New onset of AV-nodal reentrant tachycardia (AVNRT) in the elderly- an uncommon diagnosis?

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmias in elderly patients (pat) are common. In this subset of pat, atrial fibrillation is by far the most frequent sustained arrhythmia but not the only one. Clinical, ECG and electrophysiological (EP) features of AV-nodal reentrant tachycardia (AVNRT) have rarely been described in the elderly, and this represents the aim of the current study.

Methods

At 2 EP-centres in Germany, data from all pat undergoing an EP-study (EPS) and diagnosed with AVNRT between January 2018 and May 2021 were collected and analysed. Pat > 65 years constituted the study population.

Results

During the study period AVNRT was diagnosed in a total of 329 pat. 93 pat (28%) were > 65 years and represent the study population [median age 74 (65-89) years, 48% female]. In the majority (85%), the duration of symptoms was short (< 1 year), 14 pat had symptoms of paroxysmal tachycardia for longer than 10 years. Most of the pat (n=88, 94%) had at least one ECG-documentation. In SR, the PR interval was relatively long [median 180 (120-380) ms)]. In 84% of pat, sustained AVNRT [median cycle length (CL) 400 (270-800) ms] was induced during EPS. In the remaining pat, at least 2 typical AV-nodal-echo beats were induced. Slow pathway (SP) ablation/modification was performed in all but one patient presenting with a very long baseline PR-interval, low antegrade Wenckebach-point (WP) and very slow AVNRT. In this case, the pat was treated with ß-blocker after pacemaker (PM) implantation. In 3 additional pat, PM implantation was necessary after ablation due to intermittent high-degree AV-block. In comparison to the rest of the study population, these four pat had a longer baseline PQ interval [median 275 (IQR 248- 303) ms vs. 180 (IQR 160- 192) ms], a longer baseline AH interval [median 207ms (IQR 185- 234) ms vs. 95 (IQR 80- 107) ms], a lower baseline antegrade WP CL [median 510 (IQR 435- 645) vs. 390ms (IQR 355- 470) ms], and a longer tachycardia CL [TCL 557 (IQR 454- 661) ms vs. 400 (IQR 364- 443) ms; p value <0,01 for all comparisons]. The overall complication rate (other than AV block) was low (2 pat with AV fistula treated conservatively) and comparable to the one described in younger pat.

Discussion

Elderly pat also have AVNRT, there are a slight differences in physiology (i.e. relatively long baseline PR-interval and TCL, likely due to changes of the conduction system with aging), and as in young pat, ablation is curative treatment with similar (low) complication rate. A subset of pat, characterized by longer PR- and AH-intervals, lower WP and longer TCL may be at higher risk for AV-block after SP modification. Whether this is due to pre-existing damage or to posterior location of the FP remains unknown.

SP ablation is safe and effective even in elderly pat. In pat presenting with EP characteristics presumptive of a baseline impairment of the conduction properties of the FP, ablation of the FP could be attempted to avoid postprocedural high degree AV block.

New Onset of AV- Nodal Reentrant Tachycardia (AVNRT) in the elderly – an uncommon diagnosis?

Background

Arrhythmias in elderly patients (>70 years) are common in daily clinical practice. Most frequently, they are based on atrial fibrillation or other atrial tachycardia with an indication for oral anticoagulation and specific antiarrhythmic medications. The electrographic (ECG) documentation related to symptoms is essential before therapy initiation. In case of suspected AVNRT based on surface ECG, an electrophysiological study (EP) with ablation as curative strategy should be planned.

Methods

We analysed all patients >70 years with AVNRT diagnosed by electrophysiologic (EP) studies between May 2018 and December 2020.

Results

An EP study for suspected AVNRT was performed in 27 patients >70 years. The diagnosis of AVNRT was confirmed in 20 patients (75%). From all EP- studies with the diagnosis of AVNRT (n=93) in this period, 20 patients (22%) were older than 70 years (mean age 77 years with a range of 70–85 years), 12 were women. In most of the patients, the duration of symptoms was short (3 month). Only 4 patients had symptoms of paroxysmal tachycardia longer than 10 years. Except for 2 patients, all patients had at least one ECG- documentation (12- lead- ECG, Holter- ECG, telemetric ECG and/or in the loop recorder). In 12 patients, a 12- lead- ECG- documentation was available, in 5 patients the tachycardia has been registered in the Holter-ECG and in 1 in a loop recorder. In the 12- lead- ECG before ablation in sinus rhythm the PQ interval was with 196 (120- 300) ms in the upper range. In 16/ 20 patients was during the EP- study a sustained AVNRT (CL 410, 314- 538 ms) inducible. In the others, up to 3 typical AV- nodal- echo beats were induced in the EP- study. A slow pathway ablation/ modification was performed in all patients in typical position. In 2 patients, the implantation of a dual- chamber- pacemaker was necessary due to intermittent high- degree AV-nodal-block during the same hospital stay. In both patients, a first degree AV-block with PQ- interval of 250 and 300 ms was pre-existing.

