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Background: The classic symptom of peripheral arterial disease is the intermittent claudication (IC). Generally, endurance training is recommended to improve patients' walking performance. A potential benefit of the combination with strength training and the optimal duration of such an exercise program remain unclear., Methods and Results: We evaluated the effects of a supervised exercise program combining endurance and strength training lasting 6 or 12 months in patients with IC. A total of 94 patients joined this study; 42 completed the 6-month training program (group A), whereas 52 patients completed the 12-month protocol (group B). Both groups exhibited a significant increase in all parameters evaluated, but greater benefit was found in the 12-month training group. The absolute claudication distance increased similarly by 27.5 and 29.5 %, respectively, in both groups (not significant); however, group B exhibited a greater increase in walking speed (12.1 vs. 5.3 %, p < 0.001). All strength parameters increased significantly in both the groups showing an increase for "pushing" by 90.0 % (group A) and 90.2 % (group B), for "pulling" by 64.2 % (group A) and 75.3 % (group B), and for "tiptoe standing" by 70.5 % (group A) and 113.7 % (group B; p < 0.05)., Conclusion: The results of this study indicate that a combined exercise program significantly increases walking speed, absolute claudication distance, and muscle strength parameters. A greater benefit seems to result from a 12-month training program.

Background: Aim of the study was to evaluate the effects of supervised exercise training for peripheral arterial disease (PAD) on walking speed, claudication distance and quality of life., Methods and Results: Ninety-four patients in stage IIa/IIb according to Fontaine underwent a six-month exercise training at the Center for Outpatient Rehabilitation Vienna (ZAW). Walking speed and Absolute Claudication Distance (ACD) improved significantly (p < 0,001 and p = 0,007 respectively). Increase of the Initial Claudication Distance (ICD) did not reach statistical significance (p = 0,14). Quality of life, as assessed by the questionnaire "PLC" manifested no significant change., Conclusions: The exercise training achieved considerable effects on walking speed and claudication distance. Despite these improvements, patient's quality of life revealed no relevant change. This outcome could be explained by the fact that aspects of physical functioning relevant to patients with claudicatio intermittens may be underrepresented in the PLC-questionnaire core module.

Background: This retrospective cohort study analyses effectiveness and sustainability of the current cardiac Phase III (Ph-III) rehabilitation program, provided by the Centre for Outpatient Rehabilitation (ZAR)., Methods: We analysed routine data of 451 intervention group patients (IG, with Ph-III) and 781 control group patients (KG, without Ph-III)., Results: In a median observation period of 2.73 years we found 30% less cases of death in the IG based on the mortality risk observed in the KG (rr = 0.70; p = 0.108). However, we registered more re-events, mainly stent implantations in the IG (rr = 1.34; p = 0.095). Groups differed in some baseline characteristics., Conclusions: The lower mortality risk by trend might be explained by the close-meshed care, the IG patients' more health conscious behaviour or a selection bias of the KG (e.g. more severe underlying disease). The causality of potential positive effects cannot be confirmed by this study because of the study design.

