Prediction of angiographic carotid artery stenosis indexes by colour Doppler-assisted duplex imaging. A critical appraisal of the parameters used

The aim of our study was to establish colour Doppler-assisted duplex imaging (CDDI)-criteria to predict an angiographic internal carotid artery (ICA) stenosis of at least 70%, according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trialists (ECST) methods of measurement. In the following, we describe the findings in 79 patients who were screened for carotid endarterectomy by CDDI and further evaluated by digital subtraction angiography (DSA). In 158 carotid arteries, 107 stenoses of > 30% and nine occlusions were found. Receiver operator characteristic graphs were constructed in order to calculate sensitivities and specificities of the assessment by CDDI in the prediction of high-grade stenoses determined by angiography. Optimal cut-off points were defined by highest accuracy which reflects the combination of high sensitivity and specificity. The critical index of a high-grade ICA stenosis according to the ECST method could be predicted with an accuracy greater than 90% by a systolic peak velocitiy of 1.25 m/s or an area reduction by CDDI of 70%. Corresponding values, 1.6 m/s and 80% area reduction, predicted the stenosis indexes according to the NASCET method less reliably, with accuracies of between 80% and 90%. Flow velocity criterion was slightly less accurate than the area reduction criterion by CDDI. Finally, double-blind evaluation performed by two readers per examination modality showed that the measurement of area reduction in CDDI is at least as reliable as stenosis indexes according to ECST and NASCET methods.

[Dyspnea and lung function. Results of a multicenter study]

In seven pneumological centres 266 patients with different pneumological diseases were investigated. After having clarified several questions regarding the severity of the dyspnoea, cough intensity and the volume of sputum, as well as basic clinical investigation and after an x-ray of the thorax, the diagnosis was arrived at. Subsequently the lung function investigation with the flow-volume curve (including IVC, FVC, PEF, FEV1, MEF50%) and the body plethysmographic Rt and IGV were carried out. Different quality control procedures at and between the different centres ensured comparable results. All centres agreed to using methods well compatible with each other. The question as to which kind of parameters of lung function would agree best with the amount of the dyspnoea, was resolved. The causes for the large scatter of the results are described. Cough and sputum exercise an influence even on the degree of dyspnoea, but not by deteriorating the lung function. The results are shown for the entire collective (Part I) in respect of the different diagnoses (Part II). With different diagnosis the same significant correlations exist but the curves are positioned at different levels of the coordinate system.

CONCLUSION

Significant correlations exist between the dyspnoea scale and function parameters. There are individual differences between the dyspnoea scale and disturbances of the function parameters. Carefully performed lung function analyse definitely important in any case.

COPD: results of long-term treatment

During the last decades the life expectation of patients with COPD increased continually. Today the life expectation of these patients reach that of the normal general population. Most important for this effect is the improvement of the therapeutical possibilities. Following the experience over nearly 3 decades the treatment regime is described. Glucocorticosteroids are at first line as much as necessary and as less as possible, starting with the inhalative forms adjusted at the clinical course stabilizes the situation. Bronchodilatation around the clock and as good as possible is a further important step. These effects have to be functionally-analytically controlled. It is not enough to follow only the clinical impression. beta 2-sympathicomimetics are the overall dilators with strongest effects and increase even the clearing mechanisms of the bronchopulmonary system. Short- as long-acting medicaments are available, but the duration of the action at each of the different forms is sometimes clearly shorter as the mean values describe. Anticholinergics and theophyllines have weaker bronchodilatation power, but they show additive effects, which could be used at special situations. Combinations as Berodual (beta 2-sympathicomimetics and anticholinergics) can decrease the dosage of the beta 2-sympathicomimetics and therefore increase the therapeutic range. At the situation of exacerbation antibiotics can be very helpful, but sometimes an increase of the dosage of glucocorticosteroids is necessary and sometimes the increase of this dosage alone can control the situation. It is very important to detect the deterioration which can end with a severe life threatening exacerbation as early as possible and to control the situation already at this stage. It is shown at examples of 56 patients functionally-analytically controlled over 5 years that the function values do not deteriorate during the constant treatment regime any more. Even in spite of the constant treatment with beta 2-sympathicomimetics no signs of any kind of down regulation or of tachyphylaxis of the bronchodilatation power could be detected. A bronchodilatation test after 4.2 years of constant bronchodilatation treatment together with beta 2-sympathicomimetics showed at 25 patients the same effect as normally at acute tests without pre-treatment seen. Because after the start of this treatment regime to-day a further deterioration does not take place, it is important to detect signs of the disease as early as possible. This can be achieved as the basis of lung function values measure over a long time. The best basis for this is the individual norm known from measurement at healthy days.

