Heart rate dynamics at the onset of ventricular tachyarrhythmias as retrieved from implantable cardioverter-defibrillators in patients with coronary artery disease

BACKGROUND

The recent availability of implantable cardioverter-defibrillators (ICDs) that record 1024 R-R intervals preceding a ventricular tachyarrhythmia (VTA) provides a unique opportunity to analyze heart rate variability (HRV) before the onset of VTA.

METHODS AND RESULTS

Fifty-eight post-myocardial infarction patients with an implanted ICD for recurrent VTA provided 2 sets of 98 heart rate recordings in sinus rhythm: (1) before a VTA and (2) during control conditions. Three subgroups were considered according to the antiarrhythmic (AA) drug regimen. A state of sympathoexcitation was suggested by the significant reduction in HRV before VTA onset compared with control conditions. beta-Blockers and dl-sotalol enhanced HRV in control recordings; nevertheless, HRV declined before VTA independent of AA drugs. A gradual increase in heart rate and decrease in sinus arrhythmia at VTA onset were specific findings of patients who received dl-sotalol.

CONCLUSIONS

The peculiar heart rate dynamics observed before VTA onset are suggestive of a state of sympathoexcitation that is independent of AA drugs.

A DNA transfection system for generation of influenza A virus from eight plasmids

We have developed an eight-plasmid DNA transfection system for the rescue of infectious influenza A virus from cloned cDNA. In this plasmid-based expression system, viral cDNA is inserted between the RNA polymerase I (pol I) promoter and terminator sequences. This entire pol I transcription unit is flanked by an RNA polymerase II (pol II) promoter and a polyadenylation site. The orientation of the two transcription units allows the synthesis of negative-sense viral RNA and positive-sense mRNA from one viral cDNA template. This pol I-pol II system starts with the initiation of transcription of the two cellular RNA polymerase enzymes from their own promoters, presumably in different compartments of the nucleus. The interaction of all molecules derived from the cellular and viral transcription and translation machinery results in the generation of infectious influenza A virus. The utility of this system is proved by the recovery of the two influenza A viruses: A/WSN/33 (H1N1) and A/Teal/HK/W312/97 (H6N1). Seventy-two hours after the transfection of eight expression plasmids into cocultured 293T and MDCK cells, the virus yield in the supernatant of the transfected cells was between 2 x 10(5) and 2 x 10(7) infectious viruses per milliliter. We also used this eight-plasmid system for the generation of single and quadruple reassortant viruses between A/Teal/HK/W312/97 (H6N1) and A/WSN/33 (H1N1). Because the pol I-pol II system facilitates the design and recovery of both recombinant and reassortant influenza A viruses, it may also be applicable to the recovery of other RNA viruses entirely from cloned cDNA.

[Mental disorders in prisons--view of prison governors]

This article reports on experiences with prisoners with mental diseases. Due to the multitude of drug supply of all kind in Frankfurt, several addicted humans are living in this area. Their way of life is frequently accompanied by arrest and imprisonment. It is demonstrated what we experienced with these prisoners and what kind of problems has occurred. The employees of a penal institution are not prepared enough to deal with such problems. Such demands are demonstrated.

Catheter ablation of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation

AIMS

Antiarrhythmic drug treatment for atrial fibrillation can cause atrial flutter-like arrhythmias. The aim of this study was to clarify the effect of catheter ablation of the tricuspid annulus-vena cava inferior isthmus on amiodarone-induced atrial flutter and to determine the incidence of atrial fibrillation after catheter ablation of amiodarone-induced atrial flutter in comparison to regular typical flutter.

