Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996

OBJECTIVES

Published reports were reviewed to evaluate the characteristics of peripartal management and the late pregnancy outcome in women with pulmonary vascular disease (PVD).

BACKGROUND

Pulmonary hypertension poses one of the highest risks for maternal mortality, but actual data on the maternal and neonatal prognosis in this group are lacking.

METHODS

Reports published from 1978 through 1996 of Eisenmenger's syndrome (n = 73), primary pulmonary hypertension (PPH) (n = 27) and secondary vascular pulmonary hypertension (SVPH) (n = 25) complicating late pregnancy were included and analyzed using logistic regression analysis.

RESULTS

Maternal mortality was 36% in Eisenmenger's syndrome, 30% in PPH and 56% (p < 0.08 vs. other two groups) in SVPH. Except for three prepartal deaths due to Eisenmenger's syndrome, all fatalities occurred within 35 days after delivery. Neonatal survival ranging from 87% to 89% was similar in the three groups. Previous pregnancies, timing of the diagnosis and hospital admission, operative delivery and diastolic pulmonary artery pressure were significant univariate (p < 0.05) maternal risk factors. Late diagnosis (p = 0.002, odds ratio 5.4) and late hospital admission (p = 0.01, odds ratio 1.1 per week of pregnancy) were independent predictive risk factors of maternal mortality.

CONCLUSIONS

In the last two decades maternal mortality was comparable in patients with Eisenmenger's syndrome and PPH; however, it was relevantly higher in SVPH. Maternal prognosis depends on the early diagnosis of PVD, early hospital admission, individually tailored treatment during pregnancy and medical therapy and care focused on the postpartal period.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

SLICC/ACR Damage Index is valid, and renal and pulmonary organ scores are predictors of severe outcome in patients with systemic lupus erythematosus

We investigated the Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) Damage Index as a predictor of severe outcome and an indicator of morbidity in different ethnic groups, and in regard to its validity. We retrospectively studied disease course within 10 yr of diagnosis in an inception cohort of 80 patients with systemic lupus erythematosus (SLE). The mean renal damage score (DS) at 1 yr after diagnosis was a significant predictor of endstage renal failure and the mean pulmonary DS at 1 yr significantly predicted death within 10 yr of diagnosis. Compared to Caucasians, Afro-Caribbeans and Asians had significantly higher mean total DS at 5 and 10 yr, and higher mean renal DS at 10 yr. At 5 yr, the mean renal DS in Afro-Caribbeans and the mean neuropsychiatric DS in Asians were significantly higher than in Caucasians. The rate of endstage renal failure in Caucasians was significantly lower than in the other ethnic groups. Our results confirm the validity of the SLICC/ACR Damage Index.

Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery?

BACKGROUND

Following mitral valve replacement, surgical closure of paravalvular leaks is usually advised in severely symptomatic patients and in those requiring blood transfusions for persisting haemolysis. However, the long-term prognosis of less symptomatic patients or those not needing blood transfusions is unknown.

METHODS

Between 1987 and 1997, we observed 96 patients with mitral paravalvular leakage. A paraprosthetic leak was diagnosed after a median time of 119 days (range: 1 day-23 years) after primary mitral valve replacement. During an average follow-up of 5 years (range: 1-23 years), 50/96 patients were referred for surgical closure.

RESULTS

Compared with patients who received conservative treatment, those referred for surgery had a significantly lower mean preoperative haematocrit (P = 0.002) with a higher proportion of patients being in the NYHA class III/IV (P = 0.03). Age, gender, left ventricular function and number and size of leaks did not differ between the groups. The 30-day postoperative mortality for valve reoperation was 6% (3/50); during follow-up three further patients died, resulting in an overall mortality rate of 12%. In the group treated conservatively there was a mortality rate of 26% (12/46). Thus, the actuarial survival for patients referred for surgery was 98, 90 and 88% after 1, 5 and 10 years, compared with 90, 75 and 68% for patients treated conservatively (long-rank P = 0.03). In addition, there was a significant increase in mean haematocrit levels (P = 0.0001) and an improvement in NYHA class III/IV symptoms (P = 0.002), vertigo (P = 0.001) and fatigue (P = 0.001) after surgery.

