[Analysis and options for optimization of preoperative assessment for anesthesia at a university hospital]

BACKGROUND

Risk assessment prior to elective surgery is an important tool in the context of perioperative patient care; however, only a few studies have been carried out to address the processes and problems during preoperative assessment for anesthesia.

AIM

Over a period of several weeks all preoperative anesthesia evaluations prior to elective surgery were prospectively recorded in order to generate a data pool with a view to identifying options for process optimization.

MATERIAL AND METHODS

All preoperative evaluations over a period of 38 working days at the University Medical Center Regensburg were recorded and analyzed with respect to waiting time for the patient and the duration of the preoperative consultation on medication. Also documented were the patient age, ASA score, the faculty carrying out the operation, type and risk of surgery, planned time of surgery, professional experience of the anesthesiologist and the approval status for surgery. In addition, all problems which occurred during the preoperative anesthesia evaluation were documented using a questionnaire.

RESULTS

Overall 2233 preoperative assessments for anesthesia were recorded and analyzed. The number of patients attending the preoperative assessment clinic differed markedly in the course of a day and was lower at the end of the week. Approval for surgery with no reservations was given more frequently by anesthesiologists with more than 5 years professional experience and consultants compared to younger colleagues. The main reason for approval with reservations or no approval was the lack of patient records and test results, which should have been presented according to the in-house standard for preoperative assessment for anesthesia. The mean waiting time was 58.6 ± 30.3 min, the mean duration of the patient documentation review and physician-patient consultation together was 33.6 ± 16.3 min. Anesthesiologists with 2-5 years professional experience needed significantly less time for patient documentation reviews and physician-patient consultations than younger and more experienced colleagues. The duration of the preoperative assessment for anesthesia correlated with the ASA score and risks of surgery.

CONCLUSION

The analysis of processes and problems in the context of preoperative assessment for anesthesia revealed several options for optimization. Major efforts should be the implementation of an appointment system for the preoperative assessment clinic in order to generate a homogeneous distribution of patients during the course of a day. Furthermore, surgeons and case managers should be requested to refer patients to the preoperative assessment clinic only with complete records and test results according to the in-house standard.

[Placement of a central venous catheter in cases of persistent left superior vena cava]

This article presents a case report on the placement of a central venous catheter (CVC) in a patient with an unknown persistent left superior vena cava (PLSVC). Normally, PLSVCs remain asymptomatic but can be associated with disastrous consequences for the patient during placement of a CVC particularly due to vascular perforation and pulmonary injury. A PLSCV is particularly common in association with congenital heart defects; however, otherwise healthy patients can also be affected. As the presence of a PLSCV is normally unknown special attention must be paid in every patient during placement of a CVC.

Successful isavuconazole salvage therapy in a patient with invasive mucormycosis

A 45-year-old male with rhinocerebral mucormycosis (Rhizopus oryzae), refractory to liposomal amphotericin B and posaconazole, received isavuconazole salvage therapy. Initial isavuconazole plasma and tissue levels were 0.76-0.86 μg/mL and 1.09-1.38 μg/g. Plasma levels increased to 1.3-3.24 μg/mL with reduced comedication. Isavuconazole was well tolerated, and the patient has remained disease-free 24 months post-antifungal therapy.

[Secondary sclerosing cholangitis after multiple trauma and long-term intensive care treatment: case report of a characteristic course]

This article reports on a patient who needed intensive care treatment because of multiple trauma. The patient had no preexisting liver disease but developed secondary sclerosing cholangitis and finally died. The etiology, diagnosis and therapeutic options of this clinical picture are discussed and a review of the literature is presented.

Is the alpine divide becoming more permeable to biological invasions? - Insights on the invasion and establishment of the Walnut Husk Fly, Rhagoletis completa (Diptera: Tephritidae) in Switzerland

