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A 26-year-old woman, on bedrest since the 6th week of pregnancy because of threatened abortion, developed thrombosis in the left iliac, superficial femoral and common femoral veins with small pulmonary emboli in the 11th week. Inhibitor deficiency was excluded. The thrombosis was only partially recanalized by unfractionated heparin at therapeutic dosage (38,400 IU per 24 h). As thrombolysis treatment and oral anticoagulation were contraindicated because of the threatened abortion, coagulation with low molecular weight heparin (LMWH) was started in the 18th week (5000 anti-Xa units daily subcutaneously). Maximal anti-Xa activity in plasma never exceeded 0.3 U/ml and there were no complications. The patient was delivered of a healthy girl (2,660 g, 48 cm) by caesarean section in the 37th week. Immediately post-partum LMWH was demonstrated with an anti-Xa activity of 0.3 U/ml in maternal blood, but none in simultaneously obtained cord venous blood. This case suggests that treatment of phlebothrombosis with LMWH is a reasonable measure even during pregnancy.

Zur Konstruktion des Mainz-Pouch-I werden zwischen 24 und 36 cm des terminalen Ileums sowie ca. 12 cm Colon ascendens inkl. der Ileozökalklappe verwendet. Hierdurch entfällt ein Teil der Resorptionsfläche für Vitamine, Gallensäuren und Spurenlemente. Bei 137 Patienten mit einem Mainz-Pouch-I erfolgte die Bestimmung der Gallensäuren, der fett- und wasserlöslichen Vitamine (A, D, E, K, B1, B2, B6, B12), der Folsäure, des Ammoniaks und des Base excess, der Spurenelemente (Zink, Kupfer, Eisen), des Ferritins sowie eines Differentialblutbildes. Das Vitamin B12 und die Folsäure wurde zusätzlich intrakorpuskulär bestimmt. Kinder und Erwachsene wurden unterschieden und die Patienten in 3 Gruppen eingeteilt (0

30 Patienten einer internistischen Intensivstation mit dem Krankheitsbild einer Sepsis und einer beginnenden Verbrauchskoagulopathie wurden uber 7 Tage mit dem niedermolekularen Heparin Fragmin behandelt: 15 Patienten erhielten nach randomisierter Gruppenzuteilung niedermolekulares Heparin in einer Dosis von 1,5–5 E pro Kilogramm Korpergewicht/h (Low dose-Gruppe). 15 Patienten der High dose-Gruppe wurden 8–15 E niedermolekularen Heparins pro Kilogramm Korpergewicht/h infundiert. Ein Vergleich der beiden Dosierungsschemata wurde anhand verschiedener Laborparameter durchgefuhrt, wobei besonders das Prothrombinfragment 1 + 2, das D-Dimer und der Thrombin-Antithrombin III-Komplex berucksichtigt wurden. Bei allen Patienten, die in die Studie aufgenommen wurden, zeigten die drei molekularen Marker bei Therapiebeginn eine Aktivierung des Gerinnung- und Fibrinolysesystems an. Keine Gruppenunterschiede waren zu erheben fur die Indikatoren einer Entzundungsreaktion wie Temperatur, Leukozyten-Zahlen, CRP und Elastase. Auch hinsichtlich der (bei allen Patienten eingeschrankten) Nieren- oder Leberfunktion waren die beiden Gruppen gleich. In der High dose-Gruppe stellte sich ein schnellerer und starkerer Konzentrationsabfall von primar erhohtem Prothrombinfragment 1 + 2, D-Dimer und Thrombin-Antithrombin III ein. Blutungskomplikationen beobachteten wir in keinem Fall. Nach unseren Ergebnissen ist insbesondere die hochdosierte Therapie mit niedermolekularem Heparin geeignet, die im Rahmen einer Sepsis aktivierte Gerinnung zu inhibieren, ohne Blutungskomplikationen herbeizufuhren.

