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Die diastolische Herzinsuffizienz - Pathophysiologische Grundlagen, diagnostische Strategien, therapeutische Optionen
Schmidt AG,Pieske B
Journal für Kardiologie , 2012,

Abstract: Herzinsuffizienz ist die h ufigste Diagnose bei hospitalisierten Patienten im Alter 65 Jahre. Bei über der H lfte dieser Patienten liegt der Erkrankung eine prim r diastolische Funktionsst rung bei noch weitgehend erhaltener systolischer Pumpfunktion zugrunde. Das klinische Problem der diastolischen Herzinsuffizienz hat mittlerweile epidemische Ausma e angenommen. Die Pr valenz der diastolischen Herzinsuffizienz unterliegt einer deutlichen Altersabh ngigkeit; die Prognose ist schlecht und der systolischen Herzinsuffizienz vergleichbar. Zu den h ufigsten Ursachen der diastolischen Herzinsuffizienz z hlen arterielle Hypertonie, koronare Herzerkrankung und Diabetes mellitus. Die aus der jeweiligen Grunderkrankung resultierenden pathophysiologischen Mechanismen, die zu einer diastolischen Dysfunktion führen, sind noch unzureichend identifiziert. Rezente Studien zeigen zudem, dass eine Reihe von kardiovaskul ren Ver nderungen, die nicht direkt die diastolische Funktion betreffen, zum Syndrom diastolische Herzinsuffizienz beitragen. Trotz der klinischen Relevanz der diastolischen Herzinsuffizienz existiert bisher keine evidenzbasierte, die Prognose verbessernde Therapie. Einer frühzeitigen Diagnose und kausalen Therapie kommt deshalb eine besondere Bedeutung zu, um die Progression der Erkrankung zu verhindern und die Mortalit t zu senken.

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Effect of eplerenone on parathyroid hormone levels in patients with primary hyperparathyroidism: a randomized, double-blind, placebo-controlled trial
Tomaschitz Andreas,Fahrleitner-Pammer Astrid,Pieske Burkert,Verheyen Nicolas
BMC Endocrine Disorders , 2012, DOI: 10.1186/1472-6823-12-19

Abstract: Background Increasing evidence suggests the bidirectional interplay between parathyroid hormone and aldosterone as an important mechanism behind the increased risk of cardiovascular damage and bone disease observed in primary hyperparathyroidism. Our primary object is to assess the efficacy of the mineralocorticoid receptor-blocker eplerenone to reduce parathyroid hormone secretion in patients with parathyroid hormone excess. Methods/design Overall, 110 adult male and female patients with primary hyperparathyroidism will be randomly assigned to eplerenone (25 mg once daily for 4 weeks and 4 weeks with 50 mg once daily after dose titration] or placebo, over eight weeks. Each participant will undergo detailed clinical assessment, including anthropometric evaluation, 24-h ambulatory arterial blood pressure monitoring, echocardiography, kidney function and detailed laboratory determination of biomarkers of bone metabolism and cardiovascular disease. The study comprises the following exploratory endpoints: mean change from baseline to week eight in (1) parathyroid hormone(1–84) as the primary endpoint and (2) 24-h systolic and diastolic ambulatory blood pressure levels, NT-pro-BNP, biomarkers of bone metabolism, 24-h urinary protein/albumin excretion and echocardiographic parameters reflecting systolic and diastolic function as well as cardiac dimensions, as secondary endpoints. Discussion In view of the reciprocal interaction between aldosterone and parathyroid hormone and the potentially ensuing target organ damage, the EPATH trial is designed to determine whether eplerenone, compared to placebo, will effectively impact on parathyroid hormone secretion and improve cardiovascular, renal and bone health in patients with primary hyperparathyroidism. Trial registration ISRCTN33941607

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Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones
Oliver Pieske, Alexandra Wittmann, Johannes Zaspel, Thomas L？ffler, Bianka Rubenbauer, Heiko Trentzsch, Stefan Piltz
Journal of Trauma Management & Outcomes , 2009, DOI: 10.1186/1752-2897-3-11

