P3668In non-critically ill patients suffering from endocarditis partial oral antibiotic therapy is non-inferior to intravenous therapy

Introduction

Antibiotic treatment for infective endocarditis is paramount typically consisting of intravenous therapy for up to eight weeks leading to long hospital stays. This often is associated with reduced quality of life for patients and might heighten complication rates. Recently, several trials evaluating the efficacy of partial oral treatment (switching to an oral antibiotic after an initial intravenous therapy for stabilization) versus an intravenous therapy were published. We here meta-analyze all available data.

Methods and results

Overall after screening 1848 studies at title and abstract level four studies including a total of 788 patients were included. Heterogeneity was assessed using the I2 statistic. Primary endpoint was all-cause mortality, secondary endpoint endocarditis relapse. Pooled event rates were obtained for each subset of studies and combined in a fixed-effect meta-analysis, and odds ratios were calculated using a fixed-effects model (Mantel-Haenszel).

A total of 765 patients suffered from primary left-sided endocarditis. From right-sided endocarditis suffered 72 patients. All treatment regimes were adjusted to susceptibility testing. Included patients were evaluated clinically and non-critically ill.

Rate of mortality was lower in partial oral versus intravenous strategy (OR 0.34 95% CI 0.17–0.68; p=0.003; I2 30%): In partial oral group, 11 of 379 patients died, whereas in the intravenous group, 33 of 409 patients died. Endocarditis relapse rates were not dissimilar between intravenous versus oral group (OR 0.55 95% CI 0.26–1.20; p=0.13; I2 0%) with, 10 of 459 patients in the partial oral group and 18 of 456 patients in the intravenous group evidencing a relapse.

Conclusion

Partial oral therapy is non-inferior to intravenous therapy with regards to endocarditis relapse in non-critically-ill patients suffering from both left- and right-sided endocarditis. In this meta-analysis, partial oral therapy was associated with lower mortality rates. This finding certainly needs validation in further future randomized trials comparing partial oral versus intravenous antibiotic treatment in non-critically-ill patients. As partial oral therapy allows shorter hospitalization it might be preferable and improve both quality of care and patients quality of life.

P2687Impact of cardiovascular risk factors on effectiveness of remote ischemic preconditioning in the setting of ischemia/reperfusion-injury in a langendorff heart model

Introduction

Cardiovascular diseases are the most frequent cause of death in the western world. During myocardial infarction both, ischemia and reperfusion after therapeutic intervention cause myocardial damages, resulting in ischemia/reperfusion-injury (I/R-injury). Research therefore searches cardio protective interventions, aiming to reduce myocardial injury and following consequences such as heart failure. A promising method, named Remote Ischemic Preconditioning (RIPC), consists of transient local ischemia distant from the heart. Its cardio-protective effects were already proved in basic research but failed in clinical trials.

Purpose

The aim of the study is to examine the impact of cardiac risk factors like diabetes mellitus (DM) or age on effectiveness of RIPC in order to identify distinct groups of patients who might benefit from RIPC in the clinical setting and to reveal the effectiveness of cardioprotection delivered by plasma samples of these groups of patients.

Methods

RIPC (3 x 5 min arm ischemia, induced by an inflated blood pressure cuff) was performed on young and healthy volunteers and elderly patients with coronary heart disease with or without diabetes mellitus. Blood was taken before (Baseline) and 30 minutes after the intervention. The coronary system of murine hearts in a Langendorff heart model was perfused using dialysate from the human plasma obtained before and after RIPC. This was followed by 40 minutes of global ischemia. After 60 minutes of reperfusion left ventricular function was analysed. The infarct size was measured after 120 minutes reperfusion time using a TTC staining.

Results

Addition of dialysate of plasma obtained from healthy volunteers after RIPC to the coronary system of Langendorff perfused murine hearts significantly improved the recovery of left ventricular developed pressure (39±15.1 vs 26±8.5% of baseline levels, p=0.04) and reduced the infarct size (37.5±15.6 vs 21.2±11.4% of the ventricular volume, p=0.03) compared to baseline-dialysate treated controls. While plasma dialysate obtained from elderly patients with DM undergoing RIPC failed to show significant cardio protective effects of RIPC, murine hearts treated with plasma dialysate of elderly patients with coronary heart disease without diabetes after undergoing RIPC showed significant improvement of cardiac function (20±6.5 vs 24±7% of baseline levels, p=0.02) and infarct size (33.2±8.0 vs 11.1±2.5% of the ventricular volume, p=0.01).