The Walnut Husk Fly, Rhagoletis completa Cresson (Diptera: Tephritidae), is native to North America (Midwestern US and north-eastern Mexico) and has invaded several European countries in the past decades by likely crossing the alpine divide separating most parts of Switzerland from Italy. Here, we determined its current distribution in Switzerland by sampling walnuts (Juglans regia L.) in ecologically and climatically distinct regions along potential invasion corridors. R. completa was found to be firmly established in most low altitude areas of Switzerland where walnuts thrive, but notably not a single parasitoid was recovered from any of the samples. Infested fruit was recovered in 42 of the 71 localities that were surveyed, with mean fruit infestation rate varying greatly among sites. The incidence of R. completa in Switzerland is closely related to meteorological mean spring temperature patterns influencing growing season length, but not to winter temperatures, reflecting survival potential during hibernation. Importantly, areas in which the fly is absent correspond with localities where the mean spring temperatures fall below 7°C. Historical data records show that the natural cold barrier around the Alpine divide in the central Swiss Alps corresponding to such minimal temperatures has shrunk significantly from a width of more than 40 km before 1990 to around 20 km after 2000. We hypothesize on possible invasion/expansion routes along alpine valleys, dwell on distribution patterns in relation to climate, and outline future research needs as the incursion of R. completa into Switzerland; and, more recently, other European countries, such as Germany, Austria, France and Slovenia, represent an example of alien species that settle first in the Mediterranean Basin and from there become invasive by crossing the Alps.

Signals and sequences that control CD28 localization to the central region of the immunological synapse

During T cell interaction with APC, CD28 is recruited to the central region (cSMAC) of the immunological synapse. CD28-mediated signaling through PI3K results in the recruitment of protein kinase C-theta (PKCtheta) to the cSMAC, activation of NF-kappaB, and up-regulation of IL-2 transcription. However, the mechanism that mediates CD28 localization to the cSMAC and the functional consequences of CD28 localization to the cSMAC are not understood. In this report, we show that CD28 recruitment and persistence at the immunological synapse requires TCR signals and CD80 engagement. Addition of mAb to either MHC class II or CD80 results in the rapid displacement of CD28 from the immunological synapse. Ligand binding is not sufficient for CD28 localization to the immunological synapse, as truncation of the cytosolic tail of CD28 disrupts synapse localization without effecting the ability of CD28 to bind CD80. Furthermore, a single point mutation in the CD28 cytosolic tail (tyrosine 188) interferes with the ability of CD28 to preferentially accumulate at the cSMAC. PKCtheta distribution at the immunological synapse mirrors the distribution of tyrosine 188-mutated CD28, indicating that CD28 drives the localization of PKCtheta even when CD28 is not localized to the cSMAC. Mutation of tyrosine 188 also results in diminished activation of NF-kappaB, suggesting that CD28-mediated localization of PKCtheta to the cSMAC is important for efficient signal transduction. These data reinforce the importance of the interplay of signals between TCR and CD28 and suggest that CD28 signaling through PCKtheta may be mediated through localization to the cSMAC region of the immunological synapse.

Soft X-ray spectromicroscopy of phase-change microcapsules

A synchrotron-based scanning transmission X-ray microscope (STXM) is used to investigate Micronal phase-change microcapsules. Prolonged X-ray illumination of the specimen leads to the breaking of the microcapsules' protective polymer shell and a partial separation of the core-shell species occurs. The paraffin wax and acrylic polymer components are characterized by carbon K-edge near X-ray edge absorption fine structure (NEXAFS) spectroscopy and components distribution mapping of the beam-damaged specimen is performed.

Successful salvage treatment of disseminated cutaneous fusariosis with liposomal amphotericin B and terbinafine after allogeneic stem cell transplantation

Fusarium infections are associated with high mortality after allogeneic stem cell transplantation. We report on successful treatment of a disseminated cutaneous Fusarium proliferatum infection using liposomal amphotericin B and terbinafine. In vitro susceptibility tests of antifungal drugs suggest that terbinafine is a potent additional antifungal drug for disseminated cutaneous fusariosis.

LFA-1-mediated T cell costimulation through increased localization of TCR/class II complexes to the central supramolecular activation cluster and exclusion of CD45 from the immunological synapse

