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Biomedical subjects

E Nagel

Publications and source records attributed to E Nagel.

At least 37 records · Page 2Linked to original sources

[Basic ethical aspects of living organ donation].

A characteristic feature of transplanting organs from living donors is that not only patients in need for treatment but also healthy individuals are submitted to medical interventions. Ethical considerations in this field have to deal with the question of property attributes of the human body and conflicts with traditional medical principles. Altruistic organ donation, appreciated by Christianity as a sign of charity, is indeed contradictory to the classic maxim of medical ethics "primum nihil nocere, " meaning "first of all, do not harm." The autonomous choice of a potential donor has to be balanced thoroughly against his personal physical and psychological risks. Apart from organ donation with altruistic motives, commercial incentives or payment for organ donation, which are increasingly under discussion in many nations, need profound ethical reflection. Organ selling does not lead to long-term economic benefit for individual donors in developing countries and is associated with a decline in health. A market system of organ sales would foster exploitation of the poor, and it is substantially doubtful whether autonomy and self determination are valid under circumstances of poverty and coercion. Commodification of the human body risks viewing persons as marketable objects. The human body,however, is an integral element of an individual's personality and not a resource to be removed. It is therefore fundamental that the social good of altruism is preserved as the major principle in organ donation.

Altruism↗

Improved functional cardiac MR imaging using the intravascular contrast agent CLARISCAN.

PURPOSE: Using segmented k-space turbo gradient echo MR techniques (TGE) contrast between blood and myocardium is often reduced in long axis views due to reduced in plane spin-refreshment, particularly in patients with low ejection fraction. The application of an intravascular contrast agent (CA) may improve endocardial border delineation. MATERIALS AND METHODS: In 15 patients cardiac cine loops in two long axis and two short axis views were acquired during breath hold using a TGE sequence without and with increasing doses of CA (0.75, 2.0, 5.0 mg Fe/kg). Two independent observers evaluated left ventricular function (LVEF, modified Simpson's rule) and assigned a visual score (range: 0 = 'not visualized' to 6 = 'excellent visualization') for endocardial border delineation. Signal- and contrast-to-noise ratios (SNR; CNR) were determined. RESULTS: Endocardial border delineation score for TGE was 1.7 +/- 0.6 and 3.9 +/- 0.6**, 4.4 +/- 0.5**, 4.6 +/- 0.4** for 0.75, 2.0, 5.0 mg Fe/kg of CA, respectively (**p < 0.01 vs. TGE). SNR of blood increased significantly with any dose of CA with a mild drop of myocardial SNR resulting in a significant increase of CNR blood/myocardium. The maximum effect with 2.0 mg Fe/kg was a >2-fold CNR increase. Inter- and intraobserver variability assessed according to the method of Bland-Altmann was reduced at 2.0 mg Fe/kg for determination of LVEF and reached statistical significance for LVEF <50%. CONCLUSION: Intravascular CA increased CNR between blood and myocardium by a factor >2 and significantly improved the determination of cardiac volumes. The benefit in accuracy was most for patients with left ventricular ejection fraction <50%.

Aged↗

[Assessment of the quality of life of patients with peripheral vascular diseases].

The Medical Outcome Short Form 36 is commonly used as a generic quality of life measure in the assessment of vascular disease. The Claudication Scale CLAU-S, the PAVK-86 Fragebogen, and the Walking Impairment Questionnaire WIQ are validated disease-specific questionnaires for intermittent claudication. A disease specific tool for critical ischaemia is lacking. Quality of life of patients with peripheral arterial occlusive disease is not only impaired in the physical functioning domains (mobility, self care, activities of daily living), but moreover in their social and emotional wellbeing. This situation worsens under conservative treatment. Angioplasty and operation produce similar improvements in all dimensions of hrQOL. As radiological interventional procedures just aim to improve hrQOL and do not bring a definite cure for the underlying disease, patients perception of their quality of life should be taken into account both in the indication for angioplasty and for the scientific evaluation of new treatment modalities.

