Compartments in medulloblastoma with extensive nodularity are connected through differentiation along the granular precursor lineage

Medulloblastomas with extensive nodularity are cerebellar tumors characterized by two distinct compartments and variable disease progression. The mechanisms governing the balance between proliferation and differentiation in MBEN remain poorly understood. Here, we employ a multi-modal single cell transcriptome analysis to dissect this process. In the internodular compartment, we identify proliferating cerebellar granular neuronal precursor-like malignant cells, along with stromal, vascular, and immune cells. In contrast, the nodular compartment comprises postmitotic, neuronally differentiated malignant cells. Both compartments are connected through an intermediate cell stage resembling actively migrating CGNPs. Notably, we also discover astrocytic-like malignant cells, found in proximity to migrating and differentiated cells at the transition zone between the two compartments. Our study sheds light on the spatial tissue organization and its link to the developmental trajectory, resulting in a more benign tumor phenotype. This integrative approach holds promise to explore intercompartmental interactions in other cancers with varying histology.

Severe Dysbiosis and Specific Haemophilus and Neisseria Signatures as Hallmarks of the Oropharyngeal Microbiome in Critically Ill Coronavirus Disease 2019 (COVID-19) Patients

BACKGROUND

At the entry site of respiratory virus infections, the oropharyngeal microbiome has been proposed as a major hub integrating viral and host immune signals. Early studies suggested that infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are associated with changes of the upper and lower airway microbiome, and that specific microbial signatures may predict coronavirus disease 2019 (COVID-19) illness. However, the results are not conclusive, as critical illness can drastically alter a patient's microbiome through multiple confounders.

METHODS

To study oropharyngeal microbiome profiles in SARS-CoV-2 infection, clinical confounders, and prediction models in COVID-19, we performed a multicenter, cross-sectional clinical study analyzing oropharyngeal microbial metagenomes in healthy adults, patients with non-SARS-CoV-2 infections, or with mild, moderate, and severe COVID-19 (n = 322 participants).

RESULTS

In contrast to mild infections, patients admitted to a hospital with moderate or severe COVID-19 showed dysbiotic microbial configurations, which were significantly pronounced in patients treated with broad-spectrum antibiotics, receiving invasive mechanical ventilation, or when sampling was performed during prolonged hospitalization. In contrast, specimens collected early after admission allowed us to segregate microbiome features predictive of hospital COVID-19 mortality utilizing machine learning models. Taxonomic signatures were found to perform better than models utilizing clinical variables with Neisseria and Haemophilus species abundances as most important features.

CONCLUSIONS

In addition to the infection per se, several factors shape the oropharyngeal microbiome of severely affected COVID-19 patients and deserve consideration in the interpretation of the role of the microbiome in severe COVID-19. Nevertheless, we were able to extract microbial features that can help to predict clinical outcomes.

Low resting heart rates are associated with new-onset atrial fibrillation in patients with vascular disease: results of the ONTARGET/TRANSCEND studies

BACKGROUND

Elevated systolic blood pressure (SBP) and high resting heart rate (HR) are associated with cardiovascular end-points. Although the association between atrial fibrillation (AF) and SBP is well established, the relation between AF and HR remains unclear.

METHODS

In patients from the ONTARGET and TRANSCEND studies with high cardiovascular disease risk (n = 27 064), new-onset AF was evaluated in relation to mean SBP, visit-to-visit variation in SBP (SBP-CV; i.e. SD/mean × 100%), mean HR and visit-to-visit variation in HR (HR-CV).

RESULTS

Low mean HR (P < 0.0001) and high SBP (P = 0.0021) were associated with incident AF. High SBP-CV (P = 0.031) and HR-CV (P < 0.0001) were also associated with incident AF. After adjustment for confounders, SBP and SBP-CV were no longer significantly associated with AF. The detrimental effect of low HR was particularly evident in subjects who were not receiving treatment with beta-blockers (P = 0.014 for interaction between beta-blocker use and mean HR). In addition to low HR, high HR-CV and high SBP had additive effects on incident AF.

