[Terbinafine-resistant dermatophytoses and onychomycosis due to Trichophyton rubrum]

BACKGROUND

In recent years, therapy-refractory courses of dermatophytoses have increasingly become the focus of attention. The most frequent pathogens are Trichophyton (T.) rubrum and T. mentagrophytes. In addition to local therapy, first-line treatment includes terbinafine, an allylamine antifungal agent that acts by inhibiting squalene epoxidase and thus interfering with ergosterol synthesis. In refractory cases, terbinafine resistance due to point mutation in the squalene epoxidase gene has been frequently detected.

OBJECTIVES

The aim is to present specific aspects in the epidemiology of dermatophytoses with terbinafine resistance and to illustrate them on the basis of four patient cases including diagnostic procedures.

MATERIALS AND METHODS

A review of handbook knowledge, a selective literature search, and a review of four patient cases were performed.

RESULTS

Detection of the terbinafine resistance was performed by in vitro testing using the breakpoint method as well as sequencing of the Trichophyton isolate and detection of the point mutation with amino acid substitution at position L393F or F397L of squalene epoxidase.

CONCLUSION

In refractory and recurrent dermatophytoses, terbinafine resistance should be considered, especially in T. mentagrophytes and T. rubrum, and in vitro resistance testing of the dermatophyte and point mutation analysis of squalene epoxidase (SQLE) should be performed. Therapeutically, intermittent administration of itraconazole in combination with antifungal local therapy is recommended. Nevertheless, a recurrent course is to be expected and long-term therapy with itraconazole is usually necessary.

Ein EKG-Routmedokumentationssystem

Es wird die Organisation eines EKG-Dokumentationssystems für stationäre und ambulante Patienten einer internen Klinikvorgestellt. Dabei erfolgt die Datenerfassung auf Lochkarten (Identifikationsdaten, Zuweisungsdiagnose und kardiale Therapie) und Markierungsbelegen (Befundung des EKG). Ferner wird über die Erfahrungen mit diesem System während eines 8-monatigen Routineeinsatzes berichtet. Uber die Güte der dokumentierten Information wurden gezielte Untersuchungen angestellt. Dabei ergaben sich statistisch gesicherte Unterschiede zwischen den Befundern in der Qualität der Datenerhebung und zwischen den Befunden in Abhängigkeit vom Schwierigkeitsgrad. Trotz der geforderten Vollständigkeit der Befundung mittels Markierungsbelegs und der Möglichkeit der Klartextzusätze zeigte sich, daß bei der konventionellen Befundung durch Diktieren die erhobenen Daten wohl unvollständiger erfaßt waren, die Beurteilung jedoch in mehreren Fällen zutreffender war.

Complex terrain experiments in the New European Wind Atlas

The New European Wind Atlas project will create a freely accessible wind atlas covering Europe and Turkey, develop the model chain to create the atlas and perform a series of experiments on flow in many different kinds of complex terrain to validate the models. This paper describes the experiments of which some are nearly completed while others are in the planning stage. All experiments focus on the flow properties that are relevant for wind turbines, so the main focus is the mean flow and the turbulence at heights between 40 and 300 m. Also extreme winds, wind shear and veer, and diurnal and seasonal variations of the wind are of interest. Common to all the experiments is the use of Doppler lidar systems to supplement and in some cases replace completely meteorological towers. Many of the lidars will be equipped with scan heads that will allow for arbitrary scan patterns by several synchronized systems. Two pilot experiments, one in Portugal and one in Germany, show the value of using multiple synchronized, scanning lidar, both in terms of the accuracy of the measurements and the atmospheric physical processes that can be studied. The experimental data will be used for validation of atmospheric flow models and will by the end of the project be freely available.This article is part of the themed issue 'Wind energy in complex terrains'.

[Language Delay: What is the Prognosis of Late Bloomers?]

BACKGROUND

30-50% of late talkers catch-up their language delay during the third year of life. So far it is unclear whether this is a permanent or an illusionary recovery. The aim of the study was to examine the further language development of late bloomers.