In 96 patients (ductal pancreatic carcinoma, n = 34; periampullary carcinoma, n = 43; chronic pancreatitis, n = 19) the role of CA 19-9 in the diagnosis of lesions of the head of the pancreas were evaluated. The sensitivity for ductal pancreatic carcinoma was 73.3%, for periampullary carcinoma 48.8%, and specificity was 63.2%. Carcinoembryonic antigen was elevated only in every fifth patient. Even when combining the two tumor markers no increase in sensitivity could be observed. The low specificity of 63%, which decreased to 33% in the case of obstructive jaundice, does not allow adequate preoperative differentiation between cancer patients and those with chronic pancreatitis. In cases of postoperatively elevated CA 19-9 level the prognosis is worse than in patients with normal tumor markers.

Excessive postprandial triglyceride (TG) responses despite normal fasting TG levels have been described in single cases within small groups of healthy subjects and in patients with obesity or precocious atherosclerosis, known to be associated with high insulin fasting levels. To clarify this association, fasting and postprandial TG and insulin levels were studied in 113 healthy young (25.7 +/- 2.6 years), normal weight (body mass index 20.8 +/- 2.3 kg/m2) male subjects who were selected from among 117 subjects on the basis of TG fasting levels200 mg/dl. After a 12-hour fast a standardized liquid lipid load was administered containing 58 g mainly saturated fat and 1,017 kcal energy. Both fasting TG values and postprandial TG peak values showed bimodal frequency distributions. Statistical analysis of fasting TG discriminated two groups: a low fasting TG group with normally distributed values150 mg/dl (mean +/- SEM: 79.5 +/- 2.7 mg/dl; n = 104) and a high fasting TG group150 mg/dl (194.5 +/- 7.2 mg/dl; n = 13). Likewise, two groups could be differentiated according to their maximal postprandial TG response (TG max) to the lipid load: (1) normal responders with TG max260 mg/dl (mean +/- SEM: 123 +/- 4.8 mg/dl; n = 96) and (2) high responders with TG max260 mg/dl (272.5 +/- 20.5 mg/dl; n = 17). Fasting TG and TG max were highly correlated (r = 0.745; p0.0001). However, 9 of 17 (53%) high responders had fasting TG150 mg/dl, which means that the prediction of high response is only 47.0% based on fasting TG values. Fasting insulin levels were significantly higher in high responders than in normal responders, whereas they did not differ between the low and high fasting TG group. In conclusion, the bimodal frequency distribution of TG max after a lipid load permitted the differentiation of two groups, normal responders and high responders, with higher fasting insulin levels, which might indicate a link to the metabolic syndrome.

A test kit (Iso-ALP, Boehringer Mannheim) for measuring human bone alkaline phosphatase activity in serum or plasma was evaluated in five laboratories in three countries. The assay is based on the principle described by Rosalki and Foo (Clin Chem 1984;30:1182-6) and uses wheat germ lectin to precipitate bone alkaline phosphatase. Residual ALP in the supernate in comparison with total ALP is used to quantify the bone fraction. The imprecision of residual ALP measurement was low (median between-run CV 4.9%) and comparable with that of total ALP. Linearity of precipitation was demonstrable up to a bone ALP activity (diethanolamine buffer 37 degrees C) of 2000 U/L, though a matrix effect was observed for dilutions of high-activity sera in saline or bovine serum albumin. For assaying patients' samples, different batches of lectin demonstrated excellent comparability. Taking electrophoresis as a basis for standardization, we determined that the lectin precipitated approximately 90% of bone ALP, but < 5% of nonbone ALP. From this we derived serum/plasma upper reference limits for bone ALP activity in adults and children.