Background: Clinical management of hypertension needs a comprehensive therapeutic approach including both somatic and psychological aspects to ensure long-term treatment success. We have developed and evaluated an integrated outpatient training program for hypertensive patients., Methods: The impact of the integrated training program was evaluated in an open label prospective single-center study of 120 consecutive patients. The outpatient training program consisted of moderate physical exercise, patient education (relaxation techniques and stress management) and individual psychotherapy as indicated. Training sessions were held twice weekly during the initial six-month period. Anti-hypertensive medications were managed by the program director in close cooperation with the primary care physician. Hypertension control, medication and program costs were monitored prospectively. Evaluated parameters were measured at study enrolment (T1), upon completion of the six-month program (T2) and at follow-up at 18 +/- 5 months (T3)., Results: Maximum exercise capacity increased from 85.1 +/- 1.3% at enrolment (T1) to 95.8 +/- 1.5% of the expected value at 6 months (T2) (p < 0.005). There was no change in body mass index, though a reduction in anti-hypertensive medication was observed (betablockers, -30.1%; thiazides, -20.9%; ACEI/ARB, -19.8%; calcium channel antagonist, -13.4%; alpha-blockers, -41.5%; p < 0.05; p < 0.01). Blood pressure fell from 144.6 +/- 1.8/ 88.1 +/- 0.9 at enrolment (T1) to 136.8 +/- 1.4/83.5 +/- 0.8 mm Hg at 6 month (T2) (p < 0.01). A similar decrease in systolic blood pressure at submaximal workload of 8.5 +/- 1.4 (6.6-11.2) mm Hg was observed. The daily costs for anti-hypertensive medications decreased 20.7% from EUR 0.92 to 0.73 (p < 0.01). The overall costs for the program were EUR 970 per patient. At follow-up at 18 +/- 5 months (T3), there was persistence in the reduction in medication use as well as an increase in exercise capacity. Blood pressure control had deteriorated but the values were lower than at enrolment (T1) (p = 0.1, p < 0.05)., Conclusion: The integrated training program represents a comprehensive and effective approach to the treatment of hypertension. The costs of the program are likely to be offset by reduced expenses for anti-hypertensive medications over time at least in part.

Therapy of essential hypertension needs a comprehensive and broad assessment that includes somatic as well as psychological aims. We examined the effects of out-patient training for hypertensive patients on somatic parameters as well as locus of control and different relevant attitudes of patients. Psychological results are described in this paper. Out of the 50 patients analysis of somatic data distinguish so-called "responders" with clear improvement that permitted reduction of drugs from another group, called "non-responders", for which no reduction of drugs was possible. Analyses of psychological data show that "responders" develop a higher awareness of their body, a more positive attitude towards health, a freer attitude towards pleasure of life, sexuality, play and creativity. Their will to work and produce becomes less important. Internal locus of control (conviction that one is able to influence illness by oneself) is higher in "responders". Furthermore social external locus of control (conviction that following the suggestions of therapists is helpful) rises. Remnants of these effects were found in a follow up 18 months later.

Objective: To ascertain prospectively whether age is an independent prognostic factor for patients in a medical intensive care unit (MICU)., Patients and Methods: The data recorded prospectively for all patients admitted to a MICU between October 1994 and April 1996 were analysed with regard to demographic items, admission diagnosis. APACHE II score, days spent in the MICU and mortality rate. The data were arranged by age group and admission diagnosis (APACHE II score)., Results: 753 patients were admitted, 423 aged 65 or over (56.2%). Analysis of subgroups among the latter revealed a significant decrease in cardiovascular admission diagnoses with increasing age (65-74 years: 59%; 75-84: 55%; 85 or over: 32%), while the opposite trend pertained for pulmonary disease (65-74 years: 10%; 75-84%: 19%; 85 or over: 21%). There was a significant correlation for the total collective between mortality rate and severity of the disease on admission to the MICU (APACHE II score; P < 0.05). Those 65 years or older had a higher APACHE II score (17.4 vs 12.0; P < 0.05) and thus a higher mortality rate than the younger patients (25% vs > 12%; P < 0.01)., Conclusion: Many of the patients admitted to a MICU were aged over 65 years. The incidence of cardiovascular ailments on admission decreased with increasing age, while the opposite trend was true for pulmonary disease. There was no difference in mortality rate between different age groups given similar disease severity.