Discussion

Especially for the elderly patients with new onset of clinical symptoms of arrhythmia, clinical anamnesis including an ECG- documentation is required for planning the therapeutic strategy. A borderline long PQ- interval as sign of an age- dependent fibrosis in the AV- node and, therefore, altered conduction properties in the AV node can be a cause of AVNRT in these older patients. In patients with pre-existing long PQ- interval (>250 ms), the risk of pacemaker implantation after successful ablation is higher. In this group of patients, medical therapeutic options are limited and often associated with the need of pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.

Gamma nail in the treatment of closed trochanteric fractures. Results and indications of 121 cases

The Gamma Nail is the latest advance in the treatment of trochanteric fractures based on intramedullary nailing principles during closed procedures. Its design is based on Küntscher's Y-nail and locking intramedullary (IM) nails. This paper reports the results from the first-ever series of 121 patients operated between 1988 and 1990. They were followed until bone union was achieved. The mean patient age was 75 years. Most patients were in poor general health and had unstable fractures. Anatomical preoperative reduction was achieved in 72% of cases. Fixation was good in 66% of cases and acceptable in 27% of cases. Intra-operative complications consisted of nine fractures without consequences. Of the treated patients, 83.4% resumed weight-bearing during the first week. There was one case of deep infection that resolved with treatment. The mortality rate was 12.3% at three months. We noted 7 alunions in varus, 3 in valgus, 2 in external rotation and 1 in internal rotation. There were no cases of non-union. In six cases, the screw had cut out of the femoral head. The drawbacks associated with surgical treatment methods for trochanteric fractures also apply to the Gamma nail. Nevertheless, one of its primary advantages is the possibility of using a closed procedure. When compared to Ender nailing, knee pain is absent and weight-bearing can be achieved in all patients, no matter the fracture type.

[IgG4-related systemic disease with autoimmune pancreatitis and lung involvement primarily presenting as pancreatic cancer with pulmonary metastases]

BACKGROUND

After the first case publication using the term "autoimmune pancreatitis" in 1995 and the successful treatment with steroids we now can distinguish between two clinical und histopathological forms of autoimmune pancreatitis. Type 1 autoimmune pancreatitis (AIP) is usually part of an IgG4-related systemic disease. AIP Typ 2 is an IgG4-independent pancreatic disease. For both entities pancreas cancer is the most important differential diagnosis.

CASE REPORT

We report the case of an 82-year-old male patient who primarily presented with obstructive jaundice. Computed tomography (CT) revealed the typical image of a small cancer of the head of the pancreas with pulmonary metastases. After endoscopic drainage of the bile duct a CT-guided biopsy of a pulmonary nodule was performed in which cancer was ruled out. Next the patient was treated with steroids because of "tumour-associated cachexia". In the follow-up the mass in the head of the pancreas like the lung nodules had surprisingly disappeared. In the complete work-up the immune histochemical staining of the lung biopsy revealed subsequently a typical IgG4-associated inflammation. After termination of the therapy the disease relapsed as sclerosing cholangitis.

CONCLUSION

The IgG4-related systemic disease with AIP can present as cancer of the pancreas with lung metastases. Extrapancreatic IgG4-positive histopathology and response to therapy with steroids can help to diagnose the disease in complex clinical presentations.

[Imaging techniques and their impact in treatment management of patients with acute flank pain]

The purpose of this overview is to provide a general summary of the imaging techniques applied at the Vienna Hospital for the investigation of acute flank pain and the diagnosis of stone disease and the evaluation of their efficacy and impact on therapy management. The number of publications on the issue of "intravenous urography (IVU) vs computed tomography (CT)" is abundant; in recent years, advocates of CT make up the majority. In the Department of Urology at the Vienna Hospital, conventional techniques such as ultrasound and IVU besides UHCT still play an important role. This overview presents the advantages and disadvantages of the various imaging techniques for diagnosis of stone disease and evaluates their significance regarding therapy management of patients with acute flank pain.