Activities of Daily Living↗

Functional analysis of retinal vessel diameter reaction to artificially raised intraocular pressure in glaucoma patients with and without dorzolamide therapy.

BACKGROUND: Examination of the influence of dorzolamide on the autoregulation of retinal vessel diameter in glaucoma patients. PATIENTS AND METHODS: Eleven patients with primary open angle glaucoma (age 60 +/- 11) without medication and four weeks after starting therapy with dorzolamid eye drops three times daily were examined in the study. Short-time rise of intraocular pressure (IOP) was obtained via suction-cup. Functional reaction of the diameter of a segment of a retinal artery and corresponding vein were assessed by retinal vessel analyzer. RESULTS: Dorzolamid lowered the IOP from 23.3 +/- 1.3 to 17.6 +/- 2.2 mmHg (p = 0.004). Therapy did not influence the absolute diameter of retinal vessels regarding maximal dilatation caused by the pressure rising provocation. In eyes with treatment the diameter decreased faster to baseline values (arteries 100 sec, veins 220 sec) compared to those without treatment (arteries 350 sec, veins 480 sec). CONCLUSION: Dorzolamid might possibly be able to accelerate autoregulation of retinal vessels in response to short term artificial IOP increase.

Adult↗

Retinal Vessel Analysis--new possibilities.

Retinal Vessel Analysis is a new technique to assess behavior of large retinal vessels based on diameter measurements. The Retinal Vessel Analyzer (RVA) measures continuously on-line obtaining data in relation to time and local position. Possible analysis tools include (a) Time Course Analysis of physiological, pathological, or therapy induced changes; (b) Local Course Analysis to recognize local narrow or wide vessel segments along the vessel; (c) Vasomotoric Analysis to determine vasomotions and blood pressure related diameter changes; (d) Functional Analysis to examine dynamic behavior e.g. the ability to autoregulate and (e) Functional Imaging to visualize functional parameters of vessels in single vessel segments. RVA is thus able to recognize and study different autoregulation mechanisms.

Fluorescein Angiography↗

Coronary magnetic resonance angiography for the detection of coronary stenoses.

BACKGROUND: An accurate, noninvasive technique for the diagnosis of coronary disease would be an important advance. We investigated the accuracy of coronary magnetic resonance angiography among patients with suspected coronary disease in a prospective, multicenter study. METHODS: Coronary magnetic resonance angiography was performed during free breathing in 109 patients before elective x-ray coronary angiography, and the results of the two diagnostic procedures were compared. RESULTS: A total of 636 of 759 proximal and middle segments of coronary arteries (84 percent) were interpretable on magnetic resonance angiography. In these segments, 78 (83 percent) of 94 clinically significant lesions (those with a > or = 50 percent reduction in diameter on x-ray angiography) were also detected by magnetic resonance angiography. Overall, coronary magnetic resonance angiography had an accuracy of 72 percent (95 percent confidence interval, 63 to 81 percent) in diagnosing coronary artery disease. The sensitivity, specificity, and accuracy for patients with disease of the left main coronary artery or three-vessel disease were 100 percent (95 percent confidence interval, 97 to 100 percent), 85 percent (95 percent confidence interval, 78 to 92 percent), and 87 percent (95 percent confidence interval, 81 to 93 percent), respectively. The negative predictive values for any coronary artery disease and for left main artery or three-vessel disease were 81 percent (95 percent confidence interval, 73 to 89 percent) and 100 percent (95 percent confidence interval, 97 to 100 percent), respectively. CONCLUSIONS: Among patients referred for their first x-ray coronary angiogram, three-dimensional coronary magnetic resonance angiography allows for the accurate detection of coronary artery disease of the proximal and middle segments. This noninvasive approach reliably identifies (or rules out) left main coronary artery or three-vessel disease.

Adult↗

Comparison of magnetic resonance real-time imaging of left ventricular function with conventional magnetic resonance imaging and echocardiography.

