[The molecular bypass: an established method for revascularisation of non-operable PAD patients or merely a future vision]

Collateral vessel growth is a physiological process that is not equally pronounced in all people. After the development of a haemodynamically relevant stenosis in vascular systems, blood flow is directed through a collateral circulation to supply ischaemic tissue. This collateral circulation exists on the capillary level and by definition, is not composed of real new vessels. Postnatal vasculogenesis (true neovascularisation) occurs in the adult organism in tumour vascularisation, wound healing, in the endometrium, and in the context of chronic diseases such as rheumatoid arthritis and psoriasis. Reopening of the occluded vessel or use of artificial bypass grafts are the most attractive therapeutic approaches for treating peripheral arterial and coronary artery disease. These strategies have been exhausted in many patients; therefore augmentation of arteriogenesis can be more useful. Arteriogenesis, the promotion of natural collateral growth, is a hot topic in vascular research. Monocytes play a key role in arteriogenesis by "homing" to areas of collateral vessel growth and locally secrete multiple essential growth factors. Furthermore, stem cells of different origins, endothelial progenitor cells or mononuclear cells are currently being used to promote vessel growth. Also, the application of growth factors such as VEGF, MCP-1, GM-CSF have been already used in clinical trials. This review article describes the physiology and pathophysiology of vascular stenoses and their compensation mechanisms. The review also gives an overview of current treatment approaches and new strategies for non-operable PAD patients. The article presents the current cell and growth factor-related studies, as well as results of balloon dilatation and stent implantation or bypass surgery studies for improvement of revascularisation.

Paramediastinal air cyst with traumatic bronchial injury: a rare complication of neonatal resuscitation

Paramediastinal air cysts and pneumatoceles are known complications of chest trauma and mechanical ventilation. After an initial period of enlargement, these lesions tend to resolve completely with conservative management. We present a case of a premature newborn who developed an enlarging paramediastinal air cyst as a result of resuscitation around the time of delivery that ultimately required surgical excision via a right thoracotomy. To our knowledge, this is the first reported case in a neonate.

Peptide neurons in peripheral tissues including the urinary tract: immunohistochemical studies

Using the indirect immunofluorescence technique of Coons and collaborators, neurons containing substance P-, enkephalin-, vasoactive intestinal polypeptide (VIP)--and somatostatin-like immuno-reactivity have been identified in the peripheral nervous system. They have a widespread distribution, particularly in the gastrointestinal and urinary tracts. Whereas part of these peptide containing fibres may belong to sensory neurons, the majority seem to have their origin in peripheral autonomic ganglia, indicating a complex built up of the autonomic nervous system. There is evidence that some noradrenergic neurons contain somatostatin, which may suggest that one neuron can synthesize and store two transmitters. The significance of such neurons, as well as of peripheral peptide neurons in general, remains to be elucidated.

Alterations in growth and branching of Neurospora crassa caused by sub-inhibitory concentrations of antifungal agents

Six antifungal agents at subinhibitory concentrations were used for investigating their ability to affect the growth and branching in Neurospora crassa. Among the antifungals herein used, the azole agent ketoconazole at 0.5 microg/ml inhibited radial growth more than fluconazole at 5.0 microg/ml while amphotericin B at 0.05 microg/ml was more effective than nystatin at 0.05 microg/ml. Morphological alterations in hyphae were observed in the presence of griseofulvin, ketoconazole and terbinafine at the established concentrations. The antifungal agents were more effective on vegetative growth than on conidial germination. Terbinafine markedly reduced growth unit length (GU) by 54.89%, and caused mycelia to become hyperbranched. In all cases, there was a high correlation between hyphal length and number of tips (r > 0.9). All our results showed highly significant differences by ANOVA, (p < 0.001, alpha = 0.05). Considering that the hyphal tip is the main interface between the fungus and its environment/through which enzymes and toxins are secreted and nutrients absorbed, it would not be desirable to obtain a hyperbranched mycelia with inefficient doses of antifungal drugs.

The effect of physical, social and psychological factors on drug compliance in patients with mild hypertension

BACKGROUND

In patients with hypertension noncompliance with drug treatment is between 15 to 54%, and has been recognised as a relevant contributor to the burden of cardiovascular morbidity. Up to 92% of patients experience unpleasant symptoms with their condition and, particularly in these patients, the symptoms experienced may enhance compliance.