METHOD

Language skills of 83 three-year-old children (16 late bloomers [LB], 29 late talkers [LT] with persistent language problems, 38 Non-LT) were assessed with a standardized language test. Before school entry formal language skills, expressive and receptive vocabulary and precursors of written language (verbal memory, phonological awareness, verbal information-processing speed) were assessed.

RESULTS

At follow-up before school entry LB scored below Non-LT on phonological memory test. 31% of the LB in contrast to 3% of the Non-LT had slight language problems. 38% had received speech-language therapy. Nevertheless, no LB met the criteria of developmental language disorder. The language skills of LT with persistent language problems remained significantly below the level of LB and Non-LT. Every fourth of these children was language impaired.

CONCLUSION

LB as a group are not at risk for later clinically relevant language disorders. However, their language abilities are often within the lower range of normal variation. Therefore, it is recommended to facilitate their language acquisition either by kindergarten training programs or by parent-directed intervention programs to provide a more stimulating environment.

[The competent surgeon. Bridging the gap between undergraduate final year and postgraduate surgery training]

Competency-based frameworks rely on relevant professional competency rather than formal regulations. The transitional phase between final year undergraduate and common trunk postgraduate medical training is characterized by an increase of professional responsibility whereby previously acquired knowledge, skills and abilities have to be merged and applied to patients. Undergraduate and postgraduate training programs should ensure a successive transfer of responsibility for medical practice to final year students and young residents depending on individual competence. The concept of entrustable professional activities (EPA) represents a curricular concept based on concrete medical tasks which may be assigned to the responsibility of the trainee.

Surgical management of congenital chylothorax in children

PURPOSE

Aim of the study was to determine the role of surgery in the management of congenital chylothorax (CC).

METHODS

We retrospectively reviewed the data of patients with CC requiring medical or surgical treatment postnatally in our institution between January 2001 and March 2009.

RESULTS

Ten patients were treated for CC. We divided our population into 2 groups: group A consisted of patients in whom CC healed after conservative medical treatment (thoracocentesis, pleural drainage, total parental nutrition, somatostatin, intrapleural injections of povidone-iodine), and group B of patients who needed both medical and surgical treatment (pleural abrasion and/or pleurectomy). Conservative postnatal therapy was successful in 50% of cases. Of the 3 patients treated preoperatively with intrapleural injections of povidone-iodine, 2 presented with severe complications. Surgical treatment was successful in all cases, with no surgical complications. Patients in group B had a significantly lower birth term (p=0.0254) and birth weight (p=0.0021) compared to patients in group A. Patients with a massive chylothorax (≥50 mL/kg/day) needed surgery significantly more often than those with chylothorax <50 mL/kg/day (p=0.0119).

CONCLUSION

The initial postnatal medical management of CC should consist of thoracocentesis, drainage by tube thoracostomy, and total parenteral nutrition. If this treatment fails after 10 days, we propose using alternative therapies such as somatostatin (although its efficacy is not clear) and surgery. Chemical pleurodesis by intrapleural injection of povidone-iodine must be avoided in infants and small babies. Surgical management by pleural abrasion and/or pleurectomy appears to be safe and effective. Early surgical management is proposed for babies with low birth term, birth weight and massive chylothorax >50 mL/kg/day. Long-term follow-up is needed to evaluate the potential consequences of this therapy.

[Muscle strength and functional results after surgical repair of Achilles tendon rupture with fibrin gluing]

Treatment of Achilles tendon rupture is discussed controversially. Some trauma centers prefer a conservative therapy. Because of the tendency to a higher rate of reruptures and worse functional results following conservative treatment, operation is the standard therapy of fresh ruptures of the Achilles tendon in Germany. Concerning the functional postoperative outcome, only few studies with uncomparable results were published. To evaluate the functional outcome after Achilles tendon ruptures treated by fibrin gluing, we realized reactive force measurements and motion analysis of 30 patients and 25 healthy test persons. We could observe significant limitations of active range of motion in the ankle joint and a significant deficiency of maximum- and rapid-force. Force deficiency was only detected by the sensitive technical examinations. In daily routine 26 of 30 patients had no limitations. The detected force- and motion-deficiencies were completely compensated. Therefore fibrin gluing of fresh ruptures of the Achilles tendon usually allows postoperatively the same leisure sports activity level as preoperatively. In competitive sporting athletes postoperative loss of performance must be expected.

