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ZusammenfassungAktuelle epidemiologische Daten zeigen in den letzten Jahren einen Anstieg der Tuberkulose im Kindes- und Jugendalter. Es findet sich zudem auch in Deutschland ein Anstieg von Infektionen mit gegenüber Tuberkulosemedikamenten resistenten Erregern. In diesem Zusammenhang stellt die Diagnose, Prävention und Therapie der Tuberkulose vor allem im Kindesalter eine Herausforderung dar.Leitlinien für die Diagnostik und Therapie der Tuberkulose im Erwachsenenalter können nicht generell auf das Kindesalter übertragen werden, da hier relevante altersabhängige Unterschiede bzgl. der Krankheitsprogression, Krankheitsmanifestation, Unterschiede in der Anwendung von diagnostischen Maßnahmen und der Therapie bestehen.Unter Federführung der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI) e. V. wurde die S2k-Leitlinie für die Diagnostik, Prävention und Therapie der Tuberkulose im Kindes- und Jugendalter verfasst, um die adäquate Versorgung von Kindern und Jugendlichen mit Tuberkulose-Exposition, Infektion oder Erkrankung nach neuesten wissenschaftlichen Erkenntnissen zu sichern.Aktualisierte Dosierungsempfehlungen berücksichtigen die altersabhängige Pharmakokinetik in der Therapie der medikamentensensiblen, aber auch resistenten Tuberkulose. Darüber hinaus werden die Themen perinatale Exposition und Erkrankung sowie die im Kindesalter häufigeren extrapulmonalen Manifestationsformen gesondert behandelt.

Background The impact of proper aspiration of nasal secretions during upper respiratory infection on the frequency and severity of symptoms of lower airways has never been investigated. The study was aimed at testing if cleaning the nasal cavities of children with recurrent wheezing using an automatic nasal aspirator improves the upper and lower respiratory symptoms during the cold season. Methods Parents of wheezing children (age 3-72 mo.) answered questionnaires and learned using a nebulizer equipped (cases) or not equipped (controls) with an automatic nasal aspirator (DuoBaby, OMRON, Japan). During a 90-days monitoring period parents filled an electronic diary (BreathMonitor, TPS, Rome, Italy) on their child’s symptoms of the upper and lower airways. Results Eighty-nine/91 patients (43 cases, 46 controls) completed the study. Less days with upper (25.0% vs 46.4%, p = 0.004) or lower (21.8% vs 32.8%, p = 0.022) airways symptoms and less days with salbutamol inhalation (12.2% vs 16.9%, p

Figure S1. The DuoBaby nebulizer (a) and its functional scheme (b). Figure S2. Salbutamol consumption (expressed in percentage of days) among patients younger (cases n = 16, controls n = 16) or older (cases n = 27, controls n = 30) than 24 months and using a DuoBaby nebulizer equipped (cases) or not equipped (controls) with a nasal aspirator. Percentages are calculated considering the total days with symptoms over the total day of reported days (see method for definition). Chi-squared test was used to evaluate frequency differences between independent groups. Figure S3. Percentage of days with symptoms among patients using a DuoBaby nebulizer equipped (cases, n = 43) or not equipped (controls; n = 46) with an nasal aspirator. Percentage are calculated reporting the total days with symptoms on the total number of reported days. Chi-squared test was used to evaluate the association of categorical data between independent groups. Significant differences are highlighted as follows: *p

