Improved method for tuberculocidal and mycobactericidal activity testing of disinfectants based on the European Standard EN 14348

Safe measurements to prevent the transmission of (multidrug-resistant) mycobacteria such as disinfection are essential in healthcare settings. In Europe chemical disinfectants are tested for their tuberculocidal and mycobactericidal efficacy by the internationally accepted test procedure described in EN 14348. However, especially for amine-based disinfectants, invalid results may occur by this procedure due to insufficient neutralization. In this multi-laboratory study the procedure described in EN 14348 was optimized by a combination of chemical neutralization and membrane filtration in order to obtain a valid and secure method especially for amine-based disinfectants.

Patterns of revascularization in stable ischemic heart disease in the pre-ISCHEMIA era

Introduction

New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints.

Aim

To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2).

Methods and population

Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or >50% for the left main.

Results

A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p<0.001), two vessel disease without proximal LAD stenosis (23.4% vs 10.3%; p<0.001) and three vessel disease (18.5% vs 5.9%; p<0.001). These patients had higher rates of revascularization, both CABG (25.8% vs 10.8%, p<0.001) and PCI (56.5% vs 39.5%, p<0.001). However, when comparing G1 with the subset of G2 patients with obstructive CAD, G1 patients had higher rates of CABG (26.8% vs 17.8%, p=0.034) but there were no differences on the rates of PCI (58.0% vs 56.9%, p=0.916).

Conclusions

Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD.

Funding Acknowledgement

Type of funding source: None

P223 Cat bite with unexpected consequences

A 25 y/o female patient with corrected tetralogy of Fallot (1995), pulmonary valve bio-prosthesis (1999) with consequent stenosis, and finally implantation of a pulmonary valve Hancock-conduit (2005), presented to our department with night sweats, shortness of breath, and fever for the past three weeks. Leukocytes and CRP were elevated, transthoracic echocardiography revealed a large vegetation on the pulmonary valve prosthesis with relevant stenosis (peak gradient 70 mmHg). The patient reported to have an 18-year-old cat as a pet, which had bit her shortly before onset of symptoms.

Blood cultures remained negative, bacterial broad spectrum PCR revealed Bartonella species. PET-CT was ordered and confirmed pulmonary valve endocarditis.

The patient was treated with antibiotics and eventually transferred to cardiac surgery due to persistently high gradients over the valve in combination with exertional dyspnea.

Bartonella is a well-known cause of blood culture negative infective endocarditis, which must be tested for specifically. This case underlines the importance of taking complete patient history, including presence of pets and especially recent bites. Comprehensive imaging must be performed timely in every patient with known valve disease and unexplained symptoms.

Abstract P223 figure 1

P1706 Trilogy of stroke

A 53 y/o female patient presented with clinical signs of stroke. Substantial cardiovascular risk factors were present with arterial hypertension, hyperlipidemia, impaired glucose tolerance, and a history of smoking. Transthoracic echocardiography revealed a suspicious structure on the aortic valve. Consequently, transesophageal echocardiography (TEE) was ordered.

In TEE, the structure proved to be highly suspicious for fibroelastoma. In addition, significant plaque of the aortic arch, and a persistent foramen ovale (PFO) were diagnosed in this examination.

The patient was referred to cardiac surgery for excision of the mass on the aortic valve and for PFO closure.

This case stresses the importance of echo in patients presenting with stroke. Apart from left atrial thrombus, several other possible embolic substrates can be diagnosed.

Abstract P1706 figure 1

In-vitro activity of active ingredients of disinfectants against drug-resistant fungi

The biocidal activities of peracetic acid and ethanol were tested against nine clinical fungal isolates and four reference strains. Ethanol was active (≥4.0 log₁₀ reduction) against yeasts at a concentration of 50% v/v and against moulds at 80% v/v. Exposure times in both cases were 1 min. Peracetic acid was active as a 0.25% solution against yeasts and as a 0.5% solution against moulds; exposure times in both cases were 5 min. Compared with the reference strains, clinical isolates, including multi-drug-resistant strains, showed similar or higher sensitivity to the active ingredients of disinfectants in vitro.