[Secondary prevention following coronary intervention. Survey of 13 intervention centers in Austria]

Risk factor control has been shown to reduce the incidence of coronary events in patients with or without preceding infarction. Secondary prevention should therefore be borne in mind by every cardiologist. In order to test this concept and/or to promote secondary prevention in our country, the following survey was conducted by our working group for epidemiology and prevention. All interventional centres of the country (7 million inhabitants) were asked to report relevant data of 50 consecutive patients with PTCA in a structured questionnaire. Thirteen centres responded and we report the data of 650 patients. The mean proportion of women was 28%, the mean age 61.1 years and the mean stent rate 49.8%. The indications for PTCA varied widely: stable angina 10-74%, unstable angina 10-86%, primary PTCA 0-22%. The risk factor history was distributed as follows: diabetes 12-46% (mean 22.3%), hypertension 32-68% (mean 54.2%), current smoking 6-56% (mean 21.9%), and total cholesterol (TChol) > 200 mg/dl: 30-78% (mean 60.3%). Current lipid values were available for T chol. in 44-100% (mean 84.5%) and for LDL in 4-100% (mean 67.1%). Dietary counselling by a dietician was done in 4-100% of patients (mean 35.6%) Information concerning the hazards of smoking was given to 25-100% (mean 83.6%) of current smokers. Drug treatment at hospital discharge was as follows: 84-100% (mean 93.1%) received ASA, 24-74% (mean 49.8%) ticlopidine, 6-84% (mean 53.3%) nitrates, 34-82% (mean 60.2%) beta blockers, 10-70% (mean 39.5%) ACE inhibitors, 4-74% (mean 4 7.2%) lipid lowering drugs, 7-48% (mean 17.8%) calcium antagonists, 0-12% (mean 6.1%) digitalis and 0-28% (mean 13.6%) diuretics. Follow-up data were collected in 4 centres at 6 months post discharge and were available for 174 patients. Here we found an increase in the prescription of calcium antagonists, digitalis and statins. The following conclusions were drawn at a conference in which all centres participated: lipid values should be available for each patient at PTCA, dietary counselling should be initiated for every patient during hospitalisation (and continued by the family physician) and the national cardiac society should promote guidelines for the use of drugs in which the variation in use is too wide at present. It should be ensured that these guidelines are implemented not only in patients after AMI but also in those after PTCA.

[Rational cardiologic diagnosis after cerebral ischemic event]

Stroke continues to be a serious socioeconomic problem in the industrialized countries. The three disease processes responsible for most ischemic cerebrovascular events (CVE) are large-vessel and small-vessel atherothrombotic disease and, in up to 20-30% of cases, cardiac embolism. Data from the literature show that life expectancy after CVE is mainly dependent on the coexistence of cardiac disease. It is the responsibility of the cardiologist to exclude or identify the source of cardiac embolism and to initiate adequate treatment for the prevention of recurrences, as well as to diagnose, and treat any concomitant cardiac disease which may be present. We propose a cost-effective algorithmic approach to help the cardiologist in the diagnosis and treatment of patients with transient ischemic attacks and ischemic stroke.

Effect of prosthetic valve malfunction on the Doppler-catheter gradient relation for bileaflet aortic valve prostheses

BACKGROUND

Considerable discrepancies between Doppler and catheter gradients caused by localized gradients and pressure recovery have been reported for normal bileaflet aortic valve prostheses.