[Etiology and reproducibility of blood gas findings during stress testing in patients with obstructive respiratory tract diseases]

After the stabilization of the obstructive airways disease 14 patients performed 4 times exercise-tests of 6 minutes at a bicycle during one week. The basic values of the lung function showed with FEV1 of 66%, Rt of 5,74 hPa/l/s and IGV of 155% a strong disturbance of the mechanical features of the lung. At the mean during the exercise tests the PO2a remained with 69 Torr constant. PC2a increases at the same time for 3 Torr. After the exercise test a significant increase of PO2a of 11.4 Torr takes place. At the individual patients there was a great variability of the results between the different tests. Only three patients showed always a decrease of PO2a-values. The reason for this variability is the ventilation/perfusion inhomogeneity, which changes between the investigations. There are significant multilinear correlations between the FEV1%- as the IGV%-values and PO2a for the values at rest, during exercise as 5 min after the end of exercise. The exercise tests show at the PO(2a)-values the variability of the ventilation/perfusion inhomogeneity which dominates the bloodgas values. The important increase of the PO2a after the exercise test even at this patients can be of importance. The duration of this effect after multiple loads and the dependence of the workload should be investigated.

[Clinical investigation of the action of tramazoline inpatients with chronic obstructive bronchitis. The importance of mucosal swelling]

Swelling of the bronchial mucosa is discussed as part of the increased airways on patients with obstructive bronchitis (OB). The excellent effect of alpha-receptor-stimulants like tramazoline for the deblockage of the nasal mucosa has been previously established experimentally as well as clinically. On 19 patients with OB tramazoline (CAS 74195-73-6) aerosol (Rhinospray) (0.14 (n = 9) resp. 0.19 (n = 10 mg) was administered into the bronchial system. There were no effects seen on airways resistance nor on the intrathoracic gas volume. The important improvement on patients with OB and nasal blockage at the same time seen after tramazoline aerosol given into the nose is caused only by the effect on the nasal mucosa.

[Diagnostic value of right thoracic ECG recording in detection of pulmonary hypertension in chronic obstructive respiratory disease]

There are many electrocardiographic criteria of pulmonary hypertension and cor pulmonale. These criteria are generally highly specific but not sensitive. Therefore many patients with pulmonary hypertension remain undetected. The aim of this study was to delineate a sensitive as well as a specific ECG parameter for noninvasive prediction of pulmonary hypertension under special consideration of the right thoracic leads. 75 patients were included in this study, 62 male and 13 female, mean age 62.7 +/- 9.5 years. All presented with chronic obstructive lung disease known since 12.1 +/- 9.7 years. The underlying disease had been confirmed clinically and by body plethysmography. Laboratory and lung function data showed a high air way resistance with a mean value of 6.8 +/- 3.3 cm H2O/l/s and a high intrathoracic gas volume of 149.1% of the expected value. The severity of hypoxemia was variable but generally moderate with a PaO2 of 65.3 +/- 11.6 mm Hg on average. All patients applied aerosols with ipratropiumbromid, fenoterol and glucocorticoids. 92% additionally received aminophylline and 87.0% oral glucocorticoids. Diuretics and glycosides were prescribed in 50.0% and 34.8% respectively. The four right thoracic ECG leads Vr3 to Vr6 were recorded in addition to the common twelve leads I to III, a VR, aVL, aVF and V1 to V6. A modified Sokolow-Lyon-Index (SIm) as a sum of amplitudes of R in lead Vr3 and S in lead V6 and the combination of SIm with PaO2 (SIm-PaO2, n = 44) according to the formula SIm + 0.02 (100--PaO2%) were established. Additionally a right heart catherization by Swan-Ganz technique was performed. The mean values of hemodynamic data demonstrated a constellation of precapillary pulmonary hypertension with high PAPm and pulmonary resistance and low pulmonary capillary wedge pressure (26.4 +/- 12.9 mm Hg, 396.0 +/- 294.0 dyn.s./cm5 and 8.7 +/- 4.2 mm Hg, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic obstructive bronchitis. Effect of Gelomyrtol forte in a placebo-controlled double-blind study]