T cell activation is associated with a dramatic reorganization of cell surface proteins and associated signaling components into discrete subdomains within the immunological synapse in T cell:APC conjugates. However, the signals that direct the localization of these proteins and the functional significance of this organization have not been established. In this study, we have used wild-type and LFA-1-deficient, DO11.10 TCR transgenic T cells to examine the role of LFA-1 in the formation of the immunological synapse. We found that coengagement of LFA-1 is not required for the formation of the central supramolecular activation cluster (cSMAC) region, but does increase the accumulation of TCR/class II complexes within the cSMAC. In addition, LFA-1 is required for the recruitment and localization of talin into the peripheral supramolecular activation cluster region and exclusion of CD45 from the synapse. The ability of LFA-1 to increase the amount of TCR engaged during synapse formation and segregate the phosphatase, CD45, from the synapse suggests that LFA-1 might enhance proximal TCR signaling. To test this, we combined flow cytometry-based cell adhesion and calcium-signaling assays and found that coengagement of LFA-1 significantly increased the magnitude of the intracellular calcium response following Ag presentation. These data support the idea that in addition to its important role on regulating T cell:APC adhesion, coengagement of LFA-1 can enhance T cell signaling, and suggest that this may be accomplished in part through the organization of proteins within the immunological synapse.

Spinal cord ischemia after endovascular repair of the descending thoracic aorta in a sheep model

OBJECTIVES

Spinal cord ischemia remains a devastating complication after thoracic aortic surgery. The aim of this study was to investigate the pathophysiology of spinal cord ischemia after thoracic aortic endografting and the role of intercostal artery blood supply for the spinal cord in a standardized animal model.

METHODS

Female merino sheep were randomized to either I, open thoracotomy with cross-clamping of the descending aorta for 50 min (n=7), II, endograft implantation (TAG, WL Gore & Ass.), (n=6) or III open thoracotomy with clipping of all intercostal arteries (n=5) . CT-angiography was used to assess completion of surgical protocol and assess the fate of intercostal arteries. Tarloy score was used for daily neurological examination for up to 7 days post-operatively. Histological cross sections of the lumbar, thoracic and cervical spinal cords were scored for ischemic damage after stained with Hematoxylin-Eosin, Klüver-Barrrera and antibodies. Exact Kruskall-Wallis-Test was used for statistical assessment (p<0.05).

RESULTS

Incidence of paraplegia was 100% in group I and 0% in group II (p=0.0004). When compared to the endovascular group, there was a higher rate of histological changes associated with spinal cord ischemia in the animals of the control group (p=0.0096). Group III animals showed no permanent neurological deficit and only 20% infarction rate (p=0.0318 compared to group I).

CONCLUSIONS

In sheep, incidence of histological and clinical ischemic injury of the spinal cord following endografting was very low. Complete thoracic aortic stent-grafting was feasible without permanent neurologic deficit. Following endovascular coverage or clipping of their origins, there is retrograde filling of the intercostal arteries which remain patent.

Cutting edge: CD28-mediated transcriptional and posttranscriptional regulation of IL-2 expression are controlled through different signaling pathways

Despite the clear functional importance of CD28 costimulation, the signaling pathways transduced through CD28 have remained controversial. PI3K was identified early as a candidate for CD28 signaling, but conflicting data during the past decade has left the role of PI3K unresolved. In this report, we have resolved this controversy. We show that mutation of the PI3K interaction site in the cytosolic tail of CD28 site disrupts the ability of CD28 to recruit protein kinase C-theta; to the central supramolecular activation cluster (c-SMAC) region of the immunological synapse, promote NF-kappaB nuclear translocation, and enhance IL-2 gene transcription. In contrast, mutation of the PI3K interaction site had no effect on the ability of CD28 to enhance IL-2 mRNA stability. These results suggest that two distinct pathways mediate CD28-induced up-regulation of IL-2 expression, a PI3K-dependent pathway that may function through the immunological synapse to enhance IL-2 transcription and a PI3K-independent pathway that induces IL-2 mRNA stability.

The extent of akinesis is predictive of the in-hospital mortality from endoaneurysmorrhaphy

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62+/-9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality.Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30 degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the LV ejection fraction (p=0.001), the number of stenosed coronary arteries (p=0.004), and the extent of akinesis (p=0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.

Lachgas

Nitrous oxide has been used in addition to other volatile anaesthetics to provide general anaesthesia and short time sedation for more than 150 years. However, the exact mechanisms of action remain unclear. For decades nitrous oxide was considered to be the ideal anaesthetic because of his favourable physical properties and low cardiovascular side effects. However, the known side effects of nitrous oxide as well as the implementation of new anaesthetic agents and short acting opiates led to more and more criticism about the administration of this gas. Nitrous oxide is still frequently used for mask induction primarily in paediatric anaesthesia and gynaecology. However, recent studies have shown that omitting nitrous oxide can also be a risk factor because of an increased susceptibility to intraoperative awareness. Careful consideration of the illustrated contraindications and side effects as well as the available alternatives, shows that nitrous oxide is still an option in general anaesthesia.

