Pulmonary embolism in young people

Ziele: Es gibt eine anhaltende Diskussion über die Auswirkungen der hormonalen Kon-trazeption auf die Inzidenz von venösen Thromboembolien (VTE) bei jungen Frauen. Spezifische Daten für die Größe des Problems und ihre Veränderungen in den letzten Jahren in Deutschland sind nicht verfügbar. Daher untersuchten wir die Häufigkeit von VTE bei hospitalisierten jungen Menschen und analysierten geschlechtsspezifische Unterschiede.

Patienten und Methoden: Detaillierte Listen aller Lungenembolien (LE), kodiert als I26, und tiefer Venenthrombosen (TVT), kodiert als I80, bei Patienten im Alter von 10 bis 39 Jahre, die in den Jahren 2005 bis 2011 ins Krankenhaus eingeliefert worden waren, stellte das Statistische Bundesamt zur Verfügung.

Ergebnisse: Beginnend im Alter von 12–13 Jahren wurde für Frauen im Vergleich zu Männern eine höhere Anzahl von LE und TVT als Hauptdiagnose dokumentiert. Dieser geschlechtsspezifische Unterschied verschwindet im Alter von 32–33 Jahren. Dieser Unterschied in der Gesamtzahl der LE als Hauptdiagnose zwischen Männern und Frau-en innerhalb dieses Lebensabschnitts von 20 Jahre erhöhte sich von 318 in 2005 auf 606 im Jahr 2010 und sank auf 505 im Jahr 2011. Die Differenzierung in LE mit und ohne akutes cor pulmonale zeigte insbesondere eine spezifische Erhöhung der LE ohne akutes cor pulmonale bei jungen Frauen innerhalb dieser sieben Jahre. Ähnliche Änderungen konnten nicht für TVT als Hauptdiagnose gezeigt werden.

Schlussfolgerung: Die präsentierten Daten aus der deutschen DRG-Statistik zeigen einen dysproportional höheren Anstieg der Hospitalisierung junger Frauen mit Lungenembolie als Hauptdiagnose in den vergangenen Jahren. Die möglichen Ursachen der hormonalen Kon-trazeption für diesen Anstieg müssen weiter aufgeklärt werden.

Thoracal, abdominal and thoracoabdominal aortic aneurysm

AIM

Aortic aneurysm is a complex disease affecting males and females in a different way. We analysed gender specific differences in the abdominal (AAA), thoracal (TAA) and thoraco-abdominal (TA-AA) aortic aneurysm in patients hospitalized for aortic aneurysm (AAA) in Germany.

METHODS

Detailed lists for all patients suffering from AAA, TAA or TA-AA documented in the DRG-System as principal diagnosis in the years 2010 were provided by the Federal Statistical Office.

RESULTS

The total number of cases in males was 17,731. It was more than three time higher than in females with 4657. AAA were 6.2 time more frequent in males than in females, TAA and TA-AA only 1.6 and 1.5 times, respectively. The rates of ruptured aneurysms show a steep increase in the 9th and 10th decade which is more pronounced in females. In males there is an age dependent increase in the rate of endovascular treatment of TAA and AAA. There is no such trend in females. The rate for AAA even decreases with age. The same could be shown for more complex fenestrated or branched endoprotheses. In around 20% of all male cases with TA-AA such a design is used in the 7th to the 9th decade of life. In females such a rate is only reached in the 7th decade. In older females the rate stepwise decreased.

CONCLUSION

There are gender specific differences in the rate of rupture and endovascular treatment of AAA, TAA and TA-AA in males and females in Germany. The reasons for these differences should be elucidated in order to prove whether these differences are due to actual gender specific requirements, or simply a lack of compatibility in awareness and devices.

Trends in lower extremity surgical and endovascular revascularization in Germany

BACKGROUND

We analyzed trends in lower extremity endovascular and open surgical procedures in hospitalized patients in Germany.

