In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte

OBJECTIVE

To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice.

DESIGN

Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK).

PATIENTS

Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed.

RESULTS

Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397).

CONCLUSIONS

In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

Isolated unilateral tuberous sclerosis-associated renal cystic disease in a neonate

We present a male infant with antenatally detected, focal, unilateral apparently isolated renal cystic disease with morphological features of renal involvement in tuberous sclerosis. Only one previous case with similar presentation has been described. Most affected children present with either diffuse bilateral renal cystic disease or extrarenal manifestations. The major genes involved in tuberous sclerosis are now well described, and early onset of severe renal cystic disease in affected children often is related to the presence of a contiguous gene deletion syndrome involving TSC2 and PKD1 on chromosome 16.

MR-basierte Methoden der funktionellen Bildgebung des zentralen Nervensystems

This review presents the basic principles of functional imaging of the central nervous system utilizing magnetic resonance imaging. The focus is set on visualization of different functional aspects of the brain and related pathologies. Additionally, clinical cases are presented to illustrate the applications of functional imaging techniques in the clinical setting. The relevant physics and physiology of contrast-enhanced and non-contrast-enhanced methods are discussed. The two main functional MR techniques requiring contrast-enhancement are dynamic T1- and T2*-MRI to image perfusion. Based on different pharmacokinetic models of contrast enhancement diagnostic applications for neurology and radio-oncology are discussed. The functional non-contrast enhanced imaging techniques are based on "blood oxygenation level dependent (BOLD)-fMRI and arterial spin labeling (ASL) technique. They have gained clinical impact particularly in the fields of psychiatry and neurosurgery.

Angiotensin-II receptor blockers: benefits beyond blood pressure reduction?

Effective treatment of hypertension is essential to reduce the risk of renal and cardiovascular (CV) morbidity. The risks associated with hypertension are modulated by the presence of other factors. This has prompted the quest for agents that have benefits beyond blood pressure (BP) lowering. The angiotensin II receptor blocker (ARB) class of antihypertensive agents represents an important addition to the therapeutic options for elevated BP. Their ability to control BP is equivalent to existing therapies and there is a considerable and mounting evidence-base for their ability to reduce hypertension-associated target organ damage and comorbidities. Studies show that ARBs have clinical benefits across the spectrum of disease severity. In particular, recent large studies have demonstrated that these benefits extend to patients with conditions predisposing to CV events, such as diabetes, left ventricular hypertrophy and microalbuminuria, and where risk factors coexist. Data from these studies suggest that the CV protective effects of ARBs are at least, in part, independent from the BP lowering action. In addition, ARBs are extremely well tolerated, and strong evidence suggests that compliance with therapy--a key factor in achieving adequate BP control--with ARBs is higher than with other antihypertensive agents. Furthermore, flexible dosing and good tolerability profile mean that, where necessary, ARBs can be combined with other classes of antihypertensive agents to achieve adequate BP control and reduce the risk of hypertension-associated morbidity.

[Functional magnetic resonance imaging and dementia]

Currently, different cerebral neuroimaging methods are being applied to varying questions in the diagnosis of dementia. In patients with manifest Alzheimer's disease a reduction of cortical perfusion and metabolism in temporal and temporoparietal regions has been demonstrated when compared to healthy controls on a diversity of memory tasks. Since differing levels of performance and varying degrees of cortical atrophy may influence functional results considerably, an understanding of the processes associated with normal ageing is perceived as prerequisite for studies applying functional neuroimaging. The integration of knowledge concerning neuropsychological and neurobiological alterations associated with healthy ageing allows hypotheses for the differentiation of pathological ageing processes to be phrased. In this connection non-invasive methods such as fMRI and ASL are of increasing importance.

[Magnetic resonance tomography of xanthogranulomatous pyelonephritis. Epidemiology, pathogenesis and symptoms]

Xanthogranulomatous pyelonephritis (XGP) is a rare chronic infection of the kidney. In this overview article we reevaluated the magnetic resonance imaging (MRI) findings of our four patients with histologically proven XGP and correlated them with the CT and ultrasound findings described in the literature. Additionally, we give an overview of the pathogenesis and epidemiology. The following criteria were found in MRI: hydronephrosis and/or urethral stricture, vesicoureteral reflux or neurogenic bladder depletion disorders, and calculus as the origin of urinary obstruction. Moreover, in contrast to normal pyelonephritis, XGP is accompanied by fatty deposits in the peripelvic parenchyma, which demonstrate contrast enhancement and form the typical so-called bear paw sign. As XGP is often accompanied by severe kidney failure, contrast-enhanced CT with nephrotoxic contrast agents should be avoided and MRI should be performed instead. Because of proven reduced nephrotoxicity of gadolinium chelates, MRI seems to be superior to CT in patients with suspected XGP. Essential for the correct diagnosis is consideration of the complete medical history including recurrent pyelonephritis to avoid malpractice.

Post-natal development of the rat testis: steroid hormone receptor distribution and extracellular matrix deposition

The control of testicular development and differentiation depends on hormones and a variety of cell-cell interactions mediated mainly by paracrine factors. In the second and third weeks of post-natal development important changes take place in the rat testis, e.g. the tubular lumen starts to open on post-natal day 10, the blood-testis barrier starts to form on day 15, and Sertoli cell proliferation ceases on day 15. In the present study the expression in different testicular compartments of the androgen receptor (AR), progesterone receptor (PR), and extracellular matrix proteins such as laminin, entactin-1 (nidogen-1) and fibronectin, during post-natal development was examined using immunohistochemistry and semiquantitative image analysis. An intratubular AR peak on days 14-17, an increase in intratubular PR expression on days 14-16, and an increase in peritubular entactin-1 expression during the second and third weeks post-partum are demonstrated. These results suggest that a variety of changes occur at the cellular level during this period when certain milestones of testicular development occur, substantiating the hypothesis of a particular role for paracrine interactions during the development of the rat testis.

Vasopeptidase inhibitors

Vasopeptidase inhibitors are a new class of cardiovascular drug that simultaneously inhibit both neutral endopeptidase and angiotensin-converting enzyme (ACE). They increase the availability of peptides that have vasodilatory and other vascular effects; they also inhibit production of angiotensin II. In animal models vasopeptidase inhibitors decrease blood pressure in low, medium, and high renin forms of hypertension, and they also appear to confer benefits in models of heart failure and ischaemic heart disease. Studies in human hypertension show that these agents are effective in decreasing blood pressure regardless of race or age. Experience with omapatrilat, the most clinically advanced of these drugs, has shown it to be more effective than currently available ACE inhibitors or other widely used antihypertensive agents. Studies with omapatrilat in congestive heart failure have shown beneficial effects on haemodynamics and symptoms. The vasopeptidase inhibitors appear to have safety profiles similar to ACE inhibitors, though the frequency of side-effects such as angio-oedema and cough remains to be established. Large trials with clinical endpoints, some already in progress, are needed to establish the place of this class of drug beside that of established therapies in conditions such as hypertension, heart failure, ischaemic heart disease, and nephropathy.