Conclusion

The cardio-protective effect of RIPC on myocardial function and infarct size after I/R is influenced by diabetes but not by age or the presence of coronary heart disease. In consequence, RIPC might protect patients with coronary heart disease without DM but not diabetic patients from cardiac I/R injury. This important finding potentially explains why RIPC yielded promising results in various basic science experiments but failed to show cardio protective effects in clinical trials.

Acknowledgement/Funding

Forschungskommission of the Faculty of Medicine of the Heinrich-Heine-University Düsseldorf

P3739Differences in short-term outcome between balloon- and self-expandable TAVR devices relating to more than one generation

Background

Transcatheter aortic valve replacement (TAVR) is the treatment option of choice in inoperable and high-risk patients and only recently even revealed favorable outcome in an intermediate risk cohort. Morbidity- and outcome relevant factors like paravalvular aortic regurgitation, vascular access complications and the need for permanent pacemaker implantation remain key challenges during balloon- and self-expandable valve-improvement.

Purpose

We aimed to address safety and effectiveness between balloon- and self-expandable TAVR devices relating to more than one generation.

Methods

Patients treated with TAVR between 2009 and 2018 were categorized into either balloon-expandable (BAVR, n=516) or self-expandable (SAVR, n=974) groups. TAVR endpoints and adverse events were defined according to the Valve Academic Research Consortium-2. Primary endpoint was 30-day mortality.

Results

Logistic EuroSCORE I as predictor for risk stratification and 30-day mortality was comparable between both cohorts (BAVR/SAVR: 25.7%±5.2 vs 25.5%±2.5; p=n.s). Compared to SAVR devices, BAVR devices had significantly higher periprocedural gradients (BAVR/SAVR: 11.7mmHg±0.1 vs 8.3mmHg±0.8; p=0.0175), lower incidence of new renal replacement therapy (BAVR/SAVR: 1.8% vs 4.6%; p=0.0025), and new permanent pacemaker therapy for conduction disturbances (BAVR/SAVR: 8.3% vs 17.3%; p<0.0001), but more frequently disabling bleeding (BAVR/SAVR: 3.9% vs 1.0%; p=0.0003) complications. 30-day mortality was significantly reduced in SAVR-patients (BAVR/SAVR: 4.4% vs 2.4%; p=0.0395). No difference could be observed concerning primary device success (BAVR/SAVR: 1.0%vs 2.0%; p=n.s.), incidence of moderate-to-severe paravalvular leakage (BAVR/SAVR: 3.2% vs 5.0%; p=n.s.), stroke (BAVR/SAVR: 3.3% vs 2.6%; p=n.s.), and major vascular complications (BAVR/SAVR: 2.7% vs 3.5%; p=n.s.).

Conclusion

Data from the retrospective analysis indicate lower incidence of renal replacement and pacemaker therapy, but higher periprocedural gradients, disabling bleeding complications, and enhanced 30-day mortality for the BAVR device as compared to SAVR. Other issues like paravalvular leackage/aortic regurgitation and stroke still remain unacknowledged.

P3745Differences in short-term outcome between early- and new-generation TAVR devices

Background

For transcatheter aortic valve replacement (TAVR) morbidity- and outcome relevant factors like paravalvular aortic regurgitation, vascular access complications and the need for permanent pacemaker implantation remain key challenges. New-generation devices for TAVR have been optimized to improve clinical outcome.

Purpose

We aimed to address safety and effectiveness of new-generation TAVR devices compared with earlier generations in a single centre study.

Methods

We compared 30 days outcome of the new-generation repositionable MER (n=614) and MEP (n=90) and the balloon-expandable ES3 (n=414) valve with the last-generation self-expandable MCV (n=270) and the balloon-expandable SXT (n=103) in patients treated with TAVR between 2009 and 2018. TAVR endpoints and adverse events were defined according to the Valve Academic Research Consortium-2.

Results

Logistic EuroSCORE I as predictor for risk stratification and 30-day mortality was comparable between both cohorts (27.3%±2.9 new vs 23.0%±1.4 early; p=n.s.). Compared to early-generation devices (MCV/SXT), new-generation devices (MER/MEP/ES3) had significantly higher primary device success (98.9% new vs 96.8% early; p=0.0089), lower incidence of new renal replacement therapy (2.6% new vs 6.2% early; p=0.0028), new permanent pacemaker therapy for conduction disturbances (12.8% new vs 17.0% early; p=0.0394), and disabling bleeding (1.4% new vs 4.0% early; p=0.0040). No difference could be observed concerning incidence of moderate-to-severe paravalvular leakage (4.2% new vs 5.0% early; p=n.s.), stroke (3.3% new vs 2.1% early; p=n.s.), major vascular complications (2.8% new vs 3.5% early; p=n.s.) and 30-day mortality (2.7% new vs 4.4% early; p=n.s).