Preparing strategic information management plans for hospitals: a practical guideline

OBJECTIVES

Systematic information management in hospitals demands for a strategic information management plan (SIM plan). As preparing a SIM plan is a considerable challenge we provide a practical guideline that is directly applicable when a SIM plan is going to be prepared.

METHODS

The guideline recommends a detailed structure of a SIM plan and gives advice about its content and the preparation process. It may be used as template, which can be adapted to the individual demands of any hospital.

RESULTS

The guideline was used in several hospitals preparing a SIM plan. Experiences showed that the SIM plans could be prepared very efficiently and timely using the guideline, that the proposed SIM plan structure suited well, that the guideline offers enough flexibility to meet the requirements of the individual hospitals and that the specific recommendations of the guideline were very helpful.

CONCLUSIONS

Nevertheless, we must strive for a more comprehensive theory of strategic information management planning which -- in the sense of enterprise architecture planning -- represents the intrinsic correlations of the different parts of a SIM plan to a greater extent.

Mathematical modeling of regulatory mechanisms in yeast colony development

In the present study, yeast colony development serves as a model system to study growth of fungal populations with negligible nutrient and signal transport within the mycelium. Mathematical simulations address the question whether colony development is governed by diffusional limitation of nutrients. A hybrid one-dimensional cellular automaton model was developed that describes growth of discrete cells based upon microscopic interaction rules in a continuous field of nutrient and messenger. The model is scaled for the geometry of the experimental setup, cell size, growth- and substrate uptake rates. Therefore, calculated cell density profiles and nutrient distributions can be compared to experimental results and the model assumptions can be verified. In the physiologically relevant parameter range, simulations show an exponentially declining cell density along the median axis of the colonies in case of a diffusion limited growth scenario. These results are in good agreement with cell density profiles obtained in cultivations of the yeast Candida boidinii with glucose as the limiting carbon source but stand in contrast to the constant cell density profile estimated for Yarrowia lipolytica grown under the same conditions. While from the comparison of experimental results and simulations a diffusion limited growth mechanism is proposed for glucose limited C. boidinii colonies, this hypothesis is rejected for the growth of Y. lipolytica. As an alternative, a quorum sensing model was developed that can explain the evolution of constant cell density profiles based on the effect of a not further characterized unstable or volatile messenger.

Osteoprotegerin and receptor activator of nuclear factor-kappaB ligand (RANKL) in the serum of healthy adults

AIMS

Osteoprotegerin and the receptor activator of the nuclear factor-kappaB ligand (RANKL) are decisive factors for maintaining the balance between bone formation and bone resorption. As new, sensitive ELISAs have been developed recently, reference serum ranges should be established to use these analytes for possible diagnostic purposes.

METHODS

Measurements were performed in serum samples of 142 healthy adults (82 women, 60 men) between 20 and 70 years of age (mean age: 46 years) using ELISA kits from Immundiagnostik, Bensheim, Germany.

RESULTS

Serum concentrations of osteoprotegerin were age and gender independent and showed a Gaussian distribution, while RANKL concentrations were also age independent but differed between males and females, with a non-Gaussian distribution. For osteoprotegerin a gender-independent upper 97.5 percentile limit of 3.6 pmol/L was calculated while the corresponding limits for RANKL and the ratio of RANKL to osteoprotegerin amounted to 3.29 pmol/L and 2.78 in women and 1.66 pmol/L and 2.18 in men, respectively.

CONCLUSIONS

Both osteoprotegerin and RANKL were quantifiable in serum of healthy adults, which means that these compounds can be used as potential diagnostic tools.

European quadricentric evaluation of a breast MR biopsy and localization device: technical improvements based on phase-I evaluation

Our purpose was to report about technical success, problems and solutions, as experienced in a first multicentre study on MR-guided localisation or vacuum biopsy of breast lesions. The study was carried out at four European sites using a dedicated prototype breast biopsy device. Experiences with 49 scheduled localisation procedures and 188 vacuum biopsies are reported. Apart from 35 dropped indications, one localisation procedure and 9 vacuum biopsies were not possible (3 times space problems due to obesity, 2 times too strong compression, 3 times impaired access from medially, 2 times impaired access due to a metal bar). Problems due to too strong compression were recognised by repeat MR without compression. During the procedure problems leading to an uncertain result occurred in eight vacuum biopsies, two related to the procedure: one limited access, and one strong post-biopsy enhancement. Improvements after phase-I study concerned removal of the metal bar, development of an improved medial access, of a profile imitating the biopsy gun, optimisation of compression plates and improved software support. The partners agreed that the improvements answered all important technical problems.

