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Statins are the cornerstone treatment for patients with heterozygous familial hypercholesterolaemia but research suggests it could increase the risk of type 2 diabetes in the general population. A low prevalence of type 2 diabetes was reported in some familial hypercholesterolaemia cohorts, raising the question of whether these patients are protected against type 2 diabetes. Obesity is a well known risk factor for the development of type 2 diabetes. We aimed to investigate the associations of known key determinants of type 2 diabetes with its prevalence in people with heterozygous familial hypercholesterolaemia.

Dank 100 Jahren Insulintherapie können Menschen mit Typ-1-Diabetes mellitus (T1DM) alt werden, doch Folge- und Begleiterkrankungen sowie altersassoziierte Syndrome und Funktionsstörungen bleiben Herausforderungen. T1DM manifestiert sich meist in der Jugend, kann aber auch bis im sehr hohen Alter erstmals auftreten, weshalb bei entsprechender Klinik die Diagnose LADA („late autoimmune diabetes of adults“) in Betracht gezogen werden soll. Im Alter treten häufig geriatrische Syndrome auf, die das Selbstmanagement des Diabetes erschweren. Bei abnehmender Selbstständigkeit können Angehörige oder Pflegefachkräfte Teile der Therapie übernehmen. Technische Hilfsmittel bieten zusätzliche Unterstützung, smarte Assistenten und Telemedizin verbessern die Lebensqualität und Sicherheit der Betroffenen. Geriatrisches Assessment hilft, die Fähigkeiten zur selbstständigen Therapie zu beurteilen und rechtzeitig Unterstützung zu planen.

Dank 100 Jahren Insulintherapie können Menschen mit Typ-1-Diabetes mellitus (T1DM) alt werden, doch Folge- und Begleiterkrankungen sowie altersassoziierte Syndrome und Funktionsstörungen bleiben Herausforderungen. T1DM manifestiert sich meist in der Jugend, kann aber auch bis im sehr hohen Alter erstmals auftreten, weshalb bei entsprechender Klinik die Diagnose LADA („late autoimmune diabetes of adults“) in Betracht gezogen werden soll. Mit dem Älterwerden treten häufig geriatrische Syndrome auf, die das Selbstmanagement des Diabetes erschweren. Kognitive Defizite, Demenz und Depression können die Durchführung der Therapie erheblich beeinträchtigen und haben eine wechselseitige Beeinflussung mit Diabetes. Diese geriatrischen Syndrome können zu einer schlechteren Stoffwechseleinstellung, erhöhtem Risiko für Hypo- und Hyperglykämien sowie verminderter Lebensqualität führen. Therapieziele sollten im Alter regelmäßig überprüft und individuell angepasst werden. Bei abnehmender Selbstständigkeit können Angehörige oder Pflegefachkräfte Teile der Therapie übernehmen. Technische Hilfsmittel wie kontinuierliche Glukosemesssysteme, Insulinpumpen und digitale Tagebücher bieten zusätzliche Unterstützung, smarte Assistenten und Telemedizin verbessern die Lebensqualität und Sicherheit der Betroffenen. Geriatrisches Assessment hilft, die Fähigkeiten zur selbstständigen Therapie zu beurteilen und rechtzeitig Unterstützung zu planen. Eine enge Zusammenarbeit zwischen Betroffenen, Angehörigen und dem professionellen Behandlungsteam ist essenziell, um eine adäquate und flexible Diabetesbehandlung im Alter zu gewährleisten. Die Weiterentwicklung von Hilfsmitteln und technologische Lösungen spielen eine wichtige Rolle, um die Selbstständigkeit und Lebensqualität älterer Menschen mit T1DM zu erhalten.