Conclusion

Data from the retrospective analysis indicate higher primary device success and lower incidence of renal replacement, pacemaker therapy and disabling bleeding events in new-generation devices, although praised “hot-item” advantages like paravalvular leackage/aortic regurgitation, vascular complications and mortality remain unacknowledged.

P2274Single-center experience with different regimes of antiplatelet therapy and oral anticoagulation in transcatheter aortic valve replacement

Background

Antithrombotic therapy in transcatheter aortic valve replacement (TAVR) is highly controversial. Dual antiplatelet therapy (DAPT) for 3–6 months with aspirin and clopidogrel is the current recommendation. Whereas in patients with indication for OAC several regimes were described, ranging from OAC monotherapy to dual and even triple therapy. Besides vitamin K antagonists (VKA), non-Vitamin K oral anticoagulants (NOAC) are frequently used in TAVR patients with indication for permanent OAC.

Purpose

We therefore aimed to evaluated different antithrombotic regimes and their impact on outcome.

Methods

We performed a single center retrospective analysis in 1160 patients treated by transfemoral approach (TF TAVR). Primary endpoints were 30-day mortality, stroke and bleeding according to VARC-2 criteria. Secondary endpoint was all-cause mortality at 1 year.

Results

In 1160 patients with TF TAVR, a broad range of regimes occurred in clinical practice. The majority of patients were on DAPT (637 patients, 55.0%), followed by VKA + clopidogrel (186 patients, 16%). Other patients received OAC mono (98 patients; 9%), triple therapy (93 patients; 8%), NOAC mono (31 patients; 3%), single antiplatelet therapy (SAPT, 40 patients; 4%) or NOAC + clopidogrel (31 patients, 3%).

All-cause mortality 30 days after TF TAVR differed between the regimens. (SAPT/OAC+SAPT/N-OAC+DAPT 0.0% vs DAPT 3.6% vs OAC 10.2% vs. NOAC 1.3% vs NOAC+SAPT 0.3%; pANOVA<0.0001). Severe bleeding events were comparable (SAPT 5.0% vs DAPT 2.4% vs OAC 7.1% vs NOAC 1.3% vs OAC+SAPT 3.2% vs NOAC+SAPT 0.0% vs. N-OAC+SDPT 4.3%; pANOVA=0.15). Stroke rates were comparable in all subcohorts as well (SAPT 5.0% vs DAPT 3.0% vs OAC 7.1% vs NOAC 2.7% vs OAC+SAPT 1.6% vs NOAC+SAPT 0.0% vs. N-OAC+DAPT 1.1%; pANOVA=0.13). Only 2 hemorrhagic strokes (5.6%) appeared under DAPT and OAC mono respectively, whereas all others were of thromboembolic origin (94.4%). Surprisingly, all-cause mortality at one-year after TF TAVR was higher in OAC patients compared to all other used regimes (logrankoverallp=0.0012).

Conclusion

Data from our retrospective analysis indicate that a variety of different antithrombotic regimes occur even in a single centre analysis. All-cause mortality was enhanced in patients with oral anticoagulation. Therefore, clinical trials need to investigate if this is only explained by additional atrial fibrillation.

P957Survival benefits of routine glycoprotein IIb/IIIa inhibitors during primary PCI in ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials

Background

Cardiovascular guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPI) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI).

Purpose

This study aimed to evaluate routine GPI use in STEMI treated with primary PCI.

Methods

Online databases were systematically searched for randomised controlled trials (RCTs) of routine GPI vs. control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis using Mantel-Haenszel estimates of risk ratios (RR) as summary statistics.

