P5363Adherence to statin therapy drives survival of patients with symptomatic peripheral artery disease

Background

Statins reduce cardiovascular morbidity and mortality, but adherence is suboptimal. We hypothesized that adherence to statin therapy determines survival in a population at very high cardiovascular risk.

Methods

Single center observational study with 691 symptomatic PAD patients admitted to a tertiary university center between 2010 and 2017. Outcome was evaluated over a mean follow-up of 50±26 months. We related statin adherence and LDL-C target attainment to total mortality.

Results

At the first contact, 73% of our PAD patients were on statins with a significant increase in statin use to 81% (p<0.0001) at follow-up: Statin dosage, normalized to simvastatin 40 mg, increased from 50 to 58 mg/ day (p<0.0001), and was paralleled by a mean decrease of LDL-C from 97 to 82 mg/ dL (p<0.0001). The proportion of patients receiving a high intensity statin increased over time from 38 to 62% (p<0.0001). Percent LDL-C decrease over time was highest in patients with high intensity statin treatment, followed by moderate, low intensity or non-statin treatment, respectively (p=0.01).

Patients never receiving statins had a higher mortality rate (34%) as compared to patients being on statins (20%) or having newly received a statin (15%; p<0.01). Moreover, patients on intensified statin medication had the lowest mortality (10%), whereas patients who terminated statin medication or reduced the statin dosage had a higher mortality rate (33% and 43%, respectively; p<0.05).

Figure 1

Conclusion

Our data prove that statin treatment, particularly high-intensity therapy, reduces mortality in symptomatic PAD. In terms of mortality, patients benefit even from de novo statin therapy (“it is never too late”), whereas dose reduction or statin discontinuation have deleterious effects. A strategy of intensive and sustained statin therapy is worthwhile.

Acknowledgement/Funding

None

[Autologous composite grafts from the cavum conchae for reconstruction of multilayer nasal defects]

BACKGROUND

Autologous transplants comprising skin and cartilage, so-called composite grafts (cgs), are an important reconstructive tool for multilayered defects of the nose. A cg from the auricular cavum conchae needs to fulfill both functional and esthetic demands.

OBJECTIVE

This article illustrates the indications for and requirements of cgs, and also investigates graft healing and functional-aesthetic results. The current publication is a review article; the original data were published with the award of the 2014 APKO prize under the title "The auricle's cavum conchae composite graft in nasal reconstruction".

MATERIALS AND METHODS

At the ENT department of Ulm University Medical School, multilayered defects of different nasal esthetic subunits are reconstructed with cgs. Based on these experiences, the authors report on long-term functional and esthetic results in the areas of the donor and recipient sites.

CONCLUSION

Auricular cgs are versatile and reliable autologous transplants. The ease of harvesting, minimal donor site morbidity, and stable convex shape of these grafts render them ideal for reconstruction of multilayered nasal defects. Septal splints and custom-made prosthesis promote healing and prevent stenotic scarring.

[Mucosal Melanoma of the Head and Neck]

Primary mucosal malignant melanoma of the head and neck is a rare tumor entity with poor clinical outcome. Its growth pattern is characterized by an infiltrative and local destructive behavior. So far no risk factors could be identified. There are practically no early symptoms of the disease, as intermitting nose bleeding or nasal obstruction typically occur in advanced stage. The standard of care remains radical tumor resection with adjuvant radiation in cases of close margin resection. Other therapeutic options like the use of interferon, antibodies or conventional chemotherapeutics have not demonstrated significant clinical benefit so far. Current efforts to investigate the biological and genomic characteristics of these tumors have been constrained by its low incidence. In order to better characterize this rare tumor entity and to establish effective novel targeted therapies it will be necessary to establish an interdisciplinary and multicentric task force.

[Primary Parotid Carcinoma: Influence of a Two-step Procedure on the Oncological Outcome]

BACKGROUND

Malignancies of the parotid gland represent a rare form of head and neck cancer. Advanced stages are usually recognized as such, whereas early tumor stages are sometimes diagnosed only after parotidectomy due to lack of signs of malignancy. The present study investigates whether this unplanned 2-stage approach has a negative impact on the outcome.