CONCLUSIONS

Low mean HR (<60 beats min(-1) ) is independently associated with incident AF, and low HR-CV and high SBP further increase the incidence of new-onset AF in patients at high risk of cardiovascular disease.

Resting heart rate is associated with renal disease outcomes in patients with vascular disease: results of the ONTARGET and TRANSCEND studies

BACKGROUND

Resting heart rate (RHR) is associated with cardiovascular disease outcomes in high-risk patients. It is not known whether RHR is predictive of renal outcomes such as albuminuria, end-stage renal disease (ESRD) or doubling of creatinine. We evaluated whether RHR could predict renal endpoints in patients at a high risk of cardiovascular disease. We also tested the effects of RHR at different levels of systolic blood pressure (SBP).

METHODS

We analysed data from 28 757 patients in the ONTARGET and TRANSCEND trials. RHR and SBP were available for a mean of 4.9 ± 0.4 visits (range 3-5) within the first 2 years of the studies. Albuminuria was determined at baseline, at 2 years and at study end.

RESULTS

Mean RHR was predictive of incident micro-albuminuria [hazard ratio (HR) for RHR ≥80 vs. <60 beats min(-1) 1.49, 95% confidence interval (CI) 1.29-1.71, P < 0.0001], incident macro-albuminuria (HR 1.84, 95% CI 1.39-2.42, P < 0.0001), doubling of creatinine (HR 1.47, 95% CI 1.00-2.17, P = 0.050) and ESRD (HR 1.78, 95% CI 1.00-3.16, P = 0.050), and the combined renal end-point (HR 1.51, 95% CI 1.32-1.74, P < 0.0001). Associations were robust at SBPs from <120 to ≥150 mmHg, with the lowest risk at a SBP of 130-140 mmHg.

CONCLUSION

Resting heart rate is a potent predictor of these renal outcomes, as well as their combination, in patients with cardiovascular disease. RHR at all SBP levels should be considered as a possible renal disease risk predictor and should be investigated as a treatment target with RHR-reducing agents.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial

OBJECTIVES

Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year.

METHODS

The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB.

RESULTS

Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062).

CONCLUSIONS

Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Early combination therapy with telmisartan plus amlodipine for rapid achievement of blood pressure goals

BACKGROUND

Rapid and sustained blood pressure (BP) goal attainment is important to reduce cardiovascular risk. Initial use of combination therapy may improve BP goal attainment.

METHODS

The Boehringer Ingelheim trial database was searched for randomised, double-blind studies comparing telmisartan/amlodipine combination therapy with monotherapy. Eight studies were identified. Eight separate analyses were used to compare combination therapy with respective monotherapies at the earliest available time points (weeks 1, 2 and/or 4).

RESULTS

In patients initiated on combination therapy, greater systolic BP (SBP)/diastolic BP (DBP) reductions were seen with combination therapy (p < 0.0001); BP (< 140/90 mmHg), SBP (< 140 mmHg) and DBP (< 90 mmHg) goal attainment rates were significantly higher with combination therapy at all time points. In patients uncontrolled by monotherapy, greater SBP/DBP reductions were seen with combination therapy (p < 0.05 in all but one measure), and all goal attainment rates were significantly higher with combination therapy, except in one measure.

CONCLUSION

Many people can achieve their BP targets when taking a combination of telmisartan and amlodipine after failing to do so with monotherapy. Furthermore, BP targets can be achieved more rapidly using a combination of telmisartan and amlodipine as initial therapy than with either monotherapy.

[Improve your skills!: evaluation of a 2.5-day basic course in vascular surgery for surgical trainees]

BACKGROUND

The traditional surgical training in the operating room (OR) is often complemented by participation in workshops and on simulators. The foundation Vascular International offers basic courses for vascular surgery techniques with training on pulsatile circulation, lifelike anatomical models. The aim of this study was to assess the efficacy of a 2.5-day intensive course on basic skills in vascular surgery.

MATERIAL AND METHODS

A total of 24 participants (67% male with an average age of 35 years) performed a vein patch-plasty before and after the basic vascular surgery instruction course. Endpoints of the study were the time needed for suturing and the technical quality, which were evaluated by two course trainers on a scale of 0-10. Furthermore, the participants were asked to evaluate their own technical competence. The statistical analysis was carried out using MS Excel (t-test and analysis of correlation).