Results

After systematic review, twenty-one RCTs with 8,585 patients were included: ten trials randomized tirofiban (T), nine abciximab (A), one eptifibatide (E), one trial used A+T; only one trial used DAPT with prasugrel/ ticagrelor. Routine GPI were associated with a significant reduction in all-cause mortality at 30 days (2.4% (GPI) vs. 3.2%; risk ratio (RR) 0.72; p=0.01) and 6 months (3.7% vs. 4.8%; RR 0.76; p=0.02), and a reduction in recurrent MI (1.1% vs. 2.1%; RR 0.55; p=0.0006), repeat revascularization (2.5% vs. 4.1%; RR 0.63; p=0.0001), TIMI flow <3 after PCI (5.4% vs. 8.2%; RR 0.61; p<0.0001) and ischemic stroke (RR 0.42; p=0.04). Major (4.7% vs. 3.4%; RR 1.35; p=0.005) and minor bleedings (7.2% vs. 5.1%; RR 1.39; p=0.006) but not intracranial bleedings (0.1% vs. 0%; RR 2.7; p=0.37) were significantly increased under routine GPI.

Conclusions

Routine GPI administration during primary PCI in STEMI resulted in mortality reduction, driven by reductions in recurrent ischemic events – however predominantly in trials pre-prasugrel/ticagrelor. Trials in contemporary STEMI management are needed to confirm these findings.

P1853Comparative evaluation of risk model performance for prediction of 30-day mortality in transcatheter aortic valve replacement

Background and purpose

EuroSCORE (ES) and Society of Thoracic Surgeons (STS) risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR), however their accuracy remains limited, especially in very old and high-risk patients. New and updated scoring models have thus been developed to improve risk stratification. We performed a comparative evaluation of classical and new risk scoring models for prediction of 30d mortality in transcatheter aortic valve interventions.

Methods and results

A total of 1,569 patients undergoing transfemoral (TF, n=1.235) or transapical (TA, n=334) TAVR from 2009 to 2018 were included in a single-center all-comer analysis. Six risk scoring models (logES_I, ES_II, STS-PROM, FRANCE-2, OBSERVANT, GAV-2) were calculated for all patients and evaluated for prediction of 30d mortality in their model discrimination (c-indices with 95% confidence intervals (CI)) and calibration (graphical evaluation). Mean classical risk scores confirmed an intermediate-to-high-risk patient collective (logES_I 27.0±16.9%; STS-PROM 7.0±6.4%), mean 30-day mortality was 3.4% (TF 2.3%; TA 7.8%). Overall discrimination performance was best in FRANCE-2 (c-index 0.73, 95% CI 0.67–0.80), followed by STS-PROM (c-index 0.68, 95% CI 0.62–0.75), OBSERVANT (c-index 0.68, 95% CI 0.61–0.76), ES_II (c-index 0.64) and logES_I and GAV-2 (both c-indices 0.63). FRANCE-2 discriminated best in TF TAVR (c-index 0.72; range of c-indices 0.63 to 0.72), while OBSERVANT performed best in TA TAVR (c-index 0.70; range of c-indices 0.61 to 0.70). All risk scoring models – with the exception of lowest-risk deciles of STS-PROM and ES_II – showed an overestimation of mortality probability in all risk strata.

Conclusion

FRANCE-2 and OBSERVANT risk models showed superior discrimination performance to classical risk scoring models in TF and TA TAVR, however all models tended to overestimate mortality probability.

Endoscopic submucosal dissection with a novel high viscosity injection solution (LiftUp) in an ex vivo model: a prospective randomized study

Introduction  Endoscopic submucosal dissection (ESD) is increasingly being used in the western world. Submucosal injectates are an essential tool for the ESD procedure. In this study, we evaluated a novel copolymer injectate (LiftUp, Ovesco, Tübingen Germany) in an established ESD model (EASIE-R) in comparison to existing submucosal injectables. Materials and methods  We conducted a prospective, randomized ex vivo study performing ESD with three injectates: LiftUp, hydroxyethyl starch (HAES 6 %) and normal saline solution (NaCl 0.9 %). A total of 60 artificial lesions, each 3 × 3 cm in size, were resected in an ex vivo porcine model, utilizing one of the three studied injectates (n = 20 ESDs per injectate). Study parameters were: en bloc resection rate, perforation rate, lifting property, time of injection, injectate volume, general ESD procedure time, and overall procedure time. Results  All 60 lesions were successfully resected using the standard ESD technique. LiftUp had no procedure related perforations, one perforation occurred in the HAES group, and two perforations in the NaCl group ( P  > 0.05). Furthermore, adequate lifting was achieved in 16/20 (80 %) using LiftUp, 6/20 (30 %) in the HAES group and 6/20 (30 %) in the NaCl group ( P  < 0.0002). En bloc resection was achieved in 19 (95 %) with LiftUp, in 20 (100 %) with HAES, and in 16 (80 %) with NaCl. General ESD procedure time and overall procedure time were not different among the three groups. Conclusion  LiftUp appears to be a safe alternative to established fluids for ESD. It had a significantly improved lifting effect and required significantly less injected volume compared to well-established lifting solutions.