In a double-blind study involving two groups of ten patients with chronic obstructive bronchitis, the expectorant Gelomyrtol forte was tested against placebo for its effectiveness and tolerance. The parameters: amount of sputum, Rt and IGV, together with all the usual clinical laboratory parameters, were determined. In addition, the color of the sputum was always noted. On the basis of patient scores, daily entries on the ability to expectorate, attacks of coughing, general coughing, and shortness of breath were made by the patients for the duration of the 14-day treatment period. On conclusion of the study, the patients were asked to assess the effectiveness of the supplementary medication, and the care-providing physician also assessed effectiveness. All score parameters related to coughing improved, in some cases appreciably, relative to the placebo group. The findings in term of sputum volume and color, were also distinctly better in the Gelomyrtol forte group. Correspondingly, both patients and physicians assessed the effectiveness of Gelomyrtol forte to be distinctly better than that of the placebo. Although the groups are relatively too small and heterogeneous, to establish statistically significant differences, the results do strongly suggest a favorable and major effect in patients with relevant cough symptoms. Both subjective and objective tolerance was excellent.

[Obstructive airway diseases--emphysema. Diagnosis and therapy]

Spirometric examinations are suitable for the diagnosis of airway obstruction, but not of pulmonary emphysema. Whole body plethysmography, in contrast, is the most reliable diagnostic procedure for both conditions, both qualitatively and quantitatively. The basic treatment of any form of airway obstruction consists in the inhalation of beta-2-sympathomimetic drugs; theophyllines are also good bronchodilators, but are less powerful than beta-2-sympathomimetics. Glucocorticoids must always be given when bronchitis also presents, which is only rarely treatable with antibiotics alone. Although regression of pulmonary emphysema is not possible, progression of the destructive process would appear to be inhibited by intensive treatment of the inflammatory bronchitis. Only in the case of patients with congenital alpha-1-antitrypsin deficiency is it possible to administer such causal treatment in the form of substitution therapy. Surgical treatment can be considered only in the case of bullous pulmonary emphysema.

Treatment of severe chronic bronchitis with ceftazidime

The aim of this study was to determine whether ceftazidime is more effective than other antibiotics in the treatment of severe acute exacerbation of chronic bronchitis, particularly when other antibiotics have previously failed. Our investigations showed that ceftazidime is effective and well tolerated in patients with severe chronic bronchitis and purulent sputum. The effectiveness of ceftazidime was seen in a reduction of the volume of sputum produced daily and in a colour change from yellow-green to clear-white. The absence of an effect on parameters of lung function was not unexpected since our patients had long-lasting chronic bronchitis.

[Static compliance in probands with healthy lungs and patients with chronic obstructive respiratory tract disease]

From the examination of a group of subjects with healthy lungs a theoretical value formula was calculated for static compliance, the only significant disturbance value being the age dependence. In chronic obstructive airways disease there is a significant decrease in the compliance depending upon Rt.

[Liver function of patients with arterial hypoxemia in chronic obstructive respiratory tract disease and the effect of nasal oxygen insufflation]

Patients suffering from chronic obstructive airway disease often have arterial hypoxemia, which is more or less severe. If hypoxemia deteriorates the function of the liver is still unknown. The aim of this study was to determine, if a mostly oxygen dependent process of liver metabolism (galactose elimination capacity) is disturbed and if it can be increased by oxygen insufflation. Under the same conditions an oxygen independent process (indocyaninegreen clearance) should not be influenced. Our results show, that galactose elimination capacity under room air was pathologic and can be increased significantly by oxygen breathing. No change of indocyaninegreen clearance was seen under the same conditions. After termination of oxygen therapy the galactose elimination capacity was as bad as before oxygen breathing. Dysfunctions of the liver, which are caused by hypoxemia, can be positively influenced by oxygen, but only for the duration of oxygen insufflation.

Static compliance in subjects with intact lungs

The static compliance was determined in 55 subjects with healthy lungs. Average values are within 2.696 liters/kPa (age between 20 and 30 years) and 1.794 liters/kPa (age between 71 and 80 years). Static compliance was shown to be exclusively related to age (p less than 0.001). Broca index, sex, cigarette smoking and intrathoracic gas volume did not influence static compliance. The relation can best be described by a logarithmic regression equation.

Oral corticosteroids and histamine releasability of basophil granulocytes

The influence of oral corticosteroid therapy (7.5 and 15 mg prednisolon/day for 8 days) on basophil releasability by antigens was investigated in a series of 16 patients with chronic obstructive airway disease. A significantly smaller histamine release was observed after the treatment. Different types of releasing curves were observed which mostly persisted after treatment.