This study analyzes the accuracy of a new real-time magnetic resonance imaging (MRI) technique (acquisition duration, 62 ms/image) and echocardiography for the determination of left ventricular (LV) end-diastolic volume, end-systolic volume, ejection fraction, and muscle mass when compared with turbo gradient echo imaging as the reference standard. Thirty-four patients were examined with digital echocardiography, standard, and real-time MRI. A close correlation was found between the results of real-time imaging and the reference standard for end-diastolic volume, end-systolic volume, and ejection fraction (r >0.95), with a lower correlation for LV muscle mass (r = 0.81). Correlations between echocardiography and the reference standard were lower for all parameters. Real-time MRI enables the acquisition of high-quality cine loops of the entire heart in minimal time without electrocardiographic triggering or breath holding. Thus, patient setup and scan time can be reduced considerably. Results are similar to the reference standard and superior to echocardiography for determining LV volumes and ejection fraction. This technique is a valid alternative to current approaches and can form the basis of every cardiac MRI examination.

Adult↗

Multi-slice dynamic imaging: complete functional cardiac MR examination within 15 seconds.

A new magnetic resonance (MR) sequence was developed to acquire real-time images in a multi-slice dynamic imaging mode to cover the complete heart in 15 seconds without the need for electrocardiogram (ECG) triggering and multiple breath holds. In 34 patients, left ventricular function was assessed with the new technique and a standard technique. The new technique proved to be feasible and accurate for functional cardiac examinations.

Adult↗

Magnetic resonance flow measurements in real time: comparison with a standard gradient-echo technique.

Ultrafast gradient systems and hybrid imaging sequences offer the opportunity to acquire phase contrast flow data in real time. In a 1.5-Tesla magnetic resonance (MR)-tomograph, peak velocity and volume flow were assessed in 36 large vessels (aorta) and 33 medium-sized vessels (carotid and iliac artery) using a real-time (segmented k-space turbo gradient-echo planar imaging sequence) in comparison with a gradient-echo technique. With the real-time technique, the matrix was reduced from 116 to 64, and temporal resolution changed from 30 msec to 124 msec. Measurements of peak velocity correlated in large (r = 0.88) and medium-sized vessels (r = 0.81). Volume flow measurements correlated in large vessels (r = 0.87), however, a poor correlation (r = 0.64) was found in medium-sized vessels. Thus, scan time can be significantly reduced and images acquired without electrocardiogram (ECG)-triggering. Flow volume can only be determined in large vessels with sufficient accuracy, mainly due to reduced spatial resolution in smaller vessels.

Blood Flow Velocity↗

Functional cardiac MR imaging with steady-state free precession (SSFP) significantly improves endocardial border delineation without contrast agents.

Contrast between blood and myocardium in standard turbo gradient echo MR techniques (TFE) used routinely in clinical practice is mainly caused by unsaturated inflowing blood. Steady-state free precession (SSFP) has excellent contrast even in the absence of inflow effects. In 45 subjects cardiac cine loops in two long axis projections were acquired using TFE and compared with SSFP. A visual score (range 0 worst - 3 best) was assigned for endocardial border delineation for six myocardial segments in two long axis views. Endocardial border delineation score for TFE was 1.3 +/- 0.3 per segment and 2.4 +/- 0.3 for SSFP (P < 0.0001). Signal intensity blood/signal intensity myocardium was 1.5 +/- 0.4 at enddiastole and 1.4 +/- 0.3 at systole for TFE and 3.5 +/- 1.1 and 3.2 +/- 1.3 for SSFP, respectively (P < 0.0001). SSFP increases contrast between blood and myocardium more than twofold, resulting in an improved endocardial border definition. This may reduce variability for the determination of cardiac volumes and ejection fraction.

Adult↗

Accelerated coronary MRA by simultaneous acquisition of multiple 3D stacks.

The implementation and first in vivo results of a novel coronary magnetic resonance angiography (MRA) protocol allowing simultaneous acquisition of multiple geometrically independent 3D imaging stacks are presented. Each imaging stack is acquired in a separate cardiac phase using an individual magnetization preparation and navigator-based gating and prospective motion correction. Each stack covers one of the main coronary vessels. Thus, an improvement of scan efficiency was achieved, which was used in this study to reduce total scan time at standard image quality. Experiments performed in healthy volunteers and in patients using a two-stack approach yielded a total scan time reduction of 50% with an image quality equivalent to standard single-stack coronary MRA.