The Charlson Comorbidity Index (CCI) is the most widely used assessment tool to report the presence of comorbid conditions. The Barthel index (BI) is used to measure performance in activities of daily living. We prospectively investigated the performance of CCI or BI to predict length of hospital stay (LOS), mortality, cardiovascular (CV) mortality and rehospitalization in unselected older patients on admission to the emergency department (ED). We also studied the association of CCI or BI with costs. We consecutively enrolled 307 non-surgical patients ≥ 68 years presenting to the ED with a wide range of comorbid conditions. Baseline characteristic, clinical presentation, laboratory data, echocardiographic parameters and hospital costs were compared among patients. All patients were followed up for mortality, CV mortality and rehospitalization within the following 12 months. A multivariate analysis was performed. Mortality was increased for patients having a higher CCI or BI with a hazard ratio around 1.17–1.26 or 0.75–0.81 (obtained for different models) for one or ten point increase in CCI or BI, respectively. The prognostic impact of a high CCI or BI on CV mortality and rehospitalization was also significant. In a multiple linear regression using the same independent variables, CCI and BI were identified as a predictor of LOS in days. Multiple linear regression analysis did not confirm an association between CCI and costs, but for BI after adjusting for multiple factors. CCI and BI independently predict LOS, mortality, CV mortality, and rehospitalization in unselected older patients admitted to ED.

Die 83-jährige Frau A. wird mit seit einer Stunde bestehendem akutem Brustschmerz und Atemnot in der Notfallabteilung aufgenommen. Der EKG-Befund unterstützt Ihre Verdachtsdiagnose Herzinfarkt, doch die Herzkatheteruntersuchung weist auf eine andere Erkrankung hin.

Background: Risk stratification of elderly patients presenting with heart failure (HF) to an emergency department (ED) is an unmet challenge. We prospectively investigated the prognostic performance of different biomarkers in unselected older patients in the ED.Methods: We consecutively enrolled 302 non-surgical patients ?70 years presenting to the ED with a wide range of cardiovascular and non-cardiovascular comorbid conditions. N-terminal pro-B-type natriuretic peptide (NT-proBNP), mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro-endothelin-1 (CT-proET-1), ultrasensitive C-terminal pro-arginine-vasopressin (Copeptin-us) and high-sensitivity cardiac troponin T (hs-cTnT) were measured at admission. Two cardiologists independently adjudicated the final diagnosis of HF after reviewing all available baseline data using circulating NT-proBNP levels. A final diagnosis of HF was found in 120 (40%) of the 302 patients. All patients were followed up for cardiovascular death within the following 12 months. In order to test the prognostic performance of the investigated biomarkers we used boosting models with age and sex as mandatory covariates. Boosting is a statistical learning technique with built-in variable selection developed to obtain sparse and interpretable prediction models.Results: Follow-up was 100% complete. During a median follow-up time of 225 days (interquartile range (IQR) 156–319 days), 30 (9.9%) of 302 patients (aged 81±6 years) had cardiovascular deaths. Of these 30 patients, 21 had HF and nine had no HF diagnosed prior to admission. The boosting model selected MR-proADM and hs-cTNT as predictors of cardiovascular deaths. The median values of MR-proADM and hs-cTnT at presentation were significantly higher in patients with cardiovascular deaths compared to surviving patients during follow-up (2.56 nmol/L (IQR 1.62–4.48) vs. 1.11 nmol/L (IQR 0.83–1.80), P<0.001 and 81 ng/L (IQR 38–340) vs. 17 ng/L (IQR 0.9–38), P=0.004). One unit increase in the log-transformed MR-proADM levels was associated with a 1.99-fold risk of death (95% confidence interval (CI) 1.61–2.45, P<0.001). The second marker, hs-cTnT, showed an increased predicted risk but was not significantly correlated to event-free survival (hazard ratio 3.22, 95% CI 0.97–10.68, P=0.056).Conclusion: Within different biomarkers, MR-proADM was the only predictor of cardiovascular deaths in unselected older patients presenting to the ED.

Jeder vierte 80-Jährige leidet an Diabetes mellitus Typ 2. Dazu kommen im fortgeschrittenen Alter häufig Multimorbidität, Polymedikation und Funktionseinschränkungen, die der Arzt in der Therapie mitberücksichtigen muss. Welche Therapieziele bei dieser Patientengruppe gelten und worauf Sie in der Pharmakotherapie achten sollten, erfahren Sie in der folgenden CME-Fortbildung.

Bei betagten Patienten mit Vorhofflimmern ist die Antikoagulation eine Gratwanderung: Einerseits ist im Alter die Schlaganfallgefahr erhöht, gleichzeitig steigt aber auch das Risiko für schwere Blutungen. Beachtet der Arzt bei der Wahl des Präparats und der Dosierung Faktoren wie Nierenfunktion, Begleitmedikation, Therapieadhärenz und Sturzrisiko, überwiegt in vielen Fällen der Nutzen einer Antikoagulationstherapie.