[Anticholinergics as bronchodilators. An action profile]

In 3 test series comprising 107 patients the cholinergic proportion and the proportion of airway obstruction controllable by beta 2-sympathomimetics were determined. A reversible and an irreversible proportion of increased flow resistances in airways are detected. The reversible proportion has to be divided into a section controllable by beta 2-sympathomimetics. Both substance groups have an additive effect extending up to the irreversible proportion. In most cases, the proportion controllable by beta 2-sympathomimetics is larger than that controllable by anticholinergics. The cholinergic proportion of the airway obstruction can be blocked completely by 0.02 mg (0.04 mg) of the controlled dosage aerosol or by 0.125 mg iptratropium bromide (ITB), resp. The cardially recognizable anticholinergic effect is low in this connection. Complete cholinergic cardial block only occurs upon intravenous doses between 0.25 mg and 0.5 mg ITB.

Alpha 1-antitrypsin gene polymorphism related to respiratory system disease

Restriction fragment length polymorphism (RFLP) in the alpha 1-antitrypsin gene region was studied in relation to chronic obstructive airway disease (COAD) and pneumoconiosis. Genomic DNA of 122 studied subjects was digested with Hind III restriction endonuclease and hybridized with the alpha 1-antitrypsin gene probe. In eight patients with COAD an unusual 10-kb restriction fragment was found hybridizing with the probe. Three of 70 patients were homozygotes for this variant allele and 5 were heterozygotes, showing the presence of two fragments, 2.7 kb and 10 kb. The presence of 10-kb restriction fragment seems to be related to the early development of COAD in studied subjects and therefore might be used as a genetic marker of the disease.

[Ventricular arrhythmias in cor pulmonale. The effect of oxygen treatment]

Long-term ECG monitoring was carried out on 36 patients with chronic obstructive airway disease and cor pulmonale. Ventricular extrasystoles were detectable in all patients with greater than 30/h occurring in 13. Multifocal ventricular extrasystoles were seen in 29 patients, couplets in 16, runs in 6 and early (R-on-T) extrasystoles in 8 patients. When the ventricular extrasystoles exceeded 30 per hour the average oxygen partial pressure (paO2), determined in capillary blood, was 59.5 mm Hg, whereas it was higher, 66.4 mm Hg (P less than 0.0125), when there were less than or equal to 30/h. Oxygen (2 l/min) was administered to 13 patients between 20.00 h and 08.00 h and then room-air the following night via a nasal tube. After the administration of oxygen mean paO2 was 72.3 mm Hg and after breathing room-air 62.6 mm Hg (P less than 0.01). During the administration of oxygen, extrasystoles appeared less frequently than after breathing room-air (927 vs 1211; P less than 0.05). These results show that ventricular extrasystoles appear more often with decreasing paO2 and that oxygen therapy can reduce their frequency.

[Experience with 208 "screw-in" type pacemaker leads with particular reference to atrial positioning (author's transl)]

In 190 patients, 208 "screw-in" type pacemaker leads were implanted; 147 in the right ventricle and 61 in the right atrium. There was no significant difference in the time required for atrial (54.7 +/- 19 min) or ventricular fixation (56.0 +/- 25 min). Similarly, fluoroscopy times for both atrial (6.3 +/- 4 min) and ventricular positioning (8.1 +/- 6 min) were equivalent. In the subsequent follow-up period ranging from one to 23 months, only one dislocation of a "screw-in" type atrial lead was seen, and that in a patient with "twiddler syndrome". Otherwise, in patients in whom the lead was securely implanted, no evidence of dislocation has been observed. In one patient "under-sensing" developed subsequent to repositioning for exit-block. In this patient population, the use of "screw-in" type electrodes, in particular through facilitation of atrial positioning, has substantially lessened the rate of pacemaker complications.

Pulmonary haemodynamics in coal workers' pneumoconiosis and non-pneumoconiotic patients with chronic obstructive airways disease

The pulmonary haemodynamics of 22 patients with advanced forms of coal workers' pneumoconiosis (CWP) and chronic obstructive airways disease (COAD), and 24 patients with advanced forms of COAD without pneumoconiosis were studied. The results obtained permitted a haemodynamic distinction between these two groups of patients. The differences, at rest and during 25 W exercise, are discussed.

[Bone marrow insufficiency and hemangioendothelioma of the liver after thorotrast application: Late effects of thorotrast (thorium dioxide) in man (author's transl)]

The report details with the late effects following administration of thorotrast in two patients: multicentre metastating hemangioendothelioma of the liver respective bone marrow insufficiency developed after application of thorotrast 34 respective 36 years ago. The clinical and autoptical findings are described and attention is drawn to the relevance of this disease at present time.