METHODS AND RESULTS

Among 92 consecutive patients with typical atrial flutter who underwent isthmus ablation 28 patients had atrial flutter without a history of previous atrial fibrillation (group I), 10 patients had atrial flutter following the initiation of amiodarone therapy for paroxysmal atrial fibrillation (group II) and 54 patients had atrial flutter and atrial fibrillation (group III). Atrial cycle length during atrial flutter in amiodarone-treated patients (group II) (277+/-24 ms) was significantly longer as compared to the cycle length of atrial flutter in group I (247+/-33 ms) and group III patients (235+/-28 ms). The rate of successful transient entrainment and overdrive stimulation to sinus rhythm was not different between patients with (60%) or without amiodarone therapy (group I: 71%, group III: 53%). Successful isthmus ablation with bidirectional conduction block eliminating right atrial flutter was achieved in 90% of amiodarone-treated patients and 93% of patients without amiodarone therapy. In the amiodarone-treated patient group atrial conduction times during pacing in sinus rhythm were significantly prolonged by 20-30% before and after ablation in all regions of the reentrant circuit. During a mean follow-up of 8+/-3 months post-ablation, atrial fibrillation recurred in two of 10 patients on continued amiodarone therapy after successful isthmus ablation. Thus, successful catheter ablation of atrial flutter due to amiodarone therapy was associated with a markedly lower recurrence rate of paroxysmal atrial fibrillation (20%) as compared to patients with atrial flutter plus preexisting paroxysmal atrial fibrillation (76%) and was similar to the outcome of patients with successful atrial flutter ablation without preexisting atrial fibrillation (25%).

CONCLUSION

These data suggest that isthmus ablation with bidirectional block and continuation of amiodarone therapy is an effective therapy for the treatment of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation.

[Variable late potentials in long-term ECG of the post-infarct patient at risk for ventricular fibrillation]

BACKGROUND

Ventricular late potentials are found more readily in post-infarction patients who had sustained ventricular tachycardia than in those who survived ventricular fibrillation. Hypothetically, a daytime variability of late potentials might be responsible for this finding.

METHOD

Therefore a conventional late potential analysis only performed once a day was compared to a late potential analysis in time and frequency domain repeatedly performed every hour in the Holter-ECG of 160 post-infarction patients (50 patients (= VT-group) with documented, sustained ventricular tachycardia (cycle-length > 230 ms), 50 patients (= VF-group) who survived, documented ventricular fibrillation and 60 patient, without ventricular arrhythmias (= O VT/VF-group)).

RESULTS

The conventional analysis showed late potentials in time domain in 72% of the patients in the VT-group, in 40% of patients in the VF-group and in 20% of the patients in the O VT/VF-group. The Holter-ECG showed late potentials to be permanently present in frequency domain in 66% of the patients in the VT-group, in only 6% in the patients in the VF-group and in no patient in the O VT/VF-group. However, in at least one analysis we detected late potentials in 84% of patients of the VF-group, in 90% of patients in the VT-group and in 18% of patients in the O VT/VF-group. Transiently detectable late potentials in patients of the VF-group were predominantly seen at heart rate accelerations in the morning hours, ST-segment shifts or transitory decreased heart rate variability.

CONCLUSIONS

Post-infarction patients with sustained ventricular tachycardia predominantly have constantly detectable late potentials over 24 hours. In these patients conventional late potential is successful for post-infarction risk stratification at any time of the day. However, in post-infarction patients who survived ventricular fibrillation, late potentials are found to be transitory and only detectable by Holter-ECG. Thus, late potential analysis performed in the Holter-ECG might improve post-infarction risk stratification in patients prone to sudden cardiac death.

"Ambisense" approach for the generation of influenza A virus: vRNA and mRNA synthesis from one template

We present a system for creating influenza virus by generating viral RNA (vRNA) and mRNA from one template. Recently, a system for the generation of influenza A virus entirely from cloned cDNAs was established (Neumann et al., 1999, Proc. Natl. Acad. Sci. USA 96, 9345-9350). Cells were transfected with plasmids for RNA polymerase I-driven intracellular synthesis of all eight viral RNAs, and with protein expression plasmids for the synthesis of viral structural proteins. Although this system is highly efficient in virus generation, the construction and cotransfection of 17 plasmids is cumbersome and may limit the use of this system to cell lines that can be transfected with high efficiencies. Synthesizing both vRNA and mRNA from one template would reduce the number of plasmids required for virus generation. Therefore, we generated a bidirectional transcription construct that contains cDNA encoding PB1 flanked by an RNA polymerase I (pol I) promoter for vRNA synthesis and an RNA polymerase II (pol II) promoter for mRNA synthesis. The utility of this approach is proved by the generation of virus after transfecting the pol I/pol II-promoter-PB1 construct together with vRNA- and protein-expression constructs for the remaining seven segments. Because this approach reduces the number of plasmids required for virus generation, it also reduces the work necessary for cloning, probably enhances the efficiency of virus generation, and expands the use of the reverse-genetics system to cell lines for which efficient cotransfection of 17 plasmids cannot be achieved.