Aim: Biomarkers can help to identity acute heart failure (AHF) as the cause of symptoms in patients presenting to the emergency department (ED). Older patients may prove a diagnostic challenge due to co-morbidities. Therefore we prospectively investigated the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone or in combination with other biomarkers for AHF upon admission at the ED.Methods: 302 non-surgical patients aged = 70 years were consecutively enrolled upon admission to the ED. In addition to NT-proBNP, mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro-endothelin-1 (CT-proET-1) and ultra-sensitive C-terminal pro-vasopressin (Copeptin-us) were measured at admission. Two cardiologists independently adjudicated the final diagnosis of AHF after reviewing all available baseline data excluding the biomarkers. We assessed changes in C-index, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) for the multimarker approach.Results: AHF was diagnosed in 120 (40%) patients (age 81±6 years, 64 men, 56 women). Adding MR-ADM to NT-proBNP levels improved C-index (0.84 versus 0.81; p=0.045), and yielded IDI (3.3%; p=0.002), NRI (17%, p<0.001) and continuous NRI (33.3%; p=0.002). Adding CT-proET-1 to NT-proBNP levels improved C index (0.86 versus 0.81, p=0.031), and yielded robust IDI (12.4%; p<0.001), NRI (31.3%, p<0.001) and continuous NRI (69.9%; p<0.001). No other dual or triple biomarker combination showed a significant improvement of both C-index and IDI.Conclusion: In older patients presenting to the ED, the addition of CT-proET-1 or MR-proADM to NT-proBNP improves diagnostic accuracy of AHF. Both dual biomarker approaches offer significant risk reclassification improvement over NT-proBNP.

Immer wieder müssen insulinpflichtige Diabetiker als Notfallpatienten intensivmedizinisch versorgt werden. Eine der häufigsten Ursachen: das hyperglykämische Koma. Hier ist rasches Handeln geboten — denn diese Komplikationen sind häufig lebensbedrohlich.

Unsere Gesellschaft ist gezwungen, Wege zu finden, die Lebensqualität unterstützungsbedürftiger Menschen – und damit auch ihr Gefühl von Sicherheit – zu verbessern. Zu viele Betroffene werden es in Zukunft sein, zu stark ihr Wunsch nach Erhalt des gewohnten Umfeldes auch im hohen Alter, zu knapp die betreuenden (personellen) Ressourcen. Was heute schon alles technisch machbar ist, beschreibt der nachfolgende Beitrag.

Geriatrische Patienten mit Vorhofflimmern haben ein hohes Schlaganfallrisiko. Gemäß etablierter Risikoskalen besteht eine klare Indikation zur Antikoagulation. Trotzdem werden diese Patienten in der täglichen Praxis oft nicht entsprechend behandelt. Die Gründe dafür sind Komorbiditäten des Patienten und Komedikation, Bedenken wegen geringer Therapietreue oder Angst vor Blutungen, insbesondere nach Stürzen. Dieses Positionspapier fasst die Ergebnisse einer Diskussionsrunde zusammen, zu der sich ein interdisziplinäres Expertengremium traf. Die Experten waren sich darüber einig, dass geriatrische Patienten im Regelfall eine orale Antikoagulation erhalten sollten, es sei denn, eine umfassende neurologische und geriatrische Beurteilung (einschließlich klinischer Untersuchung, Ganganalyse und validierter Messinstrumente wie Modifizierter Rankin-Test, Mini-Mental-Status-Test oder Geldzähl-Test) liefert gewichtige Gründe dagegen. Alle Patienten mit wiederholten Stürzen in der Vorgeschichte sollten zur Abklärung der Sturzursachen sorgfältig untersucht werden. Patienten mit einem CHADS2-Wert ≥ 2 sollten auch bei hohem Sturzrisiko eine Antikoagulation erhalten. Die neuen oralen Antikoagulanzien (NOAK) sind bei geriatrischen Patienten mit Vorhofflimmern leichter anzuwenden (keine INR-Tests erforderlich, leichtere Antikoagulationsüberbrückung) und zeigen ein besseres Nutzen-Risiko-Verhältnis als Vitamin-K-Antagonisten. Medikamente, die vorrangig extrarenal eliminiert werden, sind bei geriatrischen Patienten sicherer und sollten daher bevorzugt werden. The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment. All patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric patients and should be preferred.

