A Clinical Comparison of Two Formulations of Tobramycin 0.3% Eyedrops in the Treatment of Acute Bacterial Conjunctivitis

Purpose

To compare the safety and efficacy of a new enhanced viscosity ophthalmic formulation of tobramycin, given twice daily (BID), with the existing four times daily (QID) treatment regimen in patients with acute bacterial conjunctivitis.

Methods

This was a 12-day, multicenter, observer-masked, randomized, parallel group study. Patients received one drop of tobramycin 0.3% (3 mg/mL) enhanced viscosity ophthalmic solution BID or tobramycin 0.3% (3 mg/mL) ophthalmic solution QID in the affected eyes for 7 days. The primary efficacy variable was the percentage of patients with sustained cure/presumed bacterial eradication based on clinical judgment at the test-of-cure visit (Day 12). Pretherapy bacterial isolates were obtained and tested for susceptibility to tobramycin by determination of minimum inhibitory concentrations (MIC).

Results

A total of 276 patients were enrolled in the study and 203 of these were culture positive and attended all follow-up examinations. In this group, 98% of those treated with tobramycin enhanced viscosity ophthalmic solution and 99% of those treated with tobramycin 0.3% ophthalmic solution were categorized as having sustained cure/presumed eradication at the test-of-cure visit (p=0.6037). Reported adverse events were not serious, mild to moderate in severity, and generally did not prevent continuation in the study. Several pretreatment pathogens demonstrated tobramycin resistance (MIC > 4 mg/mL). However, therapy with both treatments was effective in the majority of the cases.

Conclusions

Tobramycin enhanced viscosity ophthalmic solution is well tolerated and has equivalent efficacy to the established treatment regimen with a simplified posology. The formulation provides an alternative therapy for acute bacterial conjunctivitis that should improve patient compliance and satisfaction.

[Staying and working at home or considering migrating: Survey-based study of African ophthalmologists]

BACKGROUND

The shortage of ophthalmologists is a major obstacle in the struggle of fighting preventable blindness in sub-Saharan Africa. However, to date reasons affecting migration of ophthalmologists have not been completely understood.

OBJECTIVES

Evaluation of reasons reported by ophthalmologists for staying in their current work setting/country, of potential reasons for migration as well as of effects of German-African partnerships.

MATERIAL AND METHODS

In the years 2009-2011 and 2013 participants of continuous medical education courses in Ethiopia, Cameroon and Kenya were interviewed using a standardized questionnaire.

RESULTS

A total of 106 ophthalmologists participated in this survey. In the years 2009/2010 participants were mainly board certified ophthalmologists, while the 2011/2013 surveys were answered mainly by residents. The main reasons for staying in their current region/country were good working conditions, commitment to help/patriotism, possibility of further training, good income and familial ties. Professional development elsewhere and better income abroad were named as the main reasons for considering migration followed by better technical equipment elsewhere and insecurity in the home country.

CONCLUSION

Good working conditions and the possibility of further training were named as the top reasons for staying in the current region/country apart from commitment to help and familial ties. Therefore, international cooperation programs aiming at improving training of ophthalmologists and establishing an ophthalmic infrastructure may have a role in promoting ophthalmic care in Africa.

[Intravascular ultrasound for recognition of atherosclerotic plaques and plaque composition. Current state of the diagnostic value]

Coronary atherosclerosis including acute coronary syndrome (ACS) is the leading cause of death in the western world and in the majority of patients is caused by plaque rupture in flow-limiting and non-flow-limiting angiographically intermediate stenoses. Histopathologic analyses have shown the relationship of plaque composition to acute clinical events and therefore to the vulnerability of coronary lesions. Knowledge of remodeling processes of the coronary artery has focused interest on non-flow-limiting lesions of the coronary tree. Intravascular ultrasound (IVUS) can demonstrate discrepancies between the extent of coronary atherosclerosis and angiographic imaging by in vivo plaque imaging. In addition the spectral analysis of IVUS-derived radiofrequency (RF) data enables more precise analysis of the plaque composition and plaque type.As IVUS is best able to assess stent underexpansion and malapposition the guidance of catheter-based coronary interventions plays a major role in angiographically unclear lesions even in the drug-eluting stent era. In the field of percutaneous coronary interventions (PCI) IVUS can influence the therapy and therefore optimize the stratification of patients.In terms of secondary prevention it is of great clinical importance to detect progression of coronary artery disease and moreover to predict coronary lesions with significant progression up to ACS. Coronary angiography and clinical parameters are poor surrogates to predict future events in a broad cohort of patients after PCI. In addition non-invasive imaging fails to identify coronary plaques with potential rupture and subsequent ACS. This highlights the need to identify potentially high risk lesions. However, prospective studies with IVUS-RF imaging to detect lesions that are considered to be prone to rupture showed no evidence for catheter-based invasive treatment of a non-flow-limiting high risk plaque.In the future the integrated combination of multiple technologies (e.g. IVUS-RF and optical coherence tomography) can further improve the accuracy of the analysis of high risk lesions.

Clinical management of clopidogrel inefficiency by point of care platelet function testing and individual adjustment of anti-platelet therapy--initial experiences

Insufficient inhibition of ADP dependent platelet aggregation by clopidogrel is associated with an increased risk for adverse coronary events, such as stent thrombosis, after percutaneous coronary intervention. Here, we describe an approach to the clinical management of patients with insufficient inhibition of ADP dependent platelet aggregation by clopidogrel involving dose adjustment or switching of the thienoyridine. We put special emphasize on a patient who experienced recurrent acute myocardial infarction due to stent thrombosis associated with severe clopidogrel non response following elective coronary drug eluting stent implantation. In this patient, an inadequate clopidogrel effect at maintenance doses was confirmed by repeated platelet function assessment with a multiple electrode impedance point of care platelet function test. Subsequent dose adjustments still did not result in sufficient inhibition of ADP dependent platelet aggregation. Only after switching to the then shortly available new thienopyridine prasugrel could a sufficient platelet inhibition be obtained. However, our data from further patients show that although this may overcome inadequate clopidogrel efficiency in many cases, even under prasugrel suboptimal platelet inhibition may occur.