In 13 healthy, male nonsmokers (mean age: 25.7 +/- 2.4 years) with normal fasting triglycerides we investigated postprandial changes of triglycerides in several lipoprotein fractions. After a 12-hour overnight fast they ingested a standardized lipid load (1,017 kcal) including 30,000 IU retinyl palmitate. Postprandially, total triglycerides increased significantly (p0.001) to a peak value of 221 +/- 81 mg/dl at 5 h. Two subjects had an exceptionally strong triglyceride response (peak values: 363 and 390 mg/dl). They had the highest levels of retinyl palmitate in the chylomicron and the nonchylomicron fraction, and one of them showed elevated intermediate-density lipoprotein values throughout the test period. In addition, they showed an altered early and an increased late postprandial insulin response. Thus, our data provide evidence that an exaggerated postprandial triglyceride response may point to an increased atherogenic risk even in healthy subjects with normal fasting triglycerides.

The analytical performance of the selective, automatic multianalyser Olympus AU 5031 was evaluated over four months and assessed for practicability for another eight months. The evaluation followed the ECCLS guidelines. Twenty routine parameters were measured. In addition, sodium and potassium were determined on an attached flame photometric unit. Both the agreement between the eights photometers per unit and the temperature behaviour in the cuvettes was satisfactory. The imprecisions were very good. The within-run imprecision was below 1.5% for the majority of the parameters. The imprecision between days was below 5%, with the exception of creatine phosphokinase (7.4%). Glutamate dehydrogenase gave an imprecision of between 4.0% and 15.9%, which, however, is more likely due to the low activities measured rather than the fault of analyser. The recovery of the assigned values in 12 control sera was between 95% and 105% for 14 tests. Three of the remaining eight tests yielded recoveries with deviations between 10% and 18% (alanine aminotransferase, aspartate aminotransferase and bilirubin). No drift effects were observed and neither a sample carry-over nor a reagent carry-over were detected. Most tests were linear over a very wide range. Only afew tests (mainly lipase and glutamate dehydrogenase) required measurement repetitions with diluted samples. The correlation with routine instruments and tests was close. However, corrections were necessary for 14 of the 22 tests. This was not due to the performance of the analyser but, rather, to the different methodologies of compared tests, or different working temperatures on the comparison instruments, or a lack of accuracy for some of the AU tests.

Purpose Leaders of academic medical centers (AMCs) are challenged to ensure consistent high performance in quality and safety across all clinical services. The authors sought to identify organizational factors associated with AMCs that stood out from their peers in a composite scoring system for quality and safety derived from patient-level data. Method A scoring method using measures of safety, mortality, clinical effectiveness, and equity of care was applied to discharge abstract data from 79 AMCs for 2003–2004. Six institutions (three top and three average performers) were selected for site visits; the performance status of the six institutions was withheld from the site visit team. Through interviews and document review, the team sought to identify factors that were associated with the performance status of the institution. Results The scoring system discriminated performance among the 79 AMCs in a clinically meaningful way. For example, the transition of a typical 500-bed hospital from average to top levels of performance could result in 150 fewer deaths per year. Abstraction of key findings from the interview notes revealed distinctive themes in the top versus average performers. Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration. Conclusions Distinctive leadership behaviors and organizational practices are associated with measurable differences in patientlevel measures of quality and safety. Acad Med. 2007; 82:1178–1186. Pockets of clinical excellence may be found in most academic medical centers (AMCs), but the leaders of these institutions face the challenge of trying to achieve consistently high performance institution-wide, that is, across a wide variety of clinical services. The sciences of quality improvement and patient safety have focused largely on isolated clinical units or microsystems, demonstrating the

Deep vein thrombosis (DVT) is reported in up to 40% of trauma patients. The individual risk is nearly unpredictable. A daily single dose of a low molecular weight heparin (LMWH) was administered as prophylaxis to 518 trauma patients who were examined preoperatively and up to 10 days postoperatively in a prospective study. They were divided into two groups: group I comprised surgery of the hip and femur as well as total knee replacement and group II knee and lower leg surgery. Thrombin-antithrombin complex and D-dimer were analyzed. A second daily dose of LMWH was added if D-dimer exceeded the cutoff. If ultrasound was suspicious for DVT venography was added. Deep vein thrombosis was seen in five cases (group I=4, group II=1), without pulmonary embolism. TAT and D-dimer were significantly higher in group I than in group II ( p0.005). One hundred patients, 79 of them belonging to group I, were treated with a second dose of LMWH. The daily cutoff had the highest sensitivity and specificity for day 4. Due to individual monitoring of coagulation markers, the risk for thromboembolism compared to actual data in the literature seems to be reduced.

