Characteristics of Premature Radiotherapy Terminations in Patients with Oral Cavity and Laryngeal Carcinomas

PURPOSE/OBJECTIVE(S)

Premature radiation therapy (RT) terminations in patients with head and neck cancer result in poor outcomes. However, the underlying factors that contribute to early RT termination are understudied, especially in the era of hypofractionated treatment. In this retrospective single institution study, we examined causes and clinical characteristics of premature terminations in oral cavity (OC) and laryngeal carcinomas.

MATERIALS/METHODS

We reviewed charts of 188 patients treated with RT ± systemic therapy for OC and laryngeal cancer from 2017-2022. Patients were typically prescribed standard 1.8-2.0 Gy fractionation regimens, though patients deemed unlikely to complete conventional RT upon initial evaluation were given SBRT. Premature termination was defined as completion of less than 95% prescribed RT. We collected pertinent demographic, clinicopathological data on this termination cohort, which was compared to a matched cohort of patients with RT completion. We used logistic regression analysis to examine factors predictive of premature termination.

RESULTS

Of the patients included in this analysis, 72.7% were prescribed adjuvant RT [9.1% OC, 45.5% larynx] vs. 27.3% primary RT [90.9% OC, 45.5% larynx]. 84.6% received conventional IMRT, while 15.4% received SBRT. 17 patients (9.0%) had premature RT (all IMRT) terminations- 9 OC and 8 laryngeal primaries. Mean age of those who had premature termination was 79.5 years (range: 70-98). 70.6% were male, 58.8% were white, and 23.5% were single/widowed. Majority received concurrent systemic therapy (58.8%), had AJCC (8th Ed.) Stage ≥ III (76.5%), Charlson-Comorbidity Index ≥6 (64.7%), ECOG score ≥2 (70.6%), smoked >10 pack-years (76.5%), and lived >10 miles from RT facility (58.8%). The most common documented reasons for premature termination were: subjective intolerance (29.4%), death (23.5%), objective RT toxicity (23.5%), and inpatient admission (17.6%). The mean time on treatment for IMRT was 27.8 days for termination cohort vs. 47.7 days for completion cohort. The percentage of patients reporting RT toxicity (CTCAE v5.0 mucositis, severe weight loss, oral infection, e.g.) was 88.2% for termination cohort vs. 29.6% for completion cohort. On regression analysis, ECOG score at the time of initiation of RT was independently associated with premature termination (OR: 2.438, 95% CI: 1.155-5.146, p = .019).

CONCLUSION

This retrospective analysis of patients undergoing RT for OC and laryngeal cancers at our tertiary care center demonstrated nearly 1 in 10 patients are at risk for premature termination. Poor performance status was independently associated with premature termination. There was a 100% completion rate in hypofractionated treatment with SBRT. Taken together, poor performance status may identify patients at risk for premature termination and thus identify good candidates for SBRT protocols.

The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81-1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73-0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00-1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99-1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73-0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64-0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.

Evaluation of the national clinical sentinel surveillance system for sexually transmitted infections in South Africa: Analysis of provincial and district-level data

BACKGROUND

Globally, >1 million new cases of curable sexually transmitted infections (STIs) are estimated to occur daily, an alarming rate that has prevailed for over a decade. Modelled STI prevalence estimates for South Africa (SA) are among the highest globally. Robust STI surveillance systems have implications for policy and planning, antimicrobial stewardship and prevention strategies, and are critical in stemming the tide of STIs.

OBJECTIVES

To evaluate the STI clinical sentinel surveillance system (STI CSSS) in SA, to describe the population incidence of four designated STI syndromes in males and females ≥15 years, and to provide recommendations for strengthening the STI CSSS.

METHODS

This was a retrospective analysis of the STI CSSS in SA. Distribution of the primary healthcare facilities designated as STI CSSS sites was described, taking into account provincial population distribution and headcount coverage of STI CSSS facilities. Reporting compliance was evaluated to determine completion of data reporting. Further analysis was undertaken for those provinces that had good reporting compliance over a 12-month period. Population-level and demographic STI syndrome incidence were estimated from CSSS data using case reports of male urethritis syndrome (MUS) as a proxy for data extrapolation.

