Finding the fitting framework for the implementation of policies promoting healthy nutrition and physically active lifestyle: Results from a systematic review

Background

Policies are an important upstream component of health promotion to influence the general population. Various frameworks exist to help implement policies. However, there is currently no overarching synthesis that describes the differences between policy implementation frameworks. In this study, we examined frameworks for implementing policies to promote healthy eating, physical activity and reduce physical inactivity and aimed to explore the scope of the frameworks, the content of the constructs they contain (e.g. processes, determinants, evaluation), the level at which these constructs operate and the inclusion of equity factors.

Methods

A systematic review (PROSPERO registration number: CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analysed.

Results

All three constructs were covered by 18 frameworks: description of the process, determinants and evaluation of implementation. The majority of frameworks (25/38) considered constructs from three levels: the individual, organisational/community and system levels, with system level constructs being included less frequently than individual level or organisational/community level constructs. Most frameworks (32/38) contained sections that were exclusively descriptive. In addition, 19 frameworks contained prescriptive and 23 explanatory sections. The complex systems approach was included in 8 of the frameworks. More than half of the frameworks (21/38) did not consider equity constructs.

Conclusions

Most frameworks have a complex scope, include multi-level constructs, combine sections that are purely descriptive with sections that consider prescriptive and/or explanatory associations, and include few or no equity constructs. The findings of this study can facilitate the process of selecting the framework that best fits the needs and goals of policy makers, researchers and policy implementation actors seeking guidance.

Competences in the management of health regions: Germany, Poland and Spain

Background

Germany has a comprehensive and diverse network of health regions, Spain has partial health regions and in Poland this model is not yet present. The purpose of this study is to summarize and compare the experiences of Spain and Germany in terms of health network managers activity, along with a potential and conditioning for the existence of similar structures in Poland, to determine what competences they need in each country and what are the similarities and differences between them.

Methods

In the three countries, 18 in total qualitative interviews were conducted with experts and stakeholders from the health sector, public administration, the health economy and health regions. The interviews focused on the current state of the health systems as well as the required competences of a regional health network manager. They were analysed for content. The following categories were created: Health, management, social skills and other competences.

Results and discussion

There is an overlap in the required competences in the three countries. A knowledge in the field of public health, the organisation and assessment of health services as well as communication and management skills are of importance. In addition, there are competences in fund raising and legal matters. Country-specific competencies and areas must be taken into account, e.g. in Germany addressing people with a migration background is a more central issue than in Poland, while in the latter country high pressure has been put on the soft skills.

Conclusions

European competence profile for managers of regional health networks is possible, which harmonizes with and complements the competence profile of public health specialists. Nonetheless, national profiles require to highlight different critical competences adapted to local conditions.

Main message

The competences of a regional health network manager are predominantly cross-national.

Has the European Union created a healthy food environment for its citizens? Application of the Food Environment Policy Index (Food-EPI)

Background

European Union (EU) Member states' food environments are shaped by both national and EU policies. To date however, studies assessing food environment policies developed and set by the EU are scarce. The aim of this study was to assess the strength of EU policies to improve food environments as well as to assess the extent these policies could lead to a decrease or widening of socio-economic inequalities in dietary intake.

Methods

We compiled evidence on the EU policies for each of the Food-EPI 47 indicators. A European panel of independent, non-government experts (N = 30) specialized in nutrition, obesity or chronic diseases, using the Food-EPI evidence, rated the strength of EU policies to improve food environments during an online survey in February-March 2020. The experts also rated to which extent policies could lead to a decrease or widening of socio-economic inequalities in dietary intake. In addition, experts formulated actions to improve EU food environment policies, which were prioritized during a follow-up online survey.

Results

The overview of EU-level policies resulted in a 79-pages document, describing policies (or the lack thereof) for each of the 47 Food-EPI indicators. This document has been verified for completeness and accuracy by EU governmental officials. The evidence document shows that the EU has mainly binding legislation on the food labelling whereas policies on the other Food-EPI domains are mostly voluntary. Results from the online survey and the formulated prioritized actions will be presented during the conference. The results will reflect the experts' ratings supported by documented evidence and will provide meaningful guidance to EU officials and public health advocates in their efforts to improve the food environment policies set by the EU.

A study on implementation of food-related policies in Poland using the Healthy Food Environment Policy Index

Background

Existing studies indicate obesity and diseases associated with diet and sedentary lifestyle as leading health problem in Poland that cannot be solved without explicit public intervention. The purpose of this study is to evaluate actions to create a healthy food environment, undertaken by public authorities in Poland.

Methods

We used the Food Environment Policy Index (Food-EPI) to describe the Polish national food environment policy. We analysed available government documents, studies, reports, legal acts and other relevant materials to compile a evidence document, which has been then validated with government officials. In the next stage (March 2020), national policies will be subject to assessment in reference to international best practices by independent experts through an online Delphi study. Results of the survey will be then used during a national workshop (April 2020) in order to formulate and prioritize actions.

