Gender disparities in patients undergoing extracorporeal cardiopulmonary resuscitation

Introduction

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (eCPR) has emerged as a treatment option for selected patients who are experiencing refractory cardiac arrest (CA). In the light of increasing availability, the analyses of outcome-relevant predisposing characteristics are of growing importance. We evaluated the prognostic influence of gender in patients presenting with out-of-hospital cardiac arrest (OHCA) treated with eCPR.

Methods

We retrospectively analysed the data of 377 consecutive patients treated for OHCA using eCPR in our cardiac arrest centre from January 2016 to December 2022. The primary outcome was defined as the survival of patients until they were discharged from the hospital, with a favourable neurological outcome [cerebral performance category (CPC) score of ≤2]. Statistical analyses were performed using baseline comparison, survival analysis, and multivariable analyses.

Results

Out of the 377 patients included in the study, 69 (21%) were female. Female patients showed a lower prevalence rate of pre-existing coronary artery disease (48% vs. 75%, p < 0.001) and cardiomyopathy (17% vs. 34%, p = 0.01) compared with the male patients, while the mean age and prevalence rate of other cardiovascular risk factors were balanced. The primary reason for CA differed significantly (female: coronary event 45%, pulmonary embolism 23%, cardiogenic shock 17%; male: coronary event 70%, primary arrhythmia 10%, cardiogenic shock 10%; p = 0.001). The prevalence rate of witnessed collapse (97% vs. 86%; p = 0.016) and performance of bystander CPR (94% vs. 85%; p = 0.065) was higher in female patients. The mean time from collapse to the initiation of eCPR did not differ between the two groups (77 ± 39 min vs. 80 ± 37 min; p = 0.61). Overall, female patients showed a higher percentage of neurologically favourable survival (23% vs. 12%; p = 0.027) despite a higher prevalence of procedure-associated bleeding complications (33% vs. 16%, p = 0.002). The multivariable analysis identified a shorter total CPR duration (p = 0.001) and performance of bystander CPR (p = 0.03) to be associated with superior neurological outcomes. The bivariate analysis showed relevant interactions between gender and body mass index (BMI).

Conclusion

Our analysis suggests a significant survival benefit for female patients who obtain eCPR, possibly driven by a higher prevalence of witnessed collapse and bystander CPR. Interestingly, the impact of patient age and BMI on neurologically favourable outcome was higher in female patients than in male patients, warranting further investigation.

Prognostic influence of mechanical cardiopulmonary resuscitation on survival in patients with out-of-hospital cardiac arrest undergoing ECPR on VA-ECMO

Introduction

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (ECPR) in selected patients after out-of-hospital cardiac arrest (OHCA) is an established method if return of spontaneous circulation cannot be achieved. Automated chest compression devices (ACCD) facilitate transportation of patients under ongoing CPR and might improve outcome. We thus sought to evaluate prognostic influence of mechanical CPR using ACCD in patients presenting with OHCA treated with ECPR including VA-ECMO.

Methods

We retrospectively analyzed data of 171 consecutive patients treated for OHCA using ECPR in our cardiac arrest center from the years 2016 to 2022. A Cox proportional hazards model was used to identify characteristics related with survival.

Results

Of the 171 analyzed patients (84% male, mean age 56 years), 12% survived the initial hospitalization with favorable neurological outcome. The primary reason for OHCA was an acute coronary event (72%) followed by primary arrhythmia (9%) and non-ischemic cardiogenic shock (6.7%). In most cases, the collapse was witnessed (83%) and bystander CPR was performed (83%). The median time from collapse to VA-ECMO was 81 min (Q1: 69 min, Q3: 98 min). No survival benefit was seen for patients resuscitated using ACCD. Patients in whom an ACCD was used presented with overall longer times from collapse to ECMO than those who were resuscitated manually [83 min (Q1: 70 min, Q3: 98 min) vs. 69 min (Q1: 57 min, Q3: 84 min), p = 0.004].

Conclusion

No overall survival benefit of the use of ACCD before ECPR is established was found, possibly due to longer overall CPR duration. This may arguably be because of the limited availability of ACCD in pre-clinical paramedic service at the time of observation. Increasing the availability of these devices might thus improve treatment of OHCA, presumably by providing efficient CPR during transportation and transfer.

[Percutaneous revascularization of multivessel coronary disease using stents - a multicenter, prospective study]

BACKGROUND AND OBJECTIVE

Symptomatic patients with multivessel coronary disease (MVD) benefit from both coronary artery bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). The >>German Angioplasty Bypass Investigation<< (GABI-I) trial randomized patients to one of these treatment strategies between 1986 and 1991. In order to evaluate the impact of current technology, in particular coronary stents, the GABI-II trial was initiated, which in 1996 and 1997 prospectively enrolled patients according to the initial GABI-I criteria.

PATIENTS AND METHODS

Into the study 136 consecutive patients (108 men, 28 women; 63 +/- 12 years) were included. Patients from GABI-I served as controls.

RESULTS

A mean of 2.1 +/- 0.5 vessels were treated per patient (vs. 1.9 +/- 0.5 vessels in the PTCA arm of GABI-I) and 63 % of the lesions were covered with stents. With respect to the primary endpoint less patients remained with a CCS class III or IV in GABI-II after 12 months (1,5 % vs. 8 % in the PTCA arm of GABI-I, p<0,01). No patient required emergency or urgent bypass operation in GABI-II (vs. 9 % in GABI-I, p < 0.01). After 12 months, 8 % of the patients were sent for bypass surgery (CABG) vs. 21 % in GABI-I (p < 0.001), and 20 % (vs. 23 % in GABI-I) of the patients underwent Re-PTCA. The percentage of patients without reinterventions was 72 % vs. 56 % in GABI-I (p < 0.01), but remained lower compared to patients randomized to CABG in GABI-I (94 %, p < 0.001).