Background Many different symptom (medication) scores are nowadays used as measures of allergic rhinoconjunctivitis severity in individual patients and in clinical trials. Their differences contribute to the heterogeneity of the primary end-point in meta-analyses, so that calls for symptom (medication) score harmonization have been launched. Objective To prospectively compare six different severity scores for allergic rhinitis (AR) against pollen counts at both population and individual levels. Methods Two groups of children with seasonal AR and grass pollen sensitization were recruited in Ascoli, Italy (n = 76) and Berlin, Germany (n = 29). Symptoms and drug intake were monitored daily for 40 and 30 days of the grass pollen season in 2011 (Ascoli) and 2013 (Berlin), respectively, through an Internet-based platform (AllergyMonitor(™) , TPS Production srl, Rome, Italy). From the gathered data, the informatics platform automatically generated one symptom score (RTSS) and five symptom-medication scores (RC-ACS(©) , ACS, RTSS[LOCF], RTSS[WC] and AdSS). Values were then statistically normalized for reciprocal comparison and matched against the daily variations of local grass pollen counts (Spearman's rank correlation). Results The grass pollen counts were higher in Ascoli than in Berlin (peak values 194 vs. 59 grains/m(3) ). At population level, the trajectories of the normalized average values of the six scores differed only slightly in both studies and correlated well with the pollen counts (ranges r(2) : 0.38-0.50 in Ascoli, 0.41-0.56 in Berlin). By contrast, in individual patients, trajectories of different scores were often quite heterogeneous. The RTSS[WC] had a very low discriminatory power and generated in many patients long, flat horizontal segments. Conclusions Disease severity scores for seasonal AR, as evaluated via an Internet-based platform, tend to provide similar results at population level but can often produce heterogeneous slopes in individual patients. The choice of the disease severity score might have only a low impact on the outcome of a very large clinical trial, but it may be crucial in the management of individual patients.

Recently, epidemiological data shows an increase of childhood tuberculosis in Germany. In addition to this, drug resistant tuberculosis becomes more frequent. Therefore, diagnosis, prevention and therapy in childhood and adolescence remain a challenge. Adult guidelines do not work for children, as there are age specific differences in manifestation, risk of progression and diagnostic as well as therapeutic pathways.The German Society for Pediatric Infectious Diseases (DGPI) has initiated a consensus-based (S2k) process and completed a paediatric guideline in order to improve and standardize care for children and adolescents with tuberculosis exposure, infection or disease.Updated dosage recommendations take age dependant pharmacokinetics in the treatment of drug sensitive but also drug resistant tuberculosis in account. In addition to this, there is a detailed chapter on perinatal exposure and disease as well as extrapulmonary manifestations.Aktuelle epidemiologische Daten zeigen in den letzten Jahren einen Anstieg der Tuberkulose im Kindes- und Jugendalter. Es findet sich zudem auch in Deutschland ein Anstieg von Infektionen mit gegenüber Tuberkulosemedikamenten resistenten Erregern. In diesem Zusammenhang stellt die Diagnose, Prävention und Therapie der Tuberkulose vor allem im Kindesalter eine Herausforderung dar.Leitlinien für die Diagnostik und Therapie der Tuberkulose im Erwachsenenalter können nicht generell auf das Kindesalter übertragen werden, da hier relevante altersabhängige Unterschiede bzgl. der Krankheitsprogression, Krankheitsmanifestation, Unterschiede in der Anwendung von diagnostischen Maßnahmen und der Therapie bestehen.Unter Federführung der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI) e. V. wurde die S2k-Leitlinie für die Diagnostik, Prävention und Therapie der Tuberkulose im Kindes- und Jugendalter verfasst, um die adäquate Versorgung von Kindern und Jugendlichen mit Tuberkulose-Exposition, Infektion oder Erkrankung nach neuesten wissenschaftlichen Erkenntnissen zu sichern.Aktualisierte Dosierungsempfehlungen berücksichtigen die altersabhängige Pharmakokinetik in der Therapie der medikamentensensiblen, aber auch resistenten Tuberkulose. Darüber hinaus werden die Themen perinatale Exposition und Erkrankung sowie die im Kindesalter häufigeren extrapulmonalen Manifestationsformen gesondert behandelt.