METHODS AND RESULTS

To examine whether this Doppler-catheter gradient relation is affected by prosthetic valve malfunction, a 19-mm CarboMedics aortic valve was simultaneously studied with continuous-wave Doppler and catheter technique in normal function and in various states of malfunction ranging from slightly restricted opening to total occlusion of one leaflet. For each functional status, peak and mean gradients were measured at eight different flow rates (cardiac output, 2.0-6.0 L/min). Excellent correlation between Doppler and catheter gradients was found regardless of the valve function (r = 0.99, SEE = 1.0-3.3 mm Hg). However, the relation between Doppler and catheter gradient was highly dependent on the function of the valve as shown by a variation of slopes from 1.08 to 2.08. For the normally functioning valve (angle between flow axis and leaflet 5 degrees), peak and mean Doppler gradients were approximately twice the catheter gradients (slope, 2.08 and 2.03 for peak and mean gradients, respectively). Slightly restricted opening of one leaflet (22 degrees) significantly altered the Doppler-catheter gradient relation, and slopes decreased to 1.69 (p < 0.01) and 1.52 (p < 0.001) for peak and mean gradients, respectively. The differences between Doppler and catheter gradients significantly decreased with further restriction of valve opening, and slopes ranged from 1.25 to 1.41 for angles between 34 degrees and 52 degrees. When one leaflet was totally occluded, the slope finally dropped to 1.08 for both peak and mean gradients, and Doppler gradients were only slightly greater than catheter gradients. Gradients increased with malfunction of the valve caused by reduction of the effective orifice area. However, the increase of Doppler gradients was considerably smaller than the increase of simultaneous catheter gradients.

CONCLUSIONS

The discrepancies between Doppler and catheter gradients that have been reported for normally functioning bileaflet aortic valve prostheses may be reduced or even disappear in patients with malfunctioning valves. Furthermore, the increase of Doppler gradients caused by malfunction of the valve may underestimate the true hemodynamic changes.

Effect of stenosis geometry on the Doppler-catheter gradient relation in vitro: a manifestation of pressure recovery

OBJECTIVES

This study investigated the effect of stenosis geometry on the Doppler-catheter gradient relation.

BACKGROUND

Although gradient estimation by Doppler ultrasound has been shown to be accurate in various clinical and in vitro settings, there have also been reports of substantial discrepancies between Doppler and catheter gradients. These conflicting results may be due to differences in geometry and hemodynamic characteristics of flow obstructions.

METHODS

Stenoses of various geometry were simultaneously studied with continuous wave Doppler and catheter technique in a well controlled pulsatile flow model.

RESULTS

Doppler and catheter gradients correlated very well regardless of stenosis geometry and site of distal catheter measurement (r = 0.98 to 0.99, SEE = 1.8 to 5.3 mm Hg). When the catheter was pulled back through the stenosis, the highest gradients were found in or close to the stenosis. When these catheter gradients were compared with Doppler gradients, the agreement between the two techniques was excellent regardless of stenosis geometry (slope 0.97; mean difference 0.6 +/- 2.0 mm Hg). However, when distal pressures were measured 10 cm downstream from the stenotic segment, the slope of the regression line, and therefore the agreement between Doppler and catheter gradients, differed for the different stenosis types (slopes from 0.98 to 1.69). In stenoses with abrupt narrowing and abrupt expansion, agreement was acceptable. Doppler gradients were only slightly greater than catheter gradients (mean difference 4.5 +/- 5.2 mm Hg). In stenoses with a gradually tapering inlet and outlet, the Doppler-catheter gradient relation was dependent on the outflow angle. Good agreement was found for an angle of 60 degrees (mean difference 0.6 +/- 1.8 mm Hg). In stenoses with a 40 degrees outflow angle, Doppler gradients exceeded the catheter gradients by 13% on average; for stenoses with a 20 degrees outflow angle, Doppler gradients exceeded catheter gradients by 46 +/- 11.4%, with differences as great as 65 mm Hg. These results were identical for stenoses gradually tapering outward to the distal tubing diameter and those with abrupt expansion after 2 cm of gradual expansion. The results were also not affected by changing the inflow angle from 20 degrees to 60 degrees. However, an abrupt narrowing instead of a tapering inlet significantly altered the Doppler-catheter gradient relation (p < 0.001); Doppler gradients exceeded the catheter gradients by 34 +/- 10% for this stenosis type.

CONCLUSIONS

Doppler gradients accurately reflect the highest gradients across flow obstructions that occur in the vena contracta. However, these gradients may be significantly greater than catheter gradients that are measured farther downstream, as is usually the case in clinical catheterization studies. These discrepancies are due to pressure recovery. The magnitude of pressure recovery is highly dependent on the stenosis geometry, which therefore significantly affects the Doppler-catheter gradient relation. It is the outflow geometry that predominantly influences this relation, but the shape of the inlet may affect the results as well. Although pressure recovery occurs even in stenoses with abrupt narrowing and abrupt expansion, the phenomenon is most likely to become clinically relevant in stenoses with a gradually tapering inlet and outlet with an outflow angle < or = 20 degrees.