CONCLUSIONS

Following mitral valve replacement, a more aggressive surgical treatment is recommended for patients with paraprosthetic leaks. Surgery should be offered to less symptomatic patients, as well as those not requiring blood transfusion.

Comparison of effects of amphotericin B deoxycholate infused over 4 or 24 hours: randomised controlled trial

OBJECTIVE

To test the hypothesis that amphotericin B deoxycholate is less toxic when given by continuous infusion than by conventional rapid infusion.

DESIGN

Randomised, controlled, non-blinded, single centre study.

SETTING

University hospital providing tertiary clinical care.

PATIENTS

80 mostly neutropenic patients with refractory fever and suspected or proved invasive fungal infections.

INTERVENTION

Patients were randomised to receive 0.97 mg/kg amphotericin B by continuous infusion over 24 hours or 0.95 mg/kg by rapid infusion over four hours.

MAIN OUTCOME MEASURES

Patients were evaluated for side effects related to infusion, nephrotoxicity, and mortality up to three months after treatment. Analysis was on an intention to treat basis.

RESULTS

Patients in the continuous infusion group had fewer side effects and significantly reduced nephrotoxicity than those in the rapid infusion group. Overall mortality was higher during treatment and after three months' follow up in the rapid infusion than in the continuous infusion group.

CONCLUSION

Continuous infusions of amphotericin B reduce nephrotoxicity and side effects related to infusion without increasing mortality.

Twenty years of the German Environmental Survey (GerES): Human biomonitoring – Temporal and spatial (West Germany/East Germany) differences in population exposure

The German Environmental Surveys (GerESs) are nationwide population studies, which have repeatedly been carried out in Germany since the mid-1980s. The subjects were representatively selected from the regional registration offices with regard to age, gender and community size. The first survey for adults (GerES I) was carried out in 1985/1986 (West Germany) followed by GerES IIa in 1990/1991 (West Germany) and GerES IIb in 1991/1992 (East Germany). In GerES II children were also included to some extent. In 1998, the third GerES for adults was conducted in both parts of Germany (GerES III). The current survey 2003/2006 (GerES IV) is focussing exclusively on children. A 1-year pilot study was conducted in 2001-2002 to collect information on parameters influencing the response rate and to test the suitability of the different instruments intended to be used for the main study. The main goal of the surveys is to analyse and document the extent, distribution and determinants of exposure to environmental pollutants of the German general population. Three main instruments of investigation were comprised in GerES: human biomonitoring (HBM), monitoring of the domestic environment, and collecting information on exposure pathways and living conditions via questionnaires. This paper is focussed on the general design of the GerESs, the trend over time and spatial differences (West Germany and East Germany) for HBM data on arsenic, cadmium, lead, mercury, pentachlorophenol (PCP), and polycyclic aromatic hydrocarbons (PAH). These substances have been determined in blood and/or morning urine of adults and children. All GerESs have been conducted in close connection with the National Health Interview and Examination Surveys performed by the Robert Koch-Institute, Berlin.

Effect of progressive haemodilution with hydroxyethyl starch, gelatin and albumin on blood coagulation

We have compared the effects of progressive (30% and 60%) in vitro haemodilution with hydroxyethyl starch (HES), gelatin (GEL) and albumin (ALB) with haemodilution using 0.9% saline in 96 patients by thrombelastography. Haemodilution with HES, GEL and ALB significantly (P < 0.05) compromised coagulation time (k), angle alpha and maximal amplitude (MA), with HES having the most negative effect at 30% and 60% haemodilution (P < 0.05). Haemodilution with saline significantly affected all variables of blood coagulation and clot lysis measured by thrombelastography, resulting in an increased coagulability at 30% haemodilution. To specifically assess the intrinsic effect of plasma expander molecules on blood coagulation and clot lysis, we analysed the difference between saline diluted blood (same degree of haemodilution) and plasma expander diluted blood. Prolongation of reaction time (r) was found for HES at 30% and 60% haemodilution and for ALB at 60% haemodilution and an increase in clot lysis by HES, GEL and ALB became evident. We conclude that HES, GEL and ALB compromised blood coagulation, while the maximum effect was found with HES.