Hereditary hyperferritinemia cataract syndrome: clinical, genetic, and laboratory findings in 5 families

BACKGROUND

The hereditary hyperferritinemia cataract syndrome (HHCS) is an autosomal dominant disorder characterized by high serum ferritin and early onset cataract. Mutations in the iron responsive element (IRE) within the 5' untranslated region of the L-ferritin (FTL) gene lead to constitutive L-ferritin synthesis resulting in hyperferritinemia. Bilateral cataract formation is caused by the intracellular accumulation of ferritin in the lens.

PATIENTS

4 children from unrelated families were referred for further exploration of hyperferritinemia which was detected during the diagnostic work-up of gastroenterological or hematological disorders. 1 patient was primarily referred for the investigation of bilateral cataract.Diagnostics included routine blood analysis, including complete blood count, iron status, liver and kidney parameters, a physical and an ophthalmological examination. Molecular genetic analysis of the FTL IRE was performed in 4 patients by PCR from genomic DNA and subsequent direct sequencing.

RESULTS

All index patients presented with isolated hyperferritinemia without iron overload and had a positive family history for early onset cataract. Age at onset and disease severity varied between different families and among family members. Molecular genetic analysis revealed point mutations within the FTL IRE.

CONCLUSION

In patients with hyperferritinemia but without any other sign of iron overload or inflammation HHCS should be considered to avoid complex and invasive procedures. Vice versa, in patients with familial inherited cataract the early serum ferritin measurement helps to avoid unnecessary diagnostics.

Increase of serum insulin and stable c-peptide concentrations with exhaustive incremental graded exercise during acute hypoxia in sedentary subjects

Hypoxia was shown to reduce insulin concentrations at rest and during exercise. However, some studies have also demonstrated increases in the hormone associated with arterial desaturation. This study was conducted in order to decide [1] whether acute alveolar hypoxia increased or decreased the circulating insulin levels, and [2] to elucidate whether interactions of insulin with other hormones were of relevance in this respect. Glucose (GLU), insulin (INS), c-peptide (CP), adrenaline and noradrenaline (CATs), atrial natriuretic peptide (ANP) and cortisol (CORT) as well as the capillary blood gases were determined in 15 healthy fasting male volunteers (age: 26.2 +/- 2.8 years, body mass index: 22.4 +/- 2.7 kg.m-2). On two separate test days the subjects breathed, in random order, either normal air (N) or a gas mixture with reduced oxygen content (H; FIO2: 0.14). Measurements were made at rest as well as during an incremental cycle exercise in a supine position (increments of 6 min and 50 W) at 100 W and 150 W, at volitional exhaustion (N: 227 +/- 36 W; H: 200 +/- 32 W) as well as in the 5th min of recovery. Arterial desaturation was seen throughout on H-day. At rest all hormones and GLU were normal and showed no influence of H. During exercise INS remained constant on N-day, increased on H-day and was significantly higher with H than with N, most pronounced at 150 W and at volitional exhaustion with 20%, respectively. For CP and GLU no significant exercise-induced changes were seen on either test day and no influence of H was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Burkitt lymphoma in children: The Israel Society of Pediatric Hematology Oncology retrospective study