RESULTS

A significantly shortened time for the suturing (19.5 min versus 14.1 min, p < 0.001) and improved quality of the vein patch were found after the workshop (p < 0.05) with a high correlation between the two observers (r = 0.885). The participants also evaluated their own surgical competence better at the end of the training but there was no correlation between the self-assessment and the quality of the patch (r = 0.146 before and r = 0.109 after the workshop).

CONCLUSIONS

A significant improvement in the time needed for suturing and the quality of the vein patch-plasty was shown in this study. Further studies are necessary to demonstrate the long-term success and possible shortening of the learning curve in hospitals with professional training. With regard to the current curriculum of surgical trainees in Germany basic vascular surgery courses should be considered as a potential valuable part of the surgical common trunk.

Pocketcheck: updating the HLA class I peptide specificity roadmap

The structural determination of peptide:HLA (human leucocyte antigen) class I complexes by X-ray crystallography has provided valuable information for understanding how peptides bind to individual HLA class I molecules and how this may influence the immune response. We compared 101 crystal structures of 9-mer peptide:HLA class I complexes available in the protein data bank (PDB) by performing a contact analysis using the Contact Map Analysis webserver http://ligin.weizmann.ac.il/cma. An InterSystems Caché 'post-relational' database containing residue position, amino acid (AA) and buried surface that contact a particular peptide position was then created allowing data comparison for all the structures (Pocketcheck). The analysis illustrates that the HLA class I residues 24, 45, 63 and 67 show high contact frequencies to both the p1 and/or p2 position of bound peptides, indicating that they might influence the nature of a peptide anchor. To determine the influence of these residues we utilized soluble HLA technology and mass spectrometry to analyze peptides derived from HLA-B*44:06 since it differs from the previously described allele B*44:02 by seven AA exchanges located in the alpha 1 domain (residues 24, 32, 41, 45, 63, 67 and 80). HLA-B*44:06 features an anchor motif of P or A at p2 and Y or W at the C-terminal. Additionally B*44:06-derived peptides feature an auxiliary anchor motif at p1, comprising D or E. Our results illustrate that structural analysis can provide valuable information to understand allogenicity and provides a further step towards intelligent HLA mismatching.

Telmisartan in Migraine Prophylaxis: A Randomized, Placebo-Controlled Trial

We evaluated telmisartan 80 mg for migraine prophylaxis. Migraine patients ( n = 95) with three to seven migraine attacks in 3 months were randomized, double-blind to telmisartan or placebo. The primary end-point was the reduction in the number of migraine days (i.e. a day with ≥ 1 h of symptoms) between the 4-week baseline period and the last 4 weeks of the 12-week treatment period. A responder was recorded when there was a symptom reduction of ≥ 50% in these 4-week baseline and treatment periods. The reduction in migraine days was 1.65 with telmisartan and 1.14 with placebo ( P > 0.05). Post hoc analyses adjusting for baseline and centre showed a 38% reduction in migraine days with telmisartan vs. 15% with placebo ( P = 0.03), and a borderline significant difference in responders (40% vs. 25%, P = 0.07). The incidence of adverse events was similar between treatments. This study indicates that telmisartan might be effective in migraine prophylaxis.

Hybrid approach for arch and thoracoabdominal pathologies

The endovascular era began about 20 years ago and subsequently revolutionized vascular surgery as a less invasive treatment option, especially for high risk patients. In the late 1990s, a new hybrid approach for arch and thoracoabdominal pathologies was developed. Debranching and rerouting supra-aortic and visceral aortic branches with extra-anatomic bypass grafting was performed in order to achieve sufficient landing zones demanding for subsequent stent grafting. The initial single-center results of small series up to 20 patients were encouraging with acceptable complication rates. Hybrid arch procedures are feasible but seem to carry risks. However, the latest reports for thoracoabdominal hybrid procedures demand a word of caution due to high morbidity rates. The hybrid approach may be reserved for a selected comorbid patient cohort, which is regarded unfit for open reconstruction.