MR-Guided vacuum biopsy of 206 contrast-enhancing breast lesions

PURPOSE

To determine the accuracy and clinical use of MR-guided vacuum biopsy (VB) of enhancing breast lesions.

MATERIAL AND METHODS

254 lesions were referred to MR-guided vacuum-assisted breast biopsy. In 43 (16 %) patients the indication was dropped because the lesions could not be identified at the time VB was scheduled. This was due to hormonal influences (n = 37), to too strong compression (n = 3) or to misinterpretation of the initial diagnostic MRI (n = 3). In 5 cases (2 %) VB was not performed due to obesity (n = 2); problems of access (n = 2) or a defect of the MR-unit (n = 1). VB was performed on altogether 206 lesions. In 4 cases (2 %) VB was unsuccessful. This was immediately realized on the post-interventional images. Thus a false negative diagnosis was avoided. Verification included excision of the cavity in cases with proven malignancy or atypical ductal hyperplasia (ADH) and (for benign lesions) retrospective correlation of VB-histology with pre-and postinterventional MRI and subsequent follow-up.

RESULTS

51/202 successful biopsies proved malignancy. In 7 cases ADH and in 144 cases a benign lesion was diagnosed. One DCIS was underestimated as ADH. All other benign or malignant diagnoses proved to be correct.

CONCLUSION

MR-guided VB allows reliable histological work-up of contrast-enhancing small lesions which are not visible by any other modality.

Micro flow modules with combined fluid flow channel and optical detection waveguide--hyper Rayleigh scattering as a case study

Micro flow modules with optical detection have been fabricated in a way which enables optical waveguiding inside and a defined interaction length along the fluid channel. Because of the usually lower refractive index of the solution compared with that of the substrate, so-called "leaky" optical wave-guiding must be employed. The combination of the fluid flow channel function with that of the optical waveguide has advantages for all miniaturized optical detection cells. It has been shown for hyper Rayleigh scattering (HRS) that improvement of the analytical principle is inherent in the miniaturization. The detection limit can be enhanced by at least a factor of 20. The applied HRS measurement procedure also enables simultaneous detection of two photon absorption (TPA) fluorescence. The severe boundary conditions of capillary electrophoresis were used as micro flow module design constraints to enable the transfer of the approach to other types of analysis.

New isoelectric buffers for capillary electrophoresis: N-carboxymethylated polyethyleneimine as a macromolecular isoelectric buffer

Isoelectric buffers are attractive for electrophoresis because of their low conductivity, and their compatibility with indirect photometric detection in capillary electrophoresis (CE) where they do not interfere with the detection by exhibiting competitive displacement of the UV-absorbing probe ion. N-carboxymethylated polyethyleneimine (CMPEI) was prepared by introducing a half molar equivalent of carboxylate groups onto a polyethyleneimine backbone. Its isoelectric point determined by conductometric titration and from the pH of its dilute aqueous solution is approx. 6.8, which allows isoelectric buffering at a lower pH compared to histidine (pI7.7). Although the isoelectric point is somewhat diffuse, as expected for a polymeric compound, it exhibits a buffering capacity at a pI point of about twice that of histidine. Studies of electroosmotic flow (EOF) profile at various pH values in fused silica capillaries showed that CMPEI adsorbs onto the fused silica wall and reverses the EOF at pH < 6.5. CMPEI was applied as a buffer in an electrolyte containing 0.5 mM of the anionic dye tartrazine used as the probe for indirect detection of anions. The separation system exhibited a stable baseline, no system peaks, separation efficiencies of up to 195,000 theoretical plates, and detection limits down to 0.2 microM or 2 amol of injected analyte.

Fixation of odontoid fractures by an anterior screw

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation.

There were 29 patients with Anderson and D’Alonzo type-II fractures and 52 with type III. Roy-Camille’s classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%.

We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.