[The role of current diagnostic measures in hypertension]

The problems in diagnostic steps in the hypertensive patient can be grouped in 4 categories: the etiological evaluation concentrates recently especially on renovascular hypertension since. This disorder is getting more common with the ageing population and since diagnosis and treatment have been simplified; the detection of additional risk factors is important to guide individual drug selection; the detection of organ manifestations (e.g. LVH) may help in the therapeutic decision especially in borderline hypertensives; ambulatory blood pressure monitoring is becoming increasingly used despite the lack of standardized and generally accepted means to evaluate the recorded data.

Value and limitations of proximal jet dimensions for the quantitation of valvular regurgitation: an in vitro study using Doppler flow imaging

To evaluate usefulness and limitations of proximal jet dimensions for the quantitation of valvular regurgitation, fluid jets were created in a pulsatile flow model, and proximal jet width and cross-sectional area were measured by means of color Doppler flow imaging. When circular orifices with diameters from 1 to 6 mm were studied, jet width and cross-sectional jet area measured as close as possible to the orifice were directly related to the orifice diameter (r = 0.97; standard error of the estimate, 0.4 mm; y = 0.5 + 0.97x) and the orifice area (r = 0.97; standard error of the estimate, 5.7 mm2; y = 0.22 + 2.47x), respectively. No significant dependence on flow rate or pressure gradient was found for these measurements. Jet width was measured with color M-mode Doppler by use of the smallest sample volume size (1 mm) and was slightly greater than the orifice diameter (4.2 +/- 1.7 mm versus 3.8 +/- 1.7 mm). However, cross-sectional areas were approximately fourfold the orifice areas, on average (52.5 +/- 24.6 mm2 versus 12.3 +/- 9.7 mm2), with a range of twelvefold (smallest orifice) to threefold (largest orifice). When the sample volume size was reduced from 2.4 to 1.0 mm, color areas decreased by 25.6 +/- 6.0%. Slit-shaped orifices were studied with two different orientations of the slit-parallel and perpendicular to the ultrasound beam: Color M-mode measurements were again slightly greater than length and width of the slit, but cross-sectional areas were substantially larger than the orifice areas and increased between 44% and 115% when changing the orientation of the slit from perpendicular to parallel. This, again, reflected problems with lateral resolution. When cross-sectional areas were measured at increasing distances from the orifice, the cross-sectional jet area increased significantly within a few millimeters. This increase was greater with higher gradients and smaller orifice sizes. In case of a small orifice (2 mm) and a high gradient (130 to 160 mm Hg), increase in area was as great as 122% within a distance of only 5 mm. Thus, proximal jet width and cross-sectional area were directly related to the orifice size, which could be a valuable parameter for the evaluation of valvular regurgitation. Measurements of jet width by color M-mode seemed to be most accurate but are limited by the fact that in vivo valvular defects may be irregular rather than of circular shape.(ABSTRACT TRUNCATED AT 400 WORDS)

Quantitation of aortic regurgitation by colour coded cross-sectional Doppler echocardiography

In 60 patients with aortic regurgitation, angiography and cross-sectional Doppler echocardiography have been compared in order to examine the reliability of the noninvasive method in quantitating aortic regurgitation. In a parasternal short-axis view just below the aortic valve, the ratio of the cross-sectional area of the jet divided by the cross-sectional area of the left ventricular outflow tract was determined. This measurement was possible in 50 patients (83%). Grossman's classification was used as the criterion for assessing the severity of aortic regurgitation by angiography. Values for the ratio of grade I ranged from 0.03 to 0.18, II 0.06 to 0.29, III 0.30 to 0.55, and IV 0.40 to 0.65. Assuming four Doppler grades (less than 0.15, 0.15-0.29, 0.30-0.44, greater than or equal to 0.45), we found complete agreement between the two methods in 42 patients (84%). In six cases there was underestimation, in two cases overestimation, by one grade only. Considering all cases, X2 analysis gave 96.6, P less than 0.00001, the contingency coefficient was 0.81. We conclude that, using this measurement, cross-sectional Doppler is a reliable method for the quantitative evaluation of aortic regurgitation.