10051

Background: From 2000 to 2005, the Israel Society of Pediatric Hematology Oncology studied the results of the FAB-LMB 96 protocol in children with B cell lymphoma. Methods: Eighty eight patients (pts) were eligible, 63 boys, 25 girls, median age was 8.9 years. Fifty patients (57%) were classified as burkitt lymphoma, 5 (5.7%) as burkitt-like lymphoma, 22 (25%) as diffuse large B cell (DLBC), 9 (10.2%) as burkitt leukemia. Initial disease sites included the abdomen in 43%, head and neck in 45%, mediastinum in 7%. Stage I: 9.1%, Stage II in 28.4%, stage III in 45.5%, stage IV in 17%. Five pts had bone marrow involvement (BM) alone, 5 pts CNS alone and 4 both CNS and BM. Five children were treated according to group A, 69 pts group B and 14 pts group C. Results: At a median follow up of 3 years, Kaplan Meier for EFS and OS for all pts was respectively 88.6%, 90.9%, group A, 100%,100%, group B: 90%, 93%, group C 79%, 79%. In group A: there were neither events nor deaths in this group, 6 patients relapsed in group B, among them 4 patients had died, tumor lysis syndrome in 3 patients, death of toxicity in 1 patient. In group C, 3 patients had relapsed and died, no death of toxicity. EFS for LDH less then twice was 96.4%, EFS for LDH more than twice was 73.3% (p = 0.002). OS according to primary site: bone and ovary (100%), head and neck (95%), abdomen (92%) and mediastinum (50%) (p = 0.003). All of the mediastinal tumors were of DLBC origin, but when comparing the DLBC to other histologies, no significant difference in outcome were found.(DLBC: 81.8%, other B line: 90.9%). The OS for Arab ethnic origin is 79.2%, OS for Jewish is 95.3% (p = 0.02). Conclusions: In nonresected mature B cell lymphoma of childhood and adolescence with no BM or CNS involvement, a 93% cure rate was achieved. Patients with primary DLBC mediastinal mass had a significantly reduced overall survival, indicating the need for a different therapeutic approach.

No significant financial relationships to disclose.

Pacemaker endocarditis due to Propionibacterium acnes

Propionibacterium acnes belongs to the cutaneous flora of humans; it is often considered to be contaminant but has also been found to be a pathogen in human diseases. It is an uncommon causal agent in infective endocarditis and appears to have a predilection for prosthetic valves and foreign bodies. We describe a case of pacemaker endocarditis which shows that so-called harmless bacteria like P. acnes must be considered to be potential pathogens.

Painful regional anaesthesia induces an immunological stress reaction: the model of retrobulbar anaesthesia

BACKGROUND AND OBJECTIVE

Laboratory stress studies found that acute psychological stresses may elicit changes in leukocyte numbers similar to those occurring in physical stresses. Both types of stress evoke - mainly by release of catecholamines - leukocytosis resulting from a release of natural killer cells (NK-cells), of CD8+ T-cells, of monocytes and of neutrophils. However, there is little proof that laboratory stress models can be applied to daily clinical routines. As a likely inductor of an immunological stress response the setting of retrobulbar anaesthesia prior to intraocular surgery permits the study of a short-term painful anaesthetic procedure under highly standardized conditions. This was examined in 16 female patients.

METHODS

Counts of leukocyte subsets, serum cortisol and cardiovascular variables were measured 30 min and 1 min prior to retrobulbar anaesthesia as well as 2, 15 and 45 min afterwards.

RESULTS

The setting of retrobulbar anaesthesia induced an increase in total leukocytes [+380 cells microL-1; P < 0.01 (means; significance level)] mainly due to rising counts of neutrophils (+241 cells microL-1, P < 0.01). Of all lymphocyte subpopulations, natural killer cells increased most markedly (+64 cells microL-1; P < 0.01). Furthermore, the retrobulbar block induced an increase in systolic arterial pressure (+15.2 mmHg; P < 0.01).

CONCLUSION

These changes in immunological and cardiovascular variables are considered to be elements of a sympatho-adrenal stress reaction; catecholamines are considered to induce a demargination of leukocytes by binding to beta2-adrenoceptors and by modifying the avidity state of adhesion molecules.

Mutations in the connexin26/GJB2 gene are the most common event in non-syndromic hearing loss among the German population

Congenital sensorineural hearing loss affects approximately 1/1,000 live births. Mutations in the gene encoding connexin26 (GJB2) have been described as a major cause of genetic nonsyndromic hearing impairment. Additionally, another gap junction gene, connexin30 (GJB6), was found to be responsible for hereditary hearing loss. We have studied 134 patients with severe to profound hearing loss or deafness and 13 patients with mild to moderate nonsyndromic sensorineural hearing loss in order to evaluate the prevalence of connexin26 and connexin30 mutations in Germany. Mutations in the connexin26 gene were found in 30 patients (22%) with profound to severe hearing impairment whereas only one novel single nucleotide polymorphism (396G-->A) in the connexin30 gene was detected. Among the 13 patients with mild to moderate hearing loss neither mutations in the connexin26 nor in the connexin30 gene could be detected. These results demonstrate that mutations in the connexin26 gene are also a frequent cause of hereditary non-syndromic hearing loss in Germany. Therefore a screening of mutations in the connexin26 gene should be performed in every case of non-syndromic hearing loss of unknown origin.