Protein-losing gastropathy associated with cytomegalovirus in two sisters - Case reports and review of the literature

Ménétrier's disease is a protein-losing gastropathy that is uncommon in childhood. Its symptoms are unspecific, with abdominal pain, vomiting, and edema. Blood tests show hypoproteinemia and hypoalbuminemia, and upper digestive endoscopy reveals giant gastric folds. In children, cytomegalovirus has been identified as a possible cause. Here we describe two sisters presenting with Ménétrier's disease, 2 years apart. This diagnosis should be considered in the presence of hypoalbuminemia in children when a nephrotic syndrome is excluded.

Calculation of the Hadronic Vacuum Polarization Contribution to the Muon Anomalous Magnetic Moment

We present a first-principles lattice QCD+QED calculation at physical pion mass of the leading-order hadronic vacuum polarization contribution to the muon anomalous magnetic moment. The total contribution of up, down, strange, and charm quarks including QED and strong isospin breaking effects is a_{μ}^{HVP LO}=715.4(18.7)×10^{-10}. By supplementing lattice data for very short and long distances with R-ratio data, we significantly improve the precision to a_{μ}^{HVP LO}=692.5(2.7)×10^{-10}. This is the currently most precise determination of a_{μ}^{HVP LO}.

Administering atropine and ketamine before less invasive surfactant administration resulted in low pain scores in a prospective study of premature neonates

AIM

Less invasive surfactant administration (LISA) can avoid tracheal intubation for neonatal respiratory distress syndrome, but can be painful because it requires laryngoscopy. The aim of this study was to assess the efficacy and tolerance of intravenous atropine plus ketamine administration before LISA.

METHODS

We conducted a prospective observational study of all premature infants hospitalised in our French neonatal intensive care unit treated with LISA between March 2015 and March 2016. Ketamine was titrated by 0.5 mg/kg increments. The technical conditions, pain scores, emergent intubations and vital signs were collected and analysed.

RESULTS

Values are reported as medians (interquartile ranges). We included 29 patients with a gestational age of 29.6 (28.6-30.9) weeks and birth weight of 1290 (945-1600) grams. Technical conditions were satisfying for 24 infants (83%). The Faceless Acute Neonatal Pain Scale score was 2 (2-4); seven infants (24%) required tracheal intubation before LISA could be performed; 17 (59%) had a pulse oxymetry value under 80% that lasted more than 60 seconds. Heart rate and mean arterial blood pressure transiently increased.

CONCLUSION

Atropine plus ketamine before LISA resulted in low pain scores and stable haemodynamic parameters, but prolonged desaturations or apnoea leading to tracheal intubation were frequently observed.

A comparative analysis of psychological trauma experienced by children and young adults in two scenarios: evacuation after a natural disaster vs forced migration to escape armed conflict

OBJECTIVES

Little is known about the psychological trauma experienced by children and young adults (CYAs) following displacement after natural disasters vs migration from conflict zones. In both instances, the decision to leave is usually cast by the family, and the life of CYAs is suddenly disrupted by external circumstances.

STUDY DESIGN

An anonymous survey.

METHODS

The same survey instrument, provided by the National Child Traumatic Stress Network (NCTSN), was used to survey self-reported health needs among CYAs during the aftermath of Hurricane Katrina (Health Survey for Children and Adolescents After Katrina) in October 2005-February 2006 and again during the peak of refugee arrivals in Berlin between October 2015 and March 2016. A weighted index to measure cumulative exposure to traumatic stresses during migration was developed along with an unweighted psychological impact score based on the 22-item NCTS psychological impact questionnaire. Spearman's correlation coefficient (rho) was used to assess the correlation between age and the two psychological impact indices. The two-tailed t-test was used to investigate differences in trauma experienced and psychological impact by gender. Logistic regression was used to investigate differences in types of traumatic stress experienced and psychological impact among CYAs displaced because of Hurricane Katrina and those seeking asylum in Berlin.