Abstract: From 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031).With the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 €/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.The development of non-unions depends on several factors, such as energy-level of trauma, type of fracture, soft tissue involvement, type of applied treatment, and various endogenous factors [1-3]. According to literature, non-union will occur in approximately 10% of fractures after conservative or operative trea

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Natriuretic peptide vs. clinical information for diagnosis of left ventricular systolic dysfunction in primary care
Janka Koschack, Martin Scherer, Claus Lüers, Michael M Kochen, Dirk Wetzel, Sibylle Kleta, Claudia Pouwels, Rolf Wachter, Christoph Herrmann-Lingen, Burkert Pieske, Lutz Binder
BMC Family Practice , 2008, DOI: 10.1186/1471-2296-9-14

Abstract: N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, clinical information, and echocardiographic data of left ventricular systolic function were collected in 542 family practice patients with at least one cardiovascular risk factor. We determined the diagnostic power of the NT-proBNP assessment in ruling out left ventricular systolic dysfunction and compared it to a risk score derived from a logistic regression model of easily acquired clinical information.23 of 542 patients showed left ventricular systolic dysfunction. Both NT-proBNP and the clinical risk score consisting of dyspnea at exertion and ankle swelling, coronary artery disease and diuretic treatment showed excellent diagnostic power for ruling out left ventricular systolic dysfunction. AUC of NT-proBNP was 0.83 (95% CI, 0.75 to 0.92) with a sensitivity of 0.91 (95% CI, 0.71 to 0.98) and a specificity of 0.46 (95% CI, 0.41 to 0.50). AUC of the clinical risk score was 0.85 (95% CI, 0.79 to 0.91) with a sensitivity of 0.91 (95% CI, 0.71 to 0.98) and a specificity of 0.64 (95% CI, 0.59 to 0.67). 148 misclassifications using NT-proBNP and 55 using the clinical risk score revealed a significant difference (McNemar test; p < 0.001) that was based on the higher specificity of the clinical risk score.The evaluation of clinical information is at least as effective as NT-proBNP testing in ruling out left ventricular systolic dysfunction in family practice patients at risk. If these results are confirmed in larger cohorts and in different samples, family physicians should be encouraged to rely on the diagnostic power of the clinical information from their patients.Early detection of left ventricular systolic dysfunction is important, since early treatment with ACE inhibitors has been shown to delay the progression toward overt congestive heart failure (CHF) and to prolong life [1]. Since diagnosis of left ventricular systolic dysfunction solely based on clinical symptoms may be difficult [2], echocardiograph

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Heart failure therapy in diabetic patients-comparison with the recent ESC/EASD guideline
Frank Edelmann, Rolf Wachter, Hans-Dirk Düngen, Stefan St？rk, Annette Richter, Raoul Stahrenberg, Till Neumann, Claus Lüers, Christiane E Angermann, Felix Mehrhof, G？tz Gelbrich, Burkert Pieske, the German "Competence Network Heart Failure"
Cardiovascular Diabetology , 2011, DOI: 10.1186/1475-2840-10-15

Abstract: 3304 patients with heart failure from 9 different studies were included (mean age 63 ± 14 years); out of these, 711 subjects had preserved left ventricular ejection fraction (≥ 50%) and 994 patients in the whole cohort suffered from diabetes.The majority (>90%) of heart failure patients with reduced ejection fraction (SHF) and diabetes were treated with an ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) or with beta-blockers. By contrast, patients with diabetes and preserved ejection fraction (HFNEF) were less likely to receive these substance classes (p < 0.001) and had a worse blood pressure control (p < 0.001). In comparison to patients without diabetes, the probability to receive these therapies was increased in diabetic HFNEF patients (p < 0.001), but not in diabetic SHF patients. Aldosterone receptor blockers were given more often to diabetic patients with reduced ejection fraction (p < 0.001), and the presence and severity of diabetes decreased the probability to receive this substance class, irrespective of renal function.Diabetic patients with HFNEF received less heart failure medication and showed a poorer control of blood pressure as compared to diabetic patients with SHF. SHF patients with diabetes were less likely to receive aldosterone receptor blocker therapy, irrespective of renal function.Heart failure is a major public health burden and the lifetime risk of developing heart failure in a 40 year old is around 20% [1]. About 50% of patients presenting with heart failure have normal ejection fraction (HFNEF) [2,3]. Recent research revealed that mortality of hospitalized patients with HFNEF is comparable to patients with systolic heart failure (SHF). However, in most heart failure trials, HFNEF patients were largely underrepresented.Diabetes is a growing epidemiological burden and a major contributor to cardiovascular disease. In male patients with diabetes, the risk to develop heart failure is doubled in comparison to non-diabetic patients,