Impact of angiotensin receptor blockade in combination with hydrochlorothiazide 25 mg in 2121 patients with stage 1-2 hypertension

The antihypertensive effects of telmisartan 80 mg versus valsartan 160 mg, both combined with hydrochlorothiazide (HCTZ) 25 mg, were assessed in a pooled analysis from two large trials with identical study designs in patients with stage 1-2 hypertension. The trials were double-blind with a 4:4:1 randomization scheme to compare once-daily telmisartan 80 mg and HCTZ 25 mg versus once-daily valsartan 160 mg and HCTZ 25 mg versus once-daily placebo on reductions in clinic blood pressure (BP). The primary end point was changes from baseline in BP at the end of 8 weeks. In total, 2121 patients were randomized (telmisartan-HCTZ, 942, valsartan-HCTZ, 952, and placebo, 227) and had baseline seated BPs of 154/102 and 155/102 mm Hg in the two studies, respectively. Changes from baseline in BP after administration of telmisartan-HCTZ (-24.5/-18.0 mm Hg) were significantly greater than for both placebo (-4.1/-6.5 mm Hg) and valsartan-HCTZ (-22.3/-16.8 mm Hg) (versus placebo, P<0.0001 for systolic and diastolic BP; versus valsartan-HCTZ, P=0.0004 for systolic BP and P=0.0019 for diastolic BP). Adverse event rates were higher in the placebo group than in the active treatment groups (placebo, 41%, telmisartan-HCTZ, 30%, and valsartan-HCTZ, 30%, P<0.05). These data confirm that telmisartan-HCTZ at doses of 80/25 mg lowered systolic and diastolic BP to a greater extent than valsartan-HCTZ at doses of 160/25 mg in stage 1-2 hypertension. The magnitude of the BP-lowering effect provides support for the use of angiotensin receptor blockers with higher doses of a thiazide diuretic (25 mg) to improve hypertension control.

Intracranial dissection during carotid endarterectomy treated by carotid stenting

Intracranial dissection of the internal carotid artery after carotid endarterectomy (CEA) is a serious complication with a potentially fatal outcome. We report on a 67 male with a symptomatic high grad stenosis of the internal carotid artery. Intraoperative completion angiography showed a thrombotic occlusion and the internal carotid artery (ICA) was resected with interposition of a Dacron graft. Completion angiography then revealed a dissection of the petreous ICA, which was corrected by insertion of a coronary artery stent.Stenting of the ICA is a useful tool to restore cerebral perfusion without time delay and completion imaging is extremely helpful for early detection of dissection during CEA.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

OBJECTIVES

A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design.

METHODS

In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed.

RESULTS

In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge.

CONCLUSIONS

In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.

Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors reduce major cardiovascular events, but are not tolerated by about 20% of patients. We therefore assessed whether the angiotensin-receptor blocker telmisartan would be effective in patients intolerant to ACE inhibitors with cardiovascular disease or diabetes with end-organ damage.

METHODS

After a 3-week run-in period, 5926 patients, many of whom were receiving concomitant proven therapies, were randomised to receive telmisartan 80 mg/day (n=2954) or placebo (n=2972) by use of a central automated randomisation system. Randomisation was stratified by hospital. The primary outcome was the composite of cardiovascular death, myocardial infarction, stroke, or hospitalisation for heart failure. Analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00153101.

FINDINGS

The median duration of follow-up was 56 (IQR 51-64) months. All randomised patients were included in the efficacy analyses. Mean blood pressure was lower in the telmisartan group than in the placebo group throughout the study (weighted mean difference between groups 4.0/2.2 [SD 19.6/12.0] mm Hg). 465 (15.7%) patients experienced the primary outcome in the telmisartan group compared with 504 (17.0%) in the placebo group (hazard ratio 0.92, 95% CI 0.81-1.05, p=0.216). One of the secondary outcomes-a composite of cardiovascular death, myocardial infarction, or stroke-occurred in 384 (13.0%) patients on telmisartan compared with 440 (14.8%) on placebo (0.87, 0.76-1.00, p=0.048 unadjusted; p=0.068 after adjustment for multiplicity of comparisons and overlap with primary outcome). 894 (30.3%) patients receiving telmisartan were hospitalised for a cardiovascular reason, compared with 980 (33.0%) on placebo (relative risk 0.92, 95% CI 0.85-0.99; p=0.025). Fewer patients permanently discontinued study medication in the telmisartan group than in the placebo group (639 [21.6%] vs 705 [23.8%]; p=0.055); the most common reason for permanent discontinuation was hypotensive symptoms (29 [0.98%] in the telmisartan group vs 16 [0.54%] in the placebo group).