Complaints of sore throat after tracheal intubation

BACKGROUND AND OBJECTIVE

Sore throat and hoarseness rank, besides pain and nausea, among the most frequent subjective complaints after tracheal intubation for general anaesthesia. Our intention was to determine the incidence of postoperative sore throat from a large sample of patients and thus to identify the most important associated factors.

METHODS

We prospectively followed up 809 adult patients who underwent elective surgical interventions and examined their history, the applied anaesthetic techniques, perioperative course and the occurrence, intensity and duration of postoperative throat complaints. The assignment and professional experience of the involved intubators were also assessed. The influence of a multitude of variables on postoperative throat complaints was statistically analysed.

RESULTS

Postoperative sore throat was present in 40% overall being significantly higher in female than in male (44% vs. 33%; P = 0.001). The mean pain intensity in the affected patients (n = 323) was 28+/-12 mm on a visual analogue scale where 0 = no pain and 100 = extreme pain. The average duration was 16+/-11 h. Main factors associated with throat complaints were female sex; history of smoking or lung disease, duration of anaesthesia, postoperative nausea, bloodstain on the endotracheal tube and natural teeth. We could find no influence on the occurrence or intensity of throat complaints by the professional assignment or the length of professional experience of the personnel involved.

CONCLUSIONS

Postoperative throat complaints frequently arise after tracheal intubation for general anaesthesia in the first 2 postoperative days, but they are of limited intensity and duration.

Citrate storage affects Thrombelastograph analysis

BACKGROUND

Thrombelastograph analysis (TEG) is used to evaluate blood coagulation. Ideally, whole blood is immediately processed. If impossible, blood may be citrated and assessed after recalcification. No data describe the effect of such treatment and storage on TEG parameters.

METHODS

Three studies were performed in 90 surgical patients. In 30 patients, blood was citrated (1:10, 0. 129 M) and recalcified (20 microl 2 M CaCl2 to 340 microl citrated blood), and TEG was performed with native blood and after recalcification after 0, 15, and 30 min of citrate storage. In another 30 patients, TEG was performed with citrated blood recalcified immediately and after 1-72 h storage. In a third study, thrombin-antithrombin complex, prothrombin fragment 1+2, and beta-thromboglobulin were measured (using enzyme-linked immunoabsorbant assay tests) at corresponding time points. Data were compared using repeated-measures analysis of variance and post hocpaired t tests.

RESULTS

TEG parameters were different in recalcified citrated blood compared with native blood (P < 0.05) and changed significantly during 30-min (P < 0.025) and 72-h (P < 0.001) citrate storage. TEG parameters measured between 1 and 8 h of citrate storage were stable. Thrombin-antithrombin complex and prothrombin fragment 1+2 values were not elevated in native blood. After 30 min of citrate storage a gradual thrombin activation was observed, as evidenced by increasing thrombin-antithrombin complex and prothrombin fragment 1+2 values (P < 0.05). beta-Thromboglobulin level was increased after 2 and 8 h of citrate storage (P < 0.01).

CONCLUSIONS

Analysis of native blood yields the most reliable TEG results. Should immediate TEG processing not be possible, citrated blood may be used if recalcified after 1-8 h.