CONCLUSION

PTCA in patients with MVD is still associated with a higher reintervention rate as compared with CABG. However, in contrast to angioplasty a decade ago, PTCA in conjunction with stents significantly lowered the need for subsequent revascularization, which was mainly driven by the reduced necessity for bypass surgery.

Membrane-covered stents: a new treatment strategy for saphenous vein graft lesions

The restenosis rate after stenting of lesions in aortocoronary venous bypass grafts still has to be considered unsatisfactorily high. We investigated a new stent design characterized by an expandable polytetrafluorethylene (PTFE) membrane in between two layers of struts. Five consecutive male patients (age 70 +/- 6 years) were followed prospectively who presented with at least two de novo lesions in different grafts 13 +/- 3 years after bypass surgery. A total of 11 lesions were treated located in grafts anastomosed to the circumflex (n = 3), to the LAD (n = 7), and to the right coronary artery (n = 1). Within the same procedure, every patient received membrane-covered stents (n = 6) and conventional stents (n = 5) in either of their lesions. All patients underwent successful interventions. The minimal luminal diameter increased from 1.0 +/- 0.5 to 2.9 +/- 0.6 mm in lesions treated by the membrane-covered stents and from 0.8 +/- 0.4 to 2.4 +/- 0.7 mm in the lesions treated by conventional stents. During follow-up, four out of five patients required angioplasty for in-stent restenosis of lesions covered by a conventional stent, whereas no patient underwent revascularization for a lesion treated by a membrane-covered device. The mean minimal luminal diameter of lesions covered by a conventional stent decreased by 42% to 1.4 +/- 0.6 mm; the mean minimal luminal diameter of the lesions treated by a stent graft declined by 9% to 2.8 +/- 0.6 mm (P < 0.05). This series of intraindividual comparisons suggests that membrane-covered stents may have the power to reduce in-stent restenosis in obstructed aortocoronary venous bypass grafts.

Static and dynamic problems in spastic cerebral palsy

1. Analysis of the static and dynamic conditions in spastic cerebral palsy leads to the conclusion that contractures of the hip, knee and ankle should be released from above downwards, and that the full benefit is obtained only when all contractures have been corrected.<br /> 2. Only when these joints are mobilized by removal of the significant contractures is the spastic patient able, despite other handicaps, to sit, stand and walk with the least hindrance and the least cosmetic fault.<br /> 3. In our Danish experience, inadequate or poor results from the orthopaedic surgery of cerebral palsy are mainly due to the fact that patients with contractures are operated on too little and too late, or not in the correct sequence.

Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis

OBJECTIVES

This study evaluated the clinical and angiographic six-month follow-up after excimer laser coronary angioplasty (ELCA) for restenosed coronary stents.

BACKGROUND

Excimer laser coronary angioplasty has recently been shown to be safe and efficient for the treatment of in-stent restenosis.

METHODS

Ninety-six consecutive patients successfully treated with ELCA within 141 stents were included in a six-month clinical and angiographic follow-up.

RESULTS

During follow-up there was one sudden death and one patient with documented myocardial infarction. Angina pectoris classified as > or = Canadian Cardiovascular Society II reoccurred in 49 patients. Follow-up angiography was obtained in 89 patients (93%) with 133 stents. Quantitative coronary angiography revealed a mean diameter stenosis of 77 +/- 10% before intervention, 41 +/- 12% after laser treatment and 11% +/- 12% after adjunctive percutaneous transluminal coronary angioplasty (p < 0.001). Six months after ELCA the mean diameter stenosis had increased to 60 +/- 26% (p < 0.001). A > or =50% diameter stenosis was present in 48 patients (54%); in 24 of these patients diameter stenosis was > or =70%. Total occlusions occurred in an additional 10 patients (11%). There was a trend toward an increased recurrent restenosis rate in patients with diabetes mellitus and long lesions or total occlusions (p = 0.059). Forty-eight patients (50%) received medical treatment after six months. Reinterventions were necessary in 30 patients (31%), and coronary artery bypass surgery was performed in 17 patients (18%). Event-free survival was 50%.

CONCLUSIONS

Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.

Membrane-covered stents for the treatment of aortocoronary vein graft disease

We report of a 78-year-old patient who underwent angioplasty for two de novo lesions in different aortocoronary venous bypass grafts. Whereas one lesion was treated by conventional stents, two adjacent lesions in a second bypass graft were covered by two newly designed stents with a polytetrafluorethylene (PTFE) membrane in between two layers of struts. The patient was first readmitted at month 5 with recurrent angina pectoris. High-grade in-stent restenosis of the lesion covered by the conventional stent was diagnosed, whereas the lesions treated by the membrane-covered stent revealed no restenosis. The patient underwent subsequent balloon angioplasty and was readmitted with unstable angina 8 months after the initial procedure. The angiogram revealed subtotal occlusion of the vein graft due to diffuse in-stent restenosis within the conventional stent. Undergoing re-PTCA, the patient received an additional membrane-covered stent placed over the proximal device. For the following 7 months, the patient stayed asymptomatic and underwent elective reangiography, which revealed a satisfying long-term result with no relevant luminal loss at the target site. This intraindividual comparison of stents in aortocoronary vein grafts suggests that PTFE membrane-covered stents might reduce restenosis as compared to conventional stents in venous bypass grafts. Furthermore, these stents potentially represent a new treatment strategy to fight in-stent restenosis in selected lesions.