Prosthetic valve endocarditis due to Candida tropicalis complicated by multiple pseudoaneurysms

Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. We describe a case of prosthetic valve endocarditis due to Candida tropicalis, complicated by multiple pseudoaneurysms.

Neurological rehabilitation of severely disabled cardiac arrest survivors. Part I. Course of post-acute inpatient treatment

BACKGROUND

Some survivors of out-of-hospital cardiac arrest (CA) sustain anoxic brain injury. The aim of this study was to offer these patients a new treatment approach, to describe the course and outcome of rehabilitation, and to judge whether rehabilitation provided benefit.

METHODS

Twenty severely disabled patients (mean age 47.6 years, 17 M:3 F) were admitted for inpatient rehabilitation after sustaining anoxic brain damage secondary to CA. The multidisciplinary treatment approach aimed at orientation, communication, mobility, and self care. Function was assessed using Barthel index (BI) score. On discharge, placement and global outcome was noted. Medical charts of consecutive patients were reviewed retrospectively.

RESULTS

Inpatient rehabilitation lasted on for average 12 weeks. Improvement in function was slow with a median increase of 1.88 BI score per week. Patients achieved clinically significant functional improvement as measured by pre-post comparison of BI (P<0.001). On discharge, overall disability was mild in 2 (10%), moderate in 7 (35%), and severe in 11 (55%) patients.

CONCLUSION

Rehabilitation of selected CA survivors is appropriate, reducing the subsequent burden of care. Although in 55%, only minor dependence on care persisted, on a group level, the potential for rehabilitation was modest, and recovery curve was flat. Before admission, families should be given realistic information about the possible outcome, because independence was rarely achieved.

[Thrombocytopenic purpura as sole manifestation of brucellosis in children]

Thrombocytopenic purpura associated with brucellosis has rarely been described in children. The thrombocytopenic purpura is usually part of the array of manifestations of brucellosis, such as fever, malaise, arthralgia, arthritis, hepatosplenomegaly and lymphadenopathy. We describe a 4-year-old girl in whom severe thrombocytopenic purpura was the only manifestation of brucellosis and resolved after appropriate antibiotic therapy. We conclude that brucellosis should be included in the differential diagnosis of thrombocytopenic purpura in areas endemic for brucellosis, and when there is a history of exposure to infected food products.

Limitations of the transpulmonary indicator dilution method for assessment of preload changes in critically ill patients with reduced left ventricular function

OBJECTIVE

We examined whether intrathoracic blood volume (ITBV) and total end-diastolic volume (TEDV), determined by the transpulmonary indicator dilution technique, adequately reflect preload changes during fluid administration in patients with reduced left ventricular function.

DESIGN

A prospective, controlled, clinical study.

SETTING

Medical intensive care unit in a university hospital.

PATIENTS

A total of 18 sedated, mechanically ventilated, and moderately hypovolemic intensive care unit patients, eight with reduced left ventricular function (ejection fraction area, 24.9+/-8.0%, group A), ten with normal left ventricular function (ejection fraction area, 57.6+/-13.0%, group B).

INTERVENTIONS

Continuous crystalloid infusion over 120 mins at a constant rate of 8 mL/kg/30 mins.

MEASUREMENTS AND MAIN RESULTS

Stroke volume index, central venous pressure, pulmonary artery occlusion pressure (PAOP), TEDV, and ITBV were determined simultaneously at baseline and serially every 30 mins during continuous crystalloid infusion. A similar series of measurements was obtained during control conditions. Performance of various variables during fluid administration was assessed by time correlation analysis. Sensitivity for various variables defined as the ability to detect increasing amounts of administered fluid in individual patients was calculated. All examined variables increased during fluid administration and were unaffected during the control period. Mean time correlation (r2) was significantly higher for pressure monitoring (central venous pressure, r2 = 0.8281; PAOP, r2 = 0.5476) than for volume variables (TEDV, r2 = 0.0256; ITBV, r2 = 0.0729) in group A and was high for all variables in group B (central venous pressure, r2 = 0.7056; PAOP, r2 = 0.6241; TEDV, r2 = 0.49; ITBV, r2 = 0.4225). Sensitivities for central venous pressure, PAOP, TEDV, and ITBV after 120 min were 63%, 75%, 25%, and 25% in group A and 90%, 100%, 60%, and 60% in group B, respectively.