Clinical Course: We present a potentially fatal case of acute methaqualone (M) poisoning with very low serum concentrations of M but extremely high levels of its metabolite, 2-methyl-3-(2-hydroxymethyl-phenyl)-4 (3H)-chinazoline (Met-1). A 23-year-old man was admitted to the intensive care unit 2 days after ingestion of 4-5 g M in an suicidal attempt. On admission he was somnolent and poorly responsive to painful stimuli. Physical examination revealed a heart rate of 95 bpm, a blood pressure of 125/65 mmHg, and a normal body temperature. His chest was clear to auscultation, respirations were shallow, and the skin was cyanotic. The electrocardiogram was unremarkable. The chest radiograph showed a normal heart size without pulmonary infiltrates or venous congestion. The pupils were dilated but reactive to light. The neurologic examination was further remarkable for increased limb reflexes, myoclonia, and positive pyramidal signs. During the next 2 days the patient became comatose and developed respiratory insufficiency due to non-cardiogenic pulmonary oedema, which was confirmed by chest radiograph and haemodynamic investigations by means of right heart catheterisation. He required mechanical ventilation for 6 days. Finally, he recovered completely and was discharged in good condition., Diagnostics: A lumbar puncture revealed neither blood nor pleocytosis in the cerebrospinal fluid. Cranial computed tomography was carried out on an emergency basis, but no abnormality was disclosed. An electroencephalogram did not exhibit any significant pathological findings. Testing for infectious diseases or porphyria gave negative results. Toxicological screening based on enzyme immunoassays (ELISA) was negative for alcohol, tricyclic antidepressants, benzodiazepines, barbiturates, and morphine, but gave a positive result for M. From the moment of admission daily blood samples were taken and analysed by combined gas chromatography and mass spectrometry. These showed very low levels of M but extremely high levels of Met-1., Therapy: After gastric lavage, continuous enteric lavage with activated charcoal and mannitol was initiated to minimise intestinal absorption. Since M was hardly detectable in the serum, haemoperfusion was not regarded as indicated for drug elimination and treatment was restricted to general supportive measures. To rule out a central anticholinergic syndrome, an anticholinesterase drug (physostigmine) was administered but remained without therapeutic effect., Conclusions: The presented case is the first report of a life-threatening intoxication after M ingestion primarily caused by Met-1. It supports the significance of this metabolite for the toxic effects of the drug. A toxicological screening test based on ELISA proved helpful due to its cross-reactivity with metabolites. In cases similar to ours, resin haemoperfusion may be indicated to remove the metabolites despite low detectable concentrations of the parent substance in the serum.

1. Reocclusion is still a significant complication after percutaneous transluminal coronary angioplasty. The injury of coronary arteries resulting from PTCA plays an important role in the pathophysiology of both abrupt closure and late restenosis after an initially successful procedure. Cytokines play a pivotal role in the accumulation of circulating blood cells at the endothelium and are known to regulate their interaction with the vessel wall. 2. To obtain further information about this interaction, serum concentrations of soluble endothelial leukocyte adhesion molecule 1 (sELAM-1), leucocyte endothelial cell adhesion molecule 1 (sL-selectin), intercellular adhesion molecule 1 (sICAM-1), interleukin 2 receptor (sIL-2R) and interleukin 8 (IL-8) detected by enzyme-linked immunosorbent assay were monitored in 30 consecutive patients referred for elective PTCA. Fifteen patients who underwent elective coronary angiography without PTCA served as controls. 3. All patients underwent successful first PTCA. Within 24 h the serum concentrations of sELAM-1 increased gradually from 21.7 (SD 7.1) to 48.2 (SD 8.6) ng/ml (P < 0.01); levels of sL-selectin rose from 982.1 (SD 128.7) to 1541.3 (SD 104.6) ng/ml after 48 h (P < 0.01). Serum levels of IL-8 remained stable initially, but peaked at the end of the observation time of 72 h (9.4, SD 3.8, versus 16.1, SD 4.9 ng/ml; P < 0.05). A positive correlation was found between the number of dilatations and the rise in these parameters (P < 0.01). No significant changes were found in the serum concentrations of sICAM-1 and sIL-2R after PTCA or in any of the parameters in patients after coronary angiography. 4. We conclude that PTCA induces a significant rise in the concentration of certain adhesion molecules in serum. Thus, we provide preliminary data on the potential role of cytokines for blood cell-endothelium interaction after PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