MATERIAL AND METHODS

The study includes clinical and histological data of patients with parotid cancer which were treated in the Department of Oto-Rhino-Laryngology and Head and Neck Surgery of the University Medical Center Ulm between 2004 and 2014.

RESULTS

42 patients were included into the study with a median follow-up of 38 months. The RFS and OS at 5 years was 68.6 and 80.1%, respectively, which corresponds to the current literature. 24/42 patients received one-step radical surgery. In 18/42 patients a parotidectomy was performed initially followed by oncologic surgery after receiving histology. The patient group with 2-stage surgery included less advanced tumor stages and more entities with better prognosis. Interestingly, these patients presented with an excellent RFS of 84.4% compared to 56,5% (p=0,16) in the patient group with one-step procedure, correspondent to the tumor stages, entities and the current literature.

CONCLUSIONS

According to the available data and compared to the literature, an unplanned 2-stage procedure in clinically silent parotid cancer seems not necessarily to have a negative impact on the outcome. Nevertheless, the preoperative diagnosis should be improved to detect these malignancies more sensitive in early stages.

Five-year outcomes in kidney transplant patients converted from cyclosporine to everolimus: the randomized ZEUS study

ZEUS study was an open-label, 12-month, multicenter study in which 300 de novo kidney transplant recipients were randomized to continue receiving cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant. Five-year follow-up data were available for 245/269 patients (91.1%) who completed the core 12-month study (123 everolimus, 109 CsA). At 5 years, adjusted estimated GFR was 66.2 mL/min/1.73 m(2) with everolimus versus 60.9 mL/min/1.73 m(2) with CsA; the mean difference was 5.3 mL/min/1.73 m(2) in favor of everolimus (95% CI 2.4, 8.3; p < 0.001 [intent-to-treat population]). In a post hoc analysis of patients remaining on study drug at 5 years (everolimus 77, CsA 86), mean difference was 8.2 mL/min/1.73 m(2) (95% CI 4.3, 12.1; p < 0.001) in favor of everolimus. The cumulative incidence of biopsy-proven acute rejection postrandomization was 13.6% with everolimus versus 7.5% with CsA (p = 0.095), largely accounted for by grade I rejection (16/21 patients and 7/11 patients, respectively). Postrandomization, graft loss, mortality, serious adverse events and neoplasms were similar in both arms. In conclusion, conversion of kidney transplant patients to everolimus at 4.5 months posttransplant is associated with a significant improvement in renal function that is maintained to at least 5 years. The increase in early mild acute rejection did not affect long-term graft function.

[Functional and aesthetic outcome after surgery on cleft lip nasal deformities]

OBJECTIVE

Patients with cleft lip nasal deformities suffer not only from aesthetic stigmatization but also from functional problems. Many different techniques to operate on this deformity have been described.

METHODS

24 patients (16 male and 8 female, aged 20-56 years) have been enrolled in this study. A subjective value of the postoperative result of aesthetics and function was measured by a visual analogue scale ranging from - 5 (significant aggravation) to +5 (significant improvement) including 0 (no change). Additionally the primary nasal symptoms (PNS) of the SNOT-20 GAV were collected.

RESULTS

10 primary surgeries and 14 revisions were performed with 20 open and 4 endonasal approaches. In 11 cases a composite graft from the concha was used. 75% of the patients looked up to both features aesthetic and function favorably. The mean evaluation was +3.4 for aesthetics and +2.6 for function. 91% of the patients who received a composite graft looked up to the result favorably. The mean PNS were 14.

CONCLUSIONS

Altogether good results especially concerning the subjective aesthetics can be achieved by precise preoperative evaluation and the described operative algorithm. In our sample of patients better results could be accomplished by using composite grafts. Nevertheless it seems to be more difficult to improve the function of cleft lip nasal deformities than the aesthetics. More innovations and objective measurements are needed to come up to the still unsolved problems of the challenging surgery of cleft lip nasal deformities.