RESULTS

Reporting compliance exceeded 70% for seven of the nine provinces. STI syndromes with the highest incidence were MUS and vaginal discharge syndrome (VDS). The 20 - 24 years age group had the highest STI incidence, at least double the incidence estimated in the other two age groups. Overall STI incidence in females was higher than among males in all provinces, except Limpopo and Western Cape. The 15 - 19 years age group had the most prominent gender disparity, with the national STI incidence in females 70% higher than in males. District-level analysis revealed high regional STI incidence even in provinces with lower overall incidence.

CONCLUSION

The STI CSSS is pivotal to epidemiological monitoring and proactive management of STIs, especially in view of the high HIV prevalence in SA. CSSS processes and facility selection should be reviewed and revised to be representative and responsive to the current STI needs of the country, with biennial analysis and reporting to support evidence-based policy development and targeted implementation.

Flow simulation-based particle swarm optimization for developing improved hemolysis models

The improvement and development of blood-contacting devices, such as mechanical circulatory support systems, is a life saving endeavor. These devices must be designed in such a way that they ensure the highest hemocompatibility. Therefore, in-silico trials (flow simulations) offer a quick and cost-effective way to analyze and optimize the hemocompatibility and performance of medical devices. In that regard, the prediction of blood trauma, such as hemolysis, is the key element to ensure the hemocompatibility of a device. But, despite decades of research related to numerical hemolysis models, their accuracy and reliability leaves much to be desired. This study proposes a novel optimization path, which is capable of improving existing models and aid in the development of future hemolysis models. First, flow simulations of three, turbulent blood flow test cases (capillary tube, FDA nozzle, FDA pump) were performed and hemolysis was numerically predicted by the widely-applied stress-based hemolysis models. Afterward, a multiple-objective particles swarm optimization (MOPSO) was performed to tie the physiological stresses of the simulated flow field to the measured hemolysis using an equivalent of over one million numerically determined hemolysis predictions. The results show that our optimization is capable of improving upon existing hemolysis models. However, it also unveils some deficiencies and limits of hemolysis prediction with stress-based models, which will need to be addressed in order to improve its reliability.

Targeted overexpression of regnase-1 in the aorta prevents aneurysm growth in a murine model of Marfan syndrome

Background/Introduction

Marfan syndrome is a rare genetic disorder caused by mutations in the fibrillin-1 gene. This markedly affects the cardiovascular system, with patients being at a high risk of aortic aneurysm formation. The main players in the disease progression are matrix-metalloproteinases (MMPs) as well as proinflammatory cytokines, in particular interleukin-6 (IL-6). Regnase-1 is a newly identified endoribonuclease that targets the mRNA of proinflammatory markers.

Purpose

We aimed to characterize the role of regnase-1 in Marfan syndrome, particularly the effects of its overexpression on inflammatory parameters and elastin degradation in a well-characterized murine model for the disease.

Methods

Regnase-1 expression in aortic tissue was assessed using immunohistochemistry. Aortic smooth muscle cells (SMC) from mgR/mgR (Marfan) mice were transduced with vascular targeted AAV9SLR encoding either regnase-1 or enhanced green fluorescent protein (EGFP) as control. Interferon γ (IFN-γ) served as a proinflammatory stimulus and was added to cell culture medium after transduction. We measured elastin and gelatin degradation and analyzed several inflammatory parameters using real-time qPCR, Western Blot, macrophage migration assay and enzyme-linked immunosorbent assay (ELISA). For in vivo studies, mgR/mgR mice were systemically injected with NP3-tagged AAV9 expressing either regnase-1 or EGFP. 4 weeks after injection, aortic diameter was measured using echocardiography. Thoracic aorta and blood samples were taken for further analysis.

Results

Immunostaining revealed a marked decrease in regnase-1 levels in the media in aortic tissue of Marfan patients and mgR/mgR mice as compared to controls. AAV-mediated regnase-1 overexpression in vitro decreased elastin degradation and reduced secretion of proinflammatory cytokines, including IL-6, in murine Marfan SMC. It also lowered MMP9 expression and activity as well as NFkB activation. Furthermore, we could prove a marked decline in macrophage migration towards the supernatant of treated SMCs. NP3-tagged AAV9 led to efficient transduction of both aortic endothelial cells and SMC in vivo. Importantly, echocardiographic measurements showed that regnase-1 overexpression significantly reduced aortic diameter at distinct locations. In addition, elastin architecture was markedly improved in the treatment group compared to controls, male mice presented with higher numbers of structural defects. Moreover, our approach led to less expression of MMPs in the media and to lower plasma levels of IL-6 and macrophage chemoattractant protein 1 (MCP-1).