Results

For 15 out of 47 indicators we found no evidence for government actions that would meet the criteria set out in the Food-EPI definition. In case of the other 6 indicators it was observed that the existing solutions are non-binding and result from government-independent policies. The lack or limits of government involvement was observed in particular in the domains related to food promotion, food provision, food in retail, and Health in All Policies. Results from the online study and the workshop will be presented during the conference.

Conclusions

The preliminary results obtained through the review of the evidence point to the need for intensified government activities in the area of shaping food policy in Poland. Full conclusions will be formulated after the study is completed. Preliminary findings of the Food-EPI project suggest the need for strengthening food environment policy in Poland.

An emerging trend to tax sugar sweetened beverages and other junk foods: overregulation or an effective way to modify dietary behaviours?

Dietary behaviours have an important impact on rising prevalence of noncommunicable diseases responsible for 71% of deaths globally/year. Dietary behaviours also have a growing impact on quality of life, disabilities, as well as economic stability of health systems. In order to overcome the growing impact, many countries are looking for instruments to modify dietary habits of individuals. In the study presented here, we looked at solutions implemented in different countries in terms of junk food taxation, with regard to the political processes related to their implementation, adopted models of taxation, as well as their impact on social and economic reality. Throughout the world, several countries have adopted dietary taxes, such as sugar, fat, salt and soda taxes, while the other are planning or considering doing so. So far there is only one example of withdrawal from the tax that has been implemented. There are different models of taxation, including flat rates, percentages of the basic price and progressive rates on the amount of the component being subject to taxation. These solutions continue to be controversial and subject to intensive discussions in many countries. Nonetheless, the existing evidence shows that the impact on dietary habits seems to be positive.

Identifying best practices in junk food taxation and other food policies: Selected examples and their assessment

Issue/problem

Noncommunicable diseases are the main contributor to the global mortality, being responsible, as estimated, for 71% of deaths each year. About 80 of dietary dependent diseases has been identified so far, and their prevalence tends to exceed 30% in some populations.

Description of the problem

The growing prevalence of these diseases, along with impact on the quality of life, disabilities, as well as rising direct and indirect economic costs, constitute a basic foundation for emerging efforts to develop and implement new solutions within national health policies aimed at modifying dietary behaviours and reducing their negative impact on health status of individuals and populations. To address these problems the Joint Funding Action “Effectiveness of existing policies for lifestyle interventions - Policy Evaluation Network (PEN)” has been initiated, in which 28 research group across Europe are collaborating.

Results

The primary aim of the presented study will be to discuss the usage of the PEN instrument to identify best practices in food policies, including sugar sweetened beverages and junk food taxation. Previous examples of the instrument implementation will also be presented, including New Zealand, Australia and Canada, along with the results of current works on its development within the project. The second basic aspect for the study is to discuss and assess examples of food policies implemented in selected countries in terms of their effectiveness in modifying unhealthy behaviours.

Lessons

The time that has passed since the implementation of the evaluated solutions is too short to assess actual impact on health. Nonetheless, the existing evidence, including data from countries being the most successful examples of junk food taxation, like Mexico and Hungary, suggest that their impact on consumer choices, health literacy and also food industry in terms of food products composition, is positive.

Emergency medical service in Poland--current state and a need of reform

The article focuses on the question of reorganisation of Emergency Medical Service in Poland. First part of the paper contains a short description of a project of the Integrated Rescue System, which have been included in the National Emergency Medical Service Act enacted by Parliament in 2001. Considering to the fact, that implementation of this reform has been stopped after general elections in autumn 2001, in the second part of the paper some arguments supporting the postulate of urgent realisation of this project are discussed. The arguments refer to five spheres: epidemiological, social, political, legal and economical. The conclusions of the discussion are, that in every of those spheres negative consequences of blocking the reform may be observed. The final conclusion is, that reorganisation of ineffective Emergency Medical Service in Poland is still a challenge, which public authorities have to manage.

Patent ductus venosus: diagnosis by MR angiography

We report a 15-year-old boy with patent ductus venosus in whom the diagnosis was made by MR angiography. A patent ductus venosus Arantii is a rare form of portosystemic shunt. Only a few cases have been reported in adults and children. The diagnosis is usually made by US and digital subtraction angiography. In our patient, the diagnosis was first made by MR angiography. This demonstrates the excellent diagnostic potential of the method in paediatric patients.

[Results and complications of endovascular therapy of aortic aneurysms]

INTRODUCTION

Endovascular repair (ER) has been established as an alternative treatment option for aortic aneurysm (AA) in case of a suitable morphology. However, there are specific problems related to diagnostic and therapeutic management including potential complications of the new procedure.

PATIENTS AND METHODS

Between 8/1996 and 11/1999, 41 patients (6 female, mean age 67.9 (range 55-84) years) underwent an operation with the intention of ER. Modular, self-expanding stent-grafts were used for aorto-biiliacal (36), aorto-monoiliacal (1), and aorto-aortal (infrarenal-1, thoracic-1) aortic aneurysm (AA) exclusion. Postoperatively and during the follow-up period, diagnostic measures included clinical investigation, native X-ray, and color-coded Doppler sonography, and spiral computed tomography, and digital subtraction angiography. Results were analysed with special reference to complications and resulting therapeutic consequences.