This study was carried out to determine the prevalence of genetic thrombophilia in patients with retinal vascular occlusion.We investigated 116 consecutive patients with central retinal vein occlusion (CRVO, n = 48), branch retinal vein occlusion (BRVO, n = 33), central retinal artery occlusion (CRAO, n = 21), branch retinal artery occlusion (BRAO, n = 14). All patients underwent comprehensive tests for coagulation disorders including determinations of protein C, protein S, lupus anticoagulants, prothrombin gene mutation (G20210A), resistance to activated protein C (APCR), and were screened for vascular disease risk factors. APC resistance was confirmed by a PCR method to detect the factor V R506Q mutation. A PCR method was also used to detect the G20210A mutation. For comparative purposes, we screened 209 consecutive patients with deep vein thrombosis (DVT) and 581 patients with coronary heart disease (control group) for APC resistance.13 (27%) of 48 patients with CRVO had the factor V R506Q mutation. The factor V R506Q mutation was detected in six (18%) of 33 patients with BRVO, but in only one patient with CRAO and in two patients with BRAO. Other thrombophilic defects were not detected. The APCR prevalence within the CRVO group was significantly increased when compared to the control group (8%). There was no significant difference in the factor V R506Q mutation prevalence between the CRVO group and the DVT group (19%).The factor V R506Q mutation is the most common cause of genetic thrombophilia in patients with CRVO and has a similar prevalence as in DVT patients.

Resistance to activated protein C (APC) is the most common hereditary defect in patients with venous thrombosis. There are conflicting reports on the prevalence of APC resistance in patients with arterial thrombosis, e.g. coronary arteries, compared to the APC resistance prevalence among the normal population. The prevalence of APC resistance in branch retinal artery occlusion (BRAO) and central retinal artery occlusion (CRAO) is unknown.29 consecutive patients with arterial retinal occlusions (BRAO, n = 12; CRAO, n = 17) were included in this prospective study over a 23-months-period. We searched for APC resistance, protein C or S deficiencies, as well as for acquired vascular risk factors. Factor-V-deficient plasma and genetic analysis with a PCR method were employed for APC resistance determination. Protein C and protein S activity were determined with functional tests.APC resistance was found in 3 of 29 patients (10.3%). Two of these patients had BRAO and one patient CRAO. Comparing this prevalence to the APC resistance prevalence within the normal population (9%), the difference was not statistically significant. 27 patients (93.1%) had one or more vascular risk factors (arterial hypertension = 19 [65.5%], hyperlipidaemia = 14 [48.2%], smoking = 7 [24.1%], diabetes mellitus = 5 [17.2%], carotid artery stenosis = 5 [17.2%]).We could not find an increased prevalence of APC resistance in patients with CRAO or BRAO when compared to the normal population.

In a prospective study, 39 patients following aortic or mitral valve replacement underwent investigation of molecular markers (prothrombin fragment F1+2, Factor II) in the initial phase of oral anticoagulation therapy (OAT). The results demonstrate that, despite INR being in the depicted range, the levels of the molecular markers remained high, indicating an increased risk of thromboembolic events. This leads to the conclusion that molecular markers are superior to INR in the monitoring of the early phase of OAT.

Seit 1852 J. Simon beim Menschen erstmals die Harnableitung uber das Rektum versuchte, wurden zunehmend haufiger Darmsegmente zur Rekonstruktion des Urogenitaltraktes verwendet [1, 11, 20, 29, 32].