New mapping technology for atrial tachycardias

Prerequisite for succesful radiofrequency catheter ablation of tachycardias is the exact mapping during the electrophysiological study. The new mapping system CARTO allows a three-dimensional color-coded electroanatomic map of impulse propagation using electromagnetic technology. The aim of this study was to determine the feasibility and safety of the new electromagnetic mapping technology CARTO for atrial tachycardias.

RESULTS

Electrophysiologic study and CARTO mapping was performed in 38 atrial tachycardias. The mapping procedure took 26 +/- 23 min. We created 33 maps within the right atrium and 5 maps within the left atrium with a mean of 74 +/- 38 different catheter positions. The mechanism was determined as reentrant in 9, junctional in 1 and focal in 28 tachycardias. In focal tachycardias the tachycardia cycle length (CL) and the total atrial activation time (AT) were clearly different (352 +/- 98 ms vs 99 +/- 25 ms). Reentrant tachycardias had a comparable CL and AT (236 +/- 44 ms vs 240 +/- 56 ms). In 83% of the focal tachycardias and in 67% of the reentrant tachycardias, ablation was performed successfully. No complications occured.

CONCLUSION

The electroanatomic mapping system allows high resolution visualization of electrical activity and may therefore improve precision and simplify the determination of the arrhythmogenic substrate during tachycardias for successful catheter ablation.

Amiodarone: maximising survival benefit with empiric or guided therapy

Review of available data suggests that serial drug testing in patients with a history of sustained ventricular tachyarrhythmias using various antiarrhythmic drugs including amiodarone is able to identify subgroups with favorable and unfavorable outcome (patient groups with suppression vs. no suppression of inducibility of VT/VF). These results more likely reflect patient selection rather than drug effects, thus limiting the role of electrophysiologically guided antiarrhythmic therapy to actively modify outcome. All major and actual antiarrhythmic drug trials including an amiodarone arm, have chosen to deliver this drug empirically in both patients with asymptomatic as well as severely symptomatic life-threatening sustained ventricular tachyarrhythmias instead of a guided approach. The empiric approach is therefore adequate until new valid data comparing the empiric with the guidedor the invasive with the non invasiveapproach tell us otherwise.

Solar blind photocell--a simple element specific detector in Hg, As and Se speciation

An element-specific detection method, based on atomic absorption spectrometry (AAS) using solar blind photocells instead of a dispersion system, is described for the determination of Hg-, As-, and Se-species. Spectrometric investigations of AAS background lamps for As and Se measured with a CsI-cathode photocell shows its quality as narrow band detector. Species determination can be carried out subsequently to prior separation by HPLC or GC. The LODs for alkylated Hg species were below 1 ng/L, and for methylated As species below 1 microg/L. The relative standard deviation was < 10%. With the components described the production of cheap and automated dedicated speciation spectrometers is possible.

Slow pathway ablation in a patient with common AV nodal reentrant tachycardia and complete situs inversus

A 72-year-old woman with complete situs inversus underwent successful slow pathway ablation of typical AV nodal reentrant tachycardia. Catheter ablation of AV nodal reentrant tachycardia in dextrocardia required a lengthy procedure but was safe and without complications.

[Long-term efficacy of antitachycardia pacing for treatment of ventricular tachycardia in patients with implantable cardioverter/defibrillator]

Antitachycardia pacing techniques (ATP) have proved useful for termination of ventricular tachycardia (VT). However, little is known about the efficacy and safety off ATP during long-term follow-up in a larger study population. We analyzed the data of 80 ICD patients (pts) with spontaneous monormorphic VT, mean age 59 +/- 12 years, the mean follow-up was 26 +/- 17 months. 50 pts (62.5%) had coronary artery disease, 18 (22.5%) dilative cardiomyopathy (DCM), the remaining 12 pts (15%) had no or other cardiac diseases. 2926 episodes of ventricular tachycardia (cycle length 349 +/- 51 ms, 240-520 ms) occurred in 64/80 pts (80%), overall efficacy of ATP was 89.9%, acceleration occurred in 4.1% of VTs. Success of ATP did not correlate with positive ATP testing on induced arrhythmias, LVEF, NYHA class or aneurysm. Neither underlying heart disease nor antiarrhythmic medication had an impact on the ATP success rate. ATP efficacy was linked significantly to short VT cycle length (VTCL, 240-300 ms, p < 0.01) and long coupling intervals (91-97%), p < 0. 01). Acceleration occurred in 32% of pts and in 4.1% of VT episodes; it was also dependent on short VT cycle length (< 300 ms vs > 300 ms, p < 0.04) and short coupling intervals (< 81% vs >/= 81%, p </= 0. 01).