1. Serum levels of erythropoietin and the immune parameters tumour necrosis factor-alpha, soluble interleukin-2 receptor, interleukin-2, interleukin-6 and interferon-gamma were measured in patients with rheumatoid arthritis. 2. Out of 69 patients, 44 had anaemia with serum haemoglobin concentrations of 10.8 (SD 1.2) g/dl. In these patients erythropoietin levels were significantly higher than in non-anaemic patients [51.97 (SD 23.9) versus 26.06 (SD 11.9) m-units/ml; P < 0.0001; control patients: 18.1 (SD 13.8) m-units/ml]. Mean soluble interleukin-2 receptor activity was elevated in all patients with rheumatoid arthritis [1324 (SD 715) units/ml; control patients: 480 (SD 75) units/ml; P < 0.001] and was significantly higher in the anaemic group than in the non-anaemic group [1562 (SD 662) versus 696 (SD 402) units/ml; P < 0.0001]. The serum activity of soluble interleukin-2 receptor showed an inverse correlation with haemoglobin (r = 0.79; P < 0.0001) and a positive correlation with erythropoietin (r = 0.70, P < 0.0001). 3. Elevated serum tumour necrosis factor-alpha levels were found in 19 anaemic patients [20.6 (SD 9.1) pg/ml]. Concentrations of tumour necrosis factor-alpha in serum showed an inverse correlation with haemoglobin (r = 0.57, P < 0.001) and a positive correlation with erythropoietin (r = 0.46, P < 0.05). Interleukin-6 was detected in seven anaemic patients [21 (SD 14) pg/ml] and interleukin-2 activity in three anaemic patients (12, 16 and 14 units/ml, respectively). Interferon-gamma was not detected in any of the patients investigated.(ABSTRACT TRUNCATED AT 250 WORDS)

Alternans of action potential duration (APD) has been shown to be a precursor of ventricular fibrillation in ischaemic myocardium. We postulated that magnitude of alternans of APD during ischaemia depends not only on the severity of ischaemia but also on disturbed beat-to-beat restitution of APD. Monophasic action potentials were recorded simultaneously from right (RV) and left ventricular (LV) epicardial sites of isolated rabbit hearts. The inter-beat time courses of APD recovery were determined both during normal flow and ischaemia by interposing single cycle length changes ranging from 200 to 800 ms (= electrical restitution) simultaneously at the three recording sites. During normal perfusion, electrical restitution curves showed a steep initial recovery of APD, attaining steady-state values at extrastimulus cycle lengths of only 298 +/- 12 ms, with a high degree of uniformity between the three recording sites (inter-site variability < 2%). Ischaemia produced a marked slowing of electrical restitution which, on average, reached a plateau at extrastimulus cycle lengths of 415 +/- 45 ms, 650 +/- 72 ms and > 800 ms at 2 min, 5 min and 9 min of ischaemia, respectively (each P < 0.001 vs control). In addition, ischaemia resulted in a large inter-site variability, with RV and LV restitution curves deviating from each other by as much as 28.5% (P < 0.0001 vs baseline). We conclude that global ischaemia not only leads to a delayed but also non-uniform electrical restitution.(ABSTRACT TRUNCATED AT 250 WORDS)