CONCLUSION

This study demonstrates limitations of the transpulmonary indicator dilution technique for monitoring of intravascular volume in patients with reduced left ventricular function.

Imaging features of focal breast fibrosis: mammographic-pathologic correlation of noncalcified breast lesions

OBJECTIVE

Our objective was to describe the spectrum of imaging and histologic findings of focal breast fibrosis with an emphasis on noncalcified lesions, thereby offering a means of confirming mammographic-pathologic concordance on core biopsy of this increasingly encountered diagnosis.

MATERIALS AND METHODS

Retrospective review of 610 core needle biopsies revealed the histologic diagnosis of focal fibrosis in 89 (15%). Thirty-nine cases were excluded: 17 in which focal fibrosis was not the primary diagnosis and 22 in which calcifications were the main imaging findings. The 50 remaining patients with noncalcified lesions that proved on histology to be focal fibrosis constituted the basis of the study.

RESULTS

Mammographically, focal fibrosis presented as a mass in 68% of patients (n = 34), architectural distortion in 12% (n = 6), and asymmetric density in 10% (n = 5); focal fibrosis was mammographically occult in 10% (n = 5). Sonographically, 72% (n = 36) of cases of focal fibrosis presented as masses with three echo texture patterns: hypoechoic, isoechoic, and centrally echogenic with a peripheral hypoechoic rim. The sonographic margins were well circumscribed (n = 21), lobulated (n = 10), or ill defined (n = 5). Histologic review revealed three morphologic patterns of collagen deposition: perilobular, septal, and haphazard fibrosis. Correlation with the imaging findings showed that septal and perilobular fibrosis most often presented as hypoechoic or centrally echogenic masses, whereas the haphazard form was more often seen with architectural distortion.

CONCLUSION

Focal fibrosis often presents as a noncalcified mass on mammography or sonography. The diagnosis of focal fibrosis on core needle biopsy can be considered concordant for a mass exhibiting well-circumscribed or partially obscured margins. Imaging findings discordant with focal fibrosis, such as marginal spiculation, require excisional biopsy.

Therapeutic efficiency of lipoprotein(a) reduction by low-density lipoprotein immunoapheresis

This study was performed to investigate the effect of low-density lipoprotein (LDL) immunoapheresis on lipoprotein(a) [Lp(a)] reduction in patients with heterozygous and homozygous familial hyperlipidemia (N=16) and insufficient response to lipid-lowering agents. By desorption of approximately 5,700+/-500 mL of plasma, a mean reduction in total cholesterol of 62% (P < .001) and in LDL-cholesterol of 70% (P < .001) was achieved. Lp(a), which was elevated at study entry in seven of these patients (82.1+/-34.3 mg/dL; range, 48 to 148 mg/dL), was reduced during the initial LDL-apheresis procedure by 74.8%+/-14.1% (P < .001). Long-term apheresis treatment performed at weekly intervals resulted in an mean reduction in Lp(a) pretreatment values to 39.1+/-28.5 mg/dL (-54%; P < .001). Desorbed Lp(a) was measured at the waste of the columns for 31 apheresis treatments. Lp(a) concentration of the column waste was higher in patients with elevated serum Lp(a) pretreatment values as compared with those with Lp(a) serum values within the normal range (elevated Lp(a), 1,420+/-380 mg; without elevated Lp(a), 235+/-190 mg; P < .001). The rate of return of Lp(a) following apheresis treatment scheduled at weekly intervals was comparable to that of LDL-cholesterol.