Improvement of fractional flow reserve and collateral flow by treatment with external counterpulsation (Art.Net.-2 Trial)

BACKGROUND

Arteriogenesis (collateral artery growth) is nature's most efficient rescue mechanism to overcome the fatal consequences of arterial occlusion or stenosis. The goal of this trial was to investigate the effect of external counterpulsation (ECP) on coronary collateral artery growth.

MATERIALS AND METHODS

A total of 23 patients (age 61 +/- 2.5 years) with stable coronary artery disease and at least one haemodynamic significant stenosis eligible for percutaneous coronary intervention were prospectively recruited into the two study groups in a 2 : 1 manner (ECP : control). One group (ECP group, n = 16) underwent 35 1-h sessions of ECP in 7 weeks. In the control group (n = 7), the natural course of collateral circulation over 7 weeks was evaluated. All patients underwent a cardiac catheterization at baseline and after 7 weeks, with invasive measurements of the pressure-derived collateral flow index (CFIp, primary endpoint) and fractional flow reserve (FFR).

RESULTS

In the ECP group, the CFIp (from 0.08 +/- 0.01 to 0.15 +/- 0.02; P < 0.001) and FFR (from 0.68 +/- 0.03 to 0.79 +/- 0.03; P = 0.001) improved significantly, while in the control group no change was observed. Only the ECP group showed a reduction of the Canadian Cardiovascular Society (CCS, P = 0.008) and New York Heart Association (NYHA, P < 0.001) classification.

CONCLUSION

In this study, we provide direct functional evidence for the stimulation of coronary arteriogenesis via ECP in patients with stable coronary artery disease. These data might open a novel noninvasive and preventive treatment avenue for patients with non-acute vascular stenotic disease.

Prothrombotic effects of diclofenac on arteriolar platelet activation and thrombosis in vivo

BACKGROUND

Diclofenac, like selective cyclooxygenase-2 inhibitors, which alter vascular levels of platelet active prostaglandins, has been reported to increase rates of acute myocardial infarction.

OBJECTIVE

The study was performed to investigate, in an animal model of arterial thrombosis in vivo, whether diclofenac differentially influences platelet activation and thrombosis in vessels under non-stimulated conditions or during acute systemic inflammation, such as induced by tumor necrosis factor-alpha (TNF-alpha).

METHODS

Platelet-vessel wall interaction (PVWI), firm platelet adhesion and arterial thrombosis following vessel injury were analyzed by intravital microscopy in arterioles of hamsters in the dorsal skinfold chamber model. Prostacyclin [prostaglandin I(2) (PGI(2))] and thromboxane A(2) (TxA(2)) metabolites were measured. In vitro, endothelial adhesion molecule expression in cultured human microvascular endothelial cells was analyzed.

RESULTS

Under non-stimulated conditions, diclofenac (1 mg kg(-1)) enhanced PVWI, which was not mediated by increased adhesion molecule expression, but by decreased systemic PGI(2) levels. Following ferric chloride-induced endothelial injury, diclofenac accelerated thrombotic vessel occlusion time, an effect that was reversed by the stable PGI(2) analog iloprost. TNF-alpha, through induction of endothelial adhesion molecule expression, also enhanced PVWI, firm adhesion, and arterial thrombosis, but simultaneous treatment with TNF-alpha and diclofenac did not have an additive effect.

CONCLUSIONS

By decreasing levels of PGI(2) without, at the same time, altering prothrombotic TxA(2) levels, diclofenac can exert prothrombotic effects. However, this is not the case when an inflammatory situation is created by TNF-alpha treatment. These data may explain the enhanced risk of acute myocardial infarction observed in patients taking diclofenac.

Comparison of pressure measurement, dobutamine contrast stress echocardiography and SPECT for the evaluation of intermediate coronary stenoses. The COMPRESS trial

BACKGROUND

DSE and SPECT are two well-established methods to non-invasively investigate the functional significance of coronary artery stenoses in patients with coronary artery disease. The measurement of Fractional Flow Reserve has emerged a new invasive reference standard for lesion specific quantification of coronary artery stenoses. The objective of our prospective study was to compare sensitivity and specificity of Dobutamine Stress Echocardiography (DSE) and Single Photon Emission Computer tomography (SPECT) with the pressure derived Fractional Flow Reserve (FFR) for the identification of hemodynamic relevant coronary lesions in patients with predominately coronary multivessel disease and angiographically intermediate stenoses.

METHODS

Inclusion criteria were a coronary lesion of 50-75% diameter stenosis by visual assessment in patients with known or suspected CAD. SPECT, DSE and FFR testing was performed within one week of coronary angiography.

RESULTS

The study comprised 48 consecutive symptomatic patients. In 41 cases, a coronary multivessel disease was present. Mean FFR was 0.80 +/- 0.13 (0.41-1.0). Overall sensitivity of DSE and SPECT was 67% and 69% whereas specificity reached 77% and 87%. However, sensitivity was significantly reduced if the target lesion was located distally. DSE showed poor results if the lesions were located in the circumflex artery or if a history of prior myocardial infarctions was present.

CONCLUSION

DSE and SPECT are both useful methods for the non-invasive assessment of coronary artery disease. DSE showed reasonable combination of sensitivity and specificity even in patients with multivessel disease. Although use of noninvasive stress tests is only limited in patients with prior myocardial infarctions and invasive stress testing should be preferred in these patients.