Contemporary concepts of ischaemic ventricular tachyarrhythmias (VTA) are based on increased electrophysiological heterogeneity of the myocardium. We developed a multi-site monophasic action potential recording system for an isolated rabbit heart to study the effects of global ischaemia on the electrophysiological properties at different ventricular sites simultaneously. The hearts were paced from the right ventricle (RV), and conduction time (CT), action potential duration (APD) and total repolarization time (TRT = [CT + APD]) were measured during normal perfusion and ischaemia. The dispersion of these parameters was calculated as the maximal difference between simultaneous recordings. Inducibility of VTA by programmed extrastimulation (ES) was investigated under normal and ischaemic conditions. During global ischaemia, CT increased progressively, showing a faster and greater increase at the left ventricle (LV) than at the RV. After 10 min the prolongation of CT reached a plateau at the LV while it continued to rise in the RV. The dispersion of CT increased from 14.5 +/- 2.7 ms during normal perfusion to a maximum of 79.8 +/- 17.2 ms after 14 min of ischaemia (P < 0.0001). APD was uniform at the three sites (190.9 +/- 10.2, 185.0 +/- 8.6 and 179.3 +/- 9.8 ms, ns) during normal perfusion but changed non-uniformly during ischaemia. There was a transient lengthening of APD until 1 and 3 min of ischaemia at the LV sites followed by a rapid shortening of APD. At the RV site, APD continued to increase until 5 min of ischaemia and then shortened gradually. Consequently, dispersion of APD showed a rapid initial rise from 17.7 +/- 2.7 ms to 77.8 +/- 10.2 ms (P < 0.0001) followed by a slower final increase. TRT was uniform during normal perfusion (210.4 +/- 10.3, 213.1 +/- 7.8, 212.1 +/- 10.3 ms, ns) but became non-uniform during global ischaemia. The dispersion of TRT increased from 15.4 +/- 4.2 ms to 92.6 +/- 23.2 ms (P < 0.0001) during 14 min of global ischaemia. Both CT and APD contributed independently to TRT and could either augment or partially compensate for the ischaemic alterations of the other parameter. ES induced VTA only during ischaemia (3.7 +/- 1.1 VTA per heart, P < 0.0001) at coupling intervals between 220 and 380 ms. The dispersion of TRT of the last regular beat preceding VTA was 67.7 +/- 17.4 ms (P < 0.001). ES which triggered VTA showed a more than two-fold increase of CT dispersion compared to the last steady state beat (122.7 +/- 29.4%, P = 0.0001).(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical and experimental evidence relate action potential duration (APD) alternans to ischaemic heart disease and ventricular arrhythmias. The present investigation was performed to study the quantitative relationship between APD alternans and the degree of ischaemia, loading conditions and cycle length (CL) in an intact heart. Monophasic action potentials (MAP) were simultaneously recorded by contact electrodes from two left (LV) and one right ventricular (RV) sites in 20 Langendorff-perfused rabbit hearts. The preparations were subjected to global ischaemia at flow rates ranging from 40% of normal flow to complete cessation of flow. Pacing was performed at either constant or regularly changing CL. The magnitude of APD alternans was expressed as beat-to-beat differences in action potential duration of two consecutive MAPs. During normal perfusion, neither very fast pacing at a CL of 200 ms nor periodical rate switches resulted in persistent APD alternans. Pacing at a constant CL of 800 ms did not induce APD alternans at complete cessation of flow for 6 min. However, alternans developed progressively at a constant CL of 400 ms after 2.8 +/- 0.3 min of complete ischaemia at the pre-loaded LV, and after 4.6 +/- 0.4 min at the unloaded RV (P < 0.01). The reduction of preload at the LV from 15 to 5 mmHg end-diastolic pressure delayed development of APD alternans from 2.8 +/- 03 min to 4.3 +/- 0.4 min (P < 0.05) at 400 ms CL. Following graded underperfusion of 40%, 20% and 10% of initial flow, persistent APD alternans developed in relation to the degree of flow reduction and increased progressively with duration of ischaemia. APD alternans at the LV always preceded the onset of APD alternans at the RV. In experiments with identical flow rates the shortest CL of 200 ms resulted in the greatest and earliest initiation of APD alternans compared to the longer CL (P < 0.01, P < 0.001). An increase in CL from 400 to 800 ms immediately abolished APD alternans, generated by the shorter CL, at any time during the 6 min period of complete ischaemia. Similarly, increasing the cycle length from 200 or 400 to 600 ms eliminated APD alternans up to 6 min of ischaemia and significantly reduced its magnitude between 7 and 10 min within a few beats. We conclude that persistent APD alternans is a characteristic findings in the rabbit heart during global ischaemia4 It is a sensitive parameter of the severity of ischaemia and depends.(ABSTRACT TRUNCATED AT 400 WORDS)