Background Upper and lower airways diseases share in part their pathogenic mechanisms and frequently occur simultaneously as “United Airway Disease.” Local treatment with nebulizers delivers anti-symptomatic drugs in either the upper or the lower airways, according to the particle size generated by the nebulizer. To our knowledge, no nebulizer combines both application ways. The aim of this study is to test the efficacy and usability of a new nebulizer (OMRON A3 complete), generating aerosols with particles diameters of 2-4.5 μm, 4.5-7.5 μm or >7.5 μm, according to the user’s choice. Methods Seventy-seven patients between 5 and 17 years of age with a diagnosis of rhinitis or asthma were examined. Oxymetazoline or Salbutamol were prescribed according to best clinical practice guidelines. Both drugs were administered through the OMRON A3 Complete nebulizer, with a particle dimension of >7.5 μm to treat nasal obstruction and 2-4.5 μm for bronchial obstruction. The efficacy of treatment was assessed by total nasal inspiratory airflow and FEV-1, Tiffeneau index (FEV1/FVC) and MMEF 25/75 respectively, 10 min before and after treatment. Symptom improvement and usability were measured by patients’ and doctors’ questionnaires. Results Overall, 77 patients seeking care for acute respiratory symptoms were assigned to the upper (n = 39) or lower (n = 38) airways disease group. For symptoms of the upper airways, 92% (95% CI, 77-97%) of the patients reported subjective improvement, while 87% (95% CI, 73-94%) did so for the lower airways. The average total nasal inspiratory airflow improved significantly (p = 0.030) among the patients with upper airways symptoms, from 275 ml/s (95% CI, 207-342 ml/s) to 359 ml/s (95% CI, 300-419 ml/s) after Oxymetazoline administration. All selected lung function parameters (FEV1, Tiffeneau Index and MMEF25-75) significantly improved among the patients with lower airways symptoms after inhalation of Salbutamol (p < 0.001). The nebulizer was assessed as “easy to use” by over 95% of participants in both groups. Conclusions The OMRON A3 efficiently delivers anti-symptomatic drugs in both upper and lower airways in a user-friendly way. This device may be useful to facilitate adherence to a complete treatment of respiratory symptoms in patients with symptoms of the so-called United Airway Disease.

In this report, we present the successful percutaneous ventricular septal defect (VSD) closure, just 1 week post-transcatheter aortic valve implantation (TAVI). Periprocedurally, after implantation of the 31-mm CoreValve in an intentionally “high” position, we balloon postdilated, with an excellent result. A week post-TAVI, the patient started to deteriorate. Echocardiogram revealed a good working prosthesis; however, a perimembranous VSD was evident, causing significant shunt. We proceeded with interventional treatment of the defect, using an Amplatzer multifenestrated—“Cribriform”—septal occluder. Six months after the combined procedure, the patient showed marked improvement in symptoms and no shunt was observed. © 2012 Wiley Periodicals, Inc.

We describe the first reported case of a nose cone entrapment of the delivering catheter of a CoreValve self-expandable valve, during a transcatheter aortic valve implantation procedure. The complication was successfully treated after snaring the cone and retracting the system within the introducing sheath.

A 53-year-old man known to have Wolff-Parkinson-White syndrome suffered an acute posterior-wall myocardial infarction. Despite successful thrombolysis treatment with streptokinase he continued to have attacks of supraventricular tachycardia with angina. The ECG showed a short P-R interval and pre-excitation with positive delta waves in leads V1-6, as well as signs of re-infarction. The tachycardias could not be satisfactorily suppressed by drug treatment. Coronary angiography revealed triple vessel disease. During this investigation ventricular extrasystoles occurred which initiated orthodromic supraventricular tachycardia and angina, as well as monophasic S-T elevations in leads II, III and aVF. This provided the indication for immediate high-frequency catheter ablation left laterally at the mitral anulus after a left-lateral accessory conduction pathway had been identified. Three days later the stenoses of the circumflex and anterior interventricular branches were dilated. The patient has been free of symptoms for 3 months and can exercise up to 150 W. The tachycardias have not recurred.

The interaction of intravenous (i.v.) nitroglycerin (glyceryl trinitrate) on the anticoagulant effect of heparin was studied in 27 patients. The heparin dose was adjusted (800-1400 IU/h) to achieve partial thromboplastin time (PTT) of more than 100 s (130 +/- 28 s). While the heparin infusion was continued at the same dosage, the patients received 2-5 mg/h nitroglycerin i.v. (Perlinganit without propylene glycol [15 patients] or Gilustenon with propylene glycol [12 patients]). During combined heparin and nitroglycerin (NG) administration PTT decreased significantly (60 +/- 23 s; P less than 0.01). After withdrawal of NG, PTT increased to the initial levels (126 +/- 30 s). The drug interaction was seen in both groups--with or without propylene glycol. In nine of the 27 patients plasma heparin levels were measured; they remained unchanged during NG administration. The results indicate that i.v. NG induces heparin resistance. After NG is withdrawn, a rebound increase in PTT may occur. Adequate monitoring of PTT and heparin dosage adjustment are thus required during combined heparin and NG administration.