Initial experience with a hydrophilic-coated guidewire for recanalization of chronic coronary occlusions

Chronic coronary occlusions are still a therapeutic challenge to the interventional cardiologist. New techniques such as laser wire have improved recanalization rates, but outcomes are still far from satisfactory. We report the results of a nonrandomized single-center investigation using a hydrophilic-coated guidewire (Terumo Crosswire). Between September 1996 and September 1998, 107 chronic occlusions in 106 patients were approached when previous attempts with conventional guidewires failed. Median occlusion duration in these cases was 4 months (range, 0.5-122); mean occlusion length was 19 +/- 11 mm (range, 5-60). Forty-five (42%) of these attempts were successful. Attempts were successful in 42% in the left anterior descending artery, in 30% in the left circumflex artery, in 48% in the right coronary artery, and in 43% in coronary artery bypass grafts. Success rates ranged from 56% for occlusions of less than 4-month duration to 18% for occlusions of more than 36-month duration. The success rate in TIMI 1-flow lesions was significantly higher than in TIMI 0 flow lesions, 85% vs. 36%. In a multivariate regression analysis, TIMI flow grade and occlusion age were independent predictors of success. There were no deaths or Q-wave myocardial infarctions; two cases of hemopericardium were treated successfully. In five cases, pericardial contrast staining due to vessel perforation occurred. Our results indicate that the Crosswire is an effective tool in the treatment of chronic coronary occlusions, even when recanalization attempts with conventional guidewires fail. Cathet. Cardiovasc. Intervent. 49:45-50, 2000.

Protection of side-branches in coronary lesions with a new stent design

Side-branches often complicate stenting of coronary lesions. We investigated a new stent, characterized by four wider cells in its center, which can be expanded up to 3.5 mm and which are meant to be placed over the ostium of a major side-branch. Forty-seven consecutive patients with lesions involving 48 side-branches received one side-branch stent each. Stent deployment was successful in all patients. Twenty-five side-branches needed additional treatment. Nineteen side-branches received a PTCA, and 6 additional side-branches were stented. Postinterventional CK-(creatine kinase) elevation was observed in 3 patients (6%). One additional patient was sent for CABG on the day of the procedure due to loss of a stent intended to be placed into the side-branch. The investigated stent proved to be a safe and effective tool to treat this complex subgroup of stenoses in the presence of favorably preserved flow in the side-branches, with a low incidence of periprocedural complications.

[Acute results of ablation of coronary in-stent restenoses with eccentric excimer laser catheters]

Laser catheters which run eccentrically on a guide wire were developed for maximization of luminal gain by excimer laser angioplasty (ELCA). We investigated the safety and efficacy of ELCA with these new catheters plus PTCA in patients with restenoses or occlusions in coronary stents. ELCA was performed in 57 patients (60 +/- 9 years) with stenoses in 75 stents (35 AVE Micro stents, 26 Palmaz-Schatz stents, 7 NIR stents, 7 other stents). In 44 patients eccentric 1.7 mm catheters and in 13 patients 2.0 mm catheters were used. The success of the intervention was analyzed by intravascular ultrasound (IVUS) in a subgroup of 7 patients treated with five 1.7 mm and two 2.0 mm catheters. The laser catheters could be advanced through the in-stent restenoses in 56 patients. A passage inhibition occurred in one patient with an inadequately expanded stent < 2.0 mm in diameter. ELCA reduced the diameter stenoses from 77 +/- 10% before intervention to 44 +/- 8% after treatment with the 1.7 mm catheter (n = 43) or to 34 +/- 9% after passages with the 2.0 mm catheter (P < 0.001). PTCA further reduced the diameter stenosis to 11 +/- 12% (P < 0.001). The IVUS analysis revealed a smooth ablation profile in all patients. In 4 patients creatine kinase elevations > or = 2 times normal value occurred. There was no evidence of a Q-wave infarction. No dissections were observed within the stents. Outside of the stents there were dissections in 5 vessels, which required the implantation of additional stents.

CONCLUSIONS

ELCA with eccentric laser catheters for treatment of in-stent restenosis is safe and effective. The incidence of complications is acceptable.

Treatment of in-stent coronary restenosis by excimer laser angioplasty

We evaluated the efficacy and safety of excimer laser angioplasty (ELCA) with adjunctive balloon angioplasty in patients with restenotic or occluded coronary stents. ELCA was performed in 70 patients (60 +/- 9 years), who had previously been treated with Micro Stents (n = 65), Palmaz-Schatz (n = 38), Wiktor, NIR, Freedom, and Multi-Link stents (n = 1 each). Restenosis (> or =50% diameter stenosis) was documented in 90 stents, another 17 stents were occluded. Laser energy was delivered to the lesions with catheters 1.4, 1.7 (eccentric), and 2.0 mm in diameter. Procedural success was controlled by intravascular ultrasound in a subgroup. Laser catheters crossed all restenotic or occluded stents and decreased diameter stenosis from 80 +/- 13% to 44 +/- 11% (p <0.001). Adjunctive balloon angioplasty further reduced diameter stenosis to 13 +/- 13% (p <0.001). In 13 patients with 21 stents, serial intravascular ultrasound imaging revealed a reduction of plaque area within the stent by 34 +/- 22% (from 4.2 +/- 1.8 mm2 to 2.7 +/- 1.1 mm2) after ELCA and a reduction by 65 +/- 16% (to 1.5 +/- 0.7 mm2) after balloon angioplasty (p <0.01). There were 4 patients with an increase of creatine kinase levels, 8 patients with major dissections (in 7 patients they were related to adjunctive balloon angioplasty), 1 patient with distal embolization, 2 with minor perforations, and 1 patient with stent dislocation. Reintervention during hospitalization was necessary in 3 patients. ELCA is an efficient and safe technique to debulk tissue in restenotic lesions and total occlusions within stents. The incidence of procedure related complications was low.

