Ulrich Busch

Emergency Coronary Stenting for Dissection During Percutaneous Transluminal Coronary Angioplasty : Angiographic Follow-Up After Stenting and After Repeat Angioplasty of the Stented Segment

OBJECTIVESnThe purpose of this study was to assess the angiographic results after emergency coronary stenting and after repeat angioplasty for restenosis within the stent.nnnBACKGROUNDnThere is still little angiographic information about lumen renarrowing and its correlates after emergency stenting, and data with regard to the angiographic outcome of repeat angioplasty within the stent are almost nonexistent.nnnMETHODSnThis study was based on the quantitative evaluation of angiograms performed before and immediately after intervention and at 6-month follow-up. The study included 164 of the 183 eligible patients with emergency Palmaz-Schatz stent implantation and 31 of those with restenosis within the stent who had repeat angioplasty.nnnRESULTSnStenting produced an improvement in minimal lumen diameter from 0.82 +/- 0.41 to 2.76 +/- 0.47 mm (mean +/- SD) and in diameter stenosis from 74.9 +/- 11.5% to 18.3 +/- 8.1%. Elastic recoil was 0.51 +/- 0.34 mm, or 16%. At 6-month follow-up, 32.3% of the patients had restenosis (> or = 50% stenosis). Minimal lumen diameter decreased to 1.84 +/- 0.78 mm, and diameter stenosis increased to 41.7 +/- 21.0%. The degree of lumen loss correlated significantly with the length of the original stenosis and the initial lumen gain achieved by stenting. Thirty-one patients with in-stent restenosis underwent repeat angioplasty. The primary success rate was 100%, and no abrupt vessel closure was verified. Minimal lumen diameter increased from 0.85 +/- 0.35 to 2.18 +/- 0.39 mm, and diameter stenosis decreased from 69.7 +/- 12.9% to 28.6 +/- 9.4%. Elastic recoil was 0.82 +/- 0.38 mm, or 27%. At follow-up, 38.5% of the patients had restenosis. Minimal lumen diameter was reduced to 1.72 +/- 0.67 mm, and diameter stenosis increased to 42.4 +/- 18.1%.nnnCONCLUSIONSnAngiographic results of emergency coronary stenting compare favorably with those of conventional angioplasty. In-stent balloon redilation in patients with restenosis is associated with excellent short-term results and a restenosis rate not different from that reported for nonstented vessels.

Sequence analysis of ospA genes shows homogeneity within Borrelia burgdorferi sensu stricto and Borrelia afzelii strains but reveals major subgroups within the Borrelia garinii species

The genes coding for the outer surface protein A (OspA) of 19 different Borrelia burgdorferi strains belonging to the seven OspA-serotypes 1–7, previously described [Wilske et al. (1993) J Clin Microbiol, 31: 340–350], have been investigated. B. burgdorferi sensu lato strains were chosen from various biological sources (ticks, human skin and cerebrospinal fluid) as well as different geographical origins (Germany, Slovenia, Austria, United States). The open reading frames of all ospA genes consist of 819–825 nucleotides corresponding to proteins of approximately 30 kDa. The ospA sequences obtained in this study and previous published studies were compared with the results from OspA serotyping with monoclonal antibodies. The classification into the seven OspA serotypes could be confirmed on a genetic basis (ospA genotypes 1–7) for all strains analyzed so far (n=29). In addition, one strain without OspA expression could be assigned to ospA genotype 2. Genetic stability could be proven for the ospA gene of B. burgdorferi strain PWudI after inocculation and reisolation from a gerbil. However, we found evidence for intragenic recombination by cluster analysis of ospA sequence data. Accordance of ospA genotype 1 strains with B. burgdorferi sensu stricto and ospA genotype 2 strains with B. afzelii, as well as the ospA genotype strains 3–7 with B. garinii was confirmed by pulsed-field gel electrophoresis of MluI-digested genomic DNA. B. garinii is not only more heterogenous in respect to the OspA-encoding genes, but shows moreover major subgroups formed by genotypes 4, 5 and 6 and genotypes 3 and 7, respectively. The latter group has not been described previously and is specifically recognized by an OspA-specific monoclonal antibody L32 1F7.