Background and aims: The new high sensitivity cardiac Troponin T (cTnThs) assay has recently been introduced in our clinic and ensures higher sensitivity than the fourth-generation cardiac troponin T (cTnT) assay from the same manufacturer (Roche Diagnostics). We determined the diagnostic performance of the cTnThs compared with the cTnT assay in geriatric patients, especially those with non-ST elevation myocardial infarction (NSTEMI). Methods: We retrospectively analysed 253 patients (age 82±8 years; 82 men, 172 women) with diagnoses of suspected NSTEMI admitted to our Department of Geriatric Medicine. Patients were divided into one group of 113 patients using cTnThs, and another of 140 patients using cTnT for diagnosis. Each group included patients at the same months but different years, in either cTnThs or cTnT assays. NSTEMI was diagnosed according to current guidelines. Results: Baseline characteristics were similar in both groups. The proportions of patients with elevated cardiac troponin (cTn) levels significantly increased from 35% in the cTnT group to 76% in the cTnThs group (p<0.001), although no coronary cause for the elevated cTn levels was shown in about two-thirds of these patients. In patients with NSTEMI, 58% in the cTnThs group vs 42% in the cTnT group were diagnosed within 4 hours of the onset of symptoms, whereas 42% in the cTnThs group vs 58% in the cTnT group were diagnosed more than 4 hours later (p=0.018). Conclusions: The prevalence of elevated cTn has more than doubled with the use of cTnThs. However, no coronary cause was found in two-thirds of our geriatric patients, although more NSTEMI patients were diagnosed earlier by cTnThs.

Background and aims: The new high sensitivity cardiac Troponin T (cTnThs) assay has recently been introduced in our clinic and ensures higher sensitivity than the fourth-generation cardiac troponin T (cTnT) assay from the same manufacturer (Roche Diagnostics). We determined the diagnostic performance of the cTnThs compared with the cTnT assay in geriatric patients, especially those with non-ST elevation myocardial infarction (NSTEMI). Methods: We retrospectively analysed 253 patients (age 82±8 years; 82 men, 172 women) with diagnoses of suspected NSTEMI admitted to our Department of Geriatric Medicine. Patients were divided into one group of 113 patients using cTnThs, and another of 140 patients using cTnT for diagnosis. Each group included patients at the same months but different years, in either cTnThs or cTnT assays. NSTEMI was diagnosed according to current guidelines. Results: Baseline characteristics were similar in both groups. The proportions of patients with elevated cardiac troponin (cTn) levels significantly increased from 35% in the cTnT group to 76% in the cTnThs group (p<0.001), although no coronary cause for the elevated cTn levels was shown in about two-thirds of these patients. In patients with NSTEMI, 58% in the cTnThs group vs 42% in the cTnT group were diagnosed within 4 hours of the onset of symptoms, whereas 42% in the cTnThs group vs 58% in the cTnT group were diagnosed more than 4 hours later (p=0.018). Conclusions: The prevalence of elevated cTn has more than doubled with the use of cTnThs. However, no coronary cause was found in two-thirds of our geriatric patients, although more NSTEMI patients were diagnosed earlier by cTnThs.

Zusammenfassung: Diabetes mellitus ist eine klassische Alterserkrankung, die zudem selten allein kommt. Daher sind die wichtigsten Therapieziele für geriatrische Patienten mit Diabetes mellitus die Bewahrung der Lebensqualität, der Erhalt der physischen, psychischen und sozialen Kompetenz sowie Eigenständigkeit.