Intravascular therapeutic ultrasound thrombolysis in acute myocardial infarctions

Catheter-delivered, therapeutic ultrasound was shown to effectively dissolve thrombus in vitro and in vivo. This first study in 14 patients with acute myocardial infarctions demonstrates that it is a safe and effective treatment alternative that deserves further clinical evaluation.

Models of metabolism in Rhizopus oryzae

A flux analysis of glucose metabolism in Rhizopus oryzae was achieved using [14C]-labeled glucose and acetate. The rates of glucose utilization and end product production were estimated, and metabolite pool sizes and specific radioactivities were determined. These data were analysed using a specific radioactivity curve-matching program called TFLUX. The analysis is consistent with the existence of separate mitochondrial and cytosolic pools of pyruvate, malate and fumarate.

Angiographic follow-up results of a randomized study on angioplasty versus bypass surgery (GABI trial). GABI Study Group

Although several randomized trials have been performed to compare the outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with multivessel disease, there is little data available on angiographic follow-up results. The present substudy of the German angioplasty versus bypass surgery investigation (GABI Trial) compares the angiographic revascularization status in these two cases 6 months after treatment. Follow-up angiograms were available in 102 CABG patients and 117 PTCA patients. Although the protocol excluded patients with total occlusion, on follow-up 6 months after treatment we found total occlusion of 94 native arteries (36.9%) in the CABG group and of six arteries (2.5%) in the PTCA group (P < 0.001). The rate of occluded native vessels did not correlate significantly with the severity of the lesion before bypass surgery. In the CABG group 31 bypass grafts (12.2%) were found to be occluded at the 6 month follow-up examination (29/225 vein grafts [12.9%]; 2/30 mammary artery grafts [6.7%]). The main pathway, defined as the nutrient vessel (native vessel or bypass graft) providing the least resistance to blood flow, was narrowed by a lesion with a diameter stenosis of 70-100% for 36 target lesions (14.1%) in the CABG group and 39 target lesions (16.2%) in the PTCA group (P, ns). However, the prevalence of moderately severe lesions with a 50-69% diameter reduction of the main pathway was significantly greater in the PTCA group (44 lesions, 18.3%) than in the CABG group (19 lesions, 7.5%, P < 0.01). Thus, 6 months after randomized allocation to PTCA or CABG, we found comparable rates of high-grade lesions in the main pathways of both treatment groups. Whereas moderately severe lesions of the main pathway were predominantly seen in the PTCA group, there was marked disease progression to total occlusion in the native circulation after bypass grafting.

[Preliminary clinical results with intracoronary ultrasound angioplasty]

BASIS AND AIM OF STUDY: Low-frequency, high-intensity ultrasound has been shown, both in vivo and in vitro, selectively to remove arteriosclerotic plaques and thrombi. This study was undertaken to investigate the safety and effectiveness of intracoronary ultrasound angioplasty.

PATIENTS AND METHODS

Ultrasound coronary angioplasty (UCA) with highly flexible ultrasound catheters (1.2 mm or 1.7 mm probe tip) was performed in 50 patients (36 men, 14 women; mean age 64.7 [33-79] years) with coronary heart disease involving one (n = 26 or several (n = 24) vessels. Indications for treatment were exercise-induced (n = 35) or unstable (n = 14) angina or acute myocardial infarction (n = 11). Treated lesions were in the anterior interventricular branch (n = 25), circumflex branch of the left coronary artery (n = 3) and right coronary artery (n = 22). 19 vessels were occluded, 24 lesions were partially thrombosed, 19 were calcified. 22 stenoses were longer than 20 mm. According to AHA/ACC criteria, 10 type A, 17 type B1, 6 type B2 and 17 type C lesions were treated.

RESULTS

Total ultrasound time was 336 +/- 308 s; mean passing time through the stenosis was 233 +/- 289 (10-556) s. 17 of 19 occlusions were recanalised after 285 +/- 224 s. Percutaneous transluminal angioplasty (PTCA) was subsequently performed in 49 patients. The mean stenosis grade was reduced by UCA from initially 82 +/- 3 to 64 +/- 2% and by subsequent PTCA to 38 +/- 1%. Average flow grade rose from 1.5 to 1.9 after UCA and to 2.8 after PTCA. No vasospasm, atrioventricular block or perforation was caused by UCA. Angiography demonstrated dissection after PTCA in seven patients, treated in two with a stent. Both UCA and PTCA failed to achieve recanalization in one patient with a thrombotic occluded coronary artery after acute myocardial infarction. In all other patients there were no complications.

CONCLUSION

The results show UCA to be a safe method for removing high-degree coronary artery stenosis or recanalize thrombotic occlusions.