Internet-based tele-monitoring improves adherence to nasal corticosteroid treatment and disease knowledge among children and adolescents with seasonal allergic rhinoconjunctivitis., Internet-gestütztes Tele-monitoring erhöht die Therapieadhärenz von nasalem Kortikoid und den Wissenszuwachs über die Krankheit bei Kindern und Jugendlichen mit saisonaler allergischer Rhinokonjunktivitis.

In this paper we have implemented a simple DC model for CNTFETs already proposed by us in order to carry out static analysis of basic digital circuits, with a significant improvement compared to Wong model. In particular we have obtained a lighter ensuring compile and shorter execution time, without losing in accuracy.

Several experimental and clinical studies have demonstrated that platelet size and function correlate since large platelets are hemostatically more reactive than platelets of normal size. Since platelets play a crucial role in vascular remodeling after percutaneous transluminal coronary angioplasty (PTCA), we investigated the influence of the mean platelet volume (MPV), a parameter of platelet size, on restenosis after PTCA.The retrospective study comprised 174 patients who underwent elective PTCA and follow-up angiography within 6 months thereafter. According to the follow-up angiograms, the patients were assigned to group A ("restenosis", n=74) or group B ("no restenosis", n=100). Both groups were compared in regard to pre-procedural hematological routine parameters including MPV, platelet count, hematocrit, white blood cell count and fibrinogen.MPV was significantly increased in group A, compared with that in group B (8.75+/-0.99 fl vs. 8.04+/-0.74 fl, p0.001). This difference in MPV was evident in patients with stable and unstable angina pectoris. In addition, MPV had an impact on the time-related incidence of angiographic restenosis, as early restenosis was associated with higher pre-procedural MPV values. Platelet count correlated inversely with MPV (r=-0.36, p0.01) and was significantly lower in group A than in group B. The remaining hematological parameters were not different in both groups.The MPV seems to be a marker of coronary restenosis in patients undergoing PTCA. Patients with high pre-procedural MPV values might benefit from an intensified antiplatelet therapy after coronary interventions.

The release of the Principles and Standards for School Mathematics in the United States by the National Council of Teachers of Mathematics (NCTM) brought to the forefront the debate of whether research should determine the validity of the espoused Standards? Or conversely whether the Standards should influence the research agenda of the mathematics education community? How should university teacher educators address this issue? Should pre-service and practicing teachers blindly, accept the Standards as well as the research, or do we cultivate the critical thinking skills that will allow preparing teachers to resolve this dilemma? In this article a university mathematics educator and an idealistic pre-service elementary teacher try to resolve the dilemma of balancing the Standards with research and personal beliefs about the teaching and learning of mathematics.

SummaryBackground Adherence to controller therapy in allergic diseases is low. Telemonitoring has been proposed to improve adherence to treatment in chronic diseases. However, this strategy has never been tested in allergic rhinoconjunctivitis. Objective To test whether Internet-based telemonitoring during the grass-pollen season of children with allergic rhinoconjunctivitis may enhance adherence to treatment. Methods Children and adolescents, 5–18 years old, with moderate-to-severe seasonal allergic rhinoconjunctivitis to grass pollen requiring daily administration of nasal corticosteroid (NCS) (mometasone) were recruited (April 2013) in a paediatric allergy practice. Participants were randomized to Internet-based monitoring (AllergyMonitor™, AM) or to usual care (no diary at all, controls) and followed from 13 May (T0) to 15 June 2013 (T2). An intermediate visit (T1) was performed between 31 May and 2 June. Optimal adherence to therapy was expressed as the use of at least 0.190 g/day of mometasone, corresponding to 1 puff/nostril/day, and it was measured by canister weights during (T1) and at the end (T2) of the study period. Main secondary outcomes included the reported disease severity (validated self-questionnaire) and quality of life (AdoIRQLQ questionnaire), disease knowledge (multiple-choice questionnaire), nasal flow and resistance at baseline and at T2. Results The use of mometasone, expressed as both optimal adherence rate (48.4% vs. 12.5%; P = 0.002) and average daily use (0.20 ± 0.12 g/day vs. 0.15 ± 0.07 g/day; P = 0.037), was higher in the AM group (n = 31) than among controls (n = 32). Disease knowledge improved among the patients using AM (83.3% vs. 68.3%; P 0.05). No differences were observed in the reported severity of disease, nasal flow and resistance and quality of life both at baseline and at follow-up visits. Conclusions Internet-based telemonitoring improves adherence to NCS treatment and disease knowledge among children and adolescents with seasonal allergic rhinoconjunctivitis.