Conclusion

Here we show that AAV-mediated regnase-1 overexpression in the aorta ameliorates pathological remodeling in the aortic wall of Marfan mice and could thus potentially prevent progression of aortic aneurysms in Marfan syndrome. We underline, for the first time, a major role of regnase-1 in aortic aneurysm progression in the context of Marfan syndrome.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum für Herz-Kreislauf-Forschung (Oliver Müller)

Regnase-1 overexpression as a novel gene therapy approach for pulmonary hypertension

Introduction

Pulmonary hypertension (PH) is a chronic disease characterized by persistently increases pulmonary arterial pressure, leading on the long term to right ventricular overload and ultimately right heart failure. Until now, therapy focuses on alleviating symptoms and hence the development of a novel strategy for the treatment of this disease remains highly relevant.

Purpose

The importance of pro-inflammatory cytokines in progression of PH has already been established. Interestingly, patients with increased plasma levels of inflammatory markers present with more severe disease. Regnase-1 is a newly identified endoribonuclease cleaving the mRNA of pro-inflammatory cytokines therefore diminishing their levels of expression. Hence, we hypothesize that regnase-1 overexpression in lung tissue can be translated into a novel therapeutic approach for PH.

Methods

In vitro experiments were performed in human lung endothelial cells (HUVECs). For our in vivo study, mice were subjected to hypoxic conditions (10% O2) for 3 weeks. Regnase-1 overexpression was achieved in lung endothelial cells by transduction with targeted adeno-associated virus serotype 2 (AAV2-ESGHGYF), administered systemically by tail vein injection 3 days after exposure to hypoxia (early therapy approach). AAV2-EGFP treated mice served as controls. Right ventricular function was monitored by echocardiography and right ventricular systolic pressure was measured by right heart catheterization. The degree of pro-inflammatory cell infiltration was monitored by immunohistochemistry. Induction of fetal gene programme in the right ventricle was measured by real time qPCR. Fibrosis deposition in lung tissue was determined by Sirius Red staining of frozen sections.

Results

Regnase-1 overexpression led to a significantly decreased level of hypoxia-induced pro-inflammatory cytokines in HUVECs. Importantly, we could show decreased regnase-1 levels in lung endothelial cells of mice subjected to hypoxia for 3 weeks. On the other hand, regnase-1 reintroduction led to a significant improvement in right ventricular function and decreased pulmonary pressure in mice placed under hypoxic conditions. Moreover, the described gene therapy approach induced normalization of fetal gene programme in the cardiac tissue and reduced pro-inflammatory cell infiltration in lungs. Additionally, we could determine mitigation of pulmonary extracellular matrix deposition and fibrosis development in mice receiving AAV2-regnase1 as compared to controls.

Conclusion

AAV-mediated regnase-1 overexpression in lung endothelial cells results in amelioration of pathological events leading to PH in mice subjected to hypoxia, when the therapeutic AAV is delivered 3 days after disease induction. Further experiments will determine whether this method can be successful used for reversing already established PH.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DZHK

Risk prediction in patients with classical Low-flow, low-gradient aortic stenosis undergoing TAVI

Background

Patients with classical low-flow, low-gradient aortic stenosis (LFLG AS) undergoing transcatheter aortic valve implantation (TAVI) are known to suffer from poor prognosis. Risk prediction is difficult and predictors of outcome are scarce in this complex patient subset.

Purpose

This study aimed to develop a simple score system for risk prediction in patients with classical LFLG AS scheduled for TAVI including baseline clinical, echocardiographic and computed tomography (CT) parameters.

Methods

Among 9,150 patients undergoing TAVI (2008–2019) at five German centers, patients with classical LFLG AS were screened for availability of sufficient CT data for aortic valve calcification (AVC) quantification. Score variables were defined as all variables included into the best performing multivariable regression model. Score performance was assessed by Kaplan-Meier analysis for the endpoint of 1-year all-cause as well as c-index calculation.