Foot deformity and the length of the triceps surae in Danish children between 3 and 17 years old

We report the results of examination in 1991 of 759 children and adolescents between 3 and 17 years old, comprising 98% of pupils in different age groups from seven schools and ten kindergartens in Funen (Denmark). The triceps surae was considered to be short if the foot held with the talus in neutral position relative to the calcaneus could only be dorsiflexed to a right angle. The proportion of children with shortening of one or both triceps surae rose from 24% to 62% between the ages of 3 and 17 years with no difference between the sexes. In 13% of adolescents, one or both feet failed to reach a right angle by > or = 5 degrees. Footprints made in 1,520 feet showed that the proportion of feet with a high arch increased from 2% to 7%; there was a smaller number of such feet with a short triceps surae than in feet with a normal arch. The proportion of feet with a flat arch declined from 42% to 6% in spite of a strong relationship with a short triceps surae. In the oldest age group, all the flat feet had a short triceps surae, which is probably one of the reasons for the persistence of the deformity.

A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. German Angioplasty Bypass Surgery Investigation (GABI)

BACKGROUND

The standard treatment for patients with symptomatic multivessel coronary artery disease is coronary-artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) is widely used as an alternative approach to revascularization, but a systematic comparison of the two procedures is needed. We compared the outcomes in patients one year after complete revascularization with CABG or PTCA.

METHODS

A total of 8981 patients with multivessel coronary disease were screened at eight clinical sites, and 359 patients were randomly assigned to undergo CABG (177 patients) or PTCA (182 patients). Enrollment required that complete revascularization of at least two major vessels supplying different myocardial regions be deemed clinically necessary and technically feasible.

RESULTS

Among the patients in the CABG group, an average of 2.2 +/- 0.6 vessels were grafted, and among those in the PTCA group, 1.9 +/- 0.5 vessels were dilated. After CABG, hospitalization was longer (median, 19, as compared with 5 days for PTCA), and Q-wave myocardial infarction in relation to the procedure was more frequent (8.1 percent, as compared with 2.3 percent after PTCA; P = 0.022), whereas in-hospital mortality did not differ significantly between the two groups (2.5 percent in the CABG group and 1.1 percent in the PTCA group). At discharge 93 percent of the patients in the CABG group were free of angina, as compared with 82 percent of those in the PTCA group (P = 0.005). During the first year of follow-up, further interventions were necessary in 44 percent of the patients in the PTCA group (repeated PTCA in 23 percent, CABG in 18 percent, and both in 3 percent) but in only 6 percent of the patients in the CABG group (repeated CABG in 1 percent and PTCA in 5 percent; P < 0.001). Seventy-four percent of the patients in the CABG group and 71 percent of those in the PTCA group were free of angina one year after treatment. Exercise capacity improved similarly in both groups. However, 22 percent of the CABG group, as compared with only 12 percent of the PTCA group, did not require antianginal medication (P = 0.041).

CONCLUSIONS

In selected patients with multivessel coronary disease, PTCA and CABG as initial treatments resulted in equivalent improvement in angina after one year. However, in order to achieve similar clinical outcomes, the patients treated with PTCA were more likely to require further interventions and antianginal drugs, whereas the patients treated with CABG were more likely to sustain an acute myocardial infarction at the time of the procedure.

[Incidence of complaints about heel-, knee- and back-related discomfort among Danish children, possible relation to short muscles]

Four hundred and fifty-nine children and adolescents from third, sixth and ninth classes in seven schools on Funen were questioned in 1991. Seven percent had complaints from back and knee, and 3% from the heel. When the hamstrings were so short that one knee had an extension deficit gently measured to more than 40 degrees, when the hip was flexed 90 degrees, the incidence of back pain rose significantly to 15%. Furthermore 18% had complaints from the knee and 35% from the heel when the passive range of motion of the foot was less than 0 degrees of dorsiflexion measured with the knee extended. As 75% of the boys and 35% of the girls over age ten have short hamstrings and 13% of both sexes have short Achilles tendons, it is recommended that school children be involved in a daily stretching programme in order to diminish the complaints from the extremities often seen in this group.

[Foot deformities and relation to the length of leg muscles in Danish children aged 3-17 years]

Seven hundred and sixty-nine children and adolescents from three to seventeen years of age, being 98% of the pupils in different classes in seven schools and ten kindergartens on Funen, Denmark, were examined in 1991. The Triceps Surae muscle was found to be too short, if the corrected foot can only be pressed slowly to the right angle. The 1520 footprints showed an increase in the number of highly-arched feet through the age groups from 2.3% to 7.3% and a decrease in flat-footedness from 41.8% to 5.7%. In the two oldest age groups, 39% of those with a high arch, 56% of those with a normal arch and 77% of those with flat feet had short calf muscles. We therefore conclude, that it is necessary that a few minutes be spent daily in Danish kindergartens and schools on stretching the triceps surae.

[Incidence of short hamstrings and leg muscles at ages 3-17 years]

In 1991, 769 children and adolescents, 98% of the pupils in the various age groups in seven schools and ten kindergartens on Funen, were examined. Seventy-five percent of the boys and 35% of the girls over the age of ten proved to have such short hamstrings that one knee had a extension deficit without violence of > or = 40 degrees when the hip was flexed 90 degrees. More than 10% of the boys over the age of ten had an extension deficit of > or = 60 degrees. Forty-five children had a difference > or = 15 degrees between the two legs. The triceps surae muscles are too short if the corrected foot can only be pressed slowly to the right angle. This was found to be the case for 25-64% of the children from the age of three to 17. Therefore, we must conclude that it is necessary to allow time in kindergarten and school for the children to stretch their muscles a few minutes daily.