We evaluated a rapid, quantitative immunoassay for the detection of cardiac troponin I. Coefficient of variation is between 1.29 and 13.63% for intra-assay and between 3.88 and 10.15% for inter-assay imprecision. Linearity is given up to 35 micrograms/l. Possible interfering substances (haemoglobin, bilirubin, triacylglycerol and rheuma factors) do not disturb the assay. The analyte is stable under normal storage conditions (+20 degrees C/48 h and +4 degrees C/l week) with decrease up to 30% after 3 months at -20 degrees C. Reference value for apparently healthy individuals is0.1 microgram/l. In plasma cardiac troponin I is measured up to 30% depressed compared to serum. Comparison with another cardiac troponin I assay (y = 0.92x + 2.42, r = 0.940) and cardiac troponin T is good with y = 6.61x - 1.94, r = 0.91 for the first generation cardiac troponin T assay and y = 5.59x - 0.68, r = 0.87 for the second generation cardiac troponin T assay. In summary, the evaluated assay is fast, easy to perform, and can be used not only in a specialized laboratory, but is also suitable for emergency laboratory or smaller laboratory units.

In 96 patients (ductal pancreatic carcinoma, n = 34; periampullary carcinoma, n = 43; chronic pancreatitis, n = 19) the role of CA 19-9 in the diagnosis of lesions of the head of the pancreas were evaluated. The sensitivity for ductal pancreatic carcinoma was 73.3%, for periampullary carcinoma 48.8%, and specificity was 63.2%. Carcinoembryonic antigen was elevated only in every fifth patient. Even when combining the two tumor markers no increase in sensitivity could be observed. The low specificity of 63%, which decreased to 33% in the case of obstructive jaundice, does not allow adequate preoperative differentiation between cancer patients and those with chronic pancreatitis. In cases of postoperatively elevated CA 19-9 level the prognosis is worse than in patients with normal tumor markers.

In consideration of own investigations and analysis of the most important publications of other authors, a critical interpretation of the concentrations of Troponin T (cut off:1 microgram/l) and Troponin I (cut off:0.4 microgram/l) was done in patients with acute and chronic muscle diseases, with chronic renal failure, with acute myocardial infarction, and stable and unstable angina pectoris, after coronary angioplasty, following cardiac surgery and critical care patients.In all cases with acute damage of the skeletal muscles (post operationem) the concentrations of TnT and TnI were in normal ranges. - In patients with chronic muscle diseases (M. Duchenne, Dermatomyositis) in 75% the TnT concentrations increased, while TnI concentrations were0.4 microgram/l. - In end stage renal disease patients undergoing chronic maintenance hemodialysis we found in 39% constantly elevated concentrations of TnT. TnI in all cases were in normal range. - In acute myocardial infarction in 97% of all patients both Troponins were increased, beginning 2 to 4 hours after onset. A normalization was observed between the 5th and 9th day. Very important is the differentiation between stable, and instable angina pectoris. In stable angina the concentration of both Troponins were in normal range, in contrast in 33 to 41% of all patients with unstable angina TnT and TnI were increased, in 9 to 16% even if the ECG showed no alteration. Elevated TnT or TnI concentrations predicted a significantly increased mortality. After coronary angioplasty and heparin treatment all patients had once more an elevation of TnT and TnI 8 and 27 hours after the invasive therapy. One of these substantial reasons for these minor myocardial cell necrosis is beside the endothelial injury the activation of the platelets and the coagulation system. - During the therapy with hirudin increases of TnT and TnI was not observed. Following cardiac surgery (ACVB) 6 to 48 hours after aortic unclamping 76 patients with TnI1 microgram/l had no perioperative myocardial infarction, while 14 patients with TnI concentrations1 microgram/l in 71.4% (n = 10) developed an acute infarction. - In patients in critical care units we observed only increased TnI concentrations in shock, especially in septic shock with multiple organ failures.