CONCLUSIONS

First, ATP is a highly effective therapy, independent of patients characteristics. Second, short VT cycle length and long ATP coupling intervals were identified as predictors for successful ATP. Best conversation rates were obtained with coupling intervals between 90 and 97% of VTCL in tachycardias with a cycle length < 300 ms. Third, testing ATP on induced VTs before hospital discharge did not improve efficacy, empiric modes showed equal success rates. Fourth, acceleration rate of ATP depends on VT cycle length and coupling interval; therefore, aggressive ATP modes should be carefully applied in patients with VTs faster than 300 ms.

Induction of interleukin-8 synthesis integrates effects on transcription and mRNA degradation from at least three different cytokine- or stress-activated signal transduction pathways

A hallmark of inflammation is the burst-like formation of certain proteins, initiated by cellular stress and proinflammatory cytokines like interleukin 1 (IL-1) and tumor necrosis factor, stimuli which simultaneously activate different mitogen-activated protein (MAP) kinases and NF-kappaB. Cooperation of these signaling pathways to induce formation of IL-8, a prototype chemokine which causes leukocyte migration and activation, was investigated by expressing active and inactive forms of protein kinases. Constitutively active MAP kinase kinase 7 (MKK7), an activator of the stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) pathway, induced IL-8 synthesis and transcription from a minimal IL-8 promoter. Furthermore, MKK7 synergized in both effects with NF-kappaB-inducing kinase (NIK). Activation of the IL-8 promoter by either of the kinases required functional NF-kappaB and AP-1 sites. While NIK and MKK7 did not affect degradation of IL-8 mRNA, an active form of MKK6, which selectively activates p38 MAP kinase, induced marked stabilization of the transcript and further increased IL-8 protein formation induced by NIK plus MKK7. Consistently, the MAP kinase kinase kinase MEKK1, which can activate NF-kappaB, SAPK/JNK, and p38 MAP kinases, most potently induced IL-8 formation. These results provide evidence that maximal IL-8 gene expression requires the coordinate action of at least three different signal transduction pathways which cooperate to induce mRNA synthesis and suppress mRNA degradation.

Generation of influenza A viruses entirely from cloned cDNAs

We describe a new reverse-genetics system that allows one to efficiently generate influenza A viruses entirely from cloned cDNAs. Human embryonic kidney cells (293T) were transfected with eight plasmids, each encoding a viral RNA of the A/WSN/33 (H1N1) or A/PR/8/34 (H1N1) virus, flanked by the human RNA polymerase I promoter and the mouse RNA polymerase I terminator-together with plasmids encoding viral nucleoprotein and the PB2, PB1, and PA viral polymerases. This strategy yielded >1 x 10(3) plaque-forming units (pfu) of virus per ml of supernatant at 48 hr posttransfection. The addition of plasmids expressing all of the remaining viral structural proteins led to a substantial increase in virus production, 3 x 10(4)-5 x 10(7) pfu/ml. We also used reverse genetics to generate a reassortant virus containing the PB1 gene of the A/PR/8/34 virus, with all other genes representing A/WSN/33. Additional viruses produced by this method had mutations in the PA gene or possessed a foreign epitope in the head of the neuraminidase protein. This efficient system, which does not require helper virus infection, should be useful in viral mutagenesis studies and in the production of vaccines and gene therapy vectors.