RESULTS

Technical success was achieved in 36/41 patients (87.8%). There were 2 primary distal endoleaks and 3 conversions because of lacking vascular access. Of 4 primary endoleaks, a proximal one was treated successfully by overstenting, a distal one was sealed off by iliac extension, and 2 distal ones were treated conservatively. Three secondary endoleaks, a proximal and 2 distal ones, required conversion each by retro- and transperitoneal approach. Presently, there are 4 endoleaks, with the maximal aortic diameter remaining constant except one case. Five secondary occlusions of an iliac limb (4) or artery (1) were treated by thrombectomy (1), PTA (1), PTA with overstenting (1), and cross-over (1) or ilicofemoral bypass (1). Three patients died of unrelated disease during the follow-up period.

DISCUSSION

On condition of a critical indication, improved diagnostic management and further refinement of stent-graft systems ER constitutes an alternative, minimally invasive treatment option for AA. Long-term results must be obtained by means of continued prospective and comparative studies to definitely evaluate ER.

Value of bronchial artery embolisation with platinum coils in tumorous pulmonary bleeding

We performed bronchial artery embolizations (BAE) using platinum coils with Dacron fibres in 30 consecutive patients with haemoptysis due to bronchial carcinoma. The aim of the study was to compare immediate results of bleeding cessation, recurrence and survival rates with a historical control group of 15 patients with tumorous pulmonary bleeding who were treated conservatively (non-BAE-group). Bronchial artery embolisation with platinum coils stopped active bleeding in all patients immediately. Comparing the BAE group and controls the cessation of first time haemoptysis (BAE 100% versus non-BAE 93%) and the rates of bleeding recurrence (BAE 50% versus non-BAE 47%) were similar in either group. In case of recurrent bleeding, repeated BAE led to a definite cessation of pulmonary haemorrhage in every case. In contrast, all patients with recurrent haemoptysis without a repeated BAE (8 patients, 27%) and all patients with bleeding recurrence in the non-BAE group died from pulmonary haemorrhage (8 patients, 53%). The mean survival time of the BAE group was significantly longer compared with the non-BAE group, 139 (range: 1-818) days versus 62 (range: 1-186) days (P<0.05). We conclude that consistent BAE proved beneficial in tumorous pulmonary bleeding, particularly with regard to the permanent arrest of haemorrhage in case of recurrence.

Vascular complications in acute pancreatitis assessed by color duplex ultrasonography

We determined the sensitivity of computed tomography and color duplex ultrasonography in the detection and characterization of vascular complications in acute pancreatitis. The relationship of these complications with the etiology and activity of the disease was assessed. In a prospective study, 189 patients with acute pancreatitis seen in the Department of Gastroenterology. Charité Hospital in Berlin over a period of 38 months underwent color duplex ultrasonography every second day for 3 weeks and thereafter at least once a week for 2 months. Dynamic computed tomography was performed within 72 hours after admission, and follow-up computed tomography scans were obtained. In 45 patients (23%), at least temporary thromboses of portal venous vessels were demonstrated by color duplex ultrasonography. The incidence of venous thromboses was 30% in severe acute pancreatitis with fluid collections without necroses and 57% in necrotizing pancreatitis. In 27 of those 45 patients, a formation of collaterals was documented. In 13 patients, arterial pseudoaneurysms were demonstrated. Vascular complications were significantly more frequent in alcohol-induced than in gallstone-induced pancreatitis. Only 62% of all sonographically diagnosed thromboses and only 32% of all collaterals were demonstrated by computed tomography. The prevalence of vascular complications in acute pancreatitis was much higher as suspected. The risk of gastrointestinal bleeding was lower than previously reported. Color duplex sonography is the method of choice for the detection of vascular complications in acute pancreatitis.

Post-feeding hyperammonaemia in patients with transjugular intrahepatic portosystemic shunt and liver cirrhosis: role of small intestinal ammonia release and route of nutrient administration

BACKGROUND

Hyperammonaemia is a pathogenetic factor for hepatic encephalopathy that may be augmented after a transjugular intrahepatic portosystemic shunt (TIPS). Experimental data suggest that hyperammonaemia may be caused to a large extent by metabolism of small intestinal enterocytes rather than colonic bacteria.

AIMS

To evaluate if ammonia release and glutamine metabolism by small intestinal mucosa contribute to hyperammonaemia in vivo in patients with liver cirrhosis.

METHODS

Using TIPS to examine mesenteric venous blood, we measured mesenteric venous-arterial concentration differences in ammonia and glutamine in patients with liver cirrhosis before, during, and after enteral (n = 8) or parenteral (n = 8) isonitrogenous infusion of a glutamine containing amino acid solution.