OBJECTIVE

To simultaneously assess the effects of physical, social and psychological factors on noncompliance.

METHODS

Patients with mild hypertension despite drug treatment, from the departments of cardiology and internal medicine, were requested to answer a self-administered questionnaire addressing the presence of physical symptoms as well as psychosocial factors. The questionnaire was based on previously used test batteries and consisted of two lists of physical complaints and four lists addressing the four domains of planned behaviour regarding medical non-adherence according to Baron and Byrne. These domains mainly assess psychosocial factors. Each list consisted of three or more items and each item was scored on fiveto seven-point scales. Mean scores were used for assessment. The lists were also separately assessed for internal consistency and reliability using Cronbach's alphas. One-way analysis of variance and multivariate analysis of variance (MANOVA) with compliance as outcome variable and the physical, social and psychological variables as indicator variables were used for data analysis. MANOVA was adjusted for multiple testing.

RESULTS

Many patients experienced physical symptoms due to hypertension, such as tiredness (31%), hot flushes (28%), headache (24%), reduced daily life energy (23%), palpitations (22%), with 95% confidence intervals between 16 to 38%. Scores for physical symptoms and social factors did not differ between self-reported adherers (n=165) and nonadherers (n=11). However, the score for psychological factors was significantly larger in the adherers than in the non-adherers, 5.05 versus 3.06, p<0.018. The MANOVA showed a significant overall difference between the adherers and non-adherers in the data at p<0.012, which was mainly due to the score for psychological factors. Conclusion. The effect of physical symptoms on non-compliance in mildly hypertensive patients is negligible. So is the effect of social factors. Psychological factors such as lacking a sense of guilt, regret and shame are major determinants of non-compliance. Physicians may play an educational role in improving their patients' compliance by addressing these determinants. We should add that the conclusions should be made with reservations, given the small number of non-adherers in our sample. (Neth Heart J 2008;16:197-200.).

Fetoscopic laser treatment of twin-to-twintransfusion syndrome (TTTS)

The aim of this study was to report the results of the first 10 cases of fetoscopic laser surgery for twin-to-twin transfusion syndrome by the Rotunda Hospital Fetal Treatment Programme. All cases of severe TTTS managed by our team from 2006 to 2007 were included. All fetoscopic laser surgeries were performed by a single specialist in fetal medicine. All pregnancies were followed up to pregnancy completion and a minimum of six weeks neonatal life. Laser surgeries were performed with ultrasound guidance and percutaneously using local anaesthesia via a 2.8mm rigid fetoscope. Selective laser ablation of placental vessels was accomplished with a neodymium:YAG laser. The first 10 cases of severe TTTS managed by our team are reported. Laser ablation of placental vessels was accomplished successfully in all cases. Two pregnancies were complicated by preterm premature rupture of membranes before 22 weeks and both pregnancies were lost. Of the remaining 16 fetuses, one was diagnosed with significant ventriculomegaly postoperatively and underwent selective termination in the United Kingdom. The overall intact neonatal survival rate was 65%. Fetoscopic laser ablation of placental vessels for severe twin-to-twin transfusion syndrome is now available in Ireland, and our programme has delivered results that are in keeping with international best practices in this regard.

Near miss maternal morbidity

Audit of severe maternal morbidity is a potent tool in determining standards of maternity care. This study determines the incidence of severe acute maternal morbidity in our population, identifies the underlying organ dysfunction and associated obstetric risk factors, and compares them to published international reports. Over a 5 year period, 1999-2003, data were collected prospectively from patients with severe acute maternal morbidity. There were 36,802 women who delivered infants weighing more than 500 g over the 5 years with 53 cases of severe maternal morbidity. There were two indirect maternal deaths yielding an incidence of 1.4/1000 for severe maternal morbidity and 5.4/100,000 for maternal mortality. The severe maternal morbidity to mortality ratio was 26.5:1. Massive obstetric haemorrhage requiring acute blood transfusion of > or = 5 units of packed red cells occurred in 77% of cases. This study identifies the feasibility of audit of severe maternal morbidity using simple defined clinical criteria. The incidence and underlying aetiology of severe maternal morbidity in our unit is comparable to other developed countries. It is essential that data on severe maternal morbidity are reviewed and analysed continuously at local hospital and national level to assess, maintain and improve clinical standards.