Transverse Myelitis Associated with Mycoplasma pneumoniae Infection

A 14-year-old boy developed acute transverse myelitis with severe abdominal pain, bladder dysfunction, weakness, and sensory loss of the lower extremities. Magnetic resonance imaging revealed a segmental expanded central edema affecting parts of the spinal cord, including the caudal medulla oblongata. Antibody response to Mycoplasma pneumoniae was negative in microparticle agglutination assays (1:40 in the acute serum and 1:160 in the convalescent serum) and complement fixation tests (1:20 and 1:10). However, analysis of acute-phase serum revealed a specific IgA and IgG response but no IgM response. Detection of M. pneumoniae in the cerebrospinal fluid by nested polymerase chain reaction and in nasopharyngeal aspirate by culture confirmed an M. pneumoniae infection. Treatment with doxycycline (100 mg daily) was started on the second day after admission to the hospital and continued for 14 days; the patient recovered completely and was discharged 20 days after onset of the disease, with no signs of neurological deficits.

Borrelia burgdorferi sensu lato Strains Isolated from Cutaneous Lyme Borreliosis Biopsies Differentiated by Pulsed-field Gel Electrophoresis

25 skin biopsy isolates of Borrelia burgdorferi sensu lato, mainly from German patients with erythema migrans [EM], borrelial lymphocytoma [BL] and acrodermatitis chronica atrophicans [ACA], were species-differentiated using pulsed-field gel electrophoresis (PFGE). The isolates revealed 15 B. afzelii, 8 B. garinii and 2 B. burgdorferi sensu stricto species according to Miu I digestion. All 6 ACA isolates were identified as B. afzelii species, whereas the 2 borrelial lymphocytoma isolates were grouped into B. garinii species. 12 B. afzelii strains, including 4 ACA isolates, were further investigated by digestion with 5 restriction enzymes. Most of the strains revealed an individual pattern. No specific characteristically large restriction fragment pattern (LRFP) could be detected within the ACA and/or EM group. The ACA isolates could not be clearly differentiated from the EM isolates according to the LRFP patterns. PFGE is thus a highly effective method for detecting differences among B. afzelii isolates.

Kill kinetics ofBorrelia burgdorferi and bacterial findings in relation to the treatment of lyme borreliosis