Results

A total of 718 patients were included into the study. Predictors of all-cause mortality were male sex (HR 1.27 [0.98, 1.65], p=0.068), chronic obstructive pulmonary disease (HR 1.59 [1.21,2.08], p&lt;0.001), atrial fibrillation (HR 1.33 [1.03,1.70], p=0.026), stroke volume index (HR 0.96 [0.94, 0.98], p&lt;0.001), non-transfemoral access (HR 1.44 [1.09,1.91], p=0.011), pulmonary hypertension (HR 1.58 [1.20,2.08], p=0.0012) and low AVC density (HR 1.49 [1.16,1.90], p=0.0016). A score system was developed ranging from 0 points to 11 points. Kaplan-Meier analysis for low (0–2 points), moderate (3–6 points) and high score (&gt;6 points) demonstrated 1-year mortality rates of 20.9%, 28.9% and 64.3% (p&lt;0.001), respectively. C-index for prediction of 1-year mortality was 0.69 (95%-CI 0.65–0.84). The RELiEF TAVI score outperformed classical risk prediction models like the logistic euroSCORE (c-index 0.60 [95%-CI 0.51–0.72], p=0.013), the EuroSCORE II (c-index 0.57 [95%-CI 0.45–0.70], p=0.039) and the STS PROM (c-index 0.60 [0.48–0.70], p=0.035).

Conclusions

The RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in the vulnerable subset of patients with classical LFLG AS scheduled for TAVI.

Funding Acknowledgement

Type of funding sources: None. RELiEF TAVI Score

P5738Multicenter analysis of left ventricular unloading on top of VA-ECMO for treatment of cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population.

Aim

The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO.

Material and methods

We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables.

Results

A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD).

Conclusion and outlook

In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality.

To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.

[Correction of flexible lesser toe deformity : Transfer of the flexor digitorum longus tendon]

OBJECTIVE

Realignment and pain relief of toes 2-5 by flexor-to-extensor tendon transfer of the flexor digitorum longus (FDL) muscle.

INDICATIONS

As an isolated procedure in flexible proximal interphalangeal (PIP) joint flexion and/or flexible metatarsophalangeal (MTP) joint extension (hammer toe). In combination with a metatarsal osteotomy or PIP joint arthrodesis in case of flexible MTP joint extension.

CONTRAINDICATIONS

General medical contraindications to surgical interventions. Stiffness of the PIP or MTP joint.

SURGICAL TECHNIQUE

Plantar stab incision in the distal interphalangeal (DIP) flexion crease and tenotomy of the FDL tendon. More proximally transverse incision on the plantar aspect of the proximal phalanx and isolation of the FDL tendon. The tendon is split longitudinally along the raphe and the two limbs are transferred from plantar to the dorsal aspect of the proximal phalanx adjacent to the bone. The crossed limbs are sutured to each other under appropriate tension and corrected position of the toe.

POSTOPERATIVE MANAGEMENT

Postoperative dressings for 3 weeks in corrected position. Subsequently tape dressing in plantar position for 6-12 weeks. Full weight bearing.

RESULTS

A total of 24 toes with flexible PIP and/or MTP joint deformity were treated with a FDL tendon transfer. In 14 toes an isolated procedure was performed, in 10 cases an additional metatarsal osteotomy. Patients with operative treatment of the first ray, revision or reoperation were excluded. Mean follow-up was 8.4 (4-14) months. After 6 weeks 22 toes (92%) showed physiological alignment of the PIP and MTP joint. At the last follow-up, 4 (16%) toes had recurrent or persistent extension deformity of the MTP joint. There were no infections, overcorrections, impaired wound healing or transversal malalignment.

Adverse effects of orthodontic treatments

Orthodontic therapy, like any other medical intervention, in addition to its benefits carries the risk of potential complications and is associated with adverse effects-including periodontal problems, external root resorptions, pulpal changes, enamel damages (demineralization, discoloration, attrition), temporomandibular disorders, infective endocarditis, soft tissue damages, discomfort, pain and the risk of either aspiration or indigestion of medical instruments and appliances. Usually these effects are multifactorial in origin- most often a result of interactions between the patient, the dental practitioner and the technical aspects of the appliances or techniques. With preventive measurements and care, most of these complications can be either limited or completely avoided. Therefore, every dental practitioner must be fully aware of these effects and associated risk factors in order to maximize the treatment outcome. The present review aims to summarize these effects of orthodontic therapies, and provide a detailed description of factors and preventive measures, in order to minimize these damages.