RESULTS

During enteral nutrient infusion, ammonia release increased rapidly compared with the post-absorptive state (65 (58-73) v. 107 (95-119) micromol/l after 15 min; mean (95% confidence interval)) in contrast with parenteral infusion (50 (41-59) v. 62 (47-77) micromol/l). This resulted in a higher portal ammonia load (29 (21-36) v. 14 (8-21) mmol/l/240 minutes) and a higher degree of systemic hyperammonaemia (14 (11-17) v. 9 (6-12) mmol/l/240 minutes) during enteral than parenteral infusion. The mesenteric venous-arterial concentration difference in glutamine changed from net uptake to release at the end of the enteral infusion period (-100 (-58 to -141) v. 31 (-47-110) micromol/l) with no change during parenteral nutrition.

CONCLUSIONS

These data suggest that small intestinal metabolism contributes to post-feeding hyperammonaemia in patients with cirrhosis. When artificial nutrition is required, parenteral nutrition may be superior to enteral nutrition in patients with portosystemic shunting because of the lower degree of systemic hyperammonaemia.

Dissecting aneurysm of the infrarenal abdominal aorta

The aim of this study was to report the case of a patient with chronic dissecting infrarenal abdominal aortic aneurysm (AAA) and to review the literature for this rare vascular disorder. The preoperative assessment, surgical treatment, and postoperative course of a patient with a dissecting AAA and associated left iliac artery dissection were analyzed. The literature is reviewed with respect to etiology and pathogenesis as well as diagnostic and therapeutic management of infrarenal dissecting AAA. The preoperative diagnosis of dissecting infrarenal AAA was made by computed tomography and aortography and confirmed during surgery. Successful repair was accomplished by use of a bifurcated aortobiiliacal Dacron graft. A review of the literature demonstrates the rarity of dissecting aneurysm exclusively involving the infrarenal aortic segment. Primary dissecting aneurysm of the infrarenal abdominal aorta is a rare morphologic finding. Principles of diagnostic and therapeutic management of common atherosclerotic AAA also apply to dissecting AAA.

Combined surgical and endovascular removal of thrombus entirely occluding a bifurcated aortic stent-graft

PURPOSE

To explore a method combining interventional, endovascular, and conventional surgical techniques for treating a completely occluded bifurcated stent-graft after endovascular aortic aneurysm repair.

METHODS AND RESULTS

A 60-year-old patient underwent endovascular repair of an abdominal aortic aneurysm (AAA) with a Talent bifurcated stent-graft. Five months later, after chronic thrombotic occlusion of the right iliac limb, he presented with acute occlusion of the entire stent-graft. Local intra-arterial infiltration thrombolysis successfully reconstituted flow through the main aortic segment and left iliac limb. With a combination of conventional surgical and intraoperative endovascular procedures, thrombectomy and recanalization of the right iliac limb was completed by stenting a severe stenosis of the proximal iliac limb.

CONCLUSIONS

A combination of techniques may be essential for successful management of thrombotic complications after endovascular AAA repair.

A method for adjusting a malpositioned bifurcated aortic endograft

PURPOSE

To report the successful application of a method to adjust a malpositioned bifurcated stent-graft after endovascular aortic aneurysm repair.

METHOD AND RESULTS

A 62-year-old male patient underwent endovascular repair of a 5.1-cm abdominal aortic aneurysm (AAA) with a Vanguard bifurcated stent-graft. After complete deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected occlusion of the left renal artery. Intra-aortic adjustment of the bifurcated graft was possible with a crossover guidewire, which was pulled caudally. The method worked perfectly to restore blood flow to the left renal artery. The patient is well 16 months postoperatively without any evidence of endoleak or graft migration; the left renal artery remains open.

CONCLUSIONS

A technique is demonstrated for intra-aortic repositioning of a bifurcated stentgraft to correct insufficient deployment. If required, this technique should be attempted before conversion to an open procedure.

Intravascular disruption of central venous ports

Intravasal catheter disruption is a rare complication of central venous ports. Main causes are chronic trauma due to compression of the catheter between clavicle and first rib, or primary damage by sharp instruments during insertion. Utilizing the subclavian route, a more lateral insertion can minimize the risk of catheter compression. Regular postoperative X-ray controls can help to recognize progressive catheter compression. In the case of significant compression, early replacement is advisable to avoid disruption. Percutaneous transvenous snare technique is the therapy of choice to retrieve dislocated fragments.

Covalent immobilization of hirudin improves the haemocompatibility of polylactide-polyglycolide in vitro

A biodegradable polymer, poly(D,L-lactide-co-glycolide) RESOMER RG756, was modified by surface immobilization of recombinant hirudin (r-Hir) with glutaraldehyde as coupling reagent to improve the blood contacting properties of the polymer. The activity of immobilized hirudin on the polymer was estimated by a chromogenic assay to about 2.5 ATU r-Hir cm-2. The improvement of the haemocompatibility of the modified RG756 was evaluated in terms of platelet adhesion/activation, whole blood clotting times and clot formation rate. Fluorescence microscopy revealed that surface modification with r-Hir resulted in decreased platelet adhesion and activation. An ELISA for P-selectin, a marker of platelet activation, was used to confirm this result. Clotting time experiments demonstrated significantly prolonged non-activated partial thromboplastin times, and a decreased clot formation rate of whole blood in contact with r-Hir modified RG756 compared with the plain polymer. Comparison of immobilized r-Hir with bound heparin yielded equivalent improvement of blood-contacting properties of the investigated polymers. These in vitro investigations indicate that the immobilization of r-Hir on RG756 is a useful method to improve the blood contacting properties of polylactides/polyglycolides and other polymers as well.