Objective: To evaluate the effect of acute cardiogenic pulmonary edema on the concentrations of immune parameters in serum., Design: Prospective, controlled study., Setting: Medical ICU., Patients: Twenty-four consecutive patients with acute pulmonary edema who had significant clinical improvement within 30 mins and did not show any evidence of either tissue damage or infection. For comparison, 25 healthy, age-matched controls and 25 patients with mild chronic heart failure were also studied., Interventions: Treatment with oxygen, nitrates, and loop diuretics., Measurements: Lymphokines, acute-phase reactants, and cortisol concentrations were measured in serial serum and plasma samples., Main Results: Serum concentrations of soluble CD-8 antigen (soluble CD-8) decreased from 928 +/- 124 (SEM) U/mL on admission to 712 +/- 112 and 579 +/- 67 U/mL after 2 and 6 hrs, respectively (p less than .05, p less than .01), and returned to baseline values within 48 hrs (853 +/- 109 U/mL). Concentrations of soluble interleukin-2 receptor increased from 721 +/- 71 to 1078 +/- 112 and 1226 +/- 128 U/mL 12 and 36 hrs, respectively, after admission (p less than .05, p less than .01). Plasma cortisol concentrations were markedly increased on admission (56.9 +/- 4.7 vs. 13.1 +/- 1.3 micrograms/dL after recovery, p less than .001). Increased cortisol concentrations coincided with the nadir of soluble CD-8. Tumor necrosis factor-alpha remained within normal limits in all patients. Neither acute-phase reactants nor angiotensin converting enzyme activity showed significant changes during the observation period., Conclusion: The present results indicate significant alterations in the serum concentrations of immune parameters as an effect of an uncomplicated acute cardiogenic pulmonary edema.

1. Plasma levels of endothelin were measured in 30 patients with chronic renal failure, 32 patients on chronic haemodialysis treatment and 25 renal graft recipients with stable renal graft function. 2. In patients with chronic renal failure as well as in patients on regular haemodialysis treatment, mean plasma levels of endothelin were significantly increased (4.59 +/- 2.09 pg/ml, 10.08 +/- 3.12 pg/ml, respectively) when compared with normal subjects (1.88 +/- 0.6 pg/ml, P less than 0.01, P less than 0.001, respectively). 3. In the group with chronic renal failure a positive correlation between the plasma level of endothelin and the plasma concentration of creatinine was observed (P less than 0.003). 4. Renal graft recipients on cyclosporin A with stable renal graft function had a normal plasma level of endothelin suggesting that cyclosporin A nephrotoxicity is not mediated by endothelin. 5. Hypertensive patients with chronic renal failure or on regular haemodialysis and hypertensive renal graft recipients did not differ from the corresponding normotensive population with regard to the plasma level of endothelin, demonstrating that an increased plasma level of endothelin does not play a major role in the pathogenesis of renal hypertension.

The time courses of changes in pHi and cytosolic calcium were compared in isolated perfused rabbit hearts with the use of the calcium-sensitive fluorescent indicator indo-1 and the pH indicator 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein (BCECF). Cell-permeant forms of these indicators were loaded into myocytes by arterial infusion or by direct infusion into the extravascular space. Indo-1 fluorescence was recorded from the epicardial surface of the left ventricle at an excitation wavelength of 360 nm and emission wavelengths of 400 and 550 nm. BCECF fluorescence was recorded at an excitation wavelength of 490 nm and an emission wavelength of 530 nm. Calibration procedures were developed for each indicator that allowed [Ca2+]i and pHi to be quantified during ischemia. Global ischemia decreased contractility and caused a rapid increase in both the systolic and end-diastolic levels of the calcium transients. Ninety seconds of ischemia increased peak systolic [Ca2+]i from 609 +/- 29 to 1,341 +/- 159 nM, while end-diastolic [Ca2+]i increased from 315 +/- 25 to 553 +/- 52 nM. The observed increase in diastolic [Ca2+]i, was shown not to arise from indo-1-loaded endothelial cells. The initial increase in [Ca2+]i was followed by a gradual decline and then a secondary rise occurring between 5 and 15 minutes of ischemia. In contrast, ischemia caused a monotonic decrease in pHi from a baseline of 7.03 +/- 0.06 to 6.83 +/- 0.02 after 2 minutes, 6.32 +/- 0.1 after 10 minutes, and 6.11 +/- 0.04 after 15 minutes. Perfusion of hearts with acidified (hypercarbic) saline increased the systolic and diastolic levels of the calcium transients, but only when pHi fell below a threshold value, which was more acidic than values achieved during the first 2 minutes of ischemia (6.83 +/- 0.03). Lesser degrees of acidification caused a decrease in contractility but did not affect the calcium transients. Effects of pHi on the calcium transients were not due to altered calcium sensitivity of indo-1. These results suggest that cytosolic acidification may contribute to the increase in [Ca2+]i during the first 15 minutes of global ischemia, but the [Ca2+]i increase during the first 2 minutes is mediated by other factors.