The German Environmental Survey 1990/1992 (GerES II): reference concentrations of selected environmental pollutants in blood, urine, hair, house dust, drinking water and indoor air

The German Environmental Survey (GerES) is a large-scale, representative population study that has been carried out three times up to now with a time interval of about 7 years. GerES I was performed in 1985/1986, GerES IIa in 1990/1991 in West Germany, and GerES IIb in 1991/1992 in East Germany, the former German Democratic Republic (GDR). In GerES II, blood, urine, and scalp hair samples of 4021 adults aged 25-69 years and of 736 children aged 6-14 years were analysed as well as environmental samples (house dust, drinking water, indoor and personal air, diet). Characteristics of the frequency distributions of the substances analysed in the different media were calculated. The geometric mean (GM) for lead, cadmium, and mercury in the blood of adults amounted to 45.3, 0.36, and 0.51 microg/l, respectively. The corresponding values of arsenic, cadmium, and mercury in urine were 6.3, 0.29, and 0.54 microg/l, respectively. The concentrations of lead in blood, cadmium in blood and urine, and mercury in blood are lower in children than in adults. The GM ofpentachlorophenol (PCP) in urine of adults was 2.67 microg/l and in urine of children, 4.15 microg/l. These results of GerES II were compared with the so-called HBM values which represent health-based exposure guidelines and have been defined by the Human Biomonitoring Commission (HBC) of the Federal Environmental Agency, interalia for lead in blood, cadmium in urine, mercury in blood and urine, and PCP in urine. They also provided asound basis for the setting of reference values to describe the status of the German population. A total of 1.8% and 0.6% of the German females in child-bearing age had a level of lead in blood higher than HBM-I (100 microg/l) and HBM-II ( 150 microg/l), respectively. One percent of the children had a blood lead level above HBM-I. House dust and drinking water were analysed to characterise exposure in the domestic environment. Arsenic, cadmium, and lead deposition in homes amounted to 5.4 ng/(m2 day), 11.7 ng/(m2 day), and 0.29 microg/(m2 day), respectively. In the content of vacuum cleaner bags, concentrations were 2.1,0.9, and 5.9 microg/g. PCP, lindane and permethrin could be detected in the house dust of most German households. The pollutant load of the drinking water is significantly influenced by the corrosion of pipe materials and fittings. The new EC limit value of 10 microg/l for lead was exceeded in 7.7% of the first draw samples. The relatively high percentage (14%) of samples from East Germany that exceeded the current German guideline value for formaldehyde of 0.1 ppm in indoor air may be explained by the widespread use of contaminated particleboard in the former GDR.

Change of transfusion and treatment paradigm in major trauma patients

Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005-2007) and after (2012-2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. All adult (≥ 16 years) trauma patients primarily admitted to the University Hospital Zürich with an injury severity score ≥ 16 were included. In 2005-2007, the observed and trauma associated severe haemorrhage score that predicted the incidence of massive transfusion were identical, whereas in 2012-2014 the observed incidence was less than half that predicted (3.7% vs. 7.5%). Compared to 2005-2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012-2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012-2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.

Chronic beta-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection

OBJECTIVES

To compare the medical treatment of chronic type B aortic dissection with beta-blockers versus other antihypertensive treatments in terms of their requirement for surgical intervention and treatment costs.

METHODS

Case records of the 130 patients treated for aortic dissection type B in this unit between 1988 and 1997 were reviewed. Seventy-eight of 130 patients with chronic dissection have received isolated medical treatment. Seventy-one of 78 patients were discharged alive. Fifty-one of 71 received beta-blocker treatment, 20/71 were treated with other antihypertensive drugs.

RESULTS

Surgery for aortic dissection became necessary in 20/71 patients (28%) during follow-up (mean, 4.2 years): 10/51 in the beta-blocker group and 9/20 in the other antihypertensive drug group. The freedom from subsequent aortic operation was 80 and 47%, respectively (P=0.001). Indications for emergency surgery were increased aortic diameter (79%), symptomatic aortic aneurysm (11%), and renal artery hypoperfusion (5%). The median hospitalization time during follow-up (dissection-related) was 2 days for patients who received beta-blockers and 16 days for patients who received other antihypertensive drug treatments (P=0.001). The cost of treatment/patient per year amounted to 644 and 12748 euros, respectively.