[Long-term electrocardiography (quality standards and guidelines for the documentation of findings]

Indications for a Holter-ECG-recording are dizzy-spells, syncopes, ischemic attacks, dyspnoea, ischemia of the myocardium, arrythmias after myocardial infarction and with different types of cardiomyopathies, the sick-sinus-syndrome and a-v-blocks; furthermore recording of cardiac situations and the effect of drugs. The report should mention the basic rhythm, ventricular and supraventricular arrhythmias as well as temporary blocks and pauses.

[The prehospital period of acute myocardial infarct]

The duration of the prehospital phase in Austria seems to be in the high range in international comparisons. Various methods to reduce this interval have seen suggested: mobile coronary care systems and direct summoning of the ambulance systems by the patients. On the other hand it has been proposed to start relevant therapy (antiarrhythmic drugs, thrombolysis) before arrival in the hospital. Since a substantial percentage of patients experience premonitory symptoms before the acute infarction, it may be important to correctly diagnose this preinfarction syndrome including the various ECG anomalies.

[Celiprolol in acute myocardial infarct]

In a randomized trial the effect was studied of celiprolol, a cardioselective beta receptor blocker with strong intrinsic activity (ISA) on the incidence of ventricular arrhythmias in patients with acute myocardial infarction (AMI). All patients received the first (oral) dose of 100 mg celiprolol or placebo exactly 6 hours after the onset of symptoms. Arrhythmia analysis was carried out from Holter recordings using a Pathfinder system. The results in 10 patients receiving celiprolol and 11 patients receiving placebo show that there was no difference in the distribution of the Lown classes between the two groups. The hourly VPC rate was somewhat higher in the celiprolol group from the very onset of the study, but the trend toward a decrease in VPC with time was identical in both groups. There was not a single incidence of ventricular fibrillation in the study population. It is concluded that celiprolol - under the circumstances of this study - did not show a beneficial influence on ventricular arrhythmias in AMI. This may, in part, be due to the strong ISA of this substance, but possibly also to the fact that celiprolol levels in the blood (measured by HPLC) were significantly lower in patients with AMI than in healthy volunteers.

[Sulfinpyrazone-associated renal failure (author's transl)]

Three patients developed renal failure a few days after onset of sulfinpyrazone administration. In two the renal dysfunction was reversible, while the third died of a second myocardial infarction. The clinical picture of renal failure was uncharacteristic. It is recommended that renal function be tested two to four days after starting sulfinpyrazone, and to discontinue the drug immediately if there is a rise in blood urea nitrogen and creatinine. Since in two of the patients the creatinine values were elevated before sulfinpyrazone had been administered, it is clear that even minor pointers to impaired renal function should be considered as contraindications to the use of sulfinpyrazone.

[Routine serum digoxin determination on hospital admission (author's transl)]

The purpose of the present study was the collection of data concerning digitalis treatment of patients outside hospital. The investigation was carried out on 200 patients over 60 years of age, consecutively admitted to a 750-bed general hospital (35% ot a medical ward, 65% to other specialities). An ECG and serum creatinine and digoxin determinations were performed on the day of admission and a careful history taken of the drugs administered before admission. 30 patients reported the use of digoxin or other digitalis drugs, whilst another 48 patients reported taking cardiac drugs in general. The prevalence of digoxin levels exceeding 2 ng/ml was 11.5% in the group of patients known to have taken digitalis preparations, 18% among the 92 patients with positive serum digoxin levels and highest (30%) in the subgroup admitted due to cardiac failure. In patients with digoxin levels above 2 ng/ml the prevalence of elevated serum creatinine values (greater than 1.2 mg%) was markedly increased. Among patients with normal serum creatinine levels the mean age of patients with digoxin levels above 2 ng/ml was significantly higher than of those with digoxin levels below 2 ng/ml. A clear correlation between digoxin levels and ECG changes was not demonstrable; simultaneous administration of diuretics promotes the appearance of electrocardiographic signs of digitalis toxicity.