Mammographic screening in women more than 64 years old: a comparison of 1- and 2-year intervals

OBJECTIVE

The purpose of our study was to determine if annual mammographic screening was superior to biennial screening in women more than 64 years old by examining differences in various prognostic indicators.

MATERIALS AND METHODS

We reviewed the records of 119 consecutive women 65 years old and older with 120 cases of breast cancer who had a previous normal screening evaluation for breast cancer that included mammography and physical examination 8-30 months before diagnosis. A search of the computerized tumor registry, clinical records, and breast imaging records from November 1988 to April 1995 provided our cases. Screening intervals were defined as 6-18 months (annual) and 19-30 months (biennial). Mammographic, histologic, and clinical features were reviewed. Disease severity (DS) levels were assigned to each tumor as follows: DS-1 included minimal disease (ductal carcinoma in situ [TisNO], T1aN0, and T1bN0 tumors), DS-2 included all T1cN0 tumors, DS-3 included tumors larger than 2 cm in diameter with lymph nodes that were negative for cancer, and DS-4 included all metastatic disease. Statistically significant differences were calculated using the Wilcoxon rank sum test, Fisher's exact test, and the chi-square test.

RESULTS

Ninety-three tumors were found in the group of patients who were annually screened, and 27 were found in the group of patients who were screened biennially. The women who underwent yearly screening mammography had significantly smaller invasive tumors (average, 10.7 mm; median, 9.5 mm versus 16.5 mm and 15.0 mm, respectively; p = .0086). The women who were screened annually also had significantly less advanced disease than women screened biennially (annually screened patients versus biennially screened patients: DS-1, 72% versus 44%; DS-2, 23% versus 37%; DS-3, 2% versus 11%; DS-4, 3% versus 7%; p = .0071). The group of patients screened annually had fewer cases of lymph node metastases (3% versus 8%; p = .12) and three times as many cases of ductal carcinoma in situ (22% versus 7%, p = .10).

CONCLUSION

Annual screening mammography revealed significantly smaller tumors and less advanced cases of cancer than biennial screening, providing inferential support for annual mammographic screening of women more than 64 years old.

Effect of antihypertensive treatment with doxazosin on insulin sensitivity and fibrinolytic parameters

The effects of the selective alpha-1-adrenoceptor antagonist doxazosin on metabolic and fibrinolytic parameters were studied in hypertensive patients with various degrees of fasting plasma insulin levels (Group A: 22.5 +/- 3 microU/ml, Group B: 8.1 +/- 1.5 microU/ml; p <0.01) to disclose a potential link between a doxazosin-induced alteration of insulin and/or lipid metabolism and possible changes of these parameters on the fibrinolytic system. Doxazosin treatment resulted in a dose-dependent reduction of basal insulin levels in group A to 16 +/- 3 microU/ml; p <0.05. This finding was paralleled by a dose-dependent increase in t-PAmass concentration in the same patient group (basal t-PAmass from 9.7 +/- 1 to 15.5 +/- 2 ng/ml; p <0.05). As PAI-1 "active" as well as total antigen levels were not altered in parallel, the net effect on the endogenous fibrinolytic system is an increase of the fibrinolytic potential.

[Pulmonary hypertension and cor pulmonale]

Pulmonary hypertension is a severe disorder of the pulmonary circulation and occurs in a variety of vascular and parenchymal lung diseases. It leads to volume and/or pressure overload of the right ventricle and finally to right heart failure. Pulmonary vascular diseases such as chronic pulmonary embolism cause a drastic increase in pulmonary vascular resistance, which results in extremely high pulmonary artery pressures that can even reach systemic levels. On the other hand, moderate pulmonary hypertension can also occur in chronic obstructive and restrictive lung diseases. For a long time, the diagnosis of pulmonary hypertension and cor pulmonale was based upon findings in echocardiography and right heart catheterization. Today modern imaging techniques allow the radiologist to assess right ventricular and pulmonary artery morphology and function. The application of spiral CT, electron-beam CT and MRT permits the diagnosis and differential diagnosis of pulmonary hypertension and also the evaluation and follow-up of underlying vascular or parenchymal lung disorders. In addition, quantification of right ventricular function and calculation of pulmonary hemodynamic parameters are possible.