CONCLUSIONS

A substantial proportion of patients with chronic type B dissection who receive initial medical management will later need surgery. Long-term treatment with beta-blockers reduces the progression of aortic dilatation, the incidence of subsequent hospital admissions, as well as the incidence of late dissection-related aortic procedures and the cost of treatment. Patients with chronic type B dissection need, in addition to frequent follow-up of aortic diameter, continuous treatment with beta-blocking agents.

Rivaroxaban: Quantification by anti-FXa assay and influence on coagulation tests: a study in 9 Swiss laboratories

INTRODUCTION

Rivaroxaban (RXA) is licensed for prophylaxis of venous thromboembolism after major orthopaedic surgery of the lower limbs. Currently, no test to quantify RXA in plasma has been validated in an inter-laboratory setting. Our study had three aims: to assess i) the feasibility of RXA quantification with a commercial anti-FXa assay, ii) its accuracy and precision in an inter-laboratory setting, and iii) the influence of 10mg of RXA on routine coagulation tests.

METHODS

The same chromogenic anti-FXa assay (Hyphen BioMed) was used in all participating laboratories. RXA calibrators and sets of blinded probes (aim ii.) were prepared in vitro by spiking normal plasma. The precise RXA content was assessed by high-pressure liquid chromatography-tandem mass spectrometry. For ex-vivo studies (aim iii), plasma samples from 20 healthy volunteers taken before and 2 - 3hours after ingestion of 10mg of RXA were analyzed by participating laboratories.

RESULTS

RXA can be assayed chromogenically. Among the participating laboratories, the mean accuracy and the mean coefficient of variation for precision of RXA quantification were 7.0% and 8.8%, respectively. Mean RXA concentration was 114±43μg/L .RXA significantly altered prothrombin time, activated partial thromboplastin time, factor analysis for intrinsic and extrinsic factors. Determinations of thrombin time, fibrinogen, FXIII and D-Dimer levels were not affected.

CONCLUSIONS

RXA plasma levels can be quantified accurately and precisely by a chromogenic anti-FXa assay on different coagulometers in different laboratories. Ingestion of 10mg RXA results in significant alterations of both PT- and aPTT-based coagulation assays.

Maximal isometric muscle strength: normative values and gender-specific relation to age

To date, there have been very few studies on the age dependence of maximal isometric muscle strength (MIMS) in healthy subjects aged 20-80 years, based upon measurements of a large number of functional muscle groups (FMGs). Using a hand-held pull gauge it is possible to measure MIMS of nearly every FMG. The objectives of this study were to obtain normative values for MIMS, to evaluate differences in MIMS in relation to gender and body side and to compare the age dependence of muscle strength between women and men. In a convenience sample of 290 healthy women (aged 20-82 years) and 253 men (aged 21-79 years), MIMS of 51 FMGs was measured. For each FMG the age dependence of MIMS was depicted, side and gender specific, as percentile curves and was analysed using linear quantile regression analysis. MIMS was found to be significantly higher in men than in women and higher on the right than on the left side. A biphasic model with linear equations for strength medians was derived for each gender. The age at transition from phase 1 to phase 2 was 55 years (SD 8) for women and 49 years (SD 13) for men. During phase 1, MIMS did not decrease significantly. During phase 2, MIMS decreased in all FMGs in both genders with a steeper slope in women (-0.92) than in men (-0.63). The age dependence of MIMS differed significantly between women and men. The present study gives gender-specific equations which enable one to calculate normative values for MIMS, as measured with a pull gauge, based upon age. These normative values will allow an objective assessment of patients with diminished muscle strength as, for example, in myositis, rheumatoid arthritis and nerve root compression syndromes or in the elderly.