[Training program for vitreoretinal surgery in Nairobi, Kenya from 2000 - 2006]

BACKGROUND

After the U. S. Embassy bombing in 1998 in Nairobi, Kenya, a relief operation was immediately initiated by the Department of Ophthalmology of the Ludwig Maximilians University (LMU) Munich, Germany. Surgical devices and material (such as a vitrectomy unit, silicon oil, perfluorodecalin, intraocular lenses, sutures) were supplied to operate on 42 ocular-injured victims of this bombing attack. Apart from these specific operations in Kenya, there is a big need for vitreoretinal surgery in East Africa, as in all other developing countries. Therefore, a vitreoretinal training program was started in 2000 in Nairobi, Kenya. We report about the first 7 years of collaboration between the Ludwig Maximilians University of Munich, Germany and the University of Nairobi in cooperation with the Kenyatta National Hospital, Kenya.

MATERIAL AND METHODS

The training program was based on an annual project week in which the author (CLS) carried out vitreoretinal surgery himself and assisted and supervised surgery done by the local Kenyan colleagues at the Kenyatta National Hospital. Within the observation period of the present work (2000 - 2006) the following data were collected: number and kind of surgery, indications, surgeons, grading of eye pathology and the surgical procedure, time to prepare for surgery and duration of surgery.

RESULTS

In total, 293 vitreoretinal surgeries were performed during the observation period. Surgeries carried out by the local Kenyan colleagues independently, without intervention of the author, increased from 29.4 % (2000) to 78.6 % (2006). Due to a constant development in the learning process during the project week more severe cases were treated and preparation time for surgery from the nursing side has shortened.

CONCLUSIONS

By initiating a project week with high frequency surgery, supported by a highly experienced visiting surgeon, vitreoretinal surgery can be successfully set up in an ophthalmic clinic of a developing country. This approach has some advantages when compared to long-period projects, especially for the purposes of sustainability. However, to be successful it requires systematic planning which is described in this article.

[International initiatives for the prevention of blindness]

Since 1974, when the International Agency for the Prevention of Blindness (IAPB) was founded, international campaigns for blindness prevention have gained tremendous momentum in collaboration with the WHO's blindness prevention programme. In 1999 WHO and IAPB launched the campaign Vision 2020, The Right to Sight, in which WHO, IAPB, member countries of WHO and nongovernmental organizations (NGOs) that are active in this field are all working together. The major emphasis of the programme is on control of the major disorders leading to blindness and the development of infrastructures, of eye care programmes and of training and continuing education for ophthalmic staff. This campaign is unique in medicine and has the potential for reducing the prevalence of blindness in the world significantly by 2020. Even now, we can assume that 75-80% of cases of blindness can be prevented. The WHO has developed strategies for dealing with individual diseases, such as trachoma, onchocerciasis, childhood blindness and refractive errors. Programmes for glaucoma and diabetic retinopathy will follow. Early successes can already be recognized, especially in the rising numbers of cataract operations.

Thrombin inhibitors and anti-factor Xa agents in the treatment of arterial occlusion

Cardiovascular disease is the leading cause for mortality and morbidity in the western world. Arterial thrombosis has multiple origins and may present with different clinical presentations such as acute coronary syndromes, stroke, and peripheral embolization. Furthermore, thrombotic complications may occur during percutaneous interventions. The underlying causes range from atherosclerosis with plaque rupture or erosion, embolization, stasis and hypercoagulable states. Thrombotic complications lead to activation of the intrinsic coagulation system and to platelet aggregation. Despite the development of effective platelet inhibitors, there is still the need for an optimal anticoagulation regimen. While unfractionated heparin is the most commonly used antithrombotic agent, which has major inherent limitations. Direct thrombin inhibitors and anti factor Xa agents are agents which may overcome the limitation of unfractionated heparin. The potential advantages of these new compounds are discussed on the basis of available clinical data in patients with coronary artery disease.

Wirksamkeit neuer Fluorchinolone gegenüber der bakteriellen Normalflora der Bindehaut

BACKGROUND

Our aim was to determine the antibiotic susceptibility of the preoperative conjunctival bacterial flora against 25 commonly used antibiotics, especially the new fluoroquinolones levofloxacin, gatifloxacin, and moxifloxacin.

PATIENTS AND METHODS

The Kirby-Bauer disk-diffusion technique was used to test for the in vitro antibiotic susceptibility of conjunctival bacterial strains isolated from 160 patients (median=74 years, mean=71 years) undergoing cataract surgery at the Department of Ophthalmology, Stanford University, CA, USA.

RESULTS

Among the 256 bacteria isolated, 201 (79%) were coagulase-negative staphylococci (CNS), 26 Staphylococcus aureus, 15 Streptococcus group D and 14 gram-negative rods. A total of 100 of these 256 strains (39%) were classified as multiresitant (resistant to>or=five antibiotics). The resistance rate (RR) of commonly used antibiotics for all CNS was: gatifloxacin=moxifloxacin<gentamycin=tobramycin=levofloxacin=neomycin<ciprofloxacin=ofloxacin<erythromycin. The RR for S. aureus and the gram-negative rods was low and insignificant in comparison to the other antibiotics tested. None of the Streptococcus group D were resistant to gatifloxacin, levofloxacin, or moxifloxacin, however, they were highly resistant (RR over 30%) to the other antibiotics. Some 50% of the bacteria were resistant to erythromycin.

CONCLUSION

Newer generation fluoroquinolones provide excellent efficacy against coagulase-negative staphylococci and Streptococcus group D despite a high number of multiresitant bacteria.