["Alternative" effects of local anesthetic agents]

The following article summarizes different aspects of local anesthetic effects that cannot be explained purely by a sodium channel blockade. Particularly remarkable is hereby their antiinflammatory activity, e.g. the inhibition of pathological changes such as excessive stimulation of the inflammatory system, without compromising the host defense system. In contrast to other immunosuppressive drugs commonly used for treating such conditions, local anesthetics look promising for the future as a new therapeutic option. Besides general anesthetic activity, local anesthetics exert cerebroprotective effects and are furthermore, in consideration of their cardiovascular stability, of interest during neuroanesthetic procedures. In addition, local anesthetics are known for their potency to minimize bronchial hyperreactivity, although details of the underlying mechanisms are not yet elucidated. These effects of local anesthetics may represent interesting prospects for which their relevance has to be determined.

[The Ross procedure (pulmonary autograft) as an alternative for aortic valve replacement]

BACKGROUND AND OBJECTIVE

The Ross procedure (pulmonary autograft) has since the 1980s attracted growing interest as an alternative to the widely practised insertion of a prosthetic aortic valve. The 12-year experience of a consecutive series from one centre are reported here.

PATIENTS AND METHODS

Between February 1990 and January 2002 a Ross procedure, predominantly with the subcoronary technique, was performed in 244 consecutive patients with aortic valve disease (244 men, 54 women, mean age 46 +/- 13.5 years). Annual follow-up clinical examinations (mean postoperative period 32.9 +/- 29.5 months in 99 % of the cohort) were performed.

RESULTS

Perioperative mortality was 0.8 % (n=2), and there were two late deaths unrelated to the aortic valve disease. Seven patients had to be re-operated for failure of the homograft (n=4) or autograft (n=4). According to clinical criteria, 99 % of the followed-up patients were in New York Heart Association (NYHA) functional class I or II, only two patients, with pulmonary comorbidity, were in class III. Echocardiography demonstrated autografts with nearly normal transvalvular gradient (mean maximal pressure gradient 6.5 +/- 3.3 mmHg), while nine patients had second-degree aortic regurgitation. The mean maximal gradient across the homograft valve in the pulmonary position was 12.0 +/- 6.9 mmHg, while ten patients had second-degree and one had third-degree pulmonary regurgitation.

CONCLUSION

The technically demanding Ross procedure produced excellent clinical and hemodynamic mid-term results. It is thus an appealing alternative to the widely used replacement by a prosthetic valve. Definitive assessment awaits further long-term follow-up.

Prostaglandin E2 and cAMP promote B lymphocyte class switching to IgG1

Prostaglandins of the E series (PGE) have traditionally been considered as suppressive for immune responses; however, recent data suggest that PGE channels the immune response towards a T helper 2 type response and production of selected immunoglobulin isotypes. Herein, we present data showing that PGE(2) and other agents that induce intracellular rises in cAMP significantly increased B lymphocyte IgG1 production (up to sevenfold). PGE(2) acted on small resting B cells and on uncommitted B cells expressing high levels of surface IgM to increase the number of cells secreting IgG1. PGE(2) even increased IgG1 synthesis by purified B cells in the absence of exogenous IL-4. Finally, PGE(2) synergized with IL-4 to induce germline gamma1 transcripts through the switch region. This transcription is required for isotype switching. These data support the hypothesis that PGE(2) acts on uncommitted resting B cells at the level of germline gamma1 transcription to promote class switching to IgG1. PGE(2) is an important regulator of the immune response, shifting the balance towards a T helper type 2 response, directing selection of the isotypes produced, and promoting memory cell formation.

Mucormycoses

Over recent years the clinical importance of mucormycosis has significantly increased. Most frequently mucormycosis occurs in neutropenic patients with haematological diseases. It is caused by fungi of the order Mucorales. The clinical patterns of the disease produced by different genera or species of Mucorales are virtually identical. Rhizopus, Absidia, Rhizomucor and Mucor are the organisms most commonly isolated from patients who suffer from mucormycosis. Diagnosis of mucormycosis is difficult as it is based on culture methods or microscopy of clinical specimens. The diagnosis is often only made after a delay or even post-mortem. Therapy includes surgical intervention if possible and is based on systemic amphotericin B (conventional or liposomal).