Value of (18F)-FDG positron emission tomography, computed tomography, and magnetic resonance imaging in diagnosing primary and recurrent ovarian carcinoma

The aim of this study was to compare prospectively the accuracy of whole-body positron emission tomography (PET), CT and MRI in diagnosing primary and recurrent ovarian cancer. Nineteen patients (age range 23-76 years) were recruited with suspicious ovarian lesions at presentation (n = 8) or follow-up for recurrence (n = 11). All patients were scheduled for laparotomy and histological confirmation. Whole-body PET with FDG, contrast-enhanced spiral CT of the abdomen, including the pelvis, and MRI of the entire abdomen were performed. Each imaging study was evaluated separately. Imaging findings were correlated with histopathological diagnosis. The sensitivity, specificity and accuracy for lesion characterization in patients with suspicious ovarian lesions (n = 7) were, respectively: 100, 67 and 86% for PET; 100, 67 and 86% for CT; and 100, 100 and 100% for MRI. For the diagnosis of recurrent disease (n = 10), PET had a sensitivity of 100%, specificity of 50% and accuracy of 90%. The PET technique was the only technique which correctly identified a single transverse colon metastasis. Results for CT were 40, 50 and 43%, and for MRI 86, 100 and 89%, respectively. No statistically significant difference was seen. Neither FDG PET nor CT nor MRI can replace surgery in the detection of microscopic peritoneal disease. No statistically significant difference was observed for the investigated imaging modalities with regard to lesion characterization or detection of recurrent disease; thus, the methods are permissible alternatives. The PET technique, however, has the drawback of less accurate spatial assignment of small lesions compared with CT and MRI.

Ultrafast MR imaging of the fetus

OBJECTIVE

We examined the capability of ultrafast single-shot fast spin-echo imaging to assess different fetal organ systems compared with prenatal sonography, using autopsy or postpartum imaging as a standard of reference.

SUBJECTS AND METHODS

Thirty women with complicated pregnancies (mean age of gestation, 190 +/- 54 days) underwent T2-weighted ultrafast MR imaging. MR images were analyzed with regard to diagnostic confidence in assessing abnormalities of fetal organ systems, and data were correlated with postpartum findings or necropsy. Results were compared with those of prenatal sonography.

RESULTS

Using receiver operating characteristic curve analysis, diagnostic confidence of MR imaging was best for assessing the brain (area under the curve [Az] = 0.96) and spinal canal (Az = 1.0), uteroplacental unit (Az = 0.93), and lungs (Az = 0.91). Results for the heart (Az = 0.63) and extremities (Az = 0.77) were significantly lower than that of other organs (p < 0.001). Diagnostic accuracy increased with gestational age. No statistically significant difference between sonography and MR imaging was found for the detection of abnormality in any organ system. In three fetuses, MR imaging was superior to sonography in characterizing cerebral abnormalities. MR imaging was inferior to sonography in characterizing abnormalities of the heart and extremities.

CONCLUSION

Our results indicate that ultrafast MR imaging can be used for in vivo fetal imaging, especially in assessing cerebral abnormalities. However, MR imaging should be restricted to situations in which sonographic findings are ambiguous or impaired.

Cryopreserved arterial allografts in the treatment of major vascular infection: a comparison with conventional surgical techniques

OBJECTIVE

Recent findings with cryopreserved heart valve allografts in the treatment of infectious endocarditis suggest that the use of cryopreserved arterial allografts may improve the outcome in patients with vascular infections.

METHODS

Seventy-two patients with mycotic aneurysms (n = 29) or infected vascular prostheses (n = 43) of the thoracic (n = 26) or abdominal aorta (n = 46) were treated with in situ repair and extra-anatomic reconstruction using prosthetic material (n = 38) or implantation of a cryopreserved arterial allograft (n = 34). Disease-related survival and survival free of reoperation were assessed. Morbidity, cumulative lengths of intensive care, hospitalization, antibiotic treatment, and costs were calculated per year of follow-up.