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Neurohormones as Predictors of Outcome in an Elderly Heart Failure Population Na ve of Neurohormonal Blockers Results from the CIBIS III Neurohormonal Substudy
Friedrich M. Fruhwald, Astrid Fahrleitner-Pammer, Barbara Obermayer-Pietsch, Michael A. Goulder, Henry Krum, Dirk J. van Veldhuisen, Louis van de Ven, Patricia Verkenne, Burkert Pieske, Wilfried MeyerRonnie WillenheimerObjectives:Methods:Results:Conclusion:
Open Heart Failure Journal , 2008, DOI: 10.2174/1876535100801010009]

Abstract: Objectives: Although neurohormones have a well-established prognostic value in patients with chronic heart failure (CHF), little is known about this in CHF patients untreated with angiotensin-converting enzyme (ACE)-inhibitors, angiotensin-receptor blockers (ARBs) and beta-blockers. Methods: Baseline N-terminal pro atrial natriuretic peptide (NT-pro-ANP), N-terminal pro B-type natriuretic peptide (NTpro- BNP), big endothelin (big-ET) and arginine-vasopressin (AVP) were tested for prognostic importance to predict the primary endpoint (death or hospitalisation) in 109 patients participating in the third Cardiac Insufficiency BIsoprolol Study(CIBIS III). Minimum follow-up time was 12 months (6 months monotherapy followed by 6 months combinationtherapy). Results: On average, patients had moderate elevation of all neurohormones tested. In univariate analysis, both belowmedian NT-pro-BNP (HR 0.37, 95% confidence interval [CI] 0.17-0.81, p=0.013) and below-median big-ET (HR 0.39, 95% CI 0.18-0.86, p=0.02) predicted decreased risk of all-cause death or hospitalisation, compared with above-median values. NT-pro-BNP lost its predictive power in multivariate analysis, while big-ET above median as well as body mass index (BMI) below median and presence of ischemic heart disease were predictive of increased risk of death or hospitalisation. Using Cox stepwise regression analysis, only BMI (p=0.011) and big-ET (p=0.003) remained significant predictors of death or hospitalisation. Conclusion: In a cohort of elderly CHF patients na ve of ACE-inhibitors, ARBs and beta-blockers, the best predictors of all-cause death or hospitalisation were a low BMI and elevated levels of big-endothelin.

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The Mélange of Innovation and Tradition in Maltese Law: The Essence of the Maltese Mix?
B Andò
Potchefstroom Electronic Law Journal/Potchefstroomse Elektroniese Regsblad , 2012,

Abstract: Aim of this paper is to provide valuable insights into the Maltese legal system with a special focus on private law. The assumption is that this legal system is the byproduct of the "mixing" of innovation and tradition, resulting from the interaction of English law and continental law. A major role in the development of the system is played by courts. Some examples (moral damages and pre-contractual liability) are considered which highlight the importance of the function displayed by Maltese judges. KEYWORDS: Tradition; English law; continental law; hybridity; mixed legal systems; Maltese courts; moral damages; pre-contractual liability; lacunae

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PROBLEMS OF FLIGHT PERSONNEL PREPARATION FOR MODERN AIRCRAFTS П ДГОТОВКА ЛЬОТНОГО СКЛАДУ НА СУЧАСН ПОВ ТРЯН СУДНА П ДГОТОВКА ЛЬОТНОГО СКЛАДУ НА СУЧАСН ПОВ ТРЯН СУДНА
B. Харченко,О. Ал？кс？？в,Д. Бабейчук,М. Повознюк
Proceedings of National Aviation University , 2011,