Combined use of 64-slice computed tomography angiography and gated myocardial perfusion SPECT for the detection of functionally relevant coronary artery stenoses. First results in a clinical setting concerning patients with stable angina

AIM

In patients with stable angina pectoris both morphological and functional information about the coronary artery tree should be present before revascularization therapy is performed. High accuracy was shown for spiral computed tomography (MDCT) angiography acquired with a 64-slice CT scanner compared to invasive coronary angiography (ICA) in detecting "obstructive" coronary artery disease (CAD). Gated myocardial SPECT (MPI) is an established method for the noninvasive assessment of functional significance of coronary stenoses. Aim of the study was to evaluate the combination of 64-slice CT angiography plus MPI in comparison to ICA plus MPI in the detection of hemodynamically relevant coronary artery stenoses in a clinical setting.

PATIENTS, METHODS

30 patients (63 +/- 10.8 years, 23 men) with stable angina (21 with suspected, 9 with known CAD) were investigated. MPI, 64-slice CT angiography and ICA were performed, reversible and fixed perfusion defects were allocated to determining lesions separately for MDCT angiography and ICA. The combination of MDCT angiography plus MPI was compared to the results of ICA plus MPI.

RESULTS

Sensitivity, specificity, negative and positive predictive value for the combination of MDCT angiography plus MPI was 85%, 97%, 98% and 79%, respectively, on a vessel-based and 93%, 87%, 93% and 88%, respectively, on a patient-based level. 19 coronary arteries with stenoses > or =50% in both ICA and MDCT angiography showed no ischemia in MPI.

CONCLUSION

The combination of 64-slice CT angiography and gated myocardial SPECT enabled a comprehensive non-invasive view of the anatomical and functional status of the coronary artery tree.

Combined use of 64-slice computed tomography angiography and gated myocardial perfusion SPECT for the detection of functionally relevant coronary artery stenoses

Aim: In patients with stable angina pectoris both morphological and functional information about the coronary artery tree should be present before revascularization therapy is performed. High accuracy was shown for spiral computed tomography (MDCT) angiography acquired with a 64-slice CT scanner compared to invasive coronary angiography (ICA) in detecting „obstructive” coronary artery disease (CAD). Gated myocardial SPECT (MPI) is an established method for the noninvasive assessment of functional significance of coronary stenoses. Aim of the study was to evaluate the combination of 64-slice CT angiography plus MPI in comparison to ICA plus MPI in the detection of hemodynamically relevant coronary artery stenoses in a clinical setting. Patients, methods: 30 patients (63 ± 10.8 years, 23 men) with stable angina (21 with suspected, 9 with known CAD) were investigated. MPI, 64-slice CT angiography and ICA were performed, reversible and fixed perfusion defects were allocated to determining lesions separately for MDCT angiography and ICA. The combination of MDCT angiography plus MPI was compared to the results of ICA plus MPI. Results: Sensitivity, specificity, negative and positive predictive value for the combination of MDCT angiography plus MPI was 85%, 97%, 98% and 79%, respectively, on a vessel-based and 93%, 87%, 93% and 88%, respectively, on a patient-based level. 19 coronary arteries with stenoses ≥50% in both ICA and MDCT angiography showed no ischemia in MPI. Conclusion: The combination of 64-slice CT angiography and gated myocardial SPECT enabled a comprehensive non-invasive view of the anatomical and functional status of the coronary artery tree.

[Ocular changes in tropical malaria with cerebral involvement--results from the Blantyre Malaria Project]

INTRODUCTION

Malaria is a tropical disease causing an estimated 300 million infections and one million deaths per year. In sub-Saharan Africa, most infections are due to Plasmodium falciparum. The hallmark of the clinical syndrome of cerebral malaria is coma, and the associated mortality rate, even in appropriately treated patients, is 15 - 50 %. Funduscopy plays a major role for the ophthalmologist in the differential diagnosis because of the characteristic changes.

METHODS

To date more than 1000 children who satisfied the standard clinical case definition of cerebral malaria were admitted to the Blantyre Malaria Project (Malawi, Africa) for inpatient treatment and examined using indirect ophthalmoscopy through fully dilated pupils. The gender distribution was homogeneous and the children were between 2 and 14 years old. The optic nerve head, central and peripheral retina and central and peripheral vessels were described and photographed using a hand-held fundus camera (KOWA).

RESULTS

The spectrum and severity of findings of the ocular fundus in children with CM include the following distinct entities: haemorrhages (with and without a white centre), cotton wool spots, papilloedema, retinal whitening and retinal vessel abnormalities that may appear to be orange or white. Most of the retinal haemorrhages (in 40 %) have white centres and resemble Roth spots. Cotton wool spots were seen in only 5 %. Papilloedema was also not commonly seen (8 %) but is a poor prognostic sign. Retinal whitening (in 50 %) is seen more commonly at the posterior pole than in the periphery. 20 % of patients show retinal vessel abnormalities that may be orange or white in colour.

CONCLUSION

Ocular fundus changes in CM can be detected by the ophthalmologist using simple means and are decisive for the prognosis and timely therapy for this potentially lethal disease.

The validation of fractional flow reserve in patients with coronary multivessel disease: a comparison with SPECT and contrast-enhanced dobutamine stress echocardiography

Fractional flow reserve (FFR) is a new but well established parameter for the hemodynamic evaluation of coronary stenoses. A FFR below 0.75 was validated as functionally significant in coronary one or two vessel disease. This study was designed to prospectively define the best FFR cut off value (BCV) in patients with multivessel disease using two noninvasive tests, myocardial perfusion scintigraphy (SPECT) and contrast-enhanced dobutamine stress echocardiography (DSE) as reference methods.

METHODS

47 symptomatic patients (29 male, mean age 64+/-10 yrs) with angiographically intermediate coronary lesions (50-75% diameter stenosis) entered the study. DSE (5-40 microg/min/kg dobutamine) was performed after intravenous injection of a second generation transpulmonary contrast agent. SPECT (Tc-99m-MIBI) was done at peak stress. All tests (DSE, SPECT and FFR) were performed within 4 weeks.