OBJECTIVES This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS Laser angioplasty success (≤50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by ≤30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non–Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.

Introduction: Inappropriate discharge is still a major issue of implantable cardioverter defibrillator therapy. The diagnostic options of modern devices facilitate classification of the underlying abnormality.

Wir berichten uber einen 31jahrigen turkischen Patienten mit einer rechtskardialen Raumforderung, Leistungsminderung, Gewichtsabnahme und intermittierenden Fieberschuben. Im peripheren Blut bestand keine Eosinophilie, die kardiale Funktion war primar unauffallig. Neben einer Endokarditis fibroplastica Loffler bestand differentialdiagnostisch der Verdacht auf ein entzundliches Geschehen sowie einen malignen Herztumor. Bei echokardiographisch untypischer Morphologie der rechtsventrikularen Raumforderung konnte durch Myokardbiopsie die Diagnose nicht gesichert werden. Bei raschem Wachstum der Raumforderung, fulminanter Embolie und Infiltration in die Trikuspidalklappe konnte erst durch die operative Tumorexstirpation die histologisch-pathologische Diagnose einer Endokarditis fibroplastica Loffler im thrombotischen Stadium gestellt werden. Die Behandlung bestand in einer antiphlogistischen Therapie mit Kortikosteroiden. Im Auslasversuch kam es nach 6 Monaten zu einem Tumorrezidiv. Eine Steroid-Dauermedikation in Kombination mit Azathioprin fuhrte anschliesend zu einer erneuten Tumorregression und Stabilisierung seit 8 Monaten nach Beginn der Medikation.

Das Kawasaki-Syndrom ist eine akute fieberhafte Erkrankung des Kleinkindalters. Auch 30 Jahre nach der Erstbeschreibung durch Kawasaki [1] im Jahre 1967 wird es weiterhin vorwiegend durch das Vorliegen einer Kombination klinischer Symptome diagnostiziert. Seit Einfuhrung der Immunglobulintherapie im akuten Stadium der Erkrankung kommt es beim uberwiegenden Anteil der betroffenen Kinder zum folgenlosen Ausheilen. Die schwerste Komplikation ist ein Befall der Koronargefase mit Entwicklung eines akuten Ischamiesyndroms oder langerfristig der Ausbildung von Koronaraneurysmata. Wir berichten uber den Fall eines 28jahrigen Hochleistungssportlers, der 17 Jahre nach dem scheinbar folgenlosen Ausheilen einer Kawasaki-Erkrankung einen akuten Hinterwandinfarkt bei massiv dilatierten Koronargefasen erleidet.

HISTORY AND CLINICAL FINDING A 69-year-old man with severe haemophilia A sustained an acute myocardial infarction (MI) after self-administration of 3000 units factor VIII over 10 min. On admission he had no signs of heart failure. INVESTIGATIONS The ECG showed an acute posterior wall MI. Creatinekinase rose to a maximum of 321 U/l with a significant MB proportion. The echocardiogram demonstrated hypokinesia of the posterior wall. TREATMENT AND COURSE After initial thrombolysis treatment with a total of 100 mg rtPA according to an accelerated scheme coronary angiography, performed because the symptoms persisted, revealed two-vessel disease. A subtotal stenosis of the right coronary artery was balloon-dilated with good primary results. Regular factor VIII substitution was temporarily administered with the aim of initially achieving high normal levels of factor VIII activity. CONCLUSION Factor VIII substitution in haemophilia A may promote thrombotic complications. Thrombolytic treatment and balloon angioplasty of acute MI can be successfully performed even in patients with severe haemophilia A.