RESULTS

The use of cryopreserved arterial allografts was superior to conventional surgery in terms of disease-related survival (P =.008), disease-related survival free of reoperation (P =.0001), duration of intensive care per year of follow-up (median 1 vs 11 days; range 1 to 42 vs 2 to 120 days; P =.001), hospitalization (14 vs 30 days; range 7 to 150 vs 15 to 240 days; P =.002), duration of postoperative antibiotic therapy (21 vs 40 days; range 21 to 90 vs 60 to 365 days; P =.002), incidence of complications (24% vs 63%; P =.005), and elimination of infection (91% vs 53%; P =.001). In addition, costs were 40% lower in the group treated by allografts (P =.005).

CONCLUSIONS

The use of cryopreserved arterial allografts is a more effective treatment for mycotic aneurysms and infected vascular prostheses than conventional surgical techniques.

Surgical risk factors for condylar resorption after orthognathic surgery

OBJECTIVE

The purpose of this study was to look for surgical risk factors for condylar resorption after orthognathic surgery.

STUDY DESIGN

Seventeen patients of a group of 452 patients who had undergone orthognathic surgery consecutively and who were in accordance with the inclusion criteria of this study showed postoperative condylar resorption (group I). Preoperative cephalometric characteristics and surgically induced movements of this group were compared with a control group of 17 of 452 patients (group II) in whom postoperative condylar resorption and skeletal relapse did not develop, despite mandibular retrognathism (ANB angle >4 degrees) and high mandibular plane angle (>40 degrees).

RESULTS

The kind of osteosynthesis used was not significantly different between the 2 groups. The amount of surgical advancements and the vertical movements of the jaws were not significantly different between the 2 groups. However, the distal (P =.005) and proximal (P =.007) mandibular segments were rotated significantly further counterclockwise in group I. Surgically induced posterior condylar displacement occurred significantly more frequently (P =.007) in group I.

CONCLUSIONS

Counterclockwise rotation of the distal and proximal mandibular segments and surgically induced posterior condylar displacement seem to be important surgical risk factors for postoperative condylar resorption. Therefore, these movements seem to be contraindicated in patients who are at high risk.

Systematic review: probiotics in the management of lower gastrointestinal symptoms - an updated evidence-based international consensus

BACKGROUND

In 2013, a systematic review and Delphi consensus reported that specific probiotics can benefit adult patients with irritable bowel syndrome (IBS) and other gastrointestinal (GI) problems.

AIM

To update the consensus with new evidence.

METHODS

A systematic review identified randomised, placebo-controlled trials published between January 2012 and June 2017. Evidence was graded, previously developed statements were reassessed by an 8-expert panel, and agreement was reached via Delphi consensus.

RESULTS

A total of 70 studies were included (IBS, 34; diarrhoea associated with antibiotics, 13; diarrhoea associated with Helicobacter pylori eradication therapy, 7; other conditions, 16). Of 15 studies that examined global IBS symptoms as a primary endpoint, 8 reported significant benefits of probiotics vs placebo. Consensus statements with 100% agreement and "high" evidence level indicated that specific probiotics help reduce overall symptom burden and abdominal pain in some patients with IBS and duration/intensity of diarrhoea in patients prescribed antibiotics or H. pylori eradication therapy, and have favourable safety. Statements with 70%-100% agreement and "moderate" evidence indicated that, in some patients with IBS, specific probiotics help reduce bloating/distension and improve bowel movement frequency/consistency.

CONCLUSIONS

This updated review indicates that specific probiotics are beneficial in certain lower GI problems, although many of the new publications did not report benefits of probiotics, possibly due to inclusion of new, less efficacious preparations. Specific probiotics can relieve lower GI symptoms in IBS, prevent diarrhoea associated with antibiotics and H. pylori eradication therapy, and show favourable safety. This study will help clinicians recommend/prescribe probiotics for specific symptoms.