Pregnancy is accompanied by a physiological activation of intravascular coagulation; however without disorder. Normal markers of coagulation are unchanged despite activation. Special coagulation parameter--such as Thrombin-Antithrombin-III-complex (TAT) or D-Dimer are increased also in normal pregnant women. Pregnancy induced hypertension (SIH) and preeklampsia may be associated with a disorder of coagulation that precedes the well known clinical manifestation of hypertension. Therefore it was the aim of the study to distinguish both the pregnancy induced hypertension (15 patients) and preeklampsia (10 patients) as far as it is possible by coagulation parameters such as thrombin generation (by TAT), fibrinolysis (by D-Dimer), AT-III, platelets and others comparing them with 25 normotensive pregnancies. In preeklampsia, the results showed that clinical signs were associated with simultaneous coagulation abnormalities. TAT and D-Dimere are significant increased whereas a decrease of AT-III and platelets was observed. There are no significant differences between SIH and normal pregnancies. Three days after delivery there was an increase of D-Dimer, AT-III and platelets and a decrease of TAT-complex in all groups. For risk pregnancy, the parameters TAT and D-Dimer may be useful as screening test. They although may support confirming the diagnosis of preeklampsia.

A 26-year-old woman, on bedrest since the 6th week of pregnancy because of threatened abortion, developed thrombosis in the left iliac, superficial femoral and common femoral veins with small pulmonary emboli in the 11th week. Inhibitor deficiency was excluded. The thrombosis was only partially recanalized by unfractionated heparin at therapeutic dosage (38,400 IU per 24 h). As thrombolysis treatment and oral anticoagulation were contraindicated because of the threatened abortion, coagulation with low molecular weight heparin (LMWH) was started in the 18th week (5000 anti-Xa units daily subcutaneously). Maximal anti-Xa activity in plasma never exceeded 0.3 U/ml and there were no complications. The patient was delivered of a healthy girl (2,660 g, 48 cm) by caesarean section in the 37th week. Immediately post-partum LMWH was demonstrated with an anti-Xa activity of 0.3 U/ml in maternal blood, but none in simultaneously obtained cord venous blood. This case suggests that treatment of phlebothrombosis with LMWH is a reasonable measure even during pregnancy.

In a 14-years old girl, suffering from deep venous thrombosis protein C deficiency (activity: 55-58%) was diagnosed. Following rethrombosis oral anticoagulant therapy (OAT) with Phenprocoumon (Marcumar) was started. To find the required dosage for OAT the concentrations of prothrombin fragment (F1+2;0.5 nM/l) and fibrin monomers (2.5 mg/l) were measured. With this procedure an unusually high thromboplastin time (40-45%) was found to be safe.

A test kit (Iso-ALP, Boehringer Mannheim) for measuring human bone alkaline phosphatase activity in serum or plasma was evaluated in five laboratories in three countries. The assay is based on the principle described by Rosalki and Foo (Clin Chem 1984;30:1182-6) and uses wheat germ lectin to precipitate bone alkaline phosphatase. Residual ALP in the supernate in comparison with total ALP is used to quantify the bone fraction. The imprecision of residual ALP measurement was low (median between-run CV 4.9%) and comparable with that of total ALP. Linearity of precipitation was demonstrable up to a bone ALP activity (diethanolamine buffer 37 degrees C) of 2000 U/L, though a matrix effect was observed for dilutions of high-activity sera in saline or bovine serum albumin. For assaying patients' samples, different batches of lectin demonstrated excellent comparability. Taking electrophoresis as a basis for standardization, we determined that the lectin precipitated approximately 90% of bone ALP, but5% of nonbone ALP. From this we derived serum/plasma upper reference limits for bone ALP activity in adults and children.