RESULTS

The Katrina cohort included a total of 1133 CYAs, the Berlin cohort, a total of 405 CYAs. The median age in the Katrina cohort was 6.73 years (standard deviation [SD] 5.67, range 0-24; 50.13% males) compared with 17.64 years (SD, range 0-24; 83% males) in the Berlin cohort. Comparative analyses were adjusted to age and gender and revealed significant differences between the two cohorts, both with regards to the amount of trauma experienced and the psychological impact. A statistically significant and moderate positive correlation was observed between trauma experienced and psychological impact of migration in the refugee population (rho = 0.4955, P < 0.001); the correlation was less pronounced but still significant in the Katrina cohort (rho = 0.0942, P = 0.0015). Free-text responses revealed that in addition to common concerns about health, housing and safety, refugees were also pre-occupied with language acquisition and the adaptation to a new culture.

CONCLUSIONS

The observed differences in the experience and the consequences of trauma in displaced CYAs warrant additional investigation. It was replicated that human-made disaster seems to show more traumatising potential than natural disaster. Stakeholders need to be aware of the potential medium and long-term consequences of migration/evacuation and allocate resources accordingly.

Comparison of Validity of Mapping between Drug Indications and ICD-10

Background: Mapping of drug indications to ICD-10 was undertaken in Korea by a public and a private institution for their own purposes. A different mapping approach was used by each institution, which presented a good opportunity to compare the validity of the two approaches.

Objectives: This study was undertaken to compare the validity of a direct mapping approach and an indirect terminology based mapping approach of drug indications against the gold standard drawn from the results of the two mapping processes.

Methods: Three hundred and seventy-five cardiovascular reference drugs were selected from all listed cardiovascular drugs for the study. In the direct approach, two experienced nurse coders mapped the free text indications directly to ICD-10. In the indirect terminology based approach, the indications were extracted and coded in the Korean Standard Terminology of Medicine. These terminology coded indications were then manually mapped to ICD-10. The results of the two approaches were compared to the gold standard. A kappa statistic was calculated to see the compatibility of both mapping approaches. Recall, precision and F1 score of each mapping approach were calculated and analyzed using a paired t-test.

Results: The mean number of indications for the study drugs was 5.42. The mean number of ICD-10 codes that matched in direct approach was 46.32 and that of indirect terminology based approach was 56.94. The agreement of the mapping results between the two approaches were poor (kappa = 0.19). The indirect terminology based approach showed higher recall (86.78%) than direct approach (p < 0.001). However, there was no difference in precision and F1 score between the two approaches.

Conclusions: Considering no differences in the F1 scores, both approaches may be used in practice for mapping drug indications to ICD-10. However, in terms of consistency, time and manpower, better results are expected from the indirect terminology based approach.

Operative Behandlung der Torsio uteri ante partum bei Stuten unter Erhalt der Gravidität

Gegenstand und Ziel: Der Zustand einer Torsio uteri ante partum bei der Stute wird vorwiegend durch operative Retorsion unter gleichzeitiger Entfernung des Fetus mittels Hysterotomie behoben. Diese Vorgehensweise birgt jedoch das hohe Risiko der Entwicklung einer prämaturen und häufig noch nicht lebensfähigen Frucht sowie das der Nachgeburtsverhaltung mit den daraus resultierenden Konsequenzen. Die Studie ging der Frage nach, ob eine Belassung des Fohlens in utero nach Retorsion des Uterus nicht vorteilhafter ist. Material und Methoden: Das Patientenkollektiv setzte sich aus 23 Stuten verschiedener Rassen im Alter zwischen drei und 16 Jahren (10,5 ± 4,0) mit Torsio uteri ante partum zusammen. Die Stuten befanden sich zwischen dem fünften und 11. Monat (8,7 ± 1,9) der Gravidität. Bei allen Patienten wurde unter Allgemeinanästhesie eine ventromediane Laparotomie durchgeführt. Nach Exploration der Bauchhöhle und intraabdominaler Orientierung erfolgte die Retorsion des Uterus. Bei positivem Befund der fetalen Reflexe wurde das Fohlen in utero belassen und die Stute postoperativ hinsichtlich des Erhaltes der Gravidität intensiv therapiert. Ergebnisse: Zwei der 23 Stuten mussten in tabula wegen einer Magenruptur bzw. massiven, torsionsbedingten Alterationen des Uterus und der Adnexe euthanasiert werden. Bei zwei weiteren Stuten führte die Operation nicht zum gewünschten Erfolg. Sie entwickelten postoperativ eine Peritonitis respektive eine Typhlokolitis. Von den verbliebenen 19 Stuten gebaren 17 termingerecht vitale Fohlen, die sich komplikationslos weiterentwickelten. Zwei Stuten abortierten am dritten Tag respektive drei Monate post operationem. Schlussfolgerungen und klinische Relevanz: Die Ergebnisse der Studie belegen, dass bei Stuten mit einer Torsio uteri ante partum mit zum Zeitpunkt der Operation noch lebendem Fetus das Belassen der Frucht nach Retorsion des Uterus sinnvoll ist. In einem hohen Prozentsatz lässt sich bei den Stuten die Gravidität erhalten und mit einer termingerechten Geburt eines vitalen, maturen Fohlens beenden.