SummaryFor a better understanding of the persistence ofBorrelia burgdorferi sensu lato (s.l.) after antibiotic therapy the kinetics of killingB. burgdorferi s.l. under amoxicillin, doxycycline, cefotaxime, ceftriaxone, azithromycin and penicillin G were determined. The killing effect was investigated in MKP medium and human serum during a 72 h exposure to antibiotics. Twenty clinical isolates were used, including ten strains ofBorrelia afzelii and ten strains ofBorrelia garinii. The results show that the kinetics of killing borreliae differ from antibiotic to antibiotic. The killing rate of a given antibiotic is less dependent on the concentration of the antibiotic than on the reaction time. Furthermore, the data show that the strains ofB. afzelii andB. garinii have a different reaction to antibiotics used in the treatment of Lyme borreliosis and that different reactions to given antibiotics also exist within one species. TheB. garinii strains appear to be more sensitive to antibiotics used in therapy. Furthermore, the persistence ofB. burgdorferi s.l. and clinical recurrences in patients despite seemingly adequate antibiotic treatment is described. The patients had clinical disease with or without diagnostic antibody titers toB. burgdorferi.ZusammenfassungDie bakterizide Aktivität von Amoxicillin, Doxycyclin, Cefotaxim, Ceftriaxon, Azithromycin und Penicillin G gegenBorrelia burgdorferi s.l. Stämme wurde in MKP-Medium und Humanserum während der 72 Stunden Einwirkungszeit untersucht. Die Antiborrelienwirkung der Antibiotika wurde an 20 Patientenisolaten, zehnBorrelia afzelii und zehnBorrelia garinii Stämmen, getestet. Der Abtötungseffekt der einzelnen Antibiotika auf getestete Stämme ist sehr unterschiedlich. Die Unterschiede hinsichtlich der Keimreduktion bestehen zwischen den Stämmen derB. afzelii undB. garinii species als auch zwischen den Stämmen innerhalb einer Spezies. Der Anteil der abgetöteten Borrelien ist weniger abhängig von der Konzentration des Antibiotikums als von der Einwirkungszeit. DieB. garinii Stämme sind offensichtlich empfindlicher gegen die in der Therapie eingesetzten Antibiotika. Die Persistenz vonB. burgdorferi s.l. und Rezidive der Erkrankung nach der Antibiotikatherapie werden diskutiert.For a better understanding of the persistence ofBorrelia burgdorferi sensu lato (s.l.) after antibiotic therapy the kinetics of killingB. burgdorferi s.l. under amoxicillin, doxycycline, cefotaxime, ceftriaxone, azithromycin and penicillin G were determined. The killing effect was investigated in MKP medium and human serum during a 72 h exposure to antibiotics. Twenty clinical isolates were used, including ten strains ofBorrelia afzelii and ten strains ofBorrelia garinii. The results show that the kinetics of killing borreliae differ from antibiotic to antibiotic. The killing rate of a given antibiotic is less dependent on the concentration of the antibiotic than on the reaction time. Furthermore, the data show that the strains ofB. afzelii andB. garinii have a different reaction to antibiotics used in the treatment of Lyme borreliosis and that different reactions to given antibiotics also exist within one species. TheB. garinii strains appear to be more sensitive to antibiotics used in therapy. Furthermore, the persistence ofB. burgdorferi s.l. and clinical recurrences in patients despite seemingly adequate antibiotic treatment is described. The patients had clinical disease with or without diagnostic antibody titers toB. burgdorferi. Die bakterizide Aktivität von Amoxicillin, Doxycyclin, Cefotaxim, Ceftriaxon, Azithromycin und Penicillin G gegenBorrelia burgdorferi s.l. Stämme wurde in MKP-Medium und Humanserum während der 72 Stunden Einwirkungszeit untersucht. Die Antiborrelienwirkung der Antibiotika wurde an 20 Patientenisolaten, zehnBorrelia afzelii und zehnBorrelia garinii Stämmen, getestet. Der Abtötungseffekt der einzelnen Antibiotika auf getestete Stämme ist sehr unterschiedlich. Die Unterschiede hinsichtlich der Keimreduktion bestehen zwischen den Stämmen derB. afzelii undB. garinii species als auch zwischen den Stämmen innerhalb einer Spezies. Der Anteil der abgetöteten Borrelien ist weniger abhängig von der Konzentration des Antibiotikums als von der Einwirkungszeit. DieB. garinii Stämme sind offensichtlich empfindlicher gegen die in der Therapie eingesetzten Antibiotika. Die Persistenz vonB. burgdorferi s.l. und Rezidive der Erkrankung nach der Antibiotikatherapie werden diskutiert.

Long-term in vitro cultivation of Borrelia burgdorferi sensu lato strains: influence on plasmid patterns, genome stability and expression of proteins