[Interventional pneumology: procedures for pulmonary hemorrhage and tumor-induced superior vena cava syndrome]

Interventional pneumology includes both bronchological and vascular methods of diagnostic and therapy, especially in case of pneumological emergency, such as pulmonary hemorrhage and superior vena cava syndrome. In massive pulmonary hemorrhage bronchological diagnosis is needed to determine the location and activity of the bleeding, as well as angiography of bronchial arteries, and of pulmonary arteries, respectively. Bronchus occlusion by aid of balloon catheter or double lumen tube are intermediate methods to bridge over till defenitive surgery or embolisation of bronchial or pulmonal arteries as complementary methods in patients with pulmonary hemorrhage. In patients suffering from superior vena cava syndrome caused by neoplasms venous angioplasty and Wallstent implantation provide immediate clinical improvement.

Immobilization of heparin on polylactide for application to degradable biomaterials in contact with blood

The poly-(D, L-lactide) RESOMER R208 (Boehringer-Ingelheim, Germany) was modified with heparin to improve the blood contacting properties of the material. The immobilization of herapin was carried out by covalent binding with glutaraldehyde as the coupling agent. The reaction conditions, such as temperature and time, were varied to optimize the binding of heparin. The efficiency of the immobilization was monitored with respect to the total amount of coupled herapin with a toluidine blue assay and the anticoagulant activity of immobilized heparin with a factor Xa assay. The hemocompatibility of the modified polylactide was estimated after blood-material contact by the activation of platelets measured with an enzyme immuno assay for GMP140. Immobilization at ambient temperature and a reaction time of 2 h resulted in maximal heparin binding, high anticoagulant activity, and low thrombogenicity. Since the remaining unsaturated aldehyde groups of the coupling agent may cause a low hemocompatibility of the material, washing of the heparinized polylactide was carried out with ethanol. However, it was shown that washing diminished the anticoagulant activity of heparin and increased the thrombogenicity. The prolonged storage of heparinized polylactide in phosphate buffered saline for 8 days demonstrated that small quantities of heparin were released but the hemocompatibility was further improved, indicated by an increasing anticoagulant potential and a decrease in platelet activation with incubation time. A comparison of polylactide, heparinized polylactide, polypropylene, and Pellethane with respect to platelet activation by GMP140 assay and scanning electron microscopy, revealed that the heparinization of polylactide substantially improved the hemocompatibility of RESOMER R208, making the material comparable to Pellethane.

[Venous angioplasty and Wallstent implantation in emergency treatment of superior vena cava syndrome caused by tumor]

HISTORY AND CLINICAL FINDINGS

A 58-year-old man was hospitalized because of threatened asphyxia resulting from massive obstruction to neck vein flow and increased venous markings over the ventral and dorsal thorax. The previous year he had received radiotherapy (total of 55.8 Gy) for squamous cell carcinoma in the right upper lobe of the lung (primary stage T2 N2 M0). The signs of venous congestion had developed over several months.

TESTS

Emergency phlebography demonstrated obstruction to superior vena cava (SVC) flow by tumour compression.

TREATMENT AND COURSE

It was possible to pass the SVC obstruction with a hydrophilic guide-wire and then perform a balloon angioplasty, followed later by implantation of two intraluminal expandable stents ("Wallstent"). The dyspnoea quickly improved after the successful recanalization. The day after the intervention palliative radiotherapy of the SVC obstruction was begun. But increased venous markings over the thorax recurred, but without dyspnoea, after 4 1/2 months free of signs of venous congestion. Repeat phlebography again demonstrated complete obstruction of the SVC by the tumour. Recanalization by balloon angioplasty was again achieved.

CONCLUSIONS

This case underlines the value of percutaneous balloon angioplasty with stent implantation as supplementary treatment in the late stages of SVC obstruction by tumour.