Intracoronary stenting was designed to handle acute vessel closure after balloon angioplasty and to reduce the rate of restenosis. In three cardiology centers the implantation of 200 balloon-expandable Palmaz-Schatz stents was attempted in 179 patients. The implantation was successful in 170 patients (95%). During bail-out implantation for acute vessel closure or symptomatic dissections after balloon angioplasty, implantation succeeded in 60 (91%) of 66 attempted patients, who recovered immediately from ischemia. Three patients received emergency bypass surgery and three patients were kept on medical therapy. Restenosis after 4 to 6 months, defined as50% diameter reduction, was documented angiographically in 18 (15.3%) of 118 presently controlled patients. Patients with single stent implantation (n = 106) presented a late restenosis rate of 10.4% in contrast to patients with multiple stent implantation (n = 12), who presented a restenosis rate of 58.4%. Similar results on restenosis were found for patients with elective and bail-out stent implantation. Acute thrombotic stent occlusion occurred in three patients (1.8%) during the first 24 h after stenting. Three to 9 days after implantation subacute stent thrombosis occurred in 15 (8.8%) of 170 patients. Despite adequate therapy including thrombolysis, balloon angioplasty or emergency bypass surgery in 14 of 15 patients Q-wave myocardial infarction was documented in six patients and non Q-wave myocardial infarction in five patients. The following parameters were identified as risk factors for the development of subacute stent thrombosis: bail-out indication, unstable angina, type C lesion, stenosis length1.5 cm, plaque area3.5 mm2, symptomatic dissection after balloon angioplasty, incomplete wrapping of the dissection after stenting and residual distal vessel irregularities after stenting. Bleeding complications occurred in 12.4% of the patients and were related to the anticoagulation and antiaggregation therapy. In conclusion, the implantation of Palmaz-Schatz stents is an excellent bail-out device to treat acute vessel closure or symptomatic dissections after angioplasty. Elective and bail-out single stent implantation is associated with a reduced rate of restenosis when compared to conventional balloon angioplasty. At present, subacute stent thrombosis and bleeding complications are the major limitations with a combined rate of 15.9%.

Hypertriglyceridemia, which represents the main lipid disorder in patients with type2 diabetes mellitus [8], is supposed to be one of the factors contributing to the increased prevalence of atherosclerosis in these patients. In the Paris Prospective Study, hypertriglyceridemia was found to be an independent risk factor for coronary heart disease in normocholesterolemic diabetic patients [3]. More recently, these epidemiological data were confirmed by Bergstrom et al. [1]. They described an independent association of coronary heart disease with elevated fasting total triglycerides and with an impaired glucose tolerance in 219 second-generation Japanese-American men.

Postperfusion syndrome is still a problem in long cardiac operations using extracorporeal circulation (ECC). To evaluate whether or not centrifugal blood pumping during open heart surgery is beneficial, a randomized, prospective study was undertaken of 50 consecutive patients undergoing elective coronary artery bypass grafting. The patients were divided into two groups of 25 each. In group 1 a centrifugal pump (Biomedicus) was used as arterial blood pump, while in group 2 a roller pump (Stöckert) was used. The two groups did not differ significantly and the number of variables during surgery was kept low (identical perfusion set, two surgeons, minimal cardiotomy suction). The parameters studied included the cellular elements of the blood and components indicating their functional integrity, such as PMN-elastase, plasma hemoglobin, beta-thromboglobulin, and thrombin-antithrombin III complex and D-dimer as representatives for activated coagulation and secondary fibrinolysis. Blood and urine samples were taken every 15 min during ECC, on arrival in the intensive care unit, and 1, 3, 6, 12, and 24 h thereafter. No difference between the groups was found in regard to bypass time, ECC flow and volume, fluid balance, and clinical outcome. Significant differences in favor of group 1 were found in plasma hemoglobin (P less than 0.05), beta-thromboglobulin (P less than 0.01), D-dimer (P less than 0.05), and platelet counts (P less than 0.5). These differences were clearly ECC-time-dependent and became statistically significant after 90 min bypass. We conclude that roller pumps still can be safely used for standard cardiac procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