Low (7th) and high (298th/304th) in vitro passages (cultivated over a period of 3 years) of two human Borrelia burgdorferi sensu lato strains, PKo (B. afzelii) and PBi (B. garinii) were compared by pulse-field gel electrophoresis, Southern blot, sequencing of the ospA gene, SDS-PAGE and Western blot. Digestion of genomic DNA with ApaI, BssHII, KspI, MluI, SmaI and XhoI did not reveal any differences between low and high passages. The loss of two linear plasmids with sizes of 6 and 31 kbp was detected in strain PKo between passages 34-50 and 101-304, respectively, whereas the ospA-carrying plasmid remained unchanged. In contrast, analysis of linear plasmid profiles obtained from low and high passages of B. garinii strain PBi showed no differences. Sequence analysis of the ospA gene demonstrated no difference in the strain PBi and one nucleotide exchange in the strain PKo when low and high passages were compared. The observed transition (G-A) in the third codon position did not alter the amino acid sequence. However, the rate of expression of the outer surface proteins OspA, OspB and OspC of strain PKo during low and high stages of cultivation varied significantly. In summary, our data suggest that the B. burgdorferi sensu lato genome is stable during long-term in vitro cultivation.

High-dose streptokinase therapy with three million units in one hour significantly improves early coronary patency rates in acute myocardial infarction

In a prospective, randomized open trial, significantly higher patency rates were observed 60 minutes after beginning fibrinolytic therapy for acute myocardial infarction after administration of 3 million U streptokinase as compared to 1.5 million U (Thrombolysis in Myocardial Infarction [TIMI] grade 2 and 3 in 52% vs 26%; p = 0.04). Adverse events were observed with similar frequency in both groups.

Increased hemolysis during coronary perfusion via angioplasty catheters as a result of side-hole jet effect

Hemolysis is one of the known possible problems that can occur with selective coronary perfusion through the dilatation catheter. In the present study we determined in vivo and in vitro the hemolysing effect of selective blood perfusion through different catheter types, using a specially designed perfusion pump. The in-vitro tests revealed that hemolysis was not directly determined by pump pressure, but by catheter design and flow rate. The side holes of the Gruntzig catheters were found to cause hemolysis, when blood was leaving through them in a jet like fashion.

Management von Komplikationen bei PTCA in einer Klinik ohne angeschlossene Herzchirurgie

Die PTCA ist eine sehr erfolgreiche (Primarerfolg > 90%) und sichere (Letalitat < 1%, Notoperationen um 2%, Infarkte < 5%) Therapie geworden (4, 6, 10, 12). Dies hat de facto eine zunehmende Lockerung der strengen chirurgischen Stand-by-Regelung bewirkt: Die Mehrzahl der interventionell tatigen Katheterlabors in der Bundesrepublik verfugt uber keine eigene Herzchirurgie, immer mehr Koronardilatationen werden ohne direkte Absprache mit den Herzchirurgen durchgefuhrt. Die Fahigkeiten des Operateurs, die Qualitat des verfugbaren Instrumentariums sowie eine Reihe patienten- bzw. stenosespezifischer Merkmale bestimmen Auftreten und Beherrschbarkeit eines akuten Koronarverschlusses als der wesentlichsten PTCA-Komplikation (2, 12). Da prinzipiell bei jeder PTCA ein Akutverschlus induziert werden kann, mus der Operteur vor jedem Eingriff eventuelle Konsequenzen bedenken. Zu berucksichtigen sind die Grose des versorgten Myokardbezirks, die Kollateralversorgung, das Ausmas der eventuellen LVFunktionsstorung, die Wiedereroffnungschancen nach einem Verschlus, die Indikation und Dringlichkeit einer chirurgischen Notfallrevaskularisation (sofort einsatzbereiter OP-Saal zwingend, nachster frei werdender OP-Saal bei regular laufendem OP-Programm ausreichend?).

Pressure transmission characteristics of the Grüntzig superlow-profile catheter

The pressure transmission characteristics of the recently introduced Gruntzig super-low-profile catheter were evaluated for comparison with those of other coronary angioplasty catheters in clinical use. After thorough elimination of air bubbles from the pressure transmitting system the frequency response was linear (± 5%) up to 5 Hz and permitted recording of only minimally distorted arterial pressure tracings. With introduction of the 0.012’’ guide wire arterial pressure tracings remained adequate as long as the narrow catheter segment beginning just proximally to the balloon was not entered. Passage of the wire through the narrow distal segment resulted in severe overdamping even below 0.5 Hz.