The acute immune response to exercise: what does it mean?

The purpose of this article is to provide information about the exercise-induced alterations of cellular immune parameters depending on the intensity related to the individual anaerobic threshold (IAT) and duration of exercise. Immunological parameters were differential blood counts (CD14, CD45), monocyte subpopulations (CD14, CD16), lymphocyte subpopulations (CD3, CD4, CD8, CD45RO, CD19, CD16, CD56, HLA-DR) and natural killer cells (CD3, CD16, CD56), oxidative burst activity of neutrophils, and phagocytosis of neutrophils (flow cytometry). The main results were: (a) "Moderate" exercise (duration < 2h at about 85% of the IAT corresponding to a lactate steady state at about 2 mmol.l-1, < 30 min at the IAT corresponding to a lactate steady state of 4 mmol.l-1) elicits lower changes in cell concentrations and hormonal responses than strenuous exercise [exhaustive exercise at 100% IAT or above; (exhaustive) long-term (> 2-3h) endurance exercise]. Similar investigations about cell functions to decide about the positive or negative nature of these observations will have to follow in the future. (b) The neutrocytosis following exercise is more dependent on the duration than on the intensity of exercise. Especially exercise sessions that lead to a strong incline of the adrenocorticotropic hormone, beta-endorphin and cortisol are associated with this neutrocytosis. (c) Neutrophils' function during the exercise-induced neutrocytosis indicated by phagocytosis and oxidative burst activity is unchanged or reduced following strenuous endurance exercise, whereas bacterial URTI leads to similar neutrophil counts but significantly increased cell activities indicating the diverse meaning of the leukocytosis in infections (primed cells, enhanced cell activity, stimulated defense mechanism) and following exercise (impaired cell function, suppressed defense mechanism). (d) Regular monocytes (early differentiation stage) are strongly recruited into the circulation during long-term aerobic exercise, whereas mature monocyte cell counts (premacrophages) increase most with highly intensive (an)aerobic exercise above the IAT. Infections induced a maturation from regular to mature monocytes as a response to the infectious antigenic stimulus, whereas exercise does not, indicating the diversity between change of cell counts and function. (e) Long-term endurance diverse meaning leads to increases of activated CD45RO+ T cells (memory cell phenotype) but compared to the incline of cell concentrations and activation levels (% HLA-DR+ T cells) during infections like infectious mononucleosis this effect is small indicating only minor effects on T cell function by exercise. The effect of single bouts of exercise on immune cell counts is large but the effects on the cell function is - i.e. compared to bacterial URTI - relatively small.

Enhanced expression of HLA-DR, Fc gamma receptor 1 (CD64) and leukocyte common antigen (CD45) indicate activation of monocytes in regenerative training periods of endurance athletes

The aim of this study was to test the hypothesis whether endurance athletes have distinct expressions of functionally relevant surface antigens of monocytes. Under standardized experimental and laboratory conditions CD 14+ blood monocytes of 55 males (22 sedentary controls [CO], individual anaerobic threshold [IAT]: 2.2 +/- 1.2 W.kg-1, VO2 max: 47 +/- 12 ml.min-1.kg-1; 13 endurance athletes, training: 3-10 hours weekly [E1], IAT: 3.0 +/- 1.1 W.kg-1, VO2max 57 +/- 5 ml.min-1.kg-1; 20 endurance athletes training: > 10 hours weekly [E2], IAT: 3.7 +/- 1.3 W.kg-1, VO2max: 64 +/- 6 ml.min-1.kg-1) were investigated for relative surface receptor expression of CD45, CD64 and HLA-DR (direct immunofluorescence, flow cytometry). E1 and E2 showed significantly (ANOVA, Tukey's HSD test; each p < 0.01) higher relative receptor expressions for CD64 in comparison to CO (E1: +62/E2: +71%; percentage of increase compared to CO value), CD45 (+44/+32%) and HLA-DR (+22/+35%). Cell counts of four monocyte subpopulations (CD56+, CD14bright+CD16-, CD14bright+CD16dim+, CD14dim(+)-CD16bright+) did not show significant differences between the groups. These data suggest that in endurance athletes during regenerative training period circulating monocytes show an enhancement of functionally relevant surface receptors indicating an activation monocytes.