Recent Developments and Controversies in the Treatment of Resistant Hypertension

Resistant hypertension is defined as elevated blood pressure despite the appropriate use of 3 or more antihypertensive drugs, including a diuretic, and constitutes a frequent and important clinical problem with significant disease morbidity and mortality. Several sources of evidence point to the sympathetic nervous system as a major protagonist in this disease entity. The catheter-based, radiofrequency ablation of renal sympathetic nerves (renal denervation) to treat resistant hypertension has sparked great enthusiasm. However, failure of this interventional approach in the randomized, sham-controlled Symplicity HTN-3 trial to reach its efficacy endpoint of attaining a significant blood pressure reduction has called this intervention into substantial question and fueled an ongoing scientific debate. Electrical stimulation of the carotid baroreceptors (baroreflex activation therapy) represents another technique to modulate sympathetic activity currently being studied in several clinical trials. This review summarizes and comments the current literature focusing on the invasive treatment of resistant hypertension.

[Interventional mitral valve replacement. Current status]

Approximately 30 % of patients suffering from severe valvular heart disease, such as mitral valve regurgitation are non-compliant to the gold standard of minimally invasive surgery, reconstruction or valve replacement. The number of these mostly old patients with severe comorbidities is increasing; therefore, transcatheter interventions have been developed to address an unmet clinical need and may be an alternative therapeutic option to the reference standard. Apart from the successful MitraClip therapy, alternative transcatheter reconstruction technologies are being developed. As with transcatheter aortic valve implantation (TAVI) procedures, the off-pump implantation of a valved stent into the mitral position mainly via a transapical approach will be of great benefit. Recently, the feasibility of transcatheter mitral valved stent implantation in high-risk patients has already been reported.

Fistulizing Epstein-Barr virus-positive plasmablastic lymphoma in an HIV-positive man

Plasmablastic lymphoma (PBL) is an unusual subtype of non-Hodgkin lymphoma recently classified as a diffuse immunoblastic lymphoma with a plasma-cell immunophenotype. Originally described in the oral cavity of HIV-positive patients, it has also been recognized to occur rarely at other sites. We describe a previously unreported fistulizing presentation of Epstein-Barr virus (EBV)-positive PBL, reviewing its association with HIV-1 infection and its importance as an AIDS-defining malignancy.

[Distal soft-tissue procedure in hallux valgus deformity]

OBJECTIVE

Distal, lateral soft tissue release to restore mediolateral balance of the first metatarsophalangeal (MTP) joint in hallux valgus deformity. Incision of the adductor hallucis tendon from the fibular sesamoid, the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament.

INDICATIONS

Hallux valgus deformities or recurrent hallux valgus deformities with an incongruent MTP joint.

CONTRAINDICATIONS

General medical contraindications to surgical interventions. Painful stiffness of the MTP joint, osteonecrosis, congruent joint. Relative contraindications: connective tissue diseases (Marfan syndrome, Ehler-Danlos syndrome).

SURGICAL TECHNIQUE

Longitudinal, dorsal incision in the first intermetatarsal web space between the first and second MTP joint. Blunt dissection and identification of the adductor hallucis tendon. Release of the adductor tendon from the fibular sesamoid. Incision of the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament.

POSTOPERATIVE MANAGEMENT

Postoperative management depends on bony correction. In joint-preserving procedures, dressing for 3 weeks in corrected position. Subsequently hallux valgus orthosis at night and a toe spreader for a further 3 months. Passive mobilization of the first MTP joint. Postoperative weight-bearing according to the osteotomy.

RESULTS

A total of 31 patients with isolated hallux valgus deformity underwent surgery with a Chevron and Akin osteotomy and a distal medial and lateral soft tissue balancing. The mean preoperative intermetatarsal (IMA) angle was 12.3° (range 11-15°); the hallux valgus (HV) angle was 28.2° (25-36°). The mean follow-up was 16.4 months (range 12-22 months). The mean postoperative IMA correction ranged between 2 and 7° (mean 5.2°); the mean HV correction was 15.5° (range 9-21°). In all, 29 patients (93%) were satisfied or very satisfied with the postoperative outcome, while 2 patients (7%) were not satisfied due to one delayed wound healing and one recurrent hallux valgus deformity. There were no infections, clinical and radiological signs of avascular necrosis of the metatarsal head, overcorrection with hallux varus deformity, or significant stiffness of the first MTP joint.