[Coronary ventricular fistulas in patients with heart transplants]

In detailed angiographic follow-up examinations in patients after heart transplantation, coronary artery-ventricular fistulas were observed in two of ten patients. In one patient, in the first postoperative year, 19 right ventricular biopsy procedures were performed obtaining a total of 71 tissue specimens and one year after transplantation, additionally, three specimens were obtained from the left ventricle. Coronary angiography demonstrated a fistula from the first anterior ventricular branch of the right coronary artery into the right ventricle (Figure 1) as well as a second smaller fistula between from a septal perforator of the left anterior descending artery into the left ventricle. At follow-up angiography two months later, the fistulas were unchanged in site and extent (Figure 2). Angiographically there was diffuse hypokinesis of the right ventricle and moderate tricuspid regurgitation. In the second patient, in the first year after transplantation, 20 right ventricular biopsy procedures were performed obtaining a total of 80 tissue specimens. One year after transplantation coronary angiography showed a fistula between a septal perforator of the left anterior descending artery into the right ventricle (Figure 3) which, two months later, was unchanged in morphology and, as in the first case, the size of the shunt was small. Angiographically, there was moderate tricuspid regurgitation and apical hypokinesis of the left ventricle. If a relationship between the fistulas and biopsies is postulated, from a total 196 biopsy procedures obtaining 748 tissue specimens, the rate of this complication would be calculated at 1.5%. It cannot be ruled out, however, that the fistulas had been congenitally present in the donor hearts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary reserve determination by intracoronary papaverine: effects of various doses on coronary circulation and hemodynamics]

In 40 male coronary patients during heart catheterization the coronary flow reserve was investigated by continuous thermodilution in the coronary sinus after intracoronary papaverine application. Simultaneously a number of heart function parameters were recorded. Already the lowest dosage of papaverine (5 mg) was able to induce a maximal flow acceleration. Higher dosages were accompanied with haemodynamic side effects (increase of heart rate and left ventricular end-diastolic pressure, decrease of left ventricular systolic pressure, appearance of myocardial ischemia) without further increase of coronary flow. After at most 5 minutes time the papaverine effects completely disappeared. In conclusion, a safe, short-lasting and repeatable determination of the coronary flow reserve (for instance during PTCA) proved to be possible after intracoronary papaverine injection in low dosages (5 mg).

[Rehabilitation measures in patients following recovery in myocarditis and dilated cardiomyopathy]

In the frame of the attendance to patients with specific myocardial diseases differences are found in contrast to groups of patients, in particular of older age. The complex diagnostic clarification, including myocardial biopsy, is recommended. Convalescent treatment is of priority. Because of the bad prognosis of patients with impaired left-ventricular function, in particular patients with normal or slightly impaired left-ventricular ejection fraction should be mobilised using complex rehabilitative measures (psychologist, welfare worker) only after some longer convalescent treatment. Decisions as to sanatorium treatment or on further special therapeutic principles have to be made individually.

[Ultrasound sonographic diagnosis of myocarditis using quantitative texture analysis of 2-dimensional echocardiography images]

In a prospective study we tested the possibility to differentiate myocardial tissue by means of the quantitative texture analysis of two-dimensional echocardiographic images. 12 patients with a bioptically ascertained myocarditis and 12 healthy patients of a control group were echocardiographically examined. The results demonstrated that the echocardiographic image texture in myocarditis is characterized by an increase of the texture parameters entropy, second difference moment and long-run emphasis as well as by a decrease of the parameters angular second moment, inverse difference moment and run-length nonuniformity as well as by different values of the ring and sector sums of the power spectre. The digital image processing of echocardiography images seems thus to open a new way to the noninvasive diagnostic of myocarditis.

[Therapeutic principles in myocarditis]

The incomplete aetiopathogenetic knowledge, the non-uniform clinical and diagnostic criteria as well as the course of the myocarditis which is prognostically not to be foreseen cause controversial therapeutic consequences. In the first place of the treatment is the causal treatment of the factors evoking or maintaining the inflammation. By means of immunosuppression an improvement of the findings is obtained in approximately 50% of the patients with myocarditis. Thus the immunosuppressive therapy cannot be recommended in general. It is sought for new active agents. The disturbed haemodynamics is, apart from medicamentous measures, positively influenced above all by convalescent treatment. Individually reconciled measures of the complex rehabilitation are accompanyingly necessary and render possible an improvement of the quality of life at long sight. In individual cases only the heart transplantation may have a favourable influence on the prognosis of the in most cases young patients.

Enzyme pattern and lipid peroxides in endomyocardial biopsies from patients with cardiomyopathy and myocarditis

Methods have been developed for measuring several biochemical parameters (isoenzymes of LDH and ASAT, glycogen phosphorylase, lipid peroxides) in extremely small tissue samples (0.2-1.8 mg) taken using a left ventricular biopsy technique. Endomyocardial biopsies from patients with dilative and hypertrophic cardiomyopathy (CMP) and with myocarditis were investigated and compared with a reference group without actual functional and morphological evidence of chronic heart disease. Patients with myocarditis showed the highest activities of LDH and its isoenzymes, ASAT, ASATm and glycogen phosphorylase and the highest concentration of lipid peroxides. In patients with hypertrophic CMP increased activities of glycogen phosphorylase and decreased activities of ASAT and ASATm have been found. In patients with dilative CMP slightly elevated ASAT and ASATm activities have been observed. The results obtained in this study suggest that the parameters investigated could be useful in differentiating between cardiomyopathies and myocarditis.