PATIENTS AND METHODS

We used national statistics (DRG statistics) published by the Federal Statistical Office including data from almost all hospitals in Germany to calculate annual procedure rates of lower extremity endovascular and open surgical procedures in the years 2005 to 2008. Detailed lists of the OPS-codes 8 - 836, 5 - 381, 5 - 393 separated by the 6th number of the code were analyzed regarding procedures representing revascularization of peripheral arteries including the aorta.

RESULTS

Between 2005 and 2008 the total number of endovascular procedures increased from 73,584 to 98,664 and the number of surgical procedures from 74,789 to 86,172 a year. Age-adjusted incidence rates of endovascular procedures in people >= 65 years increased from 325 to 432 per 100,000 while the incidence rates of all open surgical procedures increased from 315 to 351 per 100.000. Looking only at bypass surgery the incidence remained unchanged with 177 and 176 per 100,000 in the same period. Endovascular procedures other than balloon angioplasty including percutaneous atherectomy, laser recanalization or usage of cutting balloon, account for less than 1 % in Germany.

CONCLUSIONS

The numbers of endovascular procedures overweigh the numbers of open surgical procedures for treatment of lower extremity PAD in Germany today. In contrast to data from the USA we could not demonstrate a decrease of open surgical procedures in Germany in recent years.

ABI derived from the highest and lowest ankle pressure. What is the difference?

AIM

Different modes of ankle-brachial -index (ABI) calculation lead to different information. We looked for the peripheral arterial disease (PAD) prevalence estimated from ABI-high and ABI-low and analysed the effect of age and classical risk factors.

METHODS

Based on the Arteriomobil Project data, ABI was calculated considering the lowest of the four ankle artery pressures (ABI-low) or the higher ankle artery pressure of each leg (ABI-high), respectively. ABI <0.9 were defined to prove PAD.

RESULTS

Prevalence of PAD estimated using ABI-low was much higher than those using ABI- high (15.7% vs. 8.0%). Thus 8% of men and 7.5% of women suspected for PAD were not detected if prevalence rates are based on ABI-high alone. Estimating PAD prevalence only by measuring posterior tibial artery (ATP) pressure, prevalence rates were lowest with 2.4% for the left and 2.7% for the right ATP. Estimating PAD prevalence only by measuring anterior tibial artery pressure, prevalence rates were slightly higher, but still low. ABI-high systematically shows lower prevalence rates compared to ABI-low without divergence of the prevalence rates with increasing age. This parallelism of the curves remained unchanged when prevalence rates were separated for self-reported risk-factors; smoking, hypertension, hypercholesterolemia and diabetes.

CONCLUSION

The presented analysis of the Arteriomobil Project data support the hypothesis that the differences in prevalence rates estimated from ABI-high and ABI-low are mainly determined by anatomic variations of the plantar arch. Additional angiographic controlled studies are necessary to prove this hypothesis.

[Transjugular intrahepatic portosystemic shunt in patients with portal vein thrombosis]

PURPOSE

To evaluate the feasibility of TIPS for portal vein thrombosis (PVT) with/without portal vein occlusion/cavernomatous transformation and with/without underlying cirrhosis.

MATERIALS AND METHODS

13 patients with PVT and refractory ascites (n=7) and variceal bleeding (n = 6) received TIPS placement. The function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. The rates of technical success, revision and mortality after TIPS were evaluated.

RESULTS

The TIPS was successfully placed in 85% (11/13) of the cases. TIPS placement was successful in 87.5% (7/8) of patients with occlusion of the right portal vein and in 100% (5/5) of patients with non-occlusive right portal vein (p > 0.05), in 80% (8/10) of cirrhotic (x/10) and in 100% (3/3) of non-cirrhotic patients (p > 0,05), as well as in one patient with a fresh PVT and in 1 of 2 patients with cavernous transformation. 30 and 14.3% of patients needed a TIPS revision in the first and second year, respectively. No patient with occlusion of the right portal vein required a revision. 54.5% (6/11) of patients died within 6 months. Under exclusion of 4 patients with advanced malignant diseases, the mortality rate was 28.6%.