Sampling of protein dynamics in nanosecond time scale by 15N NMR relaxation and self-diffusion measurements

This paper presents a procedure for detection of intermediate nanosecond internal dynamics in globular proteins. The procedure uses 1H-15N relaxation measurements at several spectrometer frequencies and hydrodynamic calculations based on experimental self-diffusion coefficients. New heteronuclear experiments, using pulse field gradients, are introduced for the measurement of translation diffusion coefficients of 15N labeled proteins. An advanced interpretation of recently published (Luginbühl et al., Biochemistry, 36, 7305-7312 (1997)) backbone amide 15N relaxation data, measured at two spectrometers (400 and 750 MHz for 1H) for N-terminal DNA-binding domain (1-63) of 434 repressor, is presented. Non-applicability of commonly used fast (picosecond) dynamics model (FD) was justified by (i) poor fit of relaxation data by the FD model-free spectral density function both for isotropic and anisotropic models of the overall molecular tumbling; (ii) specific dependence of the overall rotation correlation times calculated from T1/T2 ratio on the spectrometer frequency; (iii) mismatch of the ratio of longitudinal 15N relaxation times T1, measured at different spectrometer frequencies, in comparison with that anticipated for the FD model; (iv) significantly underestimated overall rotation correlation time provided by the FD model (5.50+/-0.15 and 5.80+/-0.15 ns for 750 and 400 MHz spectrometer frequency respectively) in comparison with correlation time obtained from hydrodynamics. On the other hand, all relaxation and hydrodynamics data are in good correspondence with the model of intermediate (nanoseconds) dynamics. Overall rotation correlation time of 7.5+/-0.7 ns was calculated from experimental translation self-diffusion rate using hydrodynamics formalism (Garcia de la Torre, J. and Bloomfield, V.A. Quart. Rev. Biophys., 14, 81-139 (1981)). The statistical analysis of 15N relaxation data along with the hydrodynamic consideration clearly revealed that most of the residues in 434(1-63) repressor are involved in the nanosecond internal dynamics characterized by the the mean order parameters of 0.59+/-0.06 and the correlation times of ca. 5 ns.

[Documentation of the effects of child cap pistols]

The study presents an analysis of 20 cases of acute acoustic trauma caused by toy pistols. The problem generally involves boys within the age range from 6 to 11 years. Half of the incidents involved attacks with toy pistols used as weapons. Auditory damage appeared in two types, each of which had a notch in the audiogram at the frequency range between 10 and 14 kHz. In children, a shot close to one ear can damage both ears. Great differences in the severity of tinnitus were apparent. The most severe cases of tinnitus were observed in the children with no or minor permanent auditory damage. Children experiencing long periods of uninterrupted tinnitus suffer significantly. This is not only detrimental to family life, but also to the performance of the children at school. The total expenses of treatment for these 20 cases were estimated to be approximately 80,000 DM (40,000 Euro).

Elimination of meropenem by continuous hemo(dia) filtration: an in vitro one-compartment model

Meropenem is a carbapenem antibiotic with a wide spectrum of activity against most gram positive and gram negative bacteria including anaerobes. Dose adjustments are necessary during continuous renal replacement therapies of acute renal failure. This in vitro study was conducted to investigate the influence of different filter materials, surface areas (AN-69 0.6 m2 and 0.9 m2, polysulfone 0.75 m2, polyamide 0.6 m2), and increasing flow rates (from 3.3 - 26.7 ml/min) on the elimination of meropenem in an in vitro continuous hemo(dia)filtration model. Meropenem was measured using HPLC with UV-detection. While the clearance increased proportionally to increasing dialysate flow rates in filters with a surface area of 0.9 m2, a peak clearance was reached in the small filters at flow rates of 10.0 ml/min (polyamide 0.6 m2) and 18.3 ml/min (AN-69 0.6 m2), when tested under the same conditions. This indicated incomplete dialysate saturation due to the diminished time available for meropenem to equilibrate with the dialysate solution. No adsorption to either of the tested membranes was detected. Dosage recommendations derived from clinical studies might be appropriate when different filter materials, but similar operational settings of the continuous replacement therapy, are applied. Reduction of the recommended dose might be necessary, when renal replacement therapies with lower flow rates and/or filters with smaller surface areas are carried out.

Functional changes of ventricular late potentials by provocation with increase of heart rate. Evaluation during atrial pacing

BACKGROUND

Standard methods fail to reveal late potentials in 20 to 30% of patients with ventricular arrhythmias after myocardial infarction. However, these patients may develop transient delayed ventricular activation during increases in heart rate.