Adult↗

[Comparison of various parameters for determining an index of myocardial perfusion reserve in detecting coronary stenosis with cardiovascular magnetic resonance tomography].

For the assessment of myocardial perfusion with cardiac magnetic resonance imaging, different semiquantitative parameters of the first pass signal intensity time curves can be calculated and myocardial perfusion reserve indices can be determined. In this study we evaluated the feasibility of different perfusion parameters and their perfusion reserve indices for the detection of significant coronary artery stenosis. The signal intensity time curves of the first pass of a gadolinium-DTPA bolus injected via a central vein catheter before and after dipyridamole infusion were investigated in 15 patients with single vessel (stenosis > or = 75% area reduction) and five patients without significant coronary artery disease. For the distinction of ischemic and nonischemic myocardial segments, semiquantitative parameters, such as maximal signal intensity, contrast appearance time, time to maximal signal intensity and the steepness of the signal intensity curve's upslope determined by a linear fit, were assessed after correction for the input function. For each parameter a myocardial perfusion reserve index was calculated and cut off values for the detection of significant coronary stenosis were defined. The diagnostic accuracy of each parameter was then examined prospectively in 36 patients with coronary artery disease and compared with coronary angiography. Where as a distinction of ischemic and normal myocardium was possible with myocardial perfusion reserve indices, semiquantitative parameters at rest or after vasodilation alone did not allow such a distinction. The perfusion reserve index calculated from the upslope showed the most significant difference between ischemic and nonischemic myocardial segments (1.19 +/- 0.4 and 2.38 +/- 0.45, p < 0.001) followed by maximum signal intensity, time to maximum signal intensity and contrast apperance time. Sensitivity, specificity and diagnostic accuracy was 87, 82 and 85% for the detection of hypoperfusion induced by significant coronary artery stenoses using the perfusion reserve index calculated from the upslope. The steepness of the first pass signal intensity curve's upslope, determined by a linear fit, is a feasible parameter for the detection of significant coronary artery disease with MR. Based on a myocardial perfusion reserve index of this parameter, ischemic myocardium can be identified with high diagnostic accuracy.

Adult↗

[Chronic cholecystitis simulating gallbladder tumor with liver abscess. Case report].

We report on a 58 year-old male who presented with nausea, a painful tumor palpable in the upper right epigastrium, moderate fever without leukocytosis. Both ultrasonic scan and subsequent computerized tomography lead to the primary diagnosis of a malignant tumor of the gall bladder infiltrating the liver and inducing an intrahepatic abscess formation in segments 4b and 3. The patient was scheduled for emergency operation, i.e. abscess drainage, cholezystectomy, and hemihepatectomy. However, at operation a purulent chronic cholezystitis was found without involvement of the liver itself. Consequently, a cholezystectomy was necessary and performed. Histological examination of the gall bladder revealed no signs of malignancy. The patient had an uneventful recovery and was discharged on post-operative day seven. This case report shows the difficulties in the differential diagnosis of inflammable processes and malignancies, which affect the gall bladder and adhering structures. A chronic inflammable process can mimic solid tumors. Despite cost-effective diagnostic tools the correct diagnosis was finally found by surgery.

Cholecystectomy↗

Preconditioning with the prostacyclin analog epoprostenol and cobra venom factor prevents reperfusion injury and hyperacute rejection in discordant liver xenotransplantation.