CONCLUSION

TIPS should be considered for selected patients with symptomatic occlusive PVT with/without cavernous transformation and with/without underlying cirrhosis. The frequency of TIPS revision is not greater, and the mortality rate 6 months after PVT recanalization seems to be comparable with that of patients without PVT.

Klippel-Trenaunay syndrome and pregnancy

General recommendations on how to deal with pregnancy in patients with Klippel-Trenaunay syndrome (KTS) are rare. We describe the case of a 32-year-old female with KTS, involving the head and the left arm and leg, delivering a healthy female child, and are reviewing the recent literature. The risk to deliver an ill child is low in women with KTS. At the end of the 1st trimester a sonographic investigation can exclude angiodysplastic alterations of the fetus. If the fetus shows changes compatible with KTS, a termination can be discussed because the risk of fatal complications after delivery is high. During pregnancy the careful monitoring of coagulopathic disorders is necessary. Prior to delivery an MR-scan may be useful to detect angiodysplastic vascular structures next to the spinal cord, pelvic structures or the lower abdominal wall, which might complicate peridural anesthesia or caesarean section.

Effect of atorvastatin and clopidogrel on cellular immune function

Lipid lowering therapy by statins and antiaggregation have become the basis of any anti-atherosclerotic prophylaxis either as primary or secondary prophylaxis. As several recent papers indicated immunosuppressive properties of statins we investigated changes in lymphocyte subpopulations, apoptosis markers, and cellular immune response towards mitogens after a short-term therapy with atorvastatin and clopidogrel. Nine healthy volunteers (four male, five female, age ranging from 26 to 43 years) were treated with 20 mg atorvastatin for 4 weeks and for 2 additional weeks with 20 mg atorvastatin and 75 mg clopidogrel after oral consent was given. Lymphocyte subpopulations were counted by flow cytometry. To assess cellular in vitro immune function, lymphocyte transformation tests with four mitogens (PHA, ConA, PWM, and OKT3) were performed. Absolute leucocyte counts remained unchanged as well as the granulocyte, monocyte, lymphocyte, and lymphocyte subpopulation counts. There were no detectable changes in markers of cell activation (HLA-DR, CD25, CD69, and CD86) or apoptosis (CD95, annexin). Cellular in vitro responses towards four mitogens did not show significant changes after atorvastatin nor after atorvastatin plus clopidogrel treatment.In conclusion, our data show that atorvastatin is not an immunosuppressive drug under therapeutical conditions.

Value of transesophageal echocardiography, esophago-gastroduodenoscopy and retinoscopy prior to intra-arterial fibrinolytic therapy in patients with peripheral arterial disease

BACKGROUND

We prospectively investigated the need for esophagogastroduodenoscopy (EGD), transesophageal echocardiography (TEE) and retinoscopy for pre-interventional screening in patients with peripheral arterial occlusive disease (PAD) prior to intraarterial fibrinolytic therapy.

PATIENTS AND METHODS

212 consecutive patients suffering from PAD (164 male and 48 female, mean age: 64 +/- 11 years, 161 patients stage II of Fontaine's classification, 10 patients at stage III and 41 patients at stage IV) referred for interventional treatment were included. 173 EGDs, 169 TEEs and 188 retinoscopies were performed within one week prior to fibrinolysis. 114 patients had all three examinations.