INTERPRETATION

Telmisartan was well tolerated in patients unable to tolerate ACE inhibitors. Although the drug had no significant effect on the primary outcome of this study, which included hospitalisations for heart failure, it modestly reduced the risk of the composite outcome of cardiovascular death, myocardial infarction, or stroke.

FUNDING

Boehringer Ingelheim.

Imaging modalities for the thoracic aorta

Almost 50 years after its introduction intra-arterial digital subtraction angiography (DSA) has been passed as the gold standard for diagnostic imaging of the aorta. Today's performance of multi-detector-row computed tomography angiography (CTA) as well as magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) offer remarkable improvements in the field of diagnostic cardiovascular imaging. The racy developments not only concerning image acquisition but also image postprocessing offer a multidimensional approach to assess anatomy and pathology of individual patients in a few minutes. Four-dimensional visualization assists us to select the ''adequate'' patient, quantify vascular and adjacent geometries, and select the appropriate device to realize even complex thoracic endovascular aortic reconstructions (TEVAR). There is still a discrepancy between perioperative and intraoperative imaging--but new technologies made also some progress in this field. Lifelong imaging surveillance of TEVAR and bypasses is still a critical component of patient care and requires comparable imaging and postprocessing capabilities as for the preoperative setting. Although is the most commonly used examination for imaging surveillance, MRA, chest x-ray and DSA all have their role in determining complications and their management.

Abdominoplasty as an adjunct to the management of peri-Caesarian section necrotising fasciitis

Necrotising fasciitis is a rare but potentially lethal condition, often requiring extensive soft tissue debridement and complex reconstructive surgery. The disease has been noted to complicate Caesarian section wounds, and our department has recently managed three such patients. They all required extensive abdominal wall debridements which would traditionally be closed initially by split skin grafting. We report on the clinical course of three patients, two of whom had their defects closed successfully by abdominoplasty without recourse to initial skin grafting.

[Leiomyosarcoma of the inferior vena cava]

Leiomyosarcomas of the inferior vena cava are rare and the clinical symptoms unspecific. We report a case of leiomyosarcoma of the inferior vena cava in an 82-year-old woman presenting with weight loss and abdominal pain. Following elaborate preoperative examinations, surgical resection was performed and the inferior vena cava was reconstructed. Clinical signs, diagnosis, therapy, and prognosis are discussed.

An unusual cause of peripheral artery embolism: Floating thrombus of the thoracic aorta surgically removed

Intraluminal mobile thrombus of the descending aorta are rare disorders. They are at high risk for peripheral embolism and therefore indication for treatment is mandatory. We report on a 54-year-old patient with peripheral arterial embolization who was treated by surgical thrombus removement by thoracotomy and staged peripheral bypass grafting. New diagnostic tools are presented, therapy and prognosis are discussed.

Pathology, natural history and treatment of abdominal aortic aneurysms

With increasing age of the population and improvement of diagnostic tools, the incidence of abdominal aortic aneurysms (AAA) has been rising steadily. Despite an improvement in operative and interventional treatment options, AAA is the cause of death in 1-3% of men over 65 years of age in industrial countries, mostly due to rupture [1]. Therefore, routine screening for AAA by ultrasonography has been postulated in the past: a 60 year old man with an abdominal aortic diameter of less than 3 cm has a life-time risk of developing AAA close to zero. However, routine screening has not been found to be cost effective. Despite of the results of two well-designed studies, the limits of AAA qualifying the patient for surgery or intervention in contrast to conservative treatment is still a matter of debate. The present review article summarizes the current knowledge of the pathology, incidence, risks, natural course as well as symptoms and current treatment strategies of AAA on the basis of the recent literature.