Inhibition of glucose transport by cyclic GMP in cardiomyocytes

Recent evidence points to a potential role of cyclic GMP (cGMP) in the control of cardiac glucose utilization. The present work examines whether the glucose transport system of cardiac myocyte is a site of this cGMP-dependent regulation. Treatment of isolated rat cardiomyocytes (for 10 min) with the membrane-permeant cGMP analogue 8-(4-chlorophenylthio)-cGMP (8-p-CPT-cGMP, 200 microM) caused a decrease in glucose transport in non-stimulated (basal) myocytes, as well as in cells stimulated with insulin or with the mitochondrial inhibitor oligomycin B by up to 40%. An inhibitory effect was also observed with another cGMP analogue (8-bromo-cGMP), and in cells stimulated by hydrogen peroxide or anoxia. In contrast, 8-p-CPT-cAMP (200 microM), or the beta-adrenergic agonist isoprenaline (which increases cAMP levels) did not depress glucose transport, and even potentiated the effect of insulin. Blockade of endogenous cGMP formation with the guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ, 10 microM) significantly increased basal and insulin-dependent glucose transport (by 25%), whereas addition of the guanylate cyclase activator 3-(5'-hydroxymethyl-2'furyl)-1-benzylindazol (YC-1, 30 microM) produced a depression of glucose transport (by 20%). Confocal laser scanning microscopic studies revealed that cGMP partially prevents the insulin-induced redistribution of the glucose transporter GLUT4 from intracellular stores to the cell surface. These observations suggest that the glucose transport system of cardiomyocytes represents a metabolic target of inhibition by cGMP, and that this regulation occurs at the level of the trafficking of glucose transporters.

Study status consistency and duplicate-read protection in a distributed architecture

This presentation will discuss the benefits and pitfalls of implementing a study status and duplicate-read protection mechanism within a distributed picture archiving and communication system (PACS) architecture. There are many advantages to a distributed PACS network in which image studies are proactively pushed to reading stations before they are required by a radiologist. The absence of a central server, which serves on demand, makes managing study status and protecting against duplicate reads challenging. The system to manage study status and read access must be efficient, robust, and easy to administer. A system is presented that accomplishes these goals while maintaining the advantages of a distributed architecture.

METHODS

The basic workflow of the system is that image studies acquired at a modality device are automatically sent to an archive server. Using a set of advanced routing rules, the archive automatically routes studies to diagnostic workstations where studies are candidates for diagnostic read. The workstations display a list of all local studies available for reading. A monitor application running on the workstations coordinates access to studies for diagnostic read. Once the status of a study has been changed, the workstations on the networks and the archive are notified, which causes the study to be automatically removed from any list on a workstation where it might be a read candidate.

RESULTS

Implementation of this system provides a balanced workflow throughout the system while minimizing the need for costly high-speed network hardware. Additionally studies are read as soon as they are available by the next available radiologist. This workflow is enabled without the need for specific interaction by any of the radiologists on the network. By having the images available at the workstation in an organized worklist, this methodology increases the efficiency of the radiologist.

CONCLUSION

The implementation of this system enables a radiology department, or even a specialty group within a department, to gain the benefit of a distributed system as well as the benefits provided by a central-server architecture. This can be done very cost effectively with minimal configuration overhead and hardware requirements.

Hemodynamics of semilunar valves at rest and exercise at an average of more than two years after the Ross procedure

BACKGROUND AND AIM OF THE STUDY

Rest, and especially exercise, hemodynamics are valuable determinants to assess outcome of the Ross procedure. In this study, the degree of insufficiency and pressure gradients at rest across the autograft and homograft, as well as the pressure gradients at exercise, were measured.

METHODS

Among 115 patients operated on between February 1990 and February 1999, 67 were evaluated echocardiographically at rest and moderate exercise. The mean patient age at subcoronary implantation was 52 +/- 13 years. The mean interval between surgery and investigation was 27.3 +/- 17.4 months. The exercise level was 100 W (n = 47), 75 W (n = 14) or 50 W (n = 6).