RESULTS

SPECT yielded positive results in 15 and DSE in 16 patients, respectively. Mean FFR measured in the target lesion (RCA n=10; LAD n=22, RCX n=15) was 0.80+/-0.13. FFR was <0.75 in 15 patients. By performing a ROC analysis the BCV (highest sum of sensitivity and specificity) was found at 0.75. At this cut off value using both non-invasive tests as reference method, sensitivity and specificity were 83 and 77%.

CONCLUSION

In patients with multivessel disease, a FFR <0.75 identifies a hemodynamically relevant lesion as compared to DSE and SPECT. This study underlines that FFR criteria are also applicable in patients with complex coronary artery disease.

Early time course of neointima formation and vascular remodelling following percutaneous coronary intervention and vascular brachytherapy of in-stent restenotic lesions as assessed by intravascular ultrasound analysis

In-stent restenosis (ISR) represents the major limitation of stent implantation. Treatment, although of relative technical ease, is unsatisfactory due to a high incidence of recurrent restenosis. Vascular brachytherapy (VBT) has emerged as a powerful adjunct therapeutic modality to treat ISR. Inhibition of neointima formation has been regarded as the relevant mechanism of action. Yet, positive remodelling has been suspected as another contributing factor. Since only very few precise analyses of the extent, distribution and time course of the respective mechanims exist, the goal of the present study was to describe the changes of the vessel geometry at the target lesion and at the reference site following angioplasty and VBT of ISR in 42 patients by means of quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS) before and after the index procedure and at the 3 and 6 month follow-up. By QCA the acute lumen gain measured 2.2+/-0.8 mm, the late lumen loss at 3 months was 0.1+/-0.5 mm and at 6 months 0.4+/-0.7 mm. By IVUS luminal cross-sectional area increased from 1.5+/-1.2 mm(2) to 7.9+/-1.9 mm(2) (p<0.001). The intima hyperplasia cross-sectional area at 3 months was only 0.2+/-1.0 mm(2) (p=0.191), but increased to 0.7+/-0.6 mm(2) (p<0.001) at 6 months resulting in a lumen cross-sectional area of 7.1+/-1.7 mm(2). Stent dimensions did not show any significant changes over time. The external elastic membrane cross-sectional area at 3 months increased by 1.3+/-1.9 mm(2) (p<0.001), and showed a further increase by 0.7+/-2.9 mm(2) at 6 months. Positive remodelling could be demonstrated also at the reference segment. In conclusion the absolute amount of intima hyperplasia during a 6-month follow-up period after VBT of ISR is low and most pronounced between the third and sixth month. Besides this, predominantly within the first 3 months of follow-up, significant positive remodelling could be demonstrated at the target lesion and at the reference site. Both observed effects may contribute to the preservation of the vessel lumen.

Fractional flow reserve for the prediction of cardiac events after coronary stent implantation: results of a multivariate analysis

OBJECTIVE

To determine the prognostic value of fractional flow reserve (FFR) measurements after coronary stent implantation including multiple clinical and angiographic parameters collected in one centre.

METHODS

119 consecutive patients were enrolled who had a stent implanted with the use of a pressure wire as a guidewire. Patients were followed up for at least six months. Any death, myocardial infarction, and target vessel revascularisation were considered major adverse cardiac events (MACE). Multivariate logistic regression was used to determine adjusted odds ratios (OR) and 95% confidence intervals (CI) for FFR and covariates.

RESULTS

Complete follow up data were available for all 119 patients. Pre-interventional FFR increased from 0.65 (0.15) to 0.94 (0.06) (p < 0.0001) after stent implantation. Eighteen MACE (15%) occurred during follow up including 15 (12.6%) target vessel revascularisations. Final FFR was significantly higher in patients without than in patients with an event (0.95 (0.05) v 0.88 (0.08), p = 0.001). In the multivariate logistic regression analysis, only final FFR < 0.95 (OR 6.22, 95% CI 1.79 to 21.62, p = 0.004) and reduced left ventricular function (OR 0.95, 95% CI 092 to 0.99, p = 0.021) remained as significant independent predictors for MACE.

CONCLUSION

These results including multiple parameters underline that FFR after coronary stenting is a strong and independent predictor for subsequent cardiac events after six months' follow up.

Acute limb ischemia after femoral arterial closure with a vascular sealing device: Successful endovascular treatment

We report on successful catheter therapy of acute occlusions of popliteal and crural arteries due to distal embolization from a vascular sealing device. A 45 years-old male patient underwent percutaneous coronary angiography. After primary successful closure of the right femoral artery by a sealing device the patient developed acute ipsilateral lower limb ischemia, most probably due to embolization of a collagen/thrombin plug. Occlusions of the popliteal and crural vessels were successfully treated by percutaneous thrombectomy, thrombolysis and ballon angioplasty. Combined percutaneous catheter therapy is a therapeutic option for occlusions of popliteal and crural vessels due to embolization from a vascular sealing device.

[Tropical ophthalmology--prevention and therapy"Vision 2020--the right to sight"]

Worldwide 45 million people are blind, 180 million people are visually handicapped, 90% of all blind people are living in developing countries and 80% of blindness is preventable. The global economic productivity loss due to blindness was estimated to be 19 billion US$ in the year 2000. The initiative "Vision 2020-the right to sight" aims to increase the cataract surgical rate and to eliminate diseases such as trachoma and onchocerciasis as well as avoidable blindness in children. It is planned that blindness in 100 million people can be avoided by the year 2020.