An increase in platelet aggregability is associated with unstable angina and myocardial infarction. Platelet size and activity correlate and mean platelet volume was found to be increased before acute myocardial infarction. We measured the mean platelet volume and platelet count in patients with stable angina, unstable angina and non-cardiac chest pain.We studied 981 patients (734 men; 247 women) defined clinically as stable angina (n = 688), unstable angina (n = 108) and unstable angina requiring immediate angioplasty (n = 52). After coronary angiography the patients were subdivided into single (n = 269), double (n = 304) and triple-vessel disease (n = 311) and the control group of non-cardiac chest pain (n = 97). There was no significant difference in platelet count between the control group and patients with 1, 2, or 3-vessel disease. However, the platelet size in patients with coronary artery disease was significantly larger (single: 8.7 +/- 1.19 fl; double: 8.7 +/- 1.12 fl; triple-vessel disease: 8.8 +/- 1.18 fl) than the control group (8.2 +/- 0.95 fl) (P0.01). Patients with stable angina similarly had no, significant difference in platelet count compared to the control group but did have a significantly increased mean platelet volume (8.7 +/- 1.13; P0.01). In contrast, patients with unstable angina had a decreased platelet count (245 +/- 56 x 10/l) compared to either stable angina (262 +/- 62 x 10/l; P0.05) or the control group (261 +/- 58 x 10/l; P0.05); furthermore, the mean platelet volume (9.4 +/- 1.23 fl) was significantly greater than for stable angina (P0.01). Patients with unstable angina requiring immediate PTCA had an even lower platelet count (231 +/- 55 x 10/l) and higher mean platelet volume (10.4 +/- 1.03 fl) (P0.01) than the rest of the population with unstable angina.In stable angina the platelet count is unchanged compared to patients with normal coronary arteries but the platelet size is increased. However, in unstable angina there is a decrease in platelet count and an even larger increase in platelet size. We interpret this as meaning that unstable angina might be associated or preceded by an increase in platelet destruction rate that is not completely compensated for by an increase in platelet production rate. The large, more reactive platelets might be causally related to an ongoing coronary artery obstruction in unstable angina.

The aim of this study was to assess whether N-acetylcysteine (NAC) is able to prevent tolerance to a 48-hour infusion of nitroglycerin (NTG) in the setting of normal left ventricular function. In 16 patients, the hemodynamic response to 0.8 mg sublingual (s.l.) NTG was assessed by measuring mean arterial, pulmonary artery, pulmonary capillary wedge and right atrial pressures, cardiac output, and calculation of the systemic and pulmonary vascular resistances. The parameters were obtained at baseline and 1 to 10 minutes after the s.l. NTG application (day 1). NTG was started at 1.5 microg/kg/min; concomitantly, a bolus of 2,000 mg of NAC was administered, followed by an infusion of 5 mg/kg/hour. Both infusions were continued for 48 hours, and the hemodynamic study was repeated (day 3). The same measurements were obtained in a matched control group of 15 patients with NTG infusion alone. Plasma renin activity, aldosterone, and norepinephrine were measured before and after the infusion period. The first s.l. NTG infusion (day 1) caused a significant decrease in mean arterial (p0.01), pulmonary artery (p0.001), and right atrial pressures (p0.001), and in systemic (p0.01) and pulmonary vascular resistances (p0.001) in both groups. After the 48-hour infusion (day 3), there was a total loss of nitrate-mediated vasodilation (pressure values and vascular resistances day 3day 1) in 5 of 16 patients (NAC nonresponders), whereas in the other 11 of 16 patients (NAC responders), there was significant vasodilation throughout the infusion period. Tolerance had developed in 14 of 15 patients with NTG infusion alone. The same difference (responder vs nonresponder vs NTG alone) held true regarding the response to the second s.l. NTG infusion after 48 hours. The neurohormonal counter-regulation and intravascular volume expansion (increase in plasma renin activity, p0.001, and norepinephrine, p0.05; decrease in aldosterone, p0.01) did not differ between responders and nonresponders. We conclude that NAC attenuates tolerance development to a continuous NTG infusion in a specific patient subgroup and that this occurs despite the same amount of neurohormonal counter-regulation and intravascular volume expansion compared with patients with tolerance development.