Configuration and localization of the nipple-areola complex in men

The causes of bilateral absence of the nipple-areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female-to-male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple-areola complex. Because there is very little information available in the literature, we carried out a cross-sectional study on the configuration and localization of the nipple-areola complex in men.A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple-areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space. Of the 100 subjects examined, 91 had oval and seven had a round nipple-areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple-areola complex was 27:20 mm and the mean diameter for a round nipple-areola complex was 23 mm. The center of the nipple-areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nipple-areola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 x circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 x length of sternum (cm)] + [0.1 x circumference of thorax (cm)], (R = 0.50). In cases of bilateral absence, we recommend creating an oval nipple-areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum.

Volumetry: an alternative to assess therapy response for malignant pleural mesothelioma?

The purpose of our study was to assess robustness of volumetric measurement of malignant pleural mesothelioma (MPM) before and after chemotherapy to modified RECIST (response evaluation criteria in solid tumours) criteria. 30 patients with digitally available chest computed tomography (CT) scans before and after three cycles of chemotherapy were included. Three readers independently assessed tumour response using two different methods: 1) the modified RECIST criteria; and 2) the tumour volumetric approach using dedicated software (Myrian; Intrasense, Paris, France). Inter-rater reliability of unidimensional and volumetric measurements was assessed using intraclass correlation. Tumour response classification for modified RECIST was compared to the volumetric approach applying unidimensional RECIST volumetric equivalent criteria. The determination of unidimensional tumour measurement (RECIST) revealed a low inter-rater reliability (0.55) and a low interobserver agreement for tumour response classification (general κ 0.33). Only 14 patients were classified equally. A high inter-rater reliability (0.99) and interobserver agreement (general κ 0.9) were found for absolute tumour volumes (volumetric measurements). 27 cases were classified equally. The number of cases classified as "stable disease" was higher for the volumetric approach using tumour-equivalent criteria compared to modified RECIST. Volumetric measurement of MPM on CT using Myrian software is a reliable, reproducible and sensitive method to measure tumour volume and, thus, therapy response after induction chemotherapy.

The diagnostic value of the neutrophil left shift in predicting inflammatory and infectious disease

The use of neutrophil left-shift parameters in the diagnosis of inflammatory and infective disease (ID) was evaluated. The level of C-reactive protein (CRP), currently the best quantitative parameter of inflammation, was used as the gold standard. Of 292 patients, 230 (79%) had a level of CRP of 1.0 mg/dL or greater and were classified as having inflammation, whereas 62 (21%) had normal levels. The neutrophil band count in each patient was determined by microscopic examination of 200 WBCs. The diagnostic value of the band count as an indicator for ID was evaluated in comparison to the WBC count, the neutrophil count, and the left-shift indicators of two automated hematologic analyzers, H*1 Technicon (Bayer Technicon Instruments, Tarrytown, NY) and Coulter MAX M (Coulter Electronics, Hialeah, Fla). When receiver operating characteristics were used, the band count was superior to the immature to total neutrophil count (I/T) ratio, the total WBC count, and the neutrophil count. The sensitivity and specificity in identifying ID at designated cutoff points were as follows: band count of 20% or greater of total WBC count (53% and 79%, respectively), I/T ratio of 0.25 or greater (59% and 63%), total WBC count of 9.6 x 10(6)/mL or greater (68% and 56%), and neutrophil count of 8.0 x 10(6)/mL or greater (60% and 58%). The performance of the H*1 Technicon left-shift flag was similar but slightly inferior to the band count (sensitivity, 44%; specificity, 79%), whereas the Coulter MAX M flags had a clearly higher sensitivity (79%) and lower specificity (53%). In addition, microscopic evaluation to determine the presence of reactive morphologic changes in neutrophils, such as toxic granules, Döhle bodies, and cytoplasmic vacuoles, had a high sensitivity (80%) but a low specificity (58%) in predicting ID. The diagnostic value of both microscopic and automated neutrophil left-shift parameters as indicators for ID is limited. Morphologic changes in neutrophils, however, either have a high specificity (band count) or a high sensitivity (toxic signs) in predicting ID and therefore may be a clinically useful tool.