Feasibility of Permanent Stenting with Solitaire FR as a Rescue Treatment for the Reperfusion of Acute Intracranial Artery Occlusion

BACKGROUND AND PURPOSE

The Solitaire FR can be used not only as a tool for mechanical thrombectomy but also as a detachable permanent stent. Our aim was to assess the feasibility and safety of permanent stent placement with the Solitaire FR compared with other self-expanding stents for intracranial artery recanalization for acute ischemic stroke.

MATERIALS AND METHODS

From January 2011 through January 2016, we retrospectively selected 2979 patients with acute ischemic stroke. Among them, 27 patients who underwent permanent stent placement (13 patients with the Solitaire FR [Solitaire group] and 14 patients with other self-expanding stents [other stent group]) were enrolled. The postprocedural modified TICI grade and angiographic and clinical outcomes were assessed. The safety and efficacy of permanent stent placement of the Solitaire FR for acute large-artery occlusion were evaluated.

RESULTS

Stent placement was successful in all cases. Modified TICI 2b-3 reperfusion was noted in 84.6% of the Solitaire group and in 78.6% of the other stent group. Procedural time was significantly shorter in the Solitaire group than in the other stent group (P = .022). Shorter procedural time was correlated with favorable outcome (ρ = 0.46, P = .035). No significant differences were found in the modified TICI grade, NIHSS score, mRS, and hemorrhagic transformation rate between the 2 groups. The acute in-stent thrombosis rate at discharge was significantly lower when a glycoprotein IIb/IIIa inhibitor was injected during the procedure (P = .013).

CONCLUSIONS

Permanent stent placement with the Solitaire FR compared with other self-expanding stents appears to be feasible and safe as a rescue tool for refractory intra-arterial therapy.

Diffusion-Weighted Imaging of the Head and Neck: Influence of Fat-Suppression Technique and Multishot 2D Navigated Interleaved Acquisitions

BACKGROUND AND PURPOSE

DWI of the head and neck can reveal valuable information, but the effects of fat suppression and multishot acquisition on image quality have not been thoroughly investigated. We aimed to comprehensively compare the quality of head and neck DWI at 3T using 2 fat-suppression techniques, STIR, and spectral presaturation with inversion recovery, which were used with both single- and multishot EPI.

MATERIALS AND METHODS

Sixty-five study participants underwent 3 DWI sequences of single-shot EPI-STIR, single-shot EPI-spectral presaturation with inversion recovery, and multishot EPI-spectral presaturation with inversion recovery of the head and neck. In multiple anatomic regions, 2 independent readers assessed 5-point visual scores for fat-suppression uniformity and image distortion, and 1 reader measured the contrast-to-noise ratio and ADC.

RESULTS

The mean visual score for fat-suppression uniformity was higher in single-shot EPI-STIR than in other sequences (all regions except for the orbital region, P < .05). The mean visual score for image distortion was higher in multishot EPI-spectral presaturation with inversion recovery than in single-shot EPI sequences (all regions, P < .001). Contrast-to-noise ratio was mostly lower in single-shot EPI-STIR than in other sequences (P < .001), and ADC was significantly higher in multishot EPI-spectral presaturation with inversion recovery than in single-shot EPI sequences (P ≤ .001).

CONCLUSIONS

Overall, multishot EPI-spectral presaturation with inversion recovery provided the best image quality, with relatively homogeneous fat suppression, less image distortion than single-shot EPI sequences, and higher contrast-to-noise ratio than single-shot EPI-STIR. The measured ADC values can be higher in multishot EPI-spectral presaturation with inversion recovery, which necessitates cautious application of the previously reported ADC values to clinical settings.

Multicenter evaluation of first-line endoscopic treatment with the OTSC in acute non-variceal upper gastrointestinal bleeding and comparison with the Rockall cohort: the FLETRock study

INTRODUCTION

The over-the-scope clip (OTSC) overcomes limitations of standard clips and achieves a more efficient and reliable hemostasis in non-variceal upper gastrointestinal bleeding (NVUGIB). The study aims to evaluate mortality, rebleeding, and mortality after rebleeding of patients in whom the OTSC was used as the first-line endoscopic treatment (FLET) of NVUGIB.