Fixation of odontoid fractures by an anterior screw

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D'Alonzo type-II fractures and 52 with type III. Roy-Camille's classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.

Results of breast conserving therapy for early breast cancer and the role of mammographic follow-up

PURPOSE

The following article is a review of 23 years of breast-conserving therapy in our hospital. This study was performed to assess and improve the follow-up care of women with early breast cancer and to evaluate whether or not biannual mammogram is useful.

METHODS AND MATERIALS

Between 1972 and December 1995, 3072 women with pathological size pT1 and pT2 breast cancer were treated with conservative surgery and radiation therapy. Eighty-five patients developed a recurrence in the treated breast as the first site of failure, 12 of which had positive axillary nodes. In the following patient study, those with an noninvasive recurrence were excluded. A retrospective assessment of the entire mammographic course was made, starting with the mammogram at the time of original diagnosis to the mammogram of the recurrence.

RESULTS

In our study group the probability for local failure ranged from 1 to 2% per year. At 5 and 10 years the actuarial rates were 5 and 10%. The median time to recurrence was 41 months (range 8-161). Twenty-six (31%) recurrences were detected by mammography alone, 10 (12%) by clinical examination only, and 35 (41%) by both methods. For the patients with an ipsilateral recurrence, the overall actuarial 5- and 10-year survival after treatment was 87 and 70%, respectively. The 5-year actuarial rate of survival from salvage mastectomy was 61%.

CONCLUSION

Considering the high percentage of recurrences detectable by mammography and the possibility of detection within a short-term interval, we think biannual mammographic follow-up is appropriate for the first years following breast-conserving therapy.

[Duplex sonographic studies on the pathogenesis of splenic hemodynamics in liver cirrhosis]

AIM OF STUDY

The haemodynamic role of the spleen in portal hypertension remains unclear. Duplex sonography was undertaken prospectively to discover the relationship of splenomegaly and splenic vein flow to type and severity of liver cirrhosis and portal vein flow, as well as to the degree of oesophageal varices.

PATIENTS AND METHODS

89 patients (54 men, 35 women; mean age 52 [26-81] years), diagnosed in the second half of 1993 as having liver cirrhosis were consecutively included in the study. In 40 patients the cirrhosis was in stage A (according to Child-Pugh classification), in 31 in stage B and in 18 in stage C.

RESULTS

Portal vein flow fell significantly with increasing degree of cirrhosis (stage A: 8.29 cm/s; stage B 7.03 cm/s; stage C 5.26 cm/s; P < 0.05). Splenic vein flow differed significantly only between stages B and C (stage A: 9.22 cm/s; stage B: 9.46 cm/s; stage C: 7.87 cm/s; B vs C, P < 0.05). There was no correlation between portal vein flow, splenic vein flow, degree of splenomegaly and extent of oesophageal varices.

CONCLUSION

The results may be explained by the presence of collateral circulations and by the differing pathophysiological part played by the spleen in liver cirrhosis of different aetiologies.

The role of autoimmunity in hepatitis C infection

Viral infections are considered a possible trigger of autoimmune diseases. In autoimmune liver diseases the hepatotropic viruses, especially hepatitis C virus (HCV), have received particular attention as possible etiological agents. The present study was undertaken to investigate the relation between hepatitis virus infections and autoimmune liver diseases. We found a very low incidence of HCV infection in patients with autoimmune liver diseases. Only 5% (n = 7) of patients with AIH types I and III had antibodies against HCV antigens, but only two of these seven were HCV-RNA positive. Similar results were obtained in patients with PBC and PSC. Furthermore, the coexistence of LKM autoantibodies with chronic HC is a rare event and less common than low-titer ANA and SMA in viral liver diseases. In conclusion, a link between hepatitis viruses B or C and AI-liver diseases is very unlikely. Autoantibodies in viral liver diseases appear to be an expression of a generalized immune activation by cytokines, as observed during interferon treatment in viral liver diseases.

Open adult femoral shaft fracture treated by early intramedullary nailing

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed.