Involvement of interleukin 1 and interleukin 1 antagonist in pancreatic beta-cell destruction in insulin-dependent diabetes mellitus

In this review we propose that the balance between the action of interleukin 1 (IL-1) and its natural antagonist IL-1ra on the level of the insulin-producing pancreatic beta-cell may play a decisive role in the pathogenesis of insulin-dependent diabetes mellitus (IDDM). We argue that IL-1 potentiated by other cytokines (tumor necrosis factor alpha, interferon gamma) is an important effector molecule involved in both early and late events in the immune-mediated process that leads to beta-cell destruction and IDDM. We also point out that surprisingly high molar excesses of IL-1ra over IL-1 are necessary to block the action of IL-1 on islet beta-cells compared to islet alpha-cells in vitro and in animals. We suggest that the selectivity of beta-cell destruction in IDDM may be conferred on several levels: (1) homing of beta-cell antigen specific T cells, (2) targeted delivery of cytokines by lymphocytic and monocytic cells beta-cells, (3) high molar excesses of IL-1ra over IL-1 needed to prevent IL-1 mediated beta-cell toxicity, (4) increased beta-cell sensitivity to free nitric oxide and oxygen radical formation induced by IL-1 and (5) inadequate oxidative stress response by beta-cells to cytokines. Further studies are needed to establish the in vivo role of an imbalance between the amounts of IL-1 and IL-1ra produced relative to their action in the pathogenesis of IDDM.

Repetitive in vivo treatment with human recombinant interleukin-1 beta modifies beta-cell function in normal rats

It is unknown whether interleukin-1 exerts a bimodal effect on Beta-cell function in vivo, and whether interleukin-1 has a diabetogenic action in normal animals. We therefore studied: (a) acute effects 2 h after an intraperitoneal bolus injection of 4 micrograms of recombinant human interleukin-1 beta per kg body weight on blood glucose, plasma levels of insulin, glucagon and corticosterone in Wistar Kyoto rats, either untreated or pre-treated with 4 micrograms/kg of interleukin-1 daily for 3 or 5 days; (b) the cumulative effects of repetitive intraperitoneal injections of 4 micrograms/kg interleukin-1 on blood glucose, glucose tolerance, plasma levels of insulin, glucagon and corticosterone, pancreatic insulin content and pancreatic ultrastructure; and (c) blood glucose and plasma concentrations of insulin, glucagon and corticosterone 10 h after the last of five intraperitoneal injections of interleukin-1, at which time point the inhibitory effect of short-term interleukin-1 exposure on insulin secretion reaches its nadir in vitro. A single injection of 4 micrograms/kg of interleukin-1 caused a slight, but significant lowering of blood glucose 2 h after interleukin-1 injection with no significant changes in plasma insulin and in spite of increases in plasma glucagon and corticosterone. A lowering of blood glucose 2 h after interleukin-1 administration was reproduced with 40, but not 0.4 micrograms/kg of interleukin-1, and was also seen in interleukin-1 pre-treated rats. Two hours after the fifth injection of interleukin-1, intraperitoneal glucose tolerance was impaired with elevated plasma insulin and corticosterone levels and increased pancreatic insulin content, indicating a state of insulin resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

The pharmacokinetics, distribution and degradation of human recombinant interleukin 1 beta in normal rats

Based upon in vivo rat experiments it was recently suggested that interleukin 1 in the circulation may be implicated in the initial events of beta-cell destruction leading to insulin-dependent diabetes mellitus (IDDM) in humans. The aim of the present study was to estimate half-lives of distribution (T1/2 alpha) and elimination phases (T1/2 beta) of human recombinant interleukin 1 beta (rIL-1 beta), and its tissue distribution and cellular localization by means of mono-labelled, biologically active 125I-rIL-1 beta. After intravenous (i.v.) injection, 125I-rIL-1 beta was eliminated from the circulation with a T1/2 alpha of 2.9 min and a T1/2 beta of 41.1 min. The central and peripheral volume of distribution was 20.7 and 19.1 ml/rat, respectively, and the metabolic clearance rate was 16.9 ml/min/kg. The kidney and liver showed the highest accumulation of tracer, and autoradiography demonstrated that 125I-rIL-1 beta was localized to the proximal tubules in the kidney and to the hepatocytes in the liver. Furthermore, grains were localized to the islets of Langerhans in the pancreas. Tracer-bound proteins corresponding to intact 125I-rIL-1 beta were found in the circulation after i.v., intraperitoneal (i.p.) and subcutaneous (s.c.) injections, as demonstrated by high performance size exclusion chromatography, trichloracetic acid precipitation and SDS-PAGE until 5 h after tracer injection. Pre-treatment with 'cold' rIL-1 beta enhanced degradation of a subsequent injection of tracer. The route of administration was of importance for the biological effects of rIL-1 beta, as demonstrated by a reduced food intake, increased rectal temperature and blood glucose after s.c. injection of rIL-1 beta compared with i.p. The present demonstration of intact rIL-1 beta in the circulation and the islets of Langerhans supports the hypothesis that systemic IL-1 beta may be involved in the initial beta-cell destruction leading to IDDM in humans.