BackgroundA good collateral function in patients with regional myocardial dysfunction may indicate viability with the potential for left ventricular (LV) recovery after revascularization of a chronic total coronary occlusion (CTO).MethodsA CTO (duration > 2 weeks) was successfully recanalized in 126 patients. During this procedure, the collateral function was assessed before the first balloon inflation by intracoronary Doppler and pressure wires. Collateral function indexes were calculated. Left ventricular function was assessed by the LV ejection fraction (LVEF) and the wall motion severity index (WMSI [SD/chords]). A repeat angiography was available in 119 patients after 4.9 +/- 1.4 m. An improvement of WMSI >=1 SD/chord was considered significant.ResultsLeft ventricular function was normal in 42%, regional dysfunction with LVEF >= 0.60 was observed in 16%, and regional dysfunction with LVEF < 0.60 in 42%. The former had a better collateral function than patients with LV dysfunction. In 39% of patients with LV dysfunction, a significant myocardial recovery was observed at follow-up. The collateral function was similar in patients with and without recovery. However, patients with recovery had a lower peripheral resistance as an indicator of a better preserved microvascular integrity.ConclusionsRecovery of impaired LV function after revascularization of a CTO is not directly related to the quality of collateral function, as collateral development does not appear to require the presence of viable myocardium. However, a preserved microvascular integrity may be of relevance for myocardial recovery.

After recanalization and stenting of chronic total coronary occlusions (TCO), a reduced coronary flow velocity reserve (CFVR) and rise in collateral resistance (RColl) is frequently observed. Coronary microembolization may account for these observations. ??In 86 patients (age 64±10 years; 77 men, 9 women) with TCO (duration >4 weeks), PTCA was performed with successful stent implantation in all lesions. Before PTCA, viable myocardium was detected by stress echocardiography or nuclear imaging techniques. By simultaneously measuring coronary Doppler flow velocity and pressure before and after PTCA, CFVR and RCollwere calculated. Over a period of 24 hours after intervention, creatine kinase (CK; upper limit of normal [ULN] for women 1.17 µmol/L/s, for men 1.33 µmol/L/s) and cardiac troponin I (cTNI; threshold 0.1 ng/mL) were studied. CFVR was <2 in 48% of all patients. A rise in RCollwas observed in 83% of all patients. The incidence of CK and/or cTNI elevation was only observed in 10% of all patients. These patients with CK and/or cTNI elevation did not show a significant difference of CFVR and rise in RCollas compared with patients without CK and cTNI elevation. CFVR or rise in RColldid not correlate with CK elevation. ??Coronary microembolization is not a likely cause of reduced CFVR and increased RCollafter PTCA of TCO. Other factors such as microvascular dysfunction and autoregulatory changes in collateral function may account for these observations. Nach erfolgreicher Rekanalisation chronisch verschlossener Koronargefäße (TCO) wird eine reduzierte koronare Flussreserve (CFR) gemessen. Außerdem findet sich eine Zunahme des Kollateralwiderstandes (RColl) nach Gefäßeröffnung. Periphere Mikroembolisationen könnten diese Befunde erklären. ??Bei 86 Patienten (Alter 64±10 Jahre; 77 Männer, 9 Frauen) war eine Rekanalisation der TCO (Verschlussdauer >4 Wochen) erfolgreich. Mittels simultaner intrakoronarer Fluss- sowie Druckmessung vor und nach Rekanalisation wurden CFR und RCollerrechnet. Über einen Zeitraum von 24 Stunden nach Rekanalisation wurden CK, CK-MB und TNI zum Nachweis von periprozeduralen Embolisationen erhoben. Die CFR lag bei 48% der Patienten <2,0. Bei 83% Patienten kam es zum Anstieg des RColl. Es trat nur bei 8 von 86 Patienten (10%) eine CK- und/oder TNI-Erhöhung über den oberen Normwert auf. Diese Patienten mit CK- und/oder TNI-Aktivitätsanstieg unterschieden sich nicht in ihrer CFR und im Anstieg des RCollvor und nach Rekanalisation von den Patienten ohne CK- und TNI-Aktivitätsanstieg. ??SchlussfolgerungDie beobachtete reduzierte CFR und der Anstieg des RCollunmittelbar nach Rekanalisation sind nicht durch periphere Mikroembolisationen erklärbar. Vielmehr sind andere Faktoren wie z.B. eine autoregulatorische Änderung des Kollateralgefäßtonus und Mikrozirkulationsstörungen anzunehmen.