RESULTS

Pathologic findings were detected in 56 (49%) of the 114 patients: 23 erosions, 12 ulcers, 2 esophagites, 1 gastric carcinomata, 3 intracardiac thrombi, 5 aortic thrombi, 11 diabetic and 5 hypertensive retinopathies and 1 with retinal aneurysms. 30 patients (25%) received fibrinolytic therapy, despite a contraindication: The one patient with ventricular thrombus was treated as an ultimate therapy, and amputation was prevented. Two patients showing plaques covered by large thrombi in the descending thoracic aorta were treated because cranial embolism should not occur. Four diabetic patients with multilevel disease, severe claudication and prior retinal bleeding were treated. Fibrinolytic therapy was started on 23 patients after complete healing of the mucosal lesions.

CONCLUSION

TEE revealed potential sources of embolization in 4% of the patients and is justified to reduce the individual risk. Retinoscopy should be done in patients with diabetes mellitus and hypertension, and if prior bleeding is present fibrinolysis should be done only if other treatment-regimes are not available.

Relevance of low titers of cryoglobulins and cold-agglutinins in patients with isolated Raynaud phenomenon

INTRODUCTION

A Raynaud phenomenon can be associated with cold agglutinins or cryoglobulins. Although cold agglutinins or cryoglobulins may lead to severe acral gangrene the finding of relevant titers is rare. Low titers of cold agglutinins or cryoglobulins are detected more frequently but are assumed to be without any importance.

OBJECTIVES

To prove a possible diagnostic or prognostic role of low titers of cold agglutinins or cryoglobulins in patients presenting an isolated Raynaud phenomenon we did a retrospective analysis.

SETTINGS AND SUBJECTS

In 306 patients (40+/-16 years, range: 15-83 years) with a mean duration of the history of an isolated Raynaud phenomenon of 48+/-73 months we did a clinical examination, an analysis of antinuclear antibodies, extractable antibodies, cold agglutinins, cryoglobulins, plasma and blood viscosity, erythrocyte aggregation and a nail fold capillaroscopy.

RESULTS

Low titers of cold agglutinins were found in 49 patients and of cryoglobulins in 7 patients. The finding of such low titers was not associated with extensive clinical symptoms, duration of clinical symptoms, megacapillaries or haemorrhagies in capillaroscopy, pathologic plasma and blood viscosity and erythrocyte aggregation. The follow-up investigations (mean: 3.1+/-1.2 years, range: 3-7 years) revealed no development of a haematological, vasculitic or connective tissue disease in the subgroup of patients who only had low titers of cold agglutinins.

CONCLUSION

The detection of low titers of cold agglutinins in patients with isolated Raynaud phenomenon is of no diagnostic or prognostic relevance.

Thrombangitis obliterans: leucocyte subpopulations and circulating immune complexes

BACKGROUND

The etiology of thrombangitis obliterans is still unclear. Although cellular infiltration of the vessel wall is known, no studies on peripheral blood mononuclear cells are reported. Therefore, we assessed leucocyte subpopulations and circulating immune complexes in patients with thrombangitis obliterans and a control group of normal people.

PATIENTS AND METHODS

31 patients (40 +/- 2 years, 24 male, 7 female) with thrombangitis obliterans were included, based on the following criteria: age of manifestation, acral ischemia in legs and arms, previous thrombophlebitis or phlebitis saltans. Manifestation of atherosclerosis or other vasculitic manifestations were excluded. Leucocyte subpopulations, levels of C-reactive protein (CRP) and circulating immune complexes (CIC) were investigated. An age-matched control group (n = 25) was recruited from voluntary blood donors.

RESULTS

Leucocyte counts in the thrombagitis group (mean +/- SD: 10,839 +/- 782/nl) were significantly different from the control group (6205 +/- 414/nl, p < 0.0001). The same was true for absolute counts of granulocytes, monocytes and lymphocytes. The results were independent from CRP, which was elevated only in 6 patients. Relative counts of naive helper T-cells were significantly lower in the patient group. HLA-DR expression on B-cells was lower on the patients' lymphocytes. The concentrations of IgA, IgG and IgM in CIC were higher in the thrombangitis patients compared to the control group. C1q-binding capacity and phosphatidylserine antibodies showed no differences.