[Percutaneously implantable balloon-inflatable vascular prostheses. Initial clinical results]

Restenosis and occlusion of atherosclerotic arteries are prevented by a newly developed arterial prosthesis consisting of a pliable and elastic wire mesh tube positioned to the balloon of an angioplasty catheter. As the balloon is inflated the prosthesis dilates and provides the arterial wall with a new mechanical support. This new device was successfully implanted in ten patients having an iliac artery stenosis and improved the therapeutic result of the preceding angioplasty. There were no complications.

[New aspects in the diagnosis of ischemic heart disease in females]

To investigate still uncertain aspects of the diagnosis of ischemic heart disease (IHD) in women, between 1969 and 1984, repeated exercise studies were performed in 706 asymptomatic women (between the ages of 17 and 63 years). On observation of pathologic ST-segment depression of more than 0.1 mV, the exercise study was repeated after administration of 0.8 mg nitroglycerin. Pathologic ST-segment depression was seen in 310 women (44%). In 217 patients (31%), nitroglycerin had no effect (NTG negative); in 93 women (13%), there was normalization of the ST-segment changes (NTG positive). Additionally, in selected subgroups of patients, pulmonary artery pressure was measured at rest and during exercise and ECG mapping performed (n = 114); radionuclide ventriculograms (n = 64) and 201-thallium scintigrams (n = 99) were obtained and coronary angiography (n = 85) was performed. In the NTG-negative women, ejection fraction, myocardial perfusion and coronary arteries were normal. NTG-positive women had lower mean ejection fractions but still within normal limits and indications of impaired myocardial perfusion. High-grade coronary stenoses were found in 25%. No patient with pathologic ST-segment depression had mitral valve prolapse. NTG-positive women had significantly more risk factors than NTG-negative women. In the former group, pulmonary artery pressure measurements showed pathologic exercise hemodynamics, only in 25% of whom IHD with significant stenosis was found to be the cause. For this condition, differential diagnostic considerations include cardiomyopathy or small vessel disease.

[Pathologico-anatomical peculiarities of ischemic heart disease in females]

In 364 women who died of myocardial infarction, autopsy was performed to assess the extent of chronic ischemic heart disease. The mean age at the time of death at 70.5 years was higher than that of men who died of myocardial infarction; only 4% of the women were less than 50 years of age. In all cases, there were severe arteriosclerotic changes in all coronary arteries. Three-forths of the patients had luminal narrowing of more than 50%, one-forth less than 50%. Accordingly, with respect to morphology, for acute myocardial infarction as cause of death, there were no differences between the sexes. The muscle mass averaging 440 g was less than that reported for comparable studies in men. In 59 women less than 50 years of age with complaints consistent with angina pectoris and angiographically-documented normal coronary arteries, left ventricular biopsies were examined for evidence of chronic ischemic heart disease. In ten patients changes in the terminal vascular beds were found which were considered to be compatible with small vessel disease and in 19 patients there were microscars and a fibrotic pattern as seen in chronic ischemic heart disease. Twelve patients had scarring and fibrosis similar to that seen after myocarditis and 18 patients had a round-cell myocarditis without evidence of involvement of the terminal vascular beds. Thus, heart muscle biopsies appear to be of value in the diagnosis of changes in peripheral arterial beds.

[Concentration of thiobarbituric acid reactive substances (TBARS) in serum following myocardial infarct]

The serum concentration of thiobarbituric acid reactive substances (TBARS), which can be used in the characterization of O2-radical metabolism, was analyzed in patients with myocardial infarction in the acute phase, 10-14 days, 1 month, and 6 months after infarction, and compared with the TBARS concentration of a healthy group and a group with atherosclerosis. After myocardial infarction we found increased TBARS concentration at all moments of investigation in comparison with the healthy and atherosclerosis groups. Maximum concentration was found 10-14 days after infarction, afterwards the TBARS concentration decreased, without however attaining the values which we found in the comparison groups. The increased TBARS concentration 6 months after myocardial infarction demonstrates a manifestation of disturbances in the O2-radical metabolism. Such disturbances may be regarded as a high-risk factor to the cardiovascular system.

[Relation of the impedance cardiogram to the course of myocardial contraction]

53 patients with coronary heart disease were investigated synchronously by means of impedance and angiocardiography combined with the measurement of the pressure in the aorta and the left ventricle. In these cases relatively close correlations were found between the stroke volumes and systolic time intervals, determined by the two methods, as well as between the ejection fraction on the one hand and the parameter dz/dt max on the other. The pressures, measured invasively, do not correlate significantly with the impedance cardiography parameters. With help of the relations found it is possible to coordinate the changes of the thoracic impedance curve depending on the heart action with the various phases of the left-ventricular volume change.