Due to the multitude of invasive procedures of today's intensive care medicine, infections from central venous catheters have gained increasing attention. The incidence of bacteremias arising from such devices ranges from less than 0.1 to 0.6 cases per 100 catheter-days. Factors influencing the incidence of catheter-associated infections are related to patient characteristics as well as the purpose and material of the catheter. Silicone catheters seem to carry a lower risk of infection than common polytetrafluorethylene catheters. The most frequently isolated bacteria in catheter-associated infections are coagulase-negative and coagulase-positive staphylococci, enterococci, and pseudomonas species. Septicemias due to Candida albicans frequently complicate the course of immune-compromised patients receiving total parenteral nutrition (TPE). Catheter-associated bacteremias (CAB) can arise from the contaminated hub, from which pathogens migrate intraluminally to the blood stream. When the catheter entry site is infected, bacteria may reach the blood via the extraluminal route and cause septicemia. Endemic outbreaks of CAB often originate from contaminated infusion fluids. As the clinical presentation of "catheter infections" is often uncharacteristic and insidious, a definite diagnosis depends on bacteriological examination of the catheter. Quantitative and semiquantitative culture techniques of the catheter tip help to distinguish colonization from contamination by numbers of colony-forming units per milliliter culture medium. Preliminary results can be obtained by simple Gram or acridine-orange staining of the catheter tip. The most important prophylactic measures to prevent CAB are strictly aseptic conditions when catheters are placed and meticulous care thereafter, preferably by specially trained nurses or "TPE teams".(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced oxygen tension is regarded as the primary physiologic signal for the production of erythropoietin (EPO). There is little information available about early changes of EPO production in man due to severe hypoxia. The purpose of the present study was to examine the time course of EPO in serum of patients with acute cardiogenic pulmonary edema (ACPE). In 29 patients (seventy-five +/- six years, mean age +/- SEM) who were hospitalized within two hours after onset of symptoms of ACPE, serum EPO concentrations were monitored for up to seventy-two hours. At the moment of admission all patients showed significantly increased EPO concentrations of 121 +/- 64 mU/mL (mean +/- SEM) compared with a healthy population (15-35 mU/mL). Twenty-three patients who recovered within thirty minutes (group A) exhibited a quick return of their EPO serum levels to normal. The remaining 6 patients (group B) had a protracted clinical course and their EPO concentration showed a further increase up to the end of the observation period. The comparative monitoring of concentrations of alpha-1-proteinase inhibitor, antithrombin III, C-reactive protein, fibronectin, hapotoglobin, and transerrin in serum and plasma revealed no significant changes. Thus a major contribution of fluid shifts into or from the intravascular compartment to the observed changes in EPO concentration seems to be unlikely. The data suggest that the production and release of EPO in the kidneys due to altered oxygen delivery is a fast-responding mechanism.