Effects of psychological stress on cold pressor test results

The authors evaluated the incidence of a psychological stressor in the modification of blood pressure induced by the cold pressor test in normotensive and medicated hypertensive subjects. The study was carried out in two stages: In the first, 28 (14 normotensive and 14 hypertensive) subjects were administered a cold pressor test. Fifteen days later, 14 subjects repeated the same experiment. The remaining 14 subjects (7 hypertensive and 7 normotensive) also repeated the cold pressor test, with the difference that, to add a stressful psychological situation, the physician "abandoned" them at the beginning. The addition of the psychological stress significantly increased only systolic blood pressure in both the hypertensive and the normotensive subjects. Furthermore, the hypertensive subjects did not recover their basal blood pressure values following the cold pressor test when the psychologically stressful situation had been added. These results show the importance of considering psychological aspects when applying physical pressor tests.

[The time requirement for endoscopic diagnosis and therapy: results of a multicenter study]

For evaluation of the time requirements for endoscopic diagnostic and therapeutic procedures data of 13,321 patients gathered from 155 endoscopic units were collected. Time requirements were calculated for preparation of the procedure, examination and after-care of patients and instruments. The data indicate, that time requirement is significantly influenced by the special procedure. Therefore, calculation of the time requirement of an individual unit needs exact consideration of the frequency of different procedures. Only cleaning of instruments by washing machines could be shown to reduce time requirement. Education of endoscopists was demonstrated to be time intensive. Age (exemption children) sex of patients and video-endoscopy did not effect duration of procedures.

[Therapy of choledocholithiasis using extracorporeal shock wave lithotripsy and adjuvant surgical endoscopy]

Extracorporeal shock wave lithotripsy of extra- and intrahepatic bile duct stones is indicated after failure of conventional operative endoscopic procedures including mechanical lithotripsy. An overview of the current literature (12 centers, 568 patients) indicates that this novel procedure has attracted international acceptance. It was applied in elderly patients (means = 65 years) with solitary (37.5%) or multiple (62.5%) concrements. Clearance of the bile ducts was achieved in 71.6% after 1.3 to 3.0 lithotripsy sessions (1900-4000 shocks) if additional endoscopic sphincterotomy was performed. Without sphincterotomy 61% of patients were treated successfully. The most frequent side effects were macrohematuria (6.9%), hemobilia (6.2%) cholangitis (4.5%) and pancreatitis (1.3%). A lethality of 0-3.6% (means = 0.6%) was reported. The current results demonstrate that therapy of extra- and intrahepatic bile duct stones with extracorporeal shock wave lithotripsy is effective, safe and provides high therapeutic comfort.

Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur

Thirty-seven fractures of the distal part of the femur in thirty-five patients were treated with interlocking intramedullary nailing. All fractures were nailed by a closed technique after any intercondylar extension of the fracture had been managed by reduction and stabilization with percutaneous lag-screws. Patients who had an isolated condylar fracture or a severely comminuted intercondylar fracture were treated with other types of implants. There were thirty extra-articular (type-A) fractures and seven intra-articular (type-C1 and type-C2) fractures. Postoperatively, early mobilization exercises and weight-bearing were begun. At an average duration of follow-up of 20.5 months (range, fifteen to twenty-six months), all thirty-seven fractures had healed. There were no malunions of either the supracondylar or the intercondylar fractures. Complications were infrequent and included chronic irritation from the distal screws in three patients and delayed union in one; the latter healed with two centimeters of shortening after bone-grafting. There were no infections. The functional results were assessed with the modified knee-rating system of The Hospital for Special Surgery. Thirteen knees (35 per cent) had an excellent result; twenty-two (59 per cent), a good result; and two (5 per cent), a fair result. The results correlated with the age of the patient and the presence of an intra-articular fracture. We concluded that closed interlocking intramedullary nailing is an excellent technique for both supracondylar and simple intercondylar fractures in which closed reduction and percutaneous fixation of the articular fracture is possible.

[Extrasystoles during extracorporeal biliary shockwave lithotripsy. Their incidence and clinical significance]

Incidence and clinical significance of cardiac side effects of extracorporeal shock-wave lithotripsy (ESWL) were prospectively analysed for 85 patients (26 men, 59 women; mean age 44 [17-81] years) with cholecystolithiasis (n = 70) or choledocholithiasis (n = 15). 24-hour ECG monitoring was undertaken on the day of treatment. Additionally, during ESWL cardiac rhythm and blood pressure were monitored. ESWL was performed with an electromagnetic lithotriptor under light anaesthesia with intravenous diazepam (10 mg) and pethidine (75-100 mg). There were no superventricular premature systoles in any of the patients during treatment. In 15 patients with occasional ventricular premature systoles (VPS) (6-81 per 23 hours) in the 24-hour ECG the number of VPS increased during the one-hour ESWL procedure significantly to 6-55 (P less than 0.05). 14 of these patients had an unremarkable cardiac history. Changing the lithotriptor coupling angle failed to suppress the VPS in only two patients. In these two it was necessary to trigger the shock wave with the ECG. Blood pressure rose markedly (up to 220 mm Hg systolic) during ESWL in only three patients, known hypertensives. But this rise was easily controlled with nifedipine, 10 mg sublingually. These data demonstrate that ESWL is a safe alternative to operative treatment, even in the presence of existing cardiac disease. Nonetheless, precautions should be taken in case there are complications.