[Aortic coarctation--long-term follow-up in adults]

Surgical repair of coarctation of the aorta has been performed since 1945. Although surgical techniques have improved, problems such as restenosis and aneurysm at the operation site or hypertensive cardiovascular disease, still remain. To evaluate the long-term results after surgical repair of coarctation, 41 patients, 25 male and 16 female patients (mean age: 28 +/- 11 years, range 14-57 years), were studied 16 +/- 8 years after surgery (range 3-44 years). Mean age at surgery was 12 +/- 9 years (range 0.5-35 years). In 24 patients resection and end-to-end anastomosis had been performed, patch graft aortoplasty in nine patients, tube interposition graft in seven patients and one patient had undergone the subclavian flap technique. All patients were assessed by exact physical examination, the resting arm-to-leg systolic pressure gradient was measured by Doppler sonography, a bicycle exercise test and an echocardiogram were performed. Twenty-one patients reported postoperative symptoms such as dizziness (n = 12), headache (n = 3), cold legs (n = 10) and/or dyspnea (n = 8). In two patients the resting arm-to-leg pressure gradient was greater than 30 mm Hg, in two patients it was greater than 20 mm Hg. Gradient calculated by Doppler echocardiography ranged from 0 to 80 mm Hg (21 +/- 17 mm Hg) and showed poor correlation with the arm-to-leg pressure difference. The mean functional capacity was 89 +/- 18% (range 42-110%). In 18 patients exercise-induced hypertension was found, while in only eight patients arterial hypertension had already been known. To evaluate the morphology of the aorta MRI was performed in 28 patients. No aneurysm was found. In five patients a minimal lumen diameter as small as 9-11 mm was measured. Patients were divided into two groups according to their age at operation, group I: < 9 years (n = 19) and group II: > 9 years (n = 22). Resting blood pressure was significantly higher in group II (135 +/- 27 mm Hg vs 114 +/- 20 mm Hg, p < 0.009), anti-hypertensive medication (43% vs 11%, p < 0.04) and symptoms were more frequent in these patients (15/22 vs 6/19, p < 0.04). However at time of follow-up examination the age of patients of group II was significantly higher (33 +/- 12 vs 22 +/- 5 years, p < 0.0005). Between these two groups there was no difference in follow-up time and results of echocardiography or stress test. In conclusion, despite good long-term results after surgical repair of coarctation of the aorta, patients should be followed on a regular basis primarily in order to recognize systemic hypertension as early as possible and to improve the long-term outcome in these patients by antihypertensive treatment.

Breast cancer in women 65-74 years old: earlier detection by mammographic screening

OBJECTIVE

Our objective was to investigate the value of screening mammography in 65- to 74-year-old women by determining differences in various prognostic indicators in screened and nonscreened groups.

MATERIALS AND METHODS

We reviewed 103 malignant breast tumors detected in 102 women 65-74 years old over a period of 73 consecutive months (February 1988-March 1994). A screening interval of less than 18 months was chosen to separate the screened from the nonscreened populations. Mammographic, histologic, and clinical features were reviewed. Statistically significant differences were calculated using Fisher's exact test and Wilcoxon's rank sum test.

RESULTS

Thirty-two patients were in the screened population; 70 patients were in the nonscreened population. Ninety-nine percent (102/103) of the carcinomas were apparent mammographically. We found significant differences between the screened and the non-screened groups with respect to the size of lesions revealed by mammography (11 mm versus 21 mm; p = .0002) and the incidence of minimal tumors (20/32 (63%) versus 26/70 (37%), p = .0198). The incidence of lymph node metastases was 3/27 (11%) for the screened group versus 14/47 (30%) for the nonscreened group (p = .0875). The overall positive predictive value of mammography for the 65- to 75-year-old patients was higher than in our general population, 47% versus 28%.

CONCLUSION

Screening mammography revealed significantly smaller and earlier stage tumors in 65- to 74-year-old women. This finding inferentially supports the efficacy of screening in this age population.