[Penetrating injuries of the head and neck region - a potentially life threatening situation]

Penetrating Injuries of the Head and Neck Region - A Potentially Life Threatening Situation Background: Cuts, stabs and gunshot wounds in the head and neck region are potentially life-threatening because of the high risk of vascular lesions. A consistent emergency management is usually based on an operative exploration of the wound with effective reconstruction of viable structures.

PATIENTS AND METHODS

Various penetrating injuries of the head and neck region are described in 11 cases with respect of age, gender, course of events of injury, type of injury, involved structures, diagnostic and operative procedures and outcome and compared with current literature and guidelines.

RESULTS

In 10 of 11 patients, in the context of an interdisciplinary emergency room management, CT angiography was performed following clinical examination. A surgical exploration and wound treatment was performed in 9 of these patients. The common carotid artery, the external carotid artery and large venous blood vessels of the neck were injured in 2 cases respectively. None of the patients deceased or suffered permanent damage.

CONCLUSION

The outcome of deep head and neck lesions with relevant vascular trauma is determined by a rapid and interdisciplinary approach. A rapid, systematic and interdisciplinary approach in specialized trauma centers has a significant role in ensuring that patients with penetrating wounds in the head and neck -region rarely die due to their serious injury or their consequences.

[Radiological findings of the nasal septum in CT scan in patients with deviated noses]

OBJECTIVE

The bony-cartilaginous crooked nose is characterized by a deviation of the nasal dorsum from the median sagittal plane. Since the nasal dorsum and the septum form an anatomical entity, a deviation of the external nose always results in a deviation of the cartilaginous and bony nasal septum. The aim of this study was to analyze the pathologies of the septum in patients with crooked noses based on CT images of the midface.

METHODS

The CT images of patients with a documented crooked nose, who presented between 2005 and 2011 in our hospital, were analyzed retrospectively considering photo documentation and nasal findings. The CT scans were performed due to suspected sinusitis unrelated to the study.

RESULTS

The study includes a total of 138 patients. In all patients a deviated septum was found in the CT. In particular, there was not only a deviation of the cartilaginous septum, but also a deviation of the perpendicular plate (PP) in 86% of the cases. This PP deviation distorted to the opposite side of the deviation of the crooked nose in 79% of the cases. However, the base of the PP at the cribriform plate was in a median position in 99% of the cases of the patients. Furthermore, in 96% of cases, the caudal septum was located in midline on the anterior nasal spine, -although 15% presented clinically a dislocation of the caudal septum.

CONCLUSIONS

The bony-cartilaginous crooked nose usually results in a deviation of the cartilaginous and bony septum. In particular, a high deviation of the PP to the opposite side of the deviation of the external nose was present in a majority of the -cases. Therefore, a septo-rhinoplasty with particular consideration of the deviation of the PP is necessary in patients with a deviated external nose.

[Persistent nasal obstruction following septoplasty: deviated nasal pyramid and perpendicular plate]

BACKGROUND

Functional septorhinoplasty (SRP) is a surgical procedure for improvement of symptomatic deformity of the inner and outer nose. Due to inadequate preoperative analysis and consequently insufficient surgical indication, septoplasty (SPL) alone may be performed. A frequent cause for revision septorhinoplasty (rSRP) in our institution was found to be due to a deviated bony pyramid in compound with a contralateral high deviation of the perpendicular plate, ipsilateral reluxation of the cartilaginous septum and a resulting nasal valve stenosis.

MATERIALS AND METHODS

The medical records of all patients undergoing revision septorhinoplasty in our institution from 2005-2011 were evaluated retrospectively.398 patients underwent rSRP, in 57 patients (14%) a deviated bony nose after septoplasty was diagnosed. In all cases a deviated bony nose and contralateral deviation of the perpendicular plate was found and corrected by rSRP. The nasal breathing was improved in all cases. This was also shown in an increase of endonasal volume and nasal air flow in acoustic rhinometry and active anterior rhinomanometry.

CONCLUSION

A deviated nasal pyramid and perpendicular plate was found to be a common cause for persistent nasal obstruction after septoplasty. A careful preoperative analysis of the nose, the pathology of the bony and cartilaginous septum and the nasal valves is mandatory in order to recognize anatomical details and set up the right indication for rhinosurgical interventions.