RESULTS

Fifty-two patients had no or trace aortic insufficiency, 23 were grade I/IV, and two were grade II/IV. Pulmonary insufficiency was graded as none (n = 45), mild (n = 21), and moderate (n = 1). Heart rate increased from 70 +/- 12 beats/min at rest to 108 +/- 19 beats/min at exercise. The maximal pressure gradient across the autograft increased from 6.1 +/- 2.3 mmHg at rest to 8.7 +/- 4.1 mmHg at exercise. The maximal pressure gradient across the homograft increased from 11.8 +/- 5.3 mmHg at rest to 17.7 +/- 8.2 mmHg at exercise. A pressure gradient across the homograft >25 mmHg was measured in 13 patients.

CONCLUSION

In most patients, hemodynamics at rest and moderate exercise at an average of more than two years after the Ross procedure were excellent. Some homografts developed pressure gradients at exercise; this finding will form the target of future surgical and scientific investigations.

Functional role for the class IX myosin myr5 in epithelial cell infection by Shigella flexneri

Efficient control of Shigella-induced, rho-dependent cytoskeletal rearrangements seems to be required to shape the delicate cellular structures associated with bacterial invasion of epithelial cells. We therefore studied a class IX myosin and rho antagonist, the GTPase-activating protein (GAP) myr5, for a potential role in the bacterial entry process. We show that myr5 is recruited into bacterial entry spots. The recruitment pattern resembled that of rhoC or ezrin, but not rhoA, rac or CDC42, while in vitro GAP activity of myr5 was similar for rhoA, B or C. Analysis of myr5 mutants suggested that GTPase- or ATP-binding activites are not required for Shigella-induced recruitment of this atypical myosin to the bacterial entry site. Functional studies revealed a potential dual role of the myosin functions and the GAP module of myr5 for bacterial internalization.

[Intermediate term clinical results after endoaneurysmorrhaphy in left ventricular aneurysm]

Endoaneurysmorrhaphy (EAR) in postinfarct ventricular aneurysms leads to excellent short-term results. However, the temporal response of EAR is widely unknown. Thus, the indication for surgical treatment of patients with ventricular aneurysms is not well defined. EAR was performed in 157 patients (6/1993-6/1999) with symptomatic ventricular aneurysms (median NYHA III). Factors influencing cardiac mortality and morbidity during follow-up were determined by univariate and multivariate analysis. Perioperative mortality was low: 5%. Mortality during follow-up was 3.3% per year, resulting in a 5-year survival rate of 78%. NYHA classification ameliorated significantly from the preoperative status compared to the follow-up period (median NYHA II; p < 0.001). Multivariate analysis identified preexisting arterial occlusive disease and advanced age (> 70 years) as significant factors influencing medium-term mortality. Implantation of the left internal mammary artery was associated with a better survival rate. Endoaneurysmorrhaphy can be performed with low perioperative mortality, will result in a significant amelioration of the cardiac clinical status and offers low medium-term mortality. Our data indicate that EAR seems to be the procedure of choice for patients with symptomatic ventricular aneurysms.

Disseminated mucormycosis caused by Absidia corymbifera leading to cerebral vasculitis

An 18-year-old woman was admitted to hospital because of subcutaneous hematoma and fever of unknown origin. Acute myeloid leukemia was diagnosed and empirical antimicrobial treatment and induction chemotherapy were started. After initial defervescence, fever relapsed 2 days after the onset of neutropenia. The CT scan of the lung was consistent with an invasive fungal infection. Treatment with amphotericin B was started and antimicrobial treatment was continued with liposomal amphotericin B because of an increase in creatinine later. The fever persisted and the patient suddenly developed progressive neurological symptoms. CT scan of the head suggested cerebral infarction and angiography of the extra- and intracranial arteries showed signs of vasculitis. Six days after the onset of neurological symptoms cerebral death was diagnosed. Autopsy revealed non-septate, irregularly branched hyphae in various histologic sections including brain. Absidia corymbifera could be isolated from lung tissue confirming the diagnosis of disseminated mucormycosis. In this case, angiographic findings suggested severe cerebral vasculitis which was in fact caused by thromboembolic dissemination of fungal hyphae. This case underlines the fact that cerebral symptoms in febrile neutropenic patients are highly indicative for fungal infections of the brain.