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.

Adenosine-induced cardiac arrest and EEG changes in patients with thoracic aorta endovascular repair

BACKGROUND

We studied haemodynamic and metabolic variables, and cerebral function after cardiac arrest induced by high dose of adenosine in patients undergoing thoracic aorta endovascular repair.

METHODS

Arterial blood pressure, blood gas values and EEG were recorded continuously in 15 patients undergoing anaesthesia (isoflurane) for endovascular thoracic aorta repair. Cardiac arrest was induced by different doses of adenosine (Adrekar, Sanofi-Synthelabo, Berlin, Germany; 0.4-1.8 mg kg(-1) body weight). Serum concentrations of neurone-specific enolase (NSE) were determined before and after stent graft implantation. Neurological function was assessed before and after surgery.

RESULTS

After adenosine, the heart beat stopped immediately for 18-58 s in close relation to the adenosine dose. EEG power was significantly reduced to -57%, but reached normal values within 5 min after cardiac arrest. In particular, the fast alpha- and beta-EEG-frequencies sensitively reflected patients' EEG activity during the procedure. No intraoperative increases in NSE concentrations, and no neurological dysfunctions after surgery, were observed.

CONCLUSION

After adenosine-induced cardiac arrest, changes in haemodynamic variables and EEG power spectra reversed completely within 1 and 5 min, respectively, without persistent brain dysfunction after stent graft implantation.

[Surgical management of isolated iliac aneurysms]

Isolated iliac aneurysms (IIA) are uncommon lesions that require surgical repair to prevent rupture. The aim of this article is to give an update on the current surgical management of IIA. This report also evaluates the application of endovascular repair in IIA, based on a recent Pubmed search and on our own experience in the interventional field: Open reconstruction achieves good longterm results and still represents the golden standard in surgical treatment of IIA. Transluminally placed endovascular stent grafts can be successfully used to exclude isolated iliac aneurysms in selected high risk patients with suitable anatomy. A classification based on aneurysm morphology is useful for patient selection. The value of endovascular therapy has yet to be determined.

Switch from phytotherapy to tamsulosin in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH)

The aim of this observational prospective study was to evaluate the switch from phytotherapy to tamsulosin 0.4 mg once daily (o.d.) on efficacy, sexual function and tolerability in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) who have a poor response to at least 4 weeks of phytotherapy. The switch to tamsulosin 0.4 mg o.d. improves LUTS and related quality of life. Sexual function is also slightly improved. Tamsulosin is as well tolerated as phytotherapy and abnormal ejaculation appears to be no problem. Tamsulosin is perceived by both patients and urologists to be superior to preceding phytotherapy.

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy]

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Gef��chirurgie im Alter

The prevalence of vascular disease among the elderly population is high (approximately 20%). The morbidity and mortality of many vascular operations show no differences between the fit elderly and younger patients. A major problem is that the elderly are often not diagnosed and treated early enough to prevent emergency operations, which carry a much higher mortality. Many new surgical techniques, especially endovascular interventions, have made vascular surgery less invasive. These advances have increased the potential of life saving and prolonging vascular surgery that can be offered to all patients regardless of age. Risk-benefit analysis, especially in elderly patients, is a cornerstone of proper patient selection. The main goal of vascular surgery in the elderly is preservation of quality of life and independence. Surgery of a ruptured aneurysm is a life saving exception. Indications for treatment in the elderly remains an individual decision making process. Advanced age should not be considered as a limitation or contraindication for carotid, aneurysm and bypass surgery. Age is not a disease, it is just a chapter of life.

[Surgical management of thoracic aortic lesions. Aneurysm, dissection and traumatic rupture]

Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.

Surgical Thrombectomy Followed by Intraoperative Endovascular Reconstruction for Symptomatic Ilio-femoral Venous Thrombosis

OBJECTIVES

To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis.

METHODS

Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed.

RESULTS

Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively.

CONCLUSIONS

Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.