Electromagnetically generated extracorporeal shock wave lithotripsy and adjuvant combined oral litholysis for therapy of symptomatic gallbladder stones

A prospective study was conducted to evaluate effectivity, problems and adverse effects of extracorporeal shock wave lithotripsy (ESWL) using a newly developed electromagnetic biliary lithotriptor (Lithostar Plus, Siemens, Erlangen, FRG) for the treatment of selected patients presenting with symptomatic cholecystolithiasis. In addition to generally accepted criteria for the selection of patients, gallbladder contractility was established and pigment stones were excluded by computed tomography (CT). 80 out of 486 patients (63 females, 17 males, mean age 36, range 17-76 years) were selected for ESWL using a standardized diagnostic program. 62 out of 80 patients participating in the study had solitary concrements (diameter 23.3 +/- 6.4 mm) while in 18 patients 2 or 3 stones (diameter below 10 mm) were observed. Stone fragmentation was achieved after an average of 1.35 treatment sessions (range 1-3) in 78 (97.5%) patients. No clinically relevant adverse effects were observed. Immediately after ESWL, ultrasound revealed misleading results with regard to stone fragmentation. 98.7% of patients (n = 77) were seen for follow-up investigations 3, 6 and 9 months after ESWL, and 82% at 12 months. A total of 40 (53%) patients became free of stones. Subgroup analysis showed that 68% of the patients were free of stones (stone diameter 10-20 mm), 54% (20-30 mm) and 33% (multiple stones), respectively. We therefore conclude that ESWL should be restricted to highly selected patients presenting with small (10-20 mm) solitary concrements.

[Esophageal varices: is bleeding predictable?]

Hemorrhage of oesophageal varices is still a life-threatening complication of portal hypertension. Parameters to identify patients being on risk to bleed are on demand for prophylactic therapy. Recent studies showed that bleeders present with larger varices, red color sign of the variceal wall and higher intravariceal hydrostatic pressure than patients without previous hemorrhage. Advanced liver disease (Child C) is an additional risk factor. The clinical value of the parameters appears to be decreased by a significant overlap of the findings obtained in bleeders and non-bleeders. However, patients with small varices, low variceal pressure (less than 12 mmHg) and fair condition are considered to be not on risk to bleed from varices. An additional clinical value of the parameters is provided by the potency to define patients more accurately for future clinical studies.

Electromagnetically generated extracorporeal shockwaves for fragmentation of extra-and intrahepatic bile duct stones: indications, success and problems during a 15 months clinical experience

Electromagnetically generated extracorporeal shock waves (without waterbath) were applied after intravenous premedication with 10-15 mg diazepam and 100 mg tramadol in the treatment of 33 patients (aged 32 to 91 years) with multiple intrahepatic stones (n = 4) or huge common bile duct stones (n = 29, 18-30 mm in diameter), which could not be removed by conventional endoscopy. Stone disintegration was achieved in 70% of common bile duct stones and in all intrahepatic concrements after 800-7500 discharges, which were applied during one (n = 21), two (n = 6) or three sessions (n = 6). Apart from mild fleabite-like petechiae at the side of shock wave transmission no other side effects were observed for a total of 51 procedures. We believe electromagnetically generated shock waves are safe, easy to apply, and relatively effective in the therapy of common bile duct and intrahepatic stones.