Chirurgischer Prüfarztkurs des Studienzentrums der Deutschen Gesellschaft für Chirurgie

BACKGROUND

Clinical research, especially the management of randomized controlled multicentre trials, is a challenge for surgical investigators. To provide the theoretical background and practical knowledge needed for surgical trials, it is necessary to revise standard training programmes, which focus on pharmacological research. The main differences concern regulatory aspects and content, especially in achieving and maintaining comparability, equal treatment, and outcome assessment using special randomisation techniques and standardised surgical procedures.

METHODS

In November 2005, in cooperation with the Coordinating Centre for Clinical Trials in Heidelberg, the Study Centre of the German Surgical Society Study Group (SDGC) hosted a clinical investigation course for surgeons. During 3 days, 24 participants were systematically instructed by 16 lecturers on clinical trials (planning, treatment by protocol, data management, biometrics, ethics, and law), followed by participants' evaluation of the course.

RESULTS

On a scale of 1 to 6 (excellent to insufficient, respectively) the mean grades for the course were 1.6 for content, 1.55 for clarity, and 1.55 for learning effect. Partial repetition, lack of work in small groups, and not enough materials to take home were the major criticisms.

CONCLUSIONS

The evaluation emphasised the necessity and value of the course. Further courses with continued evaluation are necessary and can be based on the same underlying concept. However, the mere qualification of surgeons as clinical investigators without substantial additional improvements in structural problems and increased financial project support will not fundamentally improve clinical research in Germany.

[The diagnosis of clinically silent thyroid disorders]

Results of tests for thyroid function are presented in two equal observation periods. Compared with the first the frequency of TSH-determinations was doubled in the second period. Data were taken from non-selected in-patients in a general hospital. In connection to clinical information TSH determination served as the first laboratory test. Prevalence data of hyperthyroid and hypothyroid dysfunction in the patients observed are given. According to controversies in health care the efficiency and efficacy of thyroid function tests are discussed. In an iodine deficient area TSH-determination uncovers many more thyroid dysfunctions in elderly patients than expected clinically. Screening of this risk group with TSH in connection with clinical information is an adequate diagnostic procedure in an area of mild iodine deficiency.

Erkennung klinisch nicht vermuteter thyreoidaler Dysfunktion

An einem endokrinologisch nicht selektierten Krankengut wird das Ergebnis von Schilddrüsenfunktionsuntersuchungen vorgestellt, wobei neben der klinischen Untersuchung die TSH-Bestimmung als Eingangsdiagnostik angewendet wurde. In zwei gleichen Zeiträumen wurden Patienten untersucht, wobei in der zweiten Periode die Zahl der Untersuchungen fast doppelt so hoch lag wie in der ersten. Die Prävalenz der so aufgedeckten Schilddrüsenfunktionsstörungen wird dargestellt. Anhand der Ergebnisse wird die klinische Relevanz und der relative ökonomische Aufwand im Sinne einer effektiven Schilddrüsendiagnostik bei älteren stationären Patienten im Jodmangelgebiet erörtert. Offenbar ist bei dieser Zielgruppe eine breite Indikationsstellung zur Schilddrüsendiagnostik gerechtfertigt. Im Unterschied zu Gebieten mit extremem Jodmangel kann sich die Eingangsuntersuchung in einer Zone milden Jodmangels auf eine TSH-Basal-Bestimmung beschränken, wobei die gleichzeitige Bewertung klinischer Befunde unerläßlich ist.

Postprandial cholylglycine serum concentration and extent of ileal inflammation or resection in Crohn's disease

Postprandial cholylglycine serum concentration was determined in 45 resected and non-resected patients with Crohn's disease of the distal ileum. Cholylglycine serum concentration after meal stimulus in patients with ileal involvement of more than 30 cm was significantly lower than in controls and in patients with minor spread of inflammation. In patients with inflammation area less than 30 cm, there was a somewhat faster and higher increase and delayed decline of postprandial cholylglycine serum concentration. The present study shows that postprandial cholylglycine serum level gives a good estimate of the extent of ileal inflammation or resection.