Bestimmung der Vitalit�t beim Myokardinfarkt

PURPOSE

The aim of the study was to compare the diagnostic accuracy in imaging viability of the myocardium with a multislice inversions recovery 2D single shot TrueFISP sequence and an established inversion recovery TurboFlash sequence.

MATERIAL AND METHODS

Twelve patients with myocardial infarction were examined at a 1.5 tesla MR system (Sonata, Siemens, Medical Systems) 10 min after application of a single dose multihance (0,1 mmol/kg body weight) with a 2D multislice technique (inversion recovery single shot TrueFISP), that allows to image the entire short axis during one breathhold and a 2D single slice technique (inversion recovery TurboFlash), that requires one breathhold per slice. Signal intensity was determined in normal myocardium, in the infarcted myocardium and in the left ventricle. The contrast/noise ratio of normal and infarcted myocardium was determined. The areas of hyperintense infarction were compared for both sequence techniques.

RESULTS

The multislice single shot 2D IR-TrueFisp sequence has a lower contrast/noise ratio than the IR-TurboFlash sequence (mean values 6.9 vs. 12.5) for viable and non viable myocardium. The assessment of the volume of the infarction is possible with excellent correlation of both techniques (r=0.97, p <0.036). In addition, an assessment of the transmural extent of the infarction is possible with identical spatial resolution.

CONCLUSION

The inversions recovery 2D single shot TrueFisp technique allows for accurate detection of the infarction, for accurate determination of the area of the infarction and for assessment of the transmural extent of the infarction with high spatial resolution.

A randomized comparison of 4 doses of intracoronary adenosine in the assessment of fractional flow reserve

BACKGROUND

Fractional flow reserve (FFR) is a measure of coronary stenosis severity that is based on pressure measurements obtained at maximal hyperemia. Therefore, achievement of maximal vasodilatation of the coronary microcirculation is a prerequisite for the measurement of FFR. The study was designed to address the hypothesis that intracoronary adenosine yields more complete vasodilatation of the coronary microcirculation when high doses are used, resulting in a more accurate FFR measurement.

METHODS

Thirty-six patients with 43 moderate lesions underwent determination of FFR during cardiac catheterization. FFR was calculated in all lesions as the ratio of the distal coronary pressure to the aortic pressure at hyperemia. Different incremental doses of intracoronary adenosine (16, 24, 32 and 40 microg for both coronary arteries) were administered in a randomized fashion.

RESULTS

No adverse events occurred with any intracoronary adenosine bolus. At baseline there were no significant differences for mean aortic and distal coronary pressure, heart rate as well as FFR values between the different doses. FFR was not significantly altered from the different incremental adenosine doses. However, in 27 (63%) out of 43 lesions there was a further reduction of FFR up to 0.23 when a dose >16 microg was injected.

CONCLUSIONS

This study suggests that doses of adenosine up to 40 microg are safe and can be used to achieve a more pronounced vasodilatation in individual patients compared to the standard doses. This may have therapeutic impact with FFR values near cut-off points in patients undergoing diagnostic coronary angiography as well as in patients in whom FFR is used to assess the outcome of interventions.

[Clinical and angiographic one-year follow-up of vascular beta-brachytherapy for coronary lesions treated by a stent with a very high risk for restenosis]

BACKGROUND

Vascular brachytherapy (VBT) has been proven to reduce restenosis rate and unwanted cardiac events in several randomized trials. Long-term data on populations at high risk for re-interventions are few. The aim of this study was to assess the acute and one-year outcome of beta-radiation in coronary in-stent restenoses with a high likelihood of recurrence.

METHODS

In 79 patients, VBT using 90Yttrium/Strontium or 32Phosphorus, was performed. Clinical and angiographic follow-up was carried out after 6 months and 1 year.

RESULTS

44.4 % of patients had three-vessel coronary artery disease and a high prevalence of cardiovascular risk factors and comorbidity. Mean lesion length was 36.8+/-18.9 mm. VBT was successful in all patients. Fractionation of VBT was necessary in 2,5 %. Acute gain of luminal diameter was 2.15+/-0.89 mm. During the hospital stay one acute myocardial infarction (AMI) not associated with VBT occurred. After 6 months loss of luminal diameter measured 0.39+/-0.47 mm, equaling a restenosis rate (RR) of 16.8 % (1 year: 0.60+/-0.56 mm, RR 33.5 %). 18.9 % of patients required revascularization of the target lesion (1 year: 29.5 %). After 6 months, all patients survived, three had an AMI after discontinuation of clopidogrel, one of them was asymptomatic (1 year: 1 cardiac death, 2 symptomatic AMI).

CONCLUSION

Beta-VBT in patients at a high risk for recurrence after angioplasty is feasible and safe. Though the clinical and angiographic results at 1 year showed some impairment as opposed to the 6-months-follow-up, they nevertheless are largely superior to those patients from historic controls not treated with VBT.

[Edge effect and late thrombosis -- inevitable complications of vascular brachytherapy?]

Restenosis is the limiting entity after percutaneous coronary angioplasty. Vascular brachytherapy for the treatment of in-stent restenosis has been shown to reduce the repeat restenosis rate and the incidence of major adverse events in several randomized trials. Besides the beneficial effects, brachytherapy yielded some unwanted side effects. The development of new stenoses at the edges of the target lesion treated with radiation is termed edge effect. It occurs after afterloading brachytherapy as well as after implantation of radioactive stents. It is characterized by extensive intimal hyperplasia and negative remodeling. As contributing factors the axial dose fall-off, inherent to all radioactive sources, and the application of vessel wall trauma by angioplasty have been identified. The combination of both factors, by insufficient overlap of the radiation length over the injured vessel segment, has been referred to as geographic miss. It has been shown to be associated with a very high incidence of the edge effect. Avoidance of geographic miss is strongly recommended in vascular brachytherapy procedures. Late thrombosis after vascular brachytherapy is of multifactorial origin. It comprises platelet recruitment, fibrin deposition, disturbed vasomotion, non-healing dissection and stent malapposition predisposing to turbulent blood flow. The strongest predictors for late thrombosis are premature discontinuation of antiplatelet therapy and implantation of new stents during the brachytherapy procedure. With a consequent and prolonged antiplatelet therapy, the incidence of late thrombosis has been reduced to placebo levels. Edge effect and late thrombosis represent unwanted side effects of vascular brachytherapy. By means of a thorough treatment planning and prolonged antiplatelet therapy their incidences can be largely reduced. With regard to the very favorable net effect, they do not constitute relevant limitations of vascular brachytherapy.