METHODS AND RESULTS

Atrial pacing was performed, at the rates of 100 min-1 and 120 min-1, in 50 patients after myocardial infarction. Twenty-six patients had a history of documented, sustained ventricular tachycardia, 12 had a history of ventricular fibrillation and 12 no history of ventricular arrhythmias. The low-noise surface electrocardiogram was analysed before and during atrial pacing in the time and frequency domains. Fifteen of 26 patients with ventricular tachycardia, four of 12 with ventricular fibrillation and three of 12 without ventricular arrhythmias experienced late potentials during sinus rhythm. Atrial pacing led to a shift of 26 +/- 15 ms of preexistent late potentials into the ST segment, this being greater in patients with anterior infarctions and to an increase in magnitude in patients with inferior infarctions. In patients without late potentials during sinus rhythm, atrial pacing provoked late potentials in eight of 11 patients with ventricular tachycardia, in four of eight patients with ventricular fibrillation and in one of nine patients without ventricular arrhythmias. Low amplitude signals (LAS) were increased in patients after inferior and filtered QRS in patients after anterior infarction. In 10 patients without cardiac disease no late potentials were detectable in the time and frequency domain either at rest or during increased heart rate.

CONCLUSIONS

Increase in heart rate may unmask late potentials in patients prone to malignant ventricular arrhythmias. Therefore, functional late potential analysis with non-invasive clinical stress tests, i.e. exercise tests, should be performed only with an adequate rate response. This might identify patients at risk of malignant ventricular arrhythmias otherwise not identified with conventional late potential analysis.

The structure of human parathyroid hormone-related protein(1-34) in near-physiological solution

Parathyroid hormone-related protein plays a major role in the pathogenesis of humoral hypercalcemia of malignancy. Under normal physiological conditions, parathyroid hormone-related protein is produced in a wide variety of tissues and acts in an autocrine or paracrine fashion. Parathyroid hormone-related protein and parathyroid hormone bind to and activate the same G-protein-coupled receptor. Here we present the structure of the biologically active NH2-terminal domain of human parathyroid hormone-related protein(1-34) in near-physiological solution in the absence of crowding reagents as determined by two-dimensional proton magnetic resonance spectroscopy. An improved strategy for structure calculation revealed the presence of two helices, His-5-Leu-8 and Gln-16-Leu-27, connected by a flexible linker. The parathyroid hormone-related protein(1-34) structure and the structure of human parathyroid hormone(1-37) as well as human parathyroid hormone(1-34) are highly similar, except for the well defined turn, His-14-Ser-17, present in parathyroid hormone. Thus, the similarity of the binding affinities of parathyroid hormone and parathyroid hormone-related protein to their common receptor may be based on their structural similarity.

Risk stratification following myocardial infarction in the thrombolytic era: a two-step strategy using noninvasive and invasive methods

OBJECTIVES

We prospectively performed a two-step risk assessment in patients in the early phase after acute myocardial infarction (MI).

BACKGROUND

Noninvasive methods like Holter electrocardiographic monitoring (HM) and determination of the left ventricular ejection fraction (EF) as well as the invasive technique of programmed ventricular stimulation (PVS) have been used to identify patients in the late phase after MI as candidates for prophylactic implantation of a cardioverter/defibrillator. However, it is unclear whether these results can be transferred to patients following acute MI.

METHODS

A series of 657 patients with acute MI (< or = 75 years) underwent HM and EF. If one of the two methods yielded abnormal findings (HM > or = 20 ventricular ectopic beats/h/> or =10 ventricular pairs/day/ventricular tachycardia; EF < or = 40%), PVS was done (abnormal PVS: induction of monomorphic ventricular tachycardia, duration >10 s, cycle length > or = 230 ms).

RESULTS

Of 657 patients, 304 (46%) had either an abnormal HM or EF. The PVS performed in 146 of 304 patients was abnormal in 22. During a mean follow-up of 37 months, there were 106 (16%) deaths, being sudden in 24 (3.6%), nonsudden cardiac in 45 (6.8%). The incidence of arrhythmic events (sudden cardiac death, symptomatic ventricular tachycardia, cardiac arrest) was 18% (4/22) with an abnormal PVS and only 4% (5/124) with a normal PVS (odds ratio 4.0, p=0.032).

CONCLUSIONS

The rate of arrhythmic events is low in post-MI patients in the 1990s. Nevertheless, a two-step risk stratification is helpful in selecting candidates for a defibrillator trial aiming at primary prevention of sudden cardiac death after MI.