1. We determined plasma levels of histamine in uraemic patients and examined their correlation with the presence of pruritus. 2. In 27 patients with chronic renal failure, plasma histamine levels were analysed by radioimmunoassay and were compared with those of 40 healthy adult subjects. The control population showed plasma histamine concentrations of 185 +/- 33 pg/ml, which were significantly lower than those of the patients with renal insufficiency. The highest levels (552 +/- 116 pg of histamine/ml) were found in 16 patients with chronic renal failure (mean serum creatinine 5.1 +/- 1.0 mg/dl) and severe itching. 3. Twelve patients with pronounced pruritus who were on maintenance haemodialysis (serum creatinine 9.2 +/- 1.2 mg/dl) had a mean plasma histamine concentration of 515 +/- 81 pg/ml. Fifteen patients on regular haemodialysis (serum creatinine 9.0 +/- 1.5 mg/dl) and who experienced itching had plasma histamine levels (322 +/- 40 pg/ml) which were significantly lower (P less than 0.01) than those of the patients with pruritus but which were elevated compared with those of the control population (P less than 0.01). 4. No correlation could be found between increased plasma histamine levels and the type of dialysis membrane used or the method of sterilization of the membrane. 5. Haemodialysis alone did not reduce plasma histamine concentrations, although high concentrations could be detected in the ultrafiltrate. In six patients a rapid decrease in plasma histamine concentration from 565 +/- 134 pg/ml to within the normal range could be detected after 60 min of combined haemodialysis and haemoperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty uremic patients on regular hemodialysis received recombinant human Erythropoietin (rhEPO) in a dosage of 50 U/kg body wt (N = 9) and 80 U/kg body wt (N = 11), respectively, three times weekly. The number of circulating hemopoietic progenitor cells colony-forming unit-granulocyte-erythrocyte-macrophage (CFU-mix), burst-forming unit-erythroid (BFU-E) and colony-forming-granulocyte-macrophage (CFU-GM) in peripheral blood were assayed weekly by means of a commonly applied in vitro clonal assay. A significant increase of peripheral CFU-mix, BFU-E and CFU-GM could be observed within one week of supplementation therapy in both groups. The increase of BFU-E was followed by a rise of hematocrit within four and three weeks, respectively. These results suggest that the stimulatory in vivo effect of rhEPO administered in therapeutical doses is not restricted to the erythroid lineage but also includes progenitor cells committed to the myeloid lineage (CFU-GM) as well as the multipotent progenitors CFU-mix. The increment of circulating progenitor cells was seen with a dosage of 80 U/kg body wt and 50 U/kg body wt as well.

The skeletal muscle has the capacity to respond adaptively to increased use. This observation could open up the feasibility of constructing pumping chambers to support or even replace cardiac work. We investigated the changes in enzyme activity due to chronic stimulation in an animal skeletal muscle. In 5 adult sheep the psoas muscle of one side was electrically stimulated through the muscle nerves, with an implantable stimulation unit for 5 weeks. The activity of the hexokinase (E.C.2.7.1.1.), lactate dehydrogenase (E.C.1.1.1.27), malate dehydrogenase (E.C.1.1.1.37), creatine kinase (E.C.2.7.3.2.) choline acetyltransferase and the contents of adenosine triphosphate and adenosine diphosphate were determined in bioptic specimen. The use of only 15 Hertz as a stimulation frequency led to a transformation of an originally fast-twitch muscle into a slow-twitch muscle with reduced susceptibility to fatigue. These results indicate a potential role of the skeletal muscle as an ideal myocardial substitute with the ability to perform hemodynamic work.

Cytomegalovirus (CMV) infection in solid organ recipients can endanger the immunosuppressed patient and increase vulnerability to secondary infections and the high risk of rejection triggered by the viral disease. The effect of passive immunization against CMV was examined in 69 heart transplant patients. The patients received weekly administrations of 1 ml/kg of CMV hyperimmunoglobulin from the day of transplantation until the 30th postoperative day. Forty-four of the patients were monitored clinically and serologically up to the 120th postoperative day. Nine patients showed clinical and serologic signs of CMV infection; in 15 the only evidence of CMV infection was a rise in antibody titers. The remaining 20 patients showed no clinical or serologic signs of CMV infection. Three patients who were seronegative preoperatively remained seronegative until the end of the observation period. The results indicate a potential therapeutic benefit of hyperimmunoglobulin prophylaxis to prevent infectious complications due to CMV in heart transplant patients.

Plasmatic coagulation parameters were studied in patients on parenteral cephalosporins with different hepatic pharmacokinetics. Sixty patients received either cefotaxime (4 g/day), ceftriaxone (2 g/day) or latamoxef (4 g/day) pre- and postoperatively for at least 5 days at random. They received parenteral nutrition without vitamin K supply and had no oral intake. A significant drop (p less than 0.05) in vitamin-K-dependent coagulation factors was recorded in patients treated with latamoxef, while patients receiving ceftriaxone and cefotaxime did not exhibit a significant change in their plasmatic coagulation parameters. Interference of some cephalosporins with the vitamin-K-dependent hepatic metabolism of clotting factors seems to be likely, rather than a suppression of intestinal vitamin K production by the intestinal microflora.