PATIENTS AND METHODS

In total, 118 patients (FLET cohort) with a median age of 73.5 years (range 29-93 years; mean (±SD) 71.39 ± 12.39 years) were included. The distribution of patients with respect to risk category revealed a median Rockall score of 7 (range 3-10). For hypothesis testing, the FLET cohort was categorized into three risk groups taking into account the Rockall score: low risk [Rockall risk category (RRC ≤3)], moderate risk (RRC 4-7), and high risk (RRC ≥8). Event rates (mortality, rebleeding, and mortality after rebleeding) observed per risk group were compared to predicted event rates (Rockall cohort) using Fisher's Exact Test.

RESULTS

Primary successful hemostasis (PSH) was achieved in 92.4% either by FLET alone or in combination with an additional hemostasis technique in 1.7% (SCS = secondary clinical success). In 7.5% of the FLET cohort PSH could not be achieved. Compared to RRC prediction, mortality after rebleeding was significantly reduced from 27.9 to 10.9% in the high-risk group (RRC ≥8) treated with FLET (p < 0.011). Furthermore, the occurrence of rebleeding or continued bleeding was significantly lower in the moderate risk group (RRC 4-7) with 4.9% as well as in the high-risk group (RRC ≥8) with 21.4% compared to the Rockall cohort 24.0 and 53.2%, respectively (p < 0.001).

CONCLUSIONS

This study shows that OTSC is superior to standard care and FLET reduces significantly rebleeding and rebleeding-associated mortality in NVUGIB. For this reason, OTSC could be the treatment of choice as the first-line treatment as an alternative to standard hemostasis techniques in high-risk patients.

In vivo liver visualizations with magnetic particle imaging based on the calibration measurement approach

Magnetic particle imaging (MPI) facilitates the rapid determination of 3D in vivo magnetic nanoparticle distributions. In this work, liver MPI following intravenous injections of ferucarbotran (Resovist^®) was studied. The image reconstruction was based on a calibration measurement, the so called system function. The application of an enhanced system function sample reflecting the particle mobility and aggregation status of ferucarbotran resulted in significantly improved image reconstructions. The finding was supported by characterizations of different ferucarbotran compositions with the magnetorelaxometry and magnetic particle spectroscopy technique. For instance, similar results were obtained between ferucarbotran embedded in freeze-dried mannitol sugar and liver tissue harvested after a ferucarbotran injection. In addition, the combination of multiple shifted measurement patches for a joint reconstruction of the MPI data enlarged the field of view and increased the covering of liver MPI on magnetic resonance images noticeably.

[Gastroesophageal reflux and sleep position of infants. A survey conducted in France by 493 pediatricians]

BACKGROUND AND AIMS

The supine sleeping position with the head higher than the legs has no impact on regurgitations in infants. Inclined ventral decubitus decreases regurgitations but is associated with an increased risk of sudden infant death syndrome (SIDS). The LUNE study aimed to evaluate the impact of regurgitations on the choice of sleeping position by pediatricians and parents.

METHODS

Cross-sectional case-control study (ratio 1:1) conducted in France in 2013. A representative sample of pediatricians recruited 3-week to 4-month-old breast- or formula-fed infants. Cases and controls were defined by the presence or absence of regurgitations. Collected data included Vandenplas codification for regurgitations (VD, range 0-6), associated symptoms, and variations in sleeping position since maternity hospital discharge.

RESULTS

A total of 1347 cases and 1346 controls were recruited by 493 pediatricians. Regurgitations were evaluated at VD1 (minor, 22 % of cases), VD2 (mild, 47 % of cases), or VD≥3 (moderate to severe, 31 % of cases). At the maternity hospital, the supine position was recommended to 96 % of parents for SIDS prevention. Since discharge, parents asked questions about the relationship between sleeping position and regurgitations (79 % of infants with GER versus 45 % of controls). The sleeping position was modified at least once since maternity discharge (42 % of infants with GER versus 35 % of controls). At inclusion, 86 % of infants with GER and 86 % of controls were sleeping on their back. Fifty-one percent of infants with GER and 28 % of controls slept in an inclined position. Pediatricians repeated the prescription of dorsal decubitus for 91 % of infants with GER and recommended an inclined position in 70 %.

CONCLUSIONS

Regurgitations had no impact on supine sleeping position. The inclined supine sleeping position was more frequent in infants with regurgitations with pediatricians' assent, which is not in agreement with evidence-based medicine.