[Improvement of chronic regionally impaired myocardial function immediately after coronary angioplasty]

The effect of PTCA on chronically impaired, regional wall motion was studied in 40 patients with stable angina and stenoses in the left anterior descending artery. Left-ventricular angiograms were obtained before, 15 min after PTCA and, additionally, in eight patients 15 +/- 5 weeks after PTCA. Left-ventricular ejection fraction and regional myocardial function were assessed by the centerline method. Patients with no (n = 18) or non-Q-wave (n = 12) infarction were compared to patients with Q-wave infarction (n = 10). After PTCA, ejection fraction increased from 54 +/- 8% to 59 +/- 8% (p less than 0.05) and regional function improved significantly (maximal standard deviation before PTCA: 2.8 +/- 0.8; after PTCA: 1.9 +/- 0.9- segments below the first standard deviation before PTCA: 31 +/- 16; after PTCA: 19 +/- 17). The improvements were found in patients with no or non-Q-wave infarction. The benefit on regional function was unchanged at follow-up.

CONCLUSIONS

PTCA reduced chronic regional myocardial dysfunction in 78% of the patients with stable angina within 15 min. Reversible myocardial dysfunction is most likely related to hibernating myocardium.

Repeated intraperitoneal injections of interleukin 1 beta induce glucose intolerance in normal rats

Previous in vitro findings suggest the involvement of interleukin 1 (IL-1) in the pathogenesis of insulin-dependent diabetes mellitus. The aims of the present study were to investigate the effects of single or repeated ip injections of recombinant IL-1 beta on blood glucose and glucose tolerance in vivo. Normal Wistar Kyoto rats were injected ip with a single injection of 4 micrograms/kg of the mature form of recombinant IL-1 beta (amino acids 117-269) or once daily on 5 consecutive days. Control rats were given vehicle and were fed ad libitum or pair-fed together with the rIL-1 beta treated rats. An ip glucose tolerance test (0.2 g D-glucose/100 g) was performed 2 h after injection of rIL-1 beta. A single injection of rIL-1 beta caused a mild depression in blood glucose and an improved glucose tolerance. Multiple injections of rIL-1 beta induced a diminished weight gain, a 24-28% reduction in food intake, a lasting mild depression of blood glucose (7 days) and a transiently impaired glucose tolerance on day 5. We conclude that systemic IL-1 should be considered an important regulator of glucose homeostasis in vivo.

Nonvalvular atrial fibrillation associated with cardioembolic stroke: the role of hypertensive heart disease

Epidemiologists have not identified high risk groups nor the entire spectrum of heart disease, especially the subclinical forms underlying nonvalvular atrial fibrillation (NVAF) predisposing to cardioembolic (CE) stroke. We analysed 36 cases of 'isolated' NVAF among 106 consecutive cases of CE stroke after excluding cases of AF associated with valvular disease, myocardial infarcts, ischaemic and other cardio-myopathies (34 cases). This revealed echocardiographic left ventricular hypertrophy (LV mass index 136 +/- 25 g, vs normal 68 +/- 12 g p less than 0.001), enlarged left atria (left atrial area 27.4 +/- 3.6 cm2 vs normal 14.3+/- 1.6 cm2 p less than 0.001), normal systolic function and formed the largest group associated with CE stroke (34%), mean age 72.6 years--Study Group D. Eighty nine per cent had known or undetected hypertension compared to 60% in matched controls (x2 = 8.3 df = 1 p less than 0.01), and hypertension remained the predominant risk factor for left ventricular hypertrophy (LVH). Although all had echocardiographic LVH, 60% had neither electrocardiographic LVH nor cardiomegaly on chest X-ray. Hence usual epidemiologic methods may fail to detect these cases. Hypertensive heart disease is known to predispose to left atrial enlargement and AF. Progressive atrial enlargement is associated with increasing risk of embolic stroke. We conclude that NVAF associated with hypertensive heart disease forms a major component of the spectrum of heart disease associated with NVAF predisposing to CE stroke. Detection and treatment of hypertension to prevent or reverse LVH and atrial enlargement should be an important preventive measure.

Functional changes in the antagonists after lengthening the agonists in cerebral palsy. II. Quadriceps strength before and after distal hamstring lengthening

In a recent study, 38 patients with spastic cerebral palsy (median age, 5.6 years) were examined before and at a median 13 months after distal lengthening of the hamstrings. Four weeks after operation, the strength of the quadriceps was reduced by a median value of 70%. Seven months after operation, the strength had been regained; by 13 months after operation, it had increased by a median value of 22%. In 20 cases, strength had increased by more than 50%. The present study confirms the theory that quadriceps function is strengthened when the antagonist function is weakened. The study also explains (1) why it often takes six months for gait to become better than before operation and (2) why spasticity of the rectus often increases after the hamstrings are lengthened.

Functional changes in the antagonists after lengthening the agonists in cerebral palsy. I. Triceps surae lengthening

In a recent study, children with spastic cerebral palsy (median age, five years) were examined before and up to a median of 14 months after 52 operations involving elongation of the tendo Achillis or aponeurotomy of the gastrocnemius. On removal of the cast four weeks postoperatively, strength in the dorsiflexors had increased by more than 50%, as evaluated by the ability to raise a weight from a scale. Postoperative function was correlated with preoperative function. Strength had increased more than 200% by 14 months postoperatively, with no instance of excessive lengthening of the triceps. In 13 cases, the dorsiflexors had been without function preoperatively. Two of those cases again lost the dorsiflexor function achieved postoperatively, when dynamic shortening recurred after one year. The study thus confirms the view that antagonist function improves when spasticity in the agonist is reduced by tendon lengthening.