[Coronary interventions in old patients presenting with cardiogenic shock]

HISTORY AND CLINICAL FINDINGS

A 80-year-old unconscious woman was admitted to our hospital. She had suffered from angina pectoris and progressive dyspnea for three days. She had been in pulmonary edema 6 months ago. Clinical examination revealed low blood pressure of 90/60 mmHg, central cyanosis and signs of pulmonary congestion.

INVESTIGATIONS

Laboratory findings comprised elevated creatinkinase, troponin and lactate dehydrogenase as well as reduced sodium.

CLINICAL COURSE

After intubation and mechanical ventilation the patient underwent cardiac catheterization because of the cardiogenic shock. Coronary angiography revealed severe coronary artery disease with high grade stenoses of the right coronary artery and of the main stem of the left coronary artery. After initiating intraaortic balloon counterpulsation, transcatheter revascularization of the right and left coronary artery was performed, leading to an improvement of the systolic left ventricular function. But the patient finally died due to cardiac pump failure.

CONCLUSION

Elderly patients presenting with cardiogenic shock and additional risk factors have the highest mortality. Thus the decision for cardiac catheterization and eventual intervention should be made on a case-by-case basis. Successful angioplasty may reduce mortality by approximately 20 %. Due to the usually severe comorbidity absolute mortality is nevertheless very high.

[From conjunctivitis to glaucoma. When is a red eye an alarm signal?]

A red eye is mostly a relatively harmless sign of simple conjunctivitis. Viral conjunctivitis may be extremely contagious. If no improvement is seen after ten days of treatment, referral to an ophthalmologist is indicated. Local corticosteroids and local anesthetics must not be prescribed. The patient should also be referred to an ophthalmologist when the red eye is chronic or recurrent, and when a unilateral red eye is associated with severe pain and vomiting (suspicious for acute glaucoma!), or generally when severe pain or impairment of sight, indicative of corneal infiltration or a hypopyon, presents. The diagnostic use of fluorescein to stain the cornea and any alteration of corneal transparency also belong in the hands of the ophthalmologist.

Stent design related neointimal tissue proliferation in human coronary arteries; an intravascular ultrasound study

AIMS

Histological restenosis models in animals have indicated that stent design has a significant impact on vessel trauma during stent implantation and on the amount of subsequent neointimal tissue proliferation. The impact of different stent designs on intimal hyperplasia in human atherosclerotic coronary arteries has not been determined.

METHODS AND RESULTS

Angiographic and intravascular ultrasound studies were performed at the 6 month follow-up in 131 consecutive native coronary lesions of 131 patients treated with 50 Multi-Link stents, 40 InFlow stents and 41 Palmaz-Schatz stents. Lumen and stent cross-sectional areas (CSA) were measured at 1 mm axial increments. Mean intimal hyperplasia cross-sectional area (stent CSA-lumen CSA) and mean intimal hyperplasia thickness were calculated. Intravascular ultrasound demonstrated different levels of intimal hyperplasia proliferation for the three stents. Mean intimal hyperplasia thickness was 0.16+/-0.08 mm for Multi-Link stents, 0.26+/-0.19 mm for Palmaz-Schatz stents and 0.39+/-0.14 mm for Inflow stents (P<0.001). Multivariate analysis proved that stent type was the only independent predictor of intimal hyperplasia thickness at follow-up (P<0.001).

CONCLUSION

Coronary stent design has a significant impact on subsequent intimal hyperplasia after implantation into atherosclerotic human coronary arteries. The corrugated ring design of the Multi-Link stent proved to result in less tissue proliferation at 6-month follow-up than the tubular slotted design of Palmaz-Schatz and InFlow stents.

[Treating carotid stenosis without surgical trauma. How safe is stenting?]

Because of the reduced stress on the patient, the obviation of surgical trauma and the need for anesthesia, and only brief hospitalization, stent angioplasty is an attractive alternative to surgical treatment of carotid artery stenosis. The data so far available suggest that the results may be expected to equal those obtained with surgery in terms of success rate and complications. The establishment of the indication for this procedure is oriented to the indication for thromboendarterectomy, with certain patient groups possibly benefitting from endoluminal treatment. However, until data from controlled studies become available, stenting of the carotid artery should be limited to scientific studies and be registered with appropriate professional associations.

[Intravascular ultrasound guided directional atherectomy and stent implantation of an unprotected main stem in a heart transplant patient with comorbidity]

Following orthotopic heart transplantation (HTx), development of transplant vasculopathy (TVP) is the limiting medical entity leading to significant morbidity and mortality beyond the first year after HTx. Selection of a suitable strategy for repeat revascularisation--transcatheter angioplasty, coronary artery bypass grafting or repeat HTx--depends on various parameters including coronary morphology, left ventricular performance, comorbidity, availability of graft material and donor organs. Catheter-based interventions on the main stem of the left coronary artery are feasible, but a relatively lower primary success rate and a higher complication rate and significantly increased mortality have to be expected. We report on a patient who underwent HTx 9 years ago and developed severe transplant vasculopathy revealing significant main stem stenosis, making reintervention necessary. Due to age, coronary artery morphology and comorbidity the patient was not considered for coronary artery bypass grafting or repeat HTx. We performed successful IVUS-guided directional coronary atherectomy and stent implantation on a distal stenosis of the unprotected main stem. Our case demonstrates a predictable procedural risk and favourable primary result of left main stem angioplasty procedures, thus providing a therapeutic option for patients who are poor candidates for operative revascularisation strategies.