Intravasale Raumforderungen der thorakalen Aorta

Aortic intraluminal mass lesions of the thoracic aorta are rare disorders with a wide range of differential diagnoses. Generalized hypercoagulation or vascular endothelial disorders have been proposed as the main etiological factor. The risk of catheter-related thrombus development or embolization after interventional procedures is as high as 17%. Malignancies of the aorta are somewhat rare. In some cases, the specific source of the thrombus could not be determined. Mainly, intraluminal tumors of the thoracic aorta become evident through peripheral embolization. Modern diagnostic tools are able to identify the structure and location of intravascular formations. Therapy options are influenced, due to the heterogenic entity, by the individual risk to the patient and the pathology of the thrombus.

A comparison of the efficacy and tolerability of tamsulosin and finasteride in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

In this multicentre, double-blind study, patients with LUTS/BPH were randomised to 26 weeks with finasteride 5 mg once daily (n=204) or tamsulosin 0.4 mg once daily (n=199). Double-blind treatment was continued for another 26 weeks (total treatment duration: 1 y). The primary efficacy parameter was the difference in mean change in total Symptom Problem Index (SPI) from baseline to end point at week-26 in the intention-to-treat (ITT) and per protocol (PP) populations. Tamsulosin induced a greater improvement in total SPI (-5.2 points or -37%) compared to finasteride (-4.5 points or -31%) at week-26 (P=0.055 in ITT and P=0.032 in PP). Tamsulosin improved urinary symptoms (particularly the more bothersome storage symptoms) and flow more quickly than finasteride. The difference was statistically significant for the SPI from week-1 (reduction, respectively, -2.5 vs -1.8 points, P=0.043) to week-18 and for Qmax from week-1 (increase, respectively, 2.3 vs 0.7 ml/s, P=0.0007) to week-12. Both treatments were well tolerated with a comparable incidence of adverse events, including urinary retention.

[Interventional therapy in renal artery dissection due to renal artery PTA. Case report]

Percutaneous angioplasty of a renal artery stenosis may lead to dissection and acute thrombosis that may put the organ at risk. In this case, it should be discussed individually how to treat the patient and the decision on interventional therapy should be based on interdisciplinary consensus. Local fibrinolysis usually allows to recognize the cause of obstruction which then is the basis for further treatments. The case report presented in this article describes how a dissection involving two thirds of the renal artery and leading to significant obstruction may successfully be treated by means of interventional radiology.

Telmisartan vs losartan plus hydrochlorothiazide in the treatment of mild-to-moderate essential hypertension--a randomised ABPM study

The objective of this prospective, randomised, open-label, blinded-end point parallel-group, multicentre study was to show that telmisartan 80 mg is not inferior to a fixed-dose combination of losartan 50 mg/hydrochlorothiazide (HCTZ) 12.5 mg in patients with mild-to-moderate hypertension. The criterion for noninferiority was a treatment difference of < or =3.0 mmHg in the reduction of 24-h mean ambulatory diastolic blood pressure (DBP) from the end of the 4-week placebo washout period to the end of the 6-week active treatment period. In the intent-to-treat analysis, the mean reduction in 24-h DBP was 8.3+/-6.7 mmHg among telmisartan-treated patients (n=332) and 10.3+/-6.3 mmHg among losartan/HCTZ-treated patients (n=350). The mean adjusted difference in 24-h DBP between the two treatment groups was 1.9 mmHg, allowing rejection of the a priori null hypothesis of a treatment difference of >3 mmHg. The reduction in mean 24-h systolic blood pressure was 13.2+/-10.2 mmHg with telmisartan and 17.1+/-10.3 mmHg with losartan/HCTZ. Both drugs provided effective control over the 24-h dosing interval. Analyses of morning (0600-1159) ambulatory blood pressure monitoring DBP means and trough cuff DBP confirmed the noninferiority hypothesis of the protocol for telmisartan 80 mg vs losartan 50 mg/HCTZ 12.5 mg. The reductions in office blood pressures measured at trough in patients treated with telmisartan were -16.3/-9.6 and -18.5/-11.1 mmHg in the patients treated with losartan/HCTZ (difference -2.4/-1.2 mmHg). There were no differences between the side-effect profiles of the two treatments.