Intra-peritoneal administration of interleukin-1 beta induces impaired insulin release from the perfused rat pancreas

Previous studies have demonstrated a stimulatory effect of interleukin-1 beta (IL-1 beta) on insulin and glucagon release from the perfused rat pancreas, accompanied by selective lysis of 20% of beta-cells as assessed by electronmicroscopy. However, we have not observed an inhibitory action of IL-1 beta on insulin release from the perfused pancreas as shown for isolated islets. To test whether periodical exposure of the endocrine pancreas to circulating IL-1 beta in vivo affects insulin release from the intact perfused pancreas, rats were treated with daily intraperitoneal injections of 4 micrograms IL-1 beta/kg or saline for 5 days. On day 5 the pancreata were isolated 2 h after the last injection and perfused from 0 to 72 min with 11 mmol/l D-glucose and from 72 to 84 min with 20 mmol/l D-glucose. Saline or IL-1 beta was added from 12 to 72 min. In pancreata from animals pre-treated with IL-1 beta glucose-stimulated as well as IL-1 beta potentiated glucose-stimulated insulin release was almost completely abolished. Furthermore, a decline in insulin release was observed at 11 mmol/l D-glucose, in contrast to an increase in insulin release in controls. The total extractable insulin content in pancreata from IL-1 beta pre-treated rats was higher than in pancreata from saline-treated controls. In contrast to the inhibitory effect of in vivo administration of IL-1 beta on beta-cell function glucagon secretion was stimulated. These observations suggest that circulating IL-1 beta is an important modulator of alpha- and beta-cell secretory function in vivo and that IL-1 beta should be considered a contributory pathogenetic factor in the development of insulin-dependent (type 1) diabetes mellitus.

Lack of insulinotropic effect of endogenous and exogenous cholecystokinin in man

Intraduodenal phenylalanine administration (333 mg/min over 60 min) released endogenous cholecystokinin in healthy young subjects as demonstrated radioimmunologically and by intraduodenal bilirubin and pancreatic enzyme output. Concomitantly, there was only a small increase over basal in circulating immunoreactive-insulin and immunoreactive-C-peptide concentrations. In healthy volunteers intraduodenal infusions of saline (10 ml/min), glucose (333 mg/min) or phenylalanine (333 mg/min) were performed for 60 min when plasma glucose was clamped at approximately 8 mmol/l. Phenylalanine enhanced immunoreactive-insulin and immunoreactive-C-peptide responses three-fold more than did the same amount of glucose. Immuno-reactive gastric inhibitory polypeptide responses were small and not different after glucose and phenylalanine administration. Immunoreactive cholecystokinin was significantly stimulated to 9.4 +/- 1.4 pmol/l only by intraduodenal phenylalanine. Plasma phenylalanine concentrations increased into the supraphysiological range (approximately 1.5 mmol/l). Intravenous infusions of phenylalanine achieving plasma concentrations of 1.2 mmol/l stimulated insulin secretion at elevated plasma glucose concentrations (approximately 8 mmol/l clamp experiments), but had no effect at basal plasma glucose concentrations. A small increase in cholecystokinin also was observed. Intravenous infusions of synthetic sulphated cholecystokinin-8 leading to plasma concentrations in the upper postprandial range (8-12 pmol/l) did not augment the immunoreactive-insulin or immunoreactive-C-peptide levels during hyperglycaemic clamp experiments, in the absence or presence of elevated plasma phenylalanine concentrations. It is concluded that the augmentation of the glucose-induced insulin release by intraduodenal administration of phenylalanine cannot be related to cholecystokinin release, but rather is explained by the combined effects of elevated glucose and phenylalanine concentrations. In man, cholecystokinin does not augment insulin secretion caused by moderate hyperglycaemia, elevations of phenylalanine concentrations, or combinations thereof.

Incidence of full containment of the femoral head after Legg-Calvé-Perthes disease and in the "normal" hip

Forty-eight children with unilateral Legg-Calvé-Perthes disease were studied to determine the extent of femoral head containment present after treatment. Only 0-4% of the hips treated with bed rest and 10-35% of the contralateral hips were fully contained. The criterion of full containment for a good result is, therefore, not valid.

Adductor transfer versus tenotomy for stability of the hip in spastic cerebral palsy

Two groups of children with cerebral palsy are compared with respect to the migration of the hip before and after 36 adductor transfers and 29 adductor tenotomies. The results in the two series are positive, with no significant difference (4 and 7%/year, respectively). Adductor transfer is a more stressful intervention for the child, with no proven advantage as yet. Therefore, we have for the time being withdrawn this procedure in favor of adductor tenotomy.

Containment of the femoral head in Legg-Calvé-Perthes' disease and its prognostic significance

The treatment of LCPD employs to an increasing degree the containment principle, in the form of femoral osteotomy, based on the hypothesis that the factor decisive for the prognosis is centralization of the femoral head, and not relief of weight-bearing by the hip. A follow-up of 48 unilateral LCPD hips treated by strict bed-rest showed a poor correlation (best value r=-0.385) between the degree of lateralization of the femoral head (the migration percentage) during the course of the disease and the spherical quotient at follow-up 12.6 years after the onset of the disease. The results reported, such as shortening of the fragmentation phase and a not unequivocally good outcome of intertrochanteric femoral osteotomy in hips "at risk", may therefore not be due to the containment principle, but perhaps to an improved venous drainage from the femoral head.