Electromagnetically generated extracorporeal shock waves for gallstone lithotripsy: in vitro experiments and clinical relevance

First generation shock wave sources have been proved to disintegrate gallstones effectively, but they require the immersion of the patient's body in a tank of water. A recently developed second generation shock wave source (Siemens-Lithostar, Erlangen, FRG) generates shock waves electromagnetically. It presents several novel features. In particular the waterbath can be omitted and due to lower shock wave pressure general anaesthesia is not required. In vitro studies showed that 36 out of 38 gallstones (11-30 mm in diameter) could be disintegrated. Two concrements resisting lithotripsy were pure white cholesterol stones. Independent of shape, size, and composition (cholesterol or pigment) the maximum diameter of remaining fragments after lithotripsy was between 1 and 8 mm. For sufficient disintegration precise focusing (+/- 1 cm) of the stones and maximum power of the shock wave generator were required.

The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing

Sixty-six cases of noninfected nonunions (27 femoral and 39 tibial) were treated with an interlocking nail. In these cases, 92.6% of the femurs and 94.8% of the tibias healed after the first operation in a mean time of 15.4 and 13.0 weeks, respectively. Deep infection complicated five nailings (7.5%, two femur and three tibia), which included three patients with reactivation of latent osteomyelitis. All cases healed after debridement and use of gentamicin PMMA beads. In one case the nail had to be removed and replaced by an external fixator. Residual angulation between 5 degrees and 10 degrees occurred in three femurs and seven tibias. Shortening occurred in all patients and averaged 0.9 cm in the femur and 0.5 cm in the tibia. Of the patients treated for femoral nonunion, 92.5% achieved full hip flexion and 77.8% full knee flexion on final follow-up examination. In patients with tibial nonunions treated with a locked nail, 92.3% had normal knee flexion and 84.6% obtained normal ankle function. Interlocking nailing offers unique advantages to patients with femoral or tibial shaft pseudarthrosis. The technique allows early weight-bearing, range of motion of adjacent joints, and reliable rates of consolidation of the nonunions.

Locked intramedullary nailing. Its application to femoral and tibial axial, rotational, lengthening, and shortening osteotomies

Interlocking nailing is an alternative method of internal fixation following corrective osteotomies for malunions or after correction of leg length inequality. Of 13 osteotomies (six femoral, seven tibial) for angular or rotational malunion, all healed following dynamic locked nailing. Eleven were considered anatomic and two had mild residual deformity. One-stage femoral lengthening was performed in 17 patients. The preferred operative technique includes a long Z-shaped osteotomy, static interlocking nailing, primary cancellous bone grafts, and one or two supplemental screws at the osteotomy site to prevent shortening following dynamization. Thirteen complications developed following one-stage lengthening of the femur, which included significant loss of length in five patients, femoral nerve palsies in four patients, three deep infections, and one nonunion. Lengthening should not exceed 4.0 cm in the femur. The recommended technique of shortening osteotomy consists of resection of a cylindric segment of bone from the distal diaphyseal metaphyseal area. Shortening should not exceed 4.5 cm in the femur or 3.0 cm in the tibia. In ten patients who were shortened, all healed, but radiologic signs of union appeared very slowly in most cases.

Testing the response of a cardiac output meter using an artificial circulatory system

The variation in the response of a cardiac output flowmeter to several variables was investigated. An artificial circulatory system was constructed to give independent control of the variables. It was found that variations in the earlobe density, the amount of dye injected and the hematocrit value have little influence on the recorded flow which does, however, depend on the shape of the dilution curve. The values given by the instrument are too low for broad curves and too high for sharp ones, with an error of up to 25%.

Closed locked intramedullary nailing. Its application to comminuted fractures of the femur

For many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescoping of the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to dynamic locking when weight-bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indications for intramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fractures complicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-two patients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that were complicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a mean time of 4.5 months for the severely comminuted fractures and seven months for the fractures that had a loss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normal motion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three after a second locked nailing and one after a third) and one had a septic non-union that eventually healed after removal of the nail and screws, débridement, and immobilization with an external fixator. Based on this experience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and early mobilization of the patient is possible.

[Radiological aspects of cerebral and spinal cysticercosis. Apropos of 2 cases]

Two cases of neurocysticercosis are reported, one cerebral and the other spinal. Results of radiologic imaging of this affection, a rare parasitosis in occidental Europe, are discussed with emphasis on computed tomography findings. In fact, when perfect conditions can be established the CT scan provides data confirming the diagnosis of cerebral cysticercosis in most cases. However, this scan is insufficient for investigation of ventricular or cisternal forms when gas or positive contrast is sometimes necessary for visualization of parasitic cysts. Radiologic diagnosis of extra- and intra-medullary forms is based an myelography with water-soluble contrast completed by a scan.