Abstract: At present, the problem who can and who should solve the question concerning the preparationand recurrent training of pilots of Ukrainian civil aviation is not solved. The necessity of updatingof aircraft’s park in aviation branch and aircraft operation, which was ripened 10 years ago,demands a corresponding infrastructure. It is necessary to understand, that the pilots ready toperform the flights on modern aircrafts, will not appear by themselves, therefore the real actions onmodernization of existing system of aircrew and the aviation personnel preparation as a whole arerequired. Main objective of this work is the determination of the basic components concerning thesolving of the problematic questions on preparation of aircrew on modern types of aircrafts. Duringthe problem analysis it was specified that the present development of system of aircrew preparationin Ukraine is not perfect, and does not correspond the ICAO and EU requirements, therefore needsan immediate intervention at the highest State level. Trainings are not complex, as do not containthe elements of selection of aircrew members cooperation. Programs of recurrent training ofaircrew, courses of pilots training flight preparation were not reconsidered for many years Розглянуто проблему п дготовки п лот в цив льно ав ац Уккра ни, яка на сьогодн нев дпов да вимогам ICAO та С. Визначено основн складов п дготовки льотного складу насучасн пов трян судна.Ключов слова: аеронав гац йне обслуговування, керована множина, керован об’ кти,рад олокац йне та рад онав гац йне забезпечення польот в, системи керування пов трянимрухом. Розглянуто проблему п дготовки п лот в цив льно ав ац Уккра ни, яка на сьогодн нев дпов да вимогам ICAO та С. Визначено основн складов п дготовки льотного складу насучасн пов трян судна.

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METHOD OF SYNTHESIS OF PROBLEM QUALITY OF THE COMPLEX NONLINEAR DYNAMIC SYSTEM CONTROL МЕТОД ГАРАНТОВАНОГО ОЦ НЮВАННЯ ОБЛАСТ ПОВН СТЮКЕРОВАНОГО СТАНУ СКЛАДНО НЕЛ Н ЙНО ДИНАМ ЧНО СИСТЕМИ МЕТОД ГАРАНТОВАНОГО ОЦ НЮВАННЯ ОБЛАСТ ПОВН СТЮ КЕРОВАНОГО СТАНУ СКЛАДНО НЕЛ Н ЙНО ДИНАМ ЧНО СИСТЕМИ
С. Павлова,B. Павлов,В. Чеп？женко
Proceedings of National Aviation University , 2011,

Abstract: Substantially nonlinear objects function at limitations of arbitrary kind. These limitations are not necessarily convex areas. For such objects the construction of area of the fully the fully-controlled state area is a serious problem. In the article it has been suggested to replace this task the task of the fully-controlled state area estimation from within. The secure estimation method of the fully-controlled state area has been developed for this purpose. Other dynamic system has been used as a tester (measure) of the fully-controlled state area. Construction and estimation of controllability and accessibility area of this dynamic system well methodically validate and deserved researchers confession. The descriptions concordance requirements of this new object with properties of initial object must be executed and provide property of immersion of new object in an initial object. Possibility is thus opened on the the fully-controlled state area of new object to define the the fully-controlled state area of the initial system На основ процедури мерсування м рних об’ кт в у вих дний об’ кт розроблено методгарантованого оц нювання област повн стю керованого стану.On the basis of procedure of immersion of the measuring objects in an initial object the secureestimation method of the fully controlled state area has been developed.На основе процедуры иммерсирования мерных объектов в исходный объект разработанметод гарантированного оценивания области полностью управляемого состояния. Показано, що для стотно нел н йних об’ кт в, що функц онують в умовах наявност обме-жень дов льного виду, як не обов’язково опуклими областями, побудова област повн стюкерованого стану проблематична. Запропоновано зам нити це завдання оц нюванням област повн стю керованого стану зсередини. Для цього розроблено метод гарантовано оц нюванняобласт повн стю керованого стану. Як вим рника (м ра) област повн стю керованого станувикористана нша динам чна система, п

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