Vascular brachytherapy for treatment of cardiac allograft vasculopathy

A high restenosis rate often follows treatment of coronary stenoses in cardiac allograft vasculopathy. We report successful coronary brachytherapy of a second in-stent restenosis in a patient after heart transplantation.

[Predictors of recurrent basalioma of the eyelids and periorbital region]

BACKGROUND AND OBJECTIVES

Basal cell carcinoma is the most common malignant tumour of the eyelids but surgical excision in the eyelid region is often in conflict with preserving lid function. The purpose of this study was to identify factors predictive of basal cell carcinoma recurrence to improve pre- and postoperative planning.

PATIENTS AND METHODS

A total of 153 patients with basal cell carcinomas without recurrence of at least 5 years were compared with 45 primary lesions of recurrent basal cell carcinomas. Using bivariate correlations and multiple regression analysis, clinical factors were analysed for their value to predict recurrence.

RESULTS

Incompletely excised tumours were most likely to recur and re-excised tumours had a higher recurrence rate than primary completely excised tumours. Morphea or sclerosing lesions had a significantly higher tendency to recur than nodular lesions. The recurrency rate decreased with the tumours distance from the lid margin. Based on these factors the calculated risk of a patient was between 47% and 63%, with an estimated risk of recurrence of 50%.

CONCLUSIONS

Predicting recurrence using these factors, is not possible in a clinically relevant dimension. So all patients with a basal cell carcinoma of the eyelids or periocular region must be re-examined regularly to detect recurrent lesions as early as possible. Of all recurrences, 89% occurred within the first 5 postoperative years, therefore this should be regarded as the minimal sufficient follow-up time.

Intravascular ultrasound for assessment of coronary allograft vasculopathy

Coronary allograft vasculopathy (CAV) is the major factor limiting the long-term survival after cardiac transplantation. Intravascular ultrasound (IVUS) markedly improved our knowledge about in vivo morphology of CAV by precise determination of vessel morphology. In vivo studies with IVUS demonstrated that transplant vasculopathy may present with a very heterogeneous morphology suggesting a dual etiology of transplant coronary artery disease. The high incidence of donor-transmitted atherosclerosis and its role in further progression of CAV could be demonstrated by the use of IVUS. Beside intimal hyperplasia, adaptive remodeling processes of vessel and lumen geometry may have physiologic and prognostic importance. IVUS is so far the only method that allows the evaluation of compensatory enlargement and shrinkage of coronary vessels in CAV. IVUS investigations allow the assessment of CAV progression in early angiographically not visible stages. The influence of different medical treatment regimens on CAV progression can be quantified. Further studies showed that IVUS parameters may have prognostic impact on subsequent clinical events and angiographic progression of CAV. However, besides all the diagnostic information provided by IVUS, the main application of this method is currently in the field of clinical research.

Antibiotic resistance pattern and visual outcome in experimentally-induced Staphylococcus epidermidis endophthalmitis in a rabbit model

OBJECTIVE

To study whether the clinical outcome of Staphylococcus epidermidis-induced endophthalmitis in rabbits is related to the antibiotic resistance pattern of the infecting strain.

DESIGN

Experimental animal study.

PARTICIPANTS

The right eyes of 36 New Zealand white albino rabbits were inoculated with strains of S. epidermidis that displayed various patterns of antibiotic resistance.

METHODS

There were 12 rabbits in each of three study groups: fully antibiotic susceptible (FS), partially antibiotic resistant (PR), and multiresistant (MR). Five days after inoculation, the eyes were enucleated and prepared for histologic studies.

MAIN OUTCOME MEASURES

Comparisons among the three groups were made based on electroretinographic (ERG) findings, histologic evaluation by a masked observer, and clinical examination.

RESULTS

Electroretinographic findings on all rabbits were made by an unmasked observer. At 30 hours after inoculation, the ERG was diminished to 65% of normal for group FS, compared with a flat ERG waveform for groups PR (P < 0.05) and MR (P < 0.05). The ERG waveform was flat for all three groups at 72 hours after inoculation. Histologic evaluation by use of a histologic score revealed that the degree of inflammation and destruction of the retina was less for group FS (n = 10) compared with groups PR (n = 8) and MR (n = 8). Clinical examination revealed that there was a trend of less ocular inflammation for group FS compared with groups PR and MR.

CONCLUSIONS

In a rabbit model of S. epidermidis-induced endophthalmitis, antibiotic-susceptible strains caused less inflammation and destruction of the infected retina than did antibiotic-resistant strains.

[Keratography (corneal tattooing) in corneal leukoma]

BACKGROUND

Since antiquity attempts have been made to minimize disfigurement and stigmatization of patients with leukoma. Keratography is a relatively new method for imprinting color pigments into the corneal stroma with an entomological needle.

MATERIALS AND METHODS

Keratography was performed in 20 patients at the University Eye Hospital, Munich, between November 1997 and September 1999. Patients had either a leukoma that did not tolerate prothesis or had another cloudy corneal disease. The operation was carried out in our outpatient clinic under local anesthesia.

RESULTS

There was a single operation in three patients, two operations in nine, three operations in six, and four operations in two. Postoperatively 33% of patients complained of pain. No postoperative bacterial keratitis or perforation occurred.

CONCLUSION

All patients were highly satisfied. The long-term stability of color pigments must still be evaluated.