In a randomized, prospective clinical trial, 50 patients undergoing elective coronary artery bypass grafting (CABG) were divided into two groups of 25 each. Group I had a centrifugal pump (CP, Biomedicus) and Group II a roller pump (RP, Stöckert) as the arterial line. Neither group differed significantly, and variables during surgery were kept to a minimum. The parameters studied included the cellular blood elements and their components, such as PMN-elastase (PMN-E), plasma hemoglobin (pHb), beta-thromboglobulin (beta-TG), and D-dimer (D-D) and thrombin-antithrombin III complex (TAT) as indicators for activated coagulation. Blood and urine samples were taken at induction of anesthesia, every 15 minutes throughout extracorporeal circulation (ECC), at arrival in the ICU, and 1, 3, 6, 12, and 24 hours thereafter. No difference between the groups was found in bypass time, ECC flow or volume, or fluid balance. Significant differences in favor of Group I were found in pHb (p less than 0.05), beta-TG (p less than 0.01), D-D (p less than 0.05), and platelet counts (p less than 0.05). These differences were clearly ECC time dependent, became significant after 90 minutes of bypass, but disappeared within hours after surgery. No difference in patient outcome, ICU time, or need for volume substitution was seen. It is concluded that the RP can be safely used for routine ECC, but should be supplied with a CP in complex and prolonged cardiosurgical procedures to avoid severe postperfusion syndrome.

In einer prospektiven klinischen Studie wurde die Wertigkeit der Leukozytenelastase in der Fruhdiagnostik postoperativer entzundhcher Komphkationen nach 103 kleineren und grosen abdominellen und thorakalen Eingriffen analysiert. Bei 15 von 17 postoperativ aufgetretenen Komphkationen sahen wir einen fruhzeitigen Anstieg der Elastase im Vergleich zu den ubrigen Entzundungsparametern und vor klinischer Manifestation der Komphkation. Die Leukozytenelastase erwies sich als weiterer sensibler Entzundungsparameter in der Differentialdiagnose septischer und nicht septischer Komphkationen. Ein normales postoperatives Elastaseverhalten schlos eine septische Komphkation aus.

After infusion of 500 ml of 6% hydroxyethyl starch into fifty-four patients an increase of serum amylase was observed which in fifty-one cases exceeded the upper limit of normal (190 U/l). In most cases serum amylase reached twice the basal value. Renal function influenced the duration of the increase in serum amylase, but not the maximum increase (201+/-15 U/l; mean+/-SEM). In patients with advanced renal failure (glomerular filtration rate (GFR) = 2-10 ml/min) serum amylase was still markedly elevated after 72 h (298+/-24 U/l; mean+/-SEM). In patients with normal renal function (GFR greater than 90 ml/min) serum amylase decreased to 183+/-40 U/l (mean+/-SEM) within 72 h without reaching basal values. After infusion of HES no changes were observed in serum lipase or in amylase or lipase activities in duodenal secretion. Amylase excretion in the urine decreased. The assumption of a macroamylasaemia caused by formation of an HES-amylase complex was confirmed by gel filtration. The elimination from plasma of this high molecular enzyme-substrate complex is slow and causes hyperamylasaemia. In no case was the macroamylasaemia associated with signs or symptoms. An awareness of this causal relationship seems to be important, to avoid the erroneous diagnosis of a pancreatic disease.

Creatine kinase MB isoenzyme was measured (using antibody inhibition) in serum of patients with exogenous intoxication, acute pancreatitis, cerebrovascular accidents, meningitis, encephalitis, skeletal muscle disease, shock, postoperative states and after coronary arteriography, cardiac catherisation of cardioversion. CK-MB activity was revealed only in sera of patients with exogenous intoxication (severity III and IV), polymyositis, scleroderma, after operation or after coronary arteriography, cardiac catherisation or cardioversion. As it is not possible to differentiate between CK-MB and CK-BB using inhibiting antibodies against CK-M subunit, CK-isoenzyme activity was determined in parallel, using precipitating antibodies. No CK-BB was found in any case. The determination of CK-MB isoenzyme after blocking of the CK-MB subunit by means of inhibiting antibodies is suitable for clinical diagnosis. The method significantly increases the value of creatine kinase measurement.