Transapical mitral valve implantation: the Lutter valve

  The development of transcatheter techniques for treatment of severe mitral valve regurgitation in the beating heart is focus of recent research. An off-pump treatment technique poses great benefits, particularly for multimorbid patients, often being non-compliant to the gold standard treatment, being open heart surgery with use of a cardiopulmonary bypass. Thereto, two approaches are being followed: transcatheter valve repair and transcatheterimplantation of a valved stent into the native mitral valve annulus. A valved stent has to provide safe and secure fixation within the high pressure system of the left heart. One of the main challenges in the development of such a valved stent is the complex anatomy of the mitral valve, with no clearly defined structures for device anchorage. Our group has developed a self-expanding nitinolvalved stent for transapical implantation in the beating heart. During the development process of thevalved stent, different design iterations were conducted to decrease the risk of paravalvular leakages, to enhance the reproducibility and to improve the overall stent performance. This article reviews the major milestones passedin the development process of our mitral valved stent and advances achieved withinthe last years. Multiple design iterations lead to a prototype providing secure stent deployment, hig h reproducibility, low paravalvular leakages and only mild stent deformation in the beating heart. In future, further long-term in vivo trials have to be conducted before attempting the step towards clinical application of this novel device.

[A case of venlafaxine-induced syndrome of inappropriate ADH secretion (SIADH) - treatment with tolvaptan]

HISTORY AND ADMISSION FINDINGS

A 74-year-old woman with known COPD was admitted to hospital because of dyspnoa. Clinical and laboratory tests showed an acute pulmonary infection which was treated with antibiotics. Additionally she was found to have a moderately severe episode of depression for which she had the preceding three weeks been treated with venlafaxine, a selective serotonin re-uptake inhibitor. During the subsequent days she gradually developed a hyponatremia with serum sodium levels down to 108 mmol/l.

INVESTIGATIONS

After excluding common causes of hyponatremia such as a cerebral or pulmonal malignancy or endocrine disorders by computed thomography and laboratory tests, a venlafaxine induced syndrome of inappropriate ADH secretion (SIADH) was assumed to be the cause of the hyponatremia.

TREATMENT AND COURSE

As neither discontinuation of venlafaxine nor strict fluid restriction led to a rise in the natrium level and the patient had a generalized seizure, oral treatment with the tolavaptan, a vasopressin-2-receptor antagonist, was initiated. This resulted within 48 hours in a rise of the sodium level to 131 mmol/l and there were no further seizures.

CONCLUSION

Hyponatremia is a relatively common side effect of medical treatment with SSRI or SSNRI in elderly patients. The therapy of choice in case of a hyponatremia due to a SIADH is to discontinue the antidepressive drugs and institute strict fluid restriction. Tolvaptan has recently emerged as a promising new therapeutic option for SIADH.

[A special soft tissue procedure for treatment of hallux valgus]

OBJECTIVE

Maintaining the corrected position of the first metatasophalangeal axis. Reducing postoperative stiffness by forgoing a medial capsular shift.

INDICATIONS

Hallux valgus deformities or recurrent hallux valgus deformities.

CONTRAINDICATIONS

Existing osteoarthritis, joint stiffness, large bone defects, osteonecrosis. General medical contraindications to surgical interventions and anesthesiological procedures.

SURGICAL TECHNIQUE

Operation under regional anesthesia (foot block) or general anesthesia. Tourniquet. Longitudinal skin incision medial over the pseudexostosis of the first metatarsal bone. Preparing the tendon of the Musculus abductor hallucis. Detaching the tendon from the capsule. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle in an L-wise manner. Osteotomy of the first metatarsal bone. Lax sutures of the capsule in correct position and reattachment of the Musculus abductor hallucis tendon shifted toward distal and dorsal, regarding the rotation of the hallux.

POSTOPERATIVE MANAGEMENT

Postoperative elevation of the operated foot. Analgesia with nonsteroidal antiinflammatory drugs. Postoperative weight-bearing according to the osteotomy. Passive mobilization of the metatarsophalangeal joint. Dressing for 4 weeks postoperatively in the corrected position. Radiologic control after 6 weeks. Hallux valgus orthosis at night and a toe spreader for a further 6 weeks.

RESULTS

A total of 30 isolated hallux valgus deformities with a mean preoperative intermetatarsal (IMA) angle of 12.9° (range 11-15°) were operated with a chevron osteotomy. The mean follow-up was 14.4 (range 8-17) months. The mean dorsiflexion at the last follow-up was 44° (range 20-60°). Only 2 patients had a dorsiflexion <40°. The mean reduction of the IM angle was 5.6° (range 3-7°). One patient required wound revision. There was no infection or avascular necrosis of the metatarsal head observed in the patients. At follow-up, 20 (67%) patients were completely satisfied, 9 (30%) satisfied, and 1 (3%) was not satisfied.