With the advent of transcatheter aortic valve implantation (TAVI), many AS patients, formerly considered inoperable, can receive effective treatment. The relief of the left ventricular pressure overload could lead, in some cases, to the occurrence of dynamic intracavity pressure gradients (DIG) with deleterious clinical impact. This phenomenon resembles the physiology seen in hypertrophic obstructive cardiomyopathy. We report a case in which alcohol septal ablation was used as a bail-out therapy for the acutely developed intracavity obstruction after TAVI. Potential dynamic intracavity gradients should always be excluded in the acutely deteriorated patient postoperatively. Alcohol septal ablation can be considered as a salvage therapeutic tool when other therapies are ineffective to treat subvalvular obstruction.

Recent experiments have demonstrated that pressure waves of several hundred atmospheres, which occur during excimer laser coronary angioplasty (ELCA), are reduced while ablating in saline in comparison to blood or contrast medium. We report the procedural outcome of ELCA (XeCI laser operating at 308 nm, 25–40 Hz, 40–60 mJ/mm2 fluence, and 135 nsec/pulse) performed with a modified saline infusion protocol (two operator technique, flush, and continuous application of saline through the guiding catheter immediately prior and during the whole losing procedure). We studied 48 patients (34 males, 14 females; mean age: 61 ± 6 years; 18 occlusions, 30 stenoses [> 60% diameter stenosis]) with 10 type A, 17 type B, and 21 type C lesions. Laser success (> 20% increase in minimal luminal diameter [MLD]) was achieved in 41 patients (85.4%), and procedural success ( 0.01) after percutaneous transluminal coronary angioplasty (PTCA). The mean percentage stenosis decreased from 81%± 6% (baseline) to 48%± 12% (P < 0.001) after laser ablation, and to 29%± 10% (P < 0.01) following PTCA. The mean diameter of the laser-catheter (LC) was 1.54 ± 0.2 and the mean diameter of the inflated balloon at maximum pressure was 2.7 ± 0.25 mm. Thus, the elastic recoil (ER) following balloon deflation was 15%± 9%, and below the reported ER for PTCA. Two major dissections occurred following ELCA; one patient required bypass surgery and developed a Q wave myocardial infarction (Ml), and one patient was successfully treated with stent implantation following abrupt closure. There were no in-hospital deaths, further Q wave MIs, and/or perforation. In conclusion, ELCA with concomitant saline infusion is effective, safe, and easy to perform. The use of this ablation procedure reduces the rate of significant dissections, favors effective tissue ablation, and thus may in part be responsible for a reduced amount of elastic recoil following additional balloon angioplasty. (J Interven Cardiol 1996;9:9–18)

The factors contributing to unequal mortality rates following Pneumocystis carinii pneumonia (PCP) in different groups at risk are poorly understood. We therefore compared the first episodes of PCP without prophylaxis in human immunodeficiency virus infected (HIV) and otherwise immunosuppressed patients in this retrospective study. A total of 58 HIV-infected and 16 otherwise immunosuppressed patients were analysed. The comparison included epidemiological, clinical, laboratory, radiological and microbiological data, as well as therapy and clinical course. A prognostic analysis was performed using a logistic regression model. The mortality was significantly different in the two groups (HIV group 17 versus non-HIV group 50%). Renal transplant patients had a higher survival rate as compared to malignancy or collagen vascular disease as underlying diseases at risk. Acute respiratory failure was more common in the non-HIV group. Variables found to be significantly associated with lethal outcome in univariate analysis were alveolar to arterial pressures difference for oxygen (P(A-a),O2), haemoglobin, platelet count, total protein, serum albumin, and gamma-globulins in the HIV-group, and serum albumin in the non-HIV group. In the multivariate analysis of the HIV group, platelet count and gamma-globulins remained independent prognostic factors. In conclusion, in the HIV-group, mortality is closely related to the severeness of PCP as well as to the severeness of the acquired immune deficiency syndrome (AIDS) disease. In the non-HIV group, malignancy and collagen vascular disease as underlying conditions at risk account for the high mortality rate. Its severeness was mainly reflected by serum albumin, which represented the only variable found to be significantly associated with death in both groups.