated type 2 diabetes mellitus. This endothelial dysfunction leads to a significant reduction in endothelium-derived vasodilation. Physical exercise can have a positive effect on endothelial dysfunction in patients with coronary artery disease, chronic heart failure and diabetes mellitus. It is not clear, however, whether an exercise program influences endothelial function in diabetics with chronic heart failure. Our study was thus aimed at investigating whether a special exercise program would affect endothelial function. Comparisons were made with insulin-treated type 2 diabetics and with non-diabetics suffering from chronic heart failure.

METHODS

42 patients with severe chronic heart failure (LVEF < or = 30%), insulin-dependent diabetics (n=20, mean age 67+/-6 yrs, 16 male, 4 female), non-diabetics (n=22, mean age 68+/-10 yrs, 20 male, 2 female) participated in a 4-week exercise program consisting of ergometer and special muscle strength training. Before (T1) and at the end (T2) of the training program endothelium-dependent and endothelium-independent vasodilatory capacity were assessed by brachial artery diameter measurement.

RESULTS

At the end of the training program, there were no significant results within the two groups. The endothelium-dependent vasodilation changed between T1 and T2 as follows: In the diabetic group, the endothelium-dependent vasodilation at T1 and T2 was 5.1+/-3.6 and 4.9+/-2.5%, respectively. For the non-diabetics, the endothelium-dependent vasodilation was 6.8+/-4.5 and 7.6+/-4.0% at T1 and T2, respectively. The endothelium-independent vasodilation in the diabetics was 10.5+/-5.6 at T1 and dropped to 8.7+/-4.1% at T2. The results for the non-diabetics were 13.2+/-5.8 and 12.3+/-6.3% at T1 and T2, respectively. The LVEF in the diabetics was 24.2+/-3.4% at T1, increasing to 27.8+/-5.8% at T2. In the non-diabetics, the LVEF was 22.9+/-3.8 at T1 vs. 28.6+/-6.9% at T2. In the groups of diabetics, the maximum oxygen uptake (VO2-max) was 10.3+/-3.9 at T1 vs. 11.4+/-2.8 ml/kg/min at T2 and in the group of non-diabetics 10.0+/-3.1 vs. 13.5+/-5.0 ml/kg/min. No correlations were found between the change in endothelium-dependent vasodilation and the increase in oxygen uptake.

CONCLUSION

In our study, a program of physical exercise had no influence on endothelium-dependent or endothelium-independent vasodilation in insulin-treated type 2 diabetics or in non-diabetics with considerably reduced ejection fraction. In both groups, however, an exercise-related influence on medical parameters and physical performance could be observed.

[Acute coronary syndrome after diclofenac induced coronary spasm]

We report about a 67-year old man, who was submitted to our clinic with acute coronary syndrome. The cardiac catheterization showed a proximal thrombus in the left anterior descending (LAD). The other coronary arteries did not have significant lesions. After percutaneous transluminal coronary angioplasty with stent-implantation into the proximal LAD the patient remained clinically stable. Cardiac enzymes confirmed no myocardial necrosis. Three days after the acute coronary syndrome the patient developed a podagra, which was treated with colchicinum, diclofenac and local cooling. Five hours after initial therapy the patient developed severe symptoms of angina pectoris and electrocardiographical signs of an acute posterior and anterior myocardial infarction. Immediate coronary angiography demonstrated extended vasospasm of the right coronary artery. Intracoronary application of verapamil and nitroglycerin resolved the coronary spasm. The patient reported about a self-indicated application of diclofenac six hours before hospital admission. This case demonstrates that oral application of diclofenac can provoke coronary vasospasm.

Biliary infarction mimicking liver metastasis

A 38-year-old man with a history of chronic alcohol abuse had suffered from numerous acute episodes of chronic pancreatitis in the last 7 years. Those episodes were complicated by the formation of a pseudocyst in the pancreatic head. He presented himself with vomiting and abdominal pain as well as diarrhoea for 10 days. In the ultrasound examination of the liver numerous circumscribed hypoechoic formations in both lobes of the liver were found. A subsequent computerised tomography scan confirmed multiple hypodense liver lesions. Because of suspected metastasis or abscesses in the liver, sonographically guided fine needle biopsies of these liver structures were carried out. The histological examination of the liver specimens showed bile infarcts and proliferated bile ducts; there were no signs of a malignant or infectious process. The bacteriological cultures of the biopsy specimens were negative.

Effects of education, self-care instruction and physical exercise on patients with chronic heart failure

BACKGROUND

Evidence is now evolving of the importance of team management for patients with chronic heart failure. This includes education, patient self-care and physical exercise training. How such programs should be implemented is still under discussion.

AIM

To assess the efficacy of an in-hospital rehabilitation clinic-based program, we studied its influence on cardiopulmonary parameters and quality of life in an outpatient setting.

METHODS AND RESULTS

75 patients (62 male, 13 female, mean age 65+/-8 years) underwent an exercise program including education, bicycle ergometer, muscle strength training and the 6-min walk test as a training unit for 4 weeks. Patients were studied at baseline (T1), before discharge (T2) and after a follow-up period of 29.9+/-5.5 weeks (T3). Baseline data (T1): left ventricular ejection fraction (LVEF): 33.8+/-7.6%, left ventricular end-diastolic volume (LVEDV): 130+/-51 ml, peak VO(2): 12.3+/-4.3 ml/kg, maximum work load (Watt max): 71+/-27 W. At discharge (T2) and follow-up (T3) LVEF increased to 36.8+/-8% and 41.8+/-9.2%, LVEDV decreased to 127+/-43 ml and 114+/-40 ml, peak VO(2) increased to 14.1+/-5.1 ml/kg and 15.2+/-5 ml/kg, and Watt max increased to 84+/-28 Wand 98+/-42 W (all p<0.01). Quality of life improved significantly at discharge and follow-up in nearly all domains and in the summary score for physical health. There were no significant changes for anxiety and depression at T2 and T3.

CONCLUSION

A specialized in hospital rehabilitation program including education, patient self management and training has a sustained positive effect on cardiopulmonary parameters and physical well-being.