CONCLUSIONS

Patients suffering from thrombangitis obliterans show alterations of leucocyte counts and their subpopulations as well as alterations of the humoral (IgCIC) immune system.

Segmental manifestation of peripheral atherosclerosis and its association to risk factors

BACKGROUND

To prove whether the aortoiliac, femoropopliteal or crural segments of the peripheral arteries might have a different sensitivity to a risk profile we did a statistical analysis of segmental peripheral atherosclerosis and risk factors.

PATIENTS AND METHODS

In 132 patients (mean age 61 +/- 13 years) with peripheral arterial occlusions the arterial segments with occlusion or stenosis were angiographically documented: 17 had occluded or stenosed aortoiliac, 45 femoropopliteal and 25 crural arteries and 45 patients had multiple manifestations. Analysis of total cholesterol, HDL- and LDL-cholesterol, triglyceride, lipoprotein a, fibrinogen, uric acid, homocysteine, hematocrit, erythrocyte sedimentation rate, HBA1, IgG- and IgM-antibodies versus Cytomegalovirus, Herpes simplex-virus, Chlamydia pneumoniae and Helicobacter pylori were done and nicotine abuse, arterial hypertension and obesity were evaluated.

RESULTS

Age of the patients had the strongest correlation with isolated segmental manifestation (p < 0.0001). Patients with isolated aortoiliac manifestation were younger than patients without this manifestation (54 +/- 9 years versus 62 +/- 13 years). Patients with isolated femoropopliteal manifestation were older than patients without this manifestation (66 +/- 11 years versus 58 +/- 13 years). None of the investigated risk factors showed a correlation with these age related differences. Independent from the age related differences for the nicotine abuse a p-value of 0.08 was estimated, but in smokers a diffuse manifestation was most frequent.

CONCLUSION

There are age dependent differences of the prevalence of isolated aortoiliac or femoropopliteal atherosclerotic occlusions or stenosis. An association of these differences to a specific risk profile was not found.

A computational algorithm for minimizing total variation in image restoration

A reliable and efficient computational algorithm for restoring blurred and noisy images is proposed. The restoration process is based on the minimal total variation principle introduced by Rudin et al. For discrete images, the proposed algorithm minimizes a piecewise linear l (1) function (a measure of total variation) subject to a single 2-norm inequality constraint (a measure of data fit). The algorithm starts by finding a feasible point for the inequality constraint using a (partial) conjugate gradient method. This corresponds to a deblurring process. Noise and other artifacts are removed by a subsequent total variation minimization process. The use of the linear l(1) objective function for the total variation measurement leads to a simpler computational algorithm. Both the steepest descent and an affine scaling Newton method are considered to solve this constrained piecewise linear l(1) minimization problem. The resulting algorithm, when viewed as an image restoration and enhancement process, has the feature that it can be used in an adaptive/interactive manner in situations when knowledge of the noise variance is either unavailable or unreliable. Numerical examples are presented to demonstrate the effectiveness of the proposed iterative image restoration and enhancement process.

Numerical considerations for interface reflections in medical ultrasound

The original concept of the echo mechanism in diagnostic medical ultrasound--of step impedance discontinuities--is investigated in terms of the numerical implications of more refined models. The effect of a discontinuity in the attenuation coefficients is found to have as much significance as the impedance discontinuity at low reflection interfaces. An approximate analytical model is developed for spatially varying changes in the impedance. Numerical calculations are presented for reflections from delta-function and Gaussian-envelope RF pulses for two different models: an impedance gradient, and a connective tissue layer. The models used are well documented in acoustics textbooks, but the numerical results for typical tissue parameters show that a wide variety of interface structures may give rise to reflected amplitudes in the same range as that determined by the step impedance model. It is suggested that experimental investigation of interface structures may increase our understanding of the tissue: ultrasound interaction in diagnostic processes.