Liver xenografts transplanted from guinea pig to rat suffer from inadequate organ reperfusion and initial dysfunction, despite sufficient complement depletion using cobra venom factor (CVF). Reperfusion injury is prevented when complement depleted donors are treated with the prostacyclin analog epoprostenol. Histological analysis suggests that epoprostenol preconditioning prevents post-reperfusion spasms of the intrahepatic branches of the portal vein and strongly reduces appearance of hepatocyte apoptosis shortly after transplantation. Cobra-venom-treated rats show breakdown of glucose metabolism and die in acute hypoglycaemia, whereas the additional application of epoprostenol restores gluconeogenesis. Consequently, recipient survival after epoprostenol and CVF treatment is significantly improved compared with animals receiving CVF only (5.1 +/- 2.6 h vs. 17.9 +/- 5.1 h). These data demonstrate that initial dysfunction of discordant liver grafts in the guinea-pig-to-rat species combination, can be overcome by the application of epoprostenol combined with CVF. Using this pharmacologic regimen, the discordant guinea-pig-to-rat model appears useful to study further questions concerning functional and immunological compatibility of a discordant liver xenograft.

Animals↗

[Measurement of the diameter of segments of retinal branch vessels in digital fundus images - An experimental study of the method and reproducibility].

PURPOSE: The aim of this study was the evaluation of new algorithms to measure diameter of segments of retinal branch vessels offline in local dependence and independent by observer. Methods 360 flashed fundus images (camera FF 450 ZEISS Germany, Visualis IMEDOS GmbH Weimar/Germany) of 12 eyes of healthy volunteers (10 independent sessions containing 3 images for every eye) were analysed. Algorithms detect the vessel diameter along the vessel course automatically. Corresponding segments of a retinal artery and vein were examined (mean length of the segment 2.5 mm) in every image of one eye. Results The marked arterial segment was detected automatically in 359 pictures and the venous segment in all pictures. The mean vessel diameter was detected in single pictures with a mean coefficient of variation (CV) for arteries of 3.4 % and for veins of 2.7 %. The differences of arterial and venous diameter between images were not significant. Analyzing sessions the CV of the mean vessel diameter were reduced for arteries to 2.7 % and for veins to 2.5 %. The standard deviation of the mean vessel diameter was independent of the vessel diameter (branch vessels with diameter of 120 to 200 micrometer). The mean CV of the vessel diameter at single locations were 5.7 % for arteries and 3.8 % for veins. Conclusions The new algorithms are useful for retinal vessel analysis, if there are no questions concerning the dynamic of vessel behaviour.

Adult↗

Improvement of myocardial perfusion reserve early after coronary intervention: assessment with cardiac magnetic resonance imaging.

OBJECTIVES: The purpose of this study was to determine the potential value of magnetic resonance myocardial perfusion in the follow-up of patients after coronary intervention. BACKGROUND: In some patients a residual impairment of myocardial perfusion reserve (MPR) early after successful coronary intervention has been observed. In this study we evaluated an MPR index before and after intervention with magnetic resonance. METHODS: Thirty-five patients with single- and multivessel coronary artery disease were studied before and 24 h after intervention. The signal intensity time curves of the first pass of a gadolinium-diethylene triamine pentacetic acid bolus injected via a central vein catheter were evaluated before and after dipyridamole infusion. The upslope was determined using a linear fit. Myocardial perfusion reserve index was estimated from the alterations of the upslope. RESULTS: The MPR index in segments perfused by the stenotic artery was significantly lower than in the control segments (1.07 +/- 0.24 vs. 2.18 +/- 0.35, p < 0.001) and improved significantly after intervention (1.89 +/- 0.39, p < 0.001) but did not normalize completely (p < 0.01). After intervention the MPR index remained significantly lower in the balloon percutaneous transluminal coronary angioplasty group (1.72 +/- 0.38; n = 13) in comparison with the stent group (1.99 +/- 0.36, n = 18, p < 0.05). In the stent group a complete normalization of the MPR index was found 24 h after stenting. CONCLUSIONS: Magnetic resonance perfusion measurements allow a reliable assessment of MPR index. An improvement of MPR index can be observed after coronary intervention, which is more pronounced after stenting. Magnetic resonance perfusion measurements allow the assessment and may be useful for the follow-up of patients with coronary artery disease after coronary intervention.

Angioplasty, Balloon, Coronary↗