ObjectivesTo evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics.DesignIndividual patient level data meta-analysis and modelling study.SettingFourteen studies from 13 countries, including randomised controlled trials and prospective observational studies.ParticipantsIndividual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated.Main outcome measureAdjudicated diagnosis of acute heart failure.ResultsOverall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure.ConclusionsIn an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach.Study registrationPROSPERO CRD42019159407.

Angiotensin II (Ang II) increases insulin sensitivity in healthy volunteers. This effect is thought to be mediated, at least in part, by an increase in skeletal muscle blood flow. In the past it had been documented that some biological actions of Ang II are altered in diabetes. We addressed the issue of whether this is also true for its action on insulin sensitivity.

Twelve healthy volunteers received single oral doses of propranolol (80 mg), metoprolol (100 mg), l‐bunolol (2 mg), and placebo in a four‐way crossover study. Blood pressure, ventricular rate, and echocardiographically determined ejection fraction, ejection time, and mean rate of circumferential fiber shortening (mVcf) were measured before dosing and at multiple time points during 10 hours after each dose, with subjects maintained in the supine position. Reductions in systolic and diastolic blood pressure following administration of each of the beta blockers were greater than those observed with placebo, but differences among the four treatments were not significant. Heart rate reductions with the beta blockers differed significantly from placebo (P < .001), but differences among the three beta blockers were not significant. Differences among the four treatments in mVcf decrement did not attain significance at the 5% level (.05 < P < .1), and there were no significant differences in ejection‐time prolongation or ejection‐fraction reduction. Thus, reduced blood pressure, heart rate slowing, and reduced cardiac contractility may be associated with placebo treatment and may indicate the need for placebo controls in studies of the cardiovascular effects of beta blockers. Despite differing secondary pharmacologic properties, the three beta blockers reduced heart rate to a similar extent. Other effects of the beta blockers on blood pressure and cardiac contractility could not be consistently distinguished from those associated with placebo.

Quaternary ammonium salts of functionalized tertiary amines may serve as ligands for transition metal catalysts in hydroformylation reactions. Besides these properties they offer special advantages for the catalyst separation using phase separation or membrane techniques.

n-Butyraldehyde, the key intermediate in the manufacture of the most important plasticizer raw material, 2-ethylhexanol, is mainly obtained by the hydroformylation of propylene. In addition to the two established processes, the Co-high pressure and the Rh-low pressure process, Ruhrchemie and Rhone-Poulenc have developed a new variant using rhodium complexes as catalysts which are modified by water-soluble phosphines. As the catalyst phase is practically insoluble in the raw aldehyde, it can be separated from the catalyst by simple phase separation. The heat of reaction can be used for other purposes. The first commercial plant operating with this process has been in service at Ruhrchemie AG since mid-1984.

Zusammenfassung Es wird über einen Fall einer Erkrankung nach Art der Periarteriitis nodosa berichtet, die im klinischen Verlauf wechselweise mit einem Asthma bronchiale in Erscheinung trat und damit geeignet erscheint, auf eine beiden gemeinsame allergisch-hyperergische Reaktionslage hinzuweisen. Im gleichen Sinne wird die bei Periarteriitis nodosa häufiger beobachtete Eosinophilie herangezogen. Weiter ergibt sich Gelegenheit, auf die selbständige Venenerkrankung bei Periarteriitis nodosa und die klinische Bedeutung der periarteriitisch bedingten Herdpneumonien hinzuweisen.

Zusammenfassung Die dem Begriff der fibrinoiden Degeneration des Bindegewebes vonNeumann zugrunde liegenden Befunde können weitgehend bestätigt werden.

Ohne Zusammenfassung:

Zusammenfassung: Es wird auf die Hufigkeit der anaeroben Keime, insbesondere gramnegativer Stbchen bei der septischen Angina und die Schwierigkeiten der bakteriologischen Diagnostik hingewiesen. Die meist in Gemischen auftretenden anaeroben Keime werden in Vergleich mit den Keimen der Appendicitis (Lhr undRafeld) als ortstndige aufgefat, die nur durch Zusammenwirken vieler Umstnde, besonders mechanischer Natur als Krankheitserreger in Erscheinung treten.

Ohne Zusammenfassung:

For Abstract see ChemInform Abstract in Full Text.