[Primary manifestation of hepatocellular carcinoma as osteolytic hand metastasis--a case report]

Osseous metastases to the hand are very rare. Only a single case of osseous metastasis of hepatocellular carcinoma to the hand has been reported in the literature to date. We report a case of osteolytic metastasis of the right first metacarpal as first manifestation of unresectable, alpha-fetoprotein-negative hepatocellular carcinoma (pT3, Nx, M1, UICC stage IVB, Okuda's stage I). The therapy consisted of R0-resection and hormonal therapy with tamoxifen 2 x 10 mg/d orally. Generally patients with metastatic cancer to the bones of the hand have a very poor prognosis.

Pharmacokinetics of meropenem in critically ill patients with acute renal failure treated by continuous hemodiafiltration

The pharmacokinetics of meropenem were studied in nine anuric critically ill patients treated by continuous venovenous hemodiafiltration. Peak levels after infusion of 1,000 mg over 30 min amounted to 103.2 +/- 45.9 microgram/ml, and trough levels at 12 h were 9.6 +/- 3.8 microgram/ml. A dosage of 1,000 mg of meropenem twice a day provides plasma drug levels covering intermediately susceptible microorganisms. Further reductions of the dosage might be appropriate for highly susceptible bacteria or when renal replacement therapies with lower clearances are applied.

[Toy cap pistols and their effect on hearing]

In order to understand the repeated occurrences of auditory impairments caused by toy pistols, an analysis of the circumstances involved was performed at Justus-Liebig University of Giessen. The acoustic impact of toy pistols on the ear was determined with a special measuring system for impulse noise. Results were compared with the acoustic impacts of the G3 common rifle of the German military on the ear of the soldier. It was apparent that all of the five randomly selected types of toy pistols were much louder than the military rifle, if fired close to the ear. The current standard of the European Union related to the safety of toys (EN 71-1) tolerates peaks of impulse noise from toy pistols that are actually illegal for workplaces without auditory protection. Measurements showed that the toy pistols tested were even louder than that tolerated by the EU standard. Problems related to acute acoustic trauma caused by these toys are discussed using recent examples. In order to prevent such injuries, we suggest limiting the loudness of the "worst case" instead of using unrealistic measurements.

MIB-1 immunohistometry on Tru-cut biopsies in inflammatory and cirrhotic liver disease

OBJECTIVE

To use immunohistometry to analyze the MIB-1 immunopositivity of normal liver parenchyma (n = 25) and of different inflammatory and degenerative liver diseases--including nonspecific inflammation (n = 12), toxic-nutritive (alcoholic) inflammation (n = 12), ascending cholangitis (n = 11), chronic-persisting hepatitis (n = 27), chronic-aggressive hepatitis (n = 28) and liver cirrhosis (n = 23).

STUDY DESIGN

Immunohistochemical reactions were performed on 3-micron sections of paraffin-embedded Tru-cut biopsies using an indirect peroxidase method. The rate of immunostained cells was determined using the CM-2 TV image analysis system. Twenty viewing fields (0.97 mm2) were measured with 20:1 objective magnification. An average of 2,600 cells were assessed in each case.

RESULTS

The values for normal liver tissue were significantly lower as compared with those of all other groups (< .0001 < P < or = .0008). In nonspecific and toxic inflammation and ascending cholangitis, the values did not differ significantly (P > .05). As compared to chronic-persisting viral hepatitis, however, the MIB-1 immunopositivity of nonspecific (P = .0056) and toxic inflammation (P = .0162) was significantly lower. Apart from ascending cholangitis, chronic-aggressive viral hepatitis revealed significantly increased MIB-1 immunopositivity as compared to all other types of inflammation (P < .0001). The MIB-1 values were significantly higher in liver cirrhosis than in the different inflammatory conditions (< .0001 < P < or = .0105) with the exception of chronic-aggressive viral hepatitis. The highest value for normal liver tissue was 0.4%; it was lower than 96% of the values in the different disease groups. Seventy-two percent of the cases with virally induced hepatitis revealed values > 1.5% as compared to only 14% in the other types of inflammation. In chronic-aggressive hepatitis and liver cirrhosis, 71% and 65%, respectively, of the values were > 2%.

CONCLUSION

MIB-1 immunohistometry allowed the detection of significantly different proliferative activity among different types of inflammatory and degenerative liver diseases, indicating diagnostic value in histologically inconclusive cases.