[Advances in non-invasive procedures to diagnose acquired and congenital cardiac valvular disease (author's transl)]

A review is presented, based upon the literature published mainly during the past 10 years and upon personal experience with these methods, of the use of non-invasive diagnostic procedures in congenital and acquired valvular disease of the heart and pericardial disorders. Special emphasis is placed on the possibility of obtaining a quantitative assessment of the severity of the disorder. It depends on the underlying disease whether mechanocardiography (phonocardiogram, external pulse recordings) or echocardiography provides optimum diagnostic information. Echocardiography is especially helpful in the diagnosis of pericardial effusion and hypertrophic cardiomyopathy.

[Precision in fixation and remounting of cast parts]

The exactitude of transferring castings was tested in two currently used methods of casting. Results showed that alginate casting from a remontage matrix and simple casting with IMPREGUM are sufficiently exact for clinical purposes. When the mixing relations between the casting substances is exactly maintained a transfer exactitude of +/- 0.11 is achieved by the methods tested. When there is a change in the relationship of the mixtures deviations of up to 0.20 mm occur.

[Arrhythmia analysis--arrhythmia control (comparative studies of 4 small computers for automatic electrocardiography control)]

Four arrhythmia computers presently available on the market were tested with respect to their efficiency in identifying abnormal QRS-complexes. A considerable variation for the calculated sensitivity and specificity has been found with a highest value for sensitivity (92.9%) combined with a low specificity (72.4%), and a highest value for specificity (100%) combined with a very low sensitivity (36.6%). The best results were obtained by a computer with a sensitivity of 90.9% and a specificity of 98.5%. For the routine use of these computers in the CCU common artifacts (e.g. muscle potentials) must influence their performance in a practical way: neither should minor artifacts stop the function completely nor should the computer continue to measure with a high level of "noise". Based upon the results of these test series suggestions for the concept of arrhythmia computers for CCU are presented.

[Attainment and preservation of normal exercise capacity after myocardial infarction (author's transl)]

Results of physical rehabilitation were studied in 2 groups of patients. Group A consisted of 16 men and at least 24 (mean 51.5) months had elapsed after myocardial infarction before they were entered into a training programme with supervised once-weekly classes in a school gymnasium. By contrast, the interval between infarction and onset of training was less than 12 (mean 7.0 months in the 21 patients of group B, who had exercise classes twice a week. Group A achieved an average increase in estimated aerobic capacity of 32% (p less than 0.001) in 10 months of training, group B of 33% (p less than 0.001) in 4.7 months. Further participation of group A for 26 more months resulted in an additional improvement of 11% (p less than 0.05). Differences between the groups in aerobic power and different methods of exercise testing and training are discussed. The results indicate that early physical training of groups of patients helps them to obtain a normal exercise capacity with a year after myocardial fixation. Without such intervention patients often remain restricted, but with supervised training their physical power may be improved significantly even if years have passed after the heart attack.

[Effect of potassium-magnesium aspartate on hemodynamics and myocardial metabolism of coronary disease patient during beta receptor stimulation]

2 series of patients with angiographically proven coronary artery disease were studied under the influence of an infusion of a beta-receptor stimulating drug (heptaminole) and of kalium-magnesium-aspartate (KMA) in high (series: I: 1000 mg of heptaminole in 25 min) and low doses (series II: 200 mg of heptaminole in 25 min) of beta-receptor stimulation. The results confirm the finding that high dose beta-receptor stimulation in patients with severe coronary artery disease results in failure of the contractile mechanism of the heart with the beta-receptor angina. However, administration of KMA simultaneously with the beta-receptor stimulator seems to be able to prevent the expected decrease of lactate extraction and results in no change in lactate AVD in series I and even in an 11% increase in lactate AVD in series II. Experimental data concerning the biochemical effects of KMA suggest that its ability to provide adequate amounts of oxaloacetone and hence to improve the function of the bricarbonic acid cycle seems to be of special importance. For this action to become relevant in coronary artery disease a situation would have to be postulated, in which an additional limiting factor of oxydative metabolism would be an inadequate supply of Krebs-cycle intermediates.