[Prevalence of obstructive airway disease in middle-age adults. Cross sectional study in three different occupations]

Medical management of COPD begins with an awareness of risk factors and identification of risk patients. To identify this patients, 179 healthy volunteers with no known obstructive airway disease (81 women, 98 men, 40,5 +/- 11,2 years) and three different occupations (43 factory workers, 33 community workers, mainly working outside and 113 office employees) participated in the cross sectional spirometry study. Demographic data concerning age, height and body weight were comparable. In the first two groups were more men and more smokers. After adjustment to sex, age and height smokers revealed significant lower data for FEV 1 (3,16 l vs. 3,44 l) and FEV 1 /IVC (74,5 % vs. 77,6 %) in the factory workers. Comparable data exists for smokers in the community workers for FEV 1 (3,21 l vs. 3,59 l) and FEV 1 /IVC (74,8 % vs. 79,6 %), but not for office employees (FEV 1 3,51 l vs. 3,54 l; FEV 1 /IVC 76,1 % vs. 78,4 %). Airway obstruction, defined by FEV 1 /IVC below 70 % could be identified in thirteen of 57 smokers (22,8 %) and in twelve of 122 non-smokers (9,8 %) or in 25 of all 179 volunteers (14 %). The influence of smoking was significant (P = 0,0123). As a consequence, first there is a need for an increased awareness and routine spirometry in ad-risk patients; second, education and smoking cessation programs have to be initiated.

Dipyridamole may be used safely in patients with ischaemic heart disease

It is thought that up to 50% of patients with cerebrovascular disease will have concurrent ischaemic heart disease. Dipyridamole co-formulated with aspirin has been shown to increase the relative reduction in risk of second stroke in patients with prior stroke/transient ischaemic attack beyond that obtaining with aspirin alone. We have sought to resolve the question of whether dipyridamole treatment increases the risk of cardiac adverse events in patients with co-existing ischaemic heart disease. The published literature, periodic safety update reports, the randomised controlled trials of antiplatelet agents in stroke prevention and those including dipyridamole in cardiovascular indications, have been reviewed and analysed. The early reports of serious adverse cardiac effect attributable to dipyridamole occurred in patients with severe coronary artery disease using dipyridamole as a stress test adjunct to cardiac imaging. The randomised controlled trials databases show no evidence of mortality and only isolated cases of significant cardiac morbidity attributable to dipyridamole at recommended oral doses in patients with ischaemic heart disease. We conclude that patients with cerebrovascular and mild to moderate concomitant ischaemic heart disease may be treated safely with dipyridamole for the secondary prevention of stroke.

A procedure for evaluation and documentation of susceptibility test methods using the susceptibility of Klebsiella pneumoniae to ciprofloxacin as a model

A new procedure for the evaluation and documentation of susceptibility test methods is described. To illustrate the procedure, four basically different susceptibility test methods were examined in a routine laboratory. The test parameter detection of decreased susceptibility to ciprofloxacin (breakpoint MIC 0.25 mg/L) among 94 selected isolates of Klebsiella pneumoniae was used. In addition to comparison of frequency histograms and regression analysis, the accuracies of the susceptibility test methods were determined using the receiver operating characteristic procedure. For each of the methods, the sensitivity (SN), specificity (SP), positive predictive value (PV+) and negative predictive value (PV-) for detection of decreased susceptibility to ciprofloxacin were calculated and plotted against a range of ciprofloxacin inhibition zones determined by the various susceptibility test methods or MICs determined by the Etest (Etest MICs). The results illustrate the accuracy and the robustness of the methods, which can be used to expose the need for training and instruction of laboratory staff. It becomes possible to optimize and justify the choice of inhibition zone breakpoints or Etest MIC breakpoints according to the SN and SP of the method employed. Furthermore, the consequences of adjustments of these breakpoints on the PV+ and PV- can be analysed and related to different clinical and epidemiological situations. We believe that our approach can be used as a model for the evaluation and documentation of susceptibility test methods in general.