[Left ventricular function following transluminal coronary dilatation or operative revascularization in chronic ischemic heart disease]

To assess changes in resting left ventricular function after reestablishment of myocardial perfusion, echocardiographic studies were performed before, at three resp. six days after as well as three months after successful PTCA in 19 patients and after coronary artery bypass grafting in 20 patients. Reference data were obtained from analog processing of values from 20 healthy control subjects. Baseline values (in addition to primary morphologic criteria) were indicative of a clearly functional selection pattern. As compared with those undergoing PTCA, patients who underwent bypass surgery had more unfavorable values for ejection fraction at rest. Immediately after the intervention, there was a consistent tendency to transiently reduced resting pump function. At three months, however, in both groups, cardiac performance had returned to control values and the global and regional parameters of contractility had either reached or exceeded the preoperative values. The mean values showed more improvement in the PTCA group, a finding most probably attributable to the more favorable baseline situation. Paradoxic septum motion was found frequently in those who had undergone bypass surgery. All patients with grafting to the right coronary artery were included in the latter group. Whether perioperative injury, the varying perfusion conditions or the pericardiotomy is responsible for this phenomenon, remains to be established.

Embolization of a large aneurysm of the brachiocephalic trunk by Gianturco coils

A successful complete embolization of a large aneurysm in the brachiocephalic trunk region, seen in a patient after bypass graft surgery, was achieved with 13 Gianturco coils. Indications and precautions for the use of embolic coils are given.

Volumetric analysis of right ventricular cadaver models viewed in axially angled projections

Axial cinematography of 15 cadaver cast models of the right ventricle was performed, using 16 different real and simulated single and biplane axial oblique projections. Heart volumes were then calculated by Dodge's area-length method and Ferlinz' method. In our volumetric studies of models, the smallest positive deviation from real volumes was 3.7% with the simulated long-axis projection (SLP2), evaluated from the frontal plane and calculated by the area-length method. Volumetric determinations of most usefulness, as ranked by mean differences and mean quadratic deviations, were achieved with the simulated long-axis projection, (SLP1--ranked third and SLP2--ranked first), evaluated from the frontal plane and calculated by Dodge's method; with biplane orientation and calculation by Ferlinz' method (SLP1 + SLP1C1-- ranked seventh, deviation from real volumes was 23%, SLP2 + SLP2C2--ranked fourth). We found that single-plane hepatoclavicular projection (HCP--ranked second and fifth), calculated by Dodge's or Ferlinz' method, as well as single-plane sitting-up projection (SUP--ranked sixth), calculated by the area-length method, were also acceptable for right ventricular volume measurements.

Detection and quantification of left main coronary artery stenosis by two-dimensional echocardiography

This study was undertaken to determine the diagnostic feasibility of detecting both qualitatively and quantitatively stenotic wall abnormalities in the left main coronary artery (LMCA) and its bifurcation. Adequate two-dimensional echocardiographic (2DE) images of the LMCA were obtained in 18 of 20 patients with angiographically proven coronary artery disease (CAD). In 15 of 18 patients the LMCA was completely imaged but in different 2DE-planes in most of the cases. Only in 4 of 18 patients could adequate images of the bifurcation, including the central parts of left anterior descending and circumflex branches, be demonstrated. On the contrary, the 2DE detected calcification of the LMCA identified by fluoroscopy in only 2 of 5 patients. As to quantitative analysis, the correlation of luminal diameters in stenotic and non-stenotic coronary artery obtained from 2DE and coronary angiography was satisfactory (r = 0.69, p less than 0.01). These results suggest that 2DE can be useful for the follow-up study of LMCA disease. However, this method is not indicated for the detection of more distal left coronary artery stenosis occurring beyond the bifurcation.

Investigation of human right ventricular cast specimens

Fifty human right ventricular cast specimens were subjected to X-ray cineangiography in biplane right anterior oblique and left anterior oblique (RAO/LAO) projection. From the silhouettes seen in the two projection planes we estimated areas and lengths using a light-pen minicomputer system and calculated the volumes using various methods. The calculated volume values were compared with the true values determined by water displacement. The methods were then arranged is order of decreasing accuracy. Criteria for judging model quality were the mean squared deviations, correlation coefficient, and residual variance. The most accurate calculation of the right ventricular volume was obtained with Ferlinz' method and our own empirical approach.

[Objective graded increase of stenosing coronary artery processes using quantitative analysis of pathologico-anatomical data and their relationships. 3. Extension and discussion of the model]

On the basis of the demonstrated mathematical valuations of pathologo-anatomical influence sizes on the defined myocardial infarction the model is extened by the calculation of total numbers for the purpose of simpler use in medical practice. The statistical influence of the characteristics on the formation of the arithmetical measure medium XI of the group with infarctions for the position of the stenosis times degree of stenosis is determined left-sided with 30.0% and right-sided with 42.3%, the heart mass is determined with 25.9% and the barriers of the ostium as well as the type of supply with 1.8%. For the judgment of the functional capacity of the developed model it is used in 126 intravitally coronarographed patients, in whom no myocardial infarction was to be proved. The false coordination is 4 cases (3.2%). Consequently, the developed model is evident not only for the initial material. It is usable post mortem and intravitally. Apart from the judgment of the severity of the stenosing coronary arteriosclerosis it serves intravitally for the estimation of the endangering by myocardial infarction. Criterion for the estimation of the degree of endangering is the distance from the point of separation TP = 558 (values of the arthmetical measure) and TP = 122 (total number).