Scoring system to predict early carotid restenosis after eversion endarterectomy by analysis of inflammatory markers.

BACKGROUND: Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high-sensitivity C-reactive protein [hs-CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA). METHODS: A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs-CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An "inflammatory score" was also created, which consisted of six predictive values of inflammatory markers (hs-CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow-up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done. RESULTS: Our results showed an increased risk of early CR within 1 year in patients with increased hs-CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins. CONCLUSIONS: Increased hs-CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

Bilateral Eagle Syndrome with Associated Internal Carotid Artery Kinking and Significant Stenosis.

BACKGROUND: Eagle syndrome represents elongated styloid process characterized by calcification and ossification of the stylohyoid ligament rarely associated with the pathology of carotid arteries. We are presenting a very rare case of bilateral Eagle syndrome with associated internal carotid artery (ICA) kinking on the right side and significant ICA stenosis on the left side. CASE REPORT: A 62-year-old female patient was admitted to our Institution for multidetector computed tomography (MDCT) angiography. Two years ago, she experienced stroke with right-sided weakness, color Doppler scan of carotid arteries described left ICA stenosis of 75% and right ICA stenosis of 50%. MDCT arteriography revealed bilateral Eagle syndrome associated with significant left ICA stenosis of >90% and right ICA kinking. Left carotid endarterectomy was performed followed by elongated styloid process resection that was in close relationship to ICA. Even more significant relationship was seen on the right side involving right ICA kinking and elongated styloid process that was treated conservatively. Postoperative course was uneventful; after 6 months, the patient was doing well. CONCLUSIONS: This is the first case that describes bilateral Eagle syndrome associated with ICA kinking on one side and significant stenosis on the other. Although rare, this syndrome should be thought of in symptomatic patients with carotid pathologies in which case computed tomography angiography is of crucial importance.

Carotid angioplasty and stenting is safe and effective for treatment of recurrent stenosis after eversion endarterectomy.

OBJECTIVE: This study was conducted to determine the efficiency and long-term durability of percutaneous transluminal angioplasty and carotid artery stenting in carotid restenosis (CR) treatment after eversion endarterectomy, with emphasis on variables that could influence the outcome. METHODS: We analyzed 319 patients (220 asymptomatic and 99 symptomatic) who underwent carotid angioplasty from 2002 until 2012 for CR that occurred after eversion endarterectomy. During this period, 7993 eversion endarterectomies were done for significant carotid artery stenosis. Significant CR was detected by ultrasound examination and confirmed by digital subtraction angiography or multidetector computed tomography angiography. After angioplasty (with or without stenting), color duplex ultrasound imaging was done after 1 month, 6 months, 1 year, and annually thereafter. End points encompassed myocardial infarction, stroke, and cardiovascular death (fatal myocardial infarction, fatal cardiac failure, fatal stroke), and also puncture site hematoma and recurrent restenosis. Primary end points were analyzed as early results (≤30 days after the procedure), and secondary end points were long-term results (>30 days). Variables and risk factors influencing the early-term and long-term results were also analyzed. Median follow-up was 49.8 ± 22.8 months (range, 17-121 months). RESULTS: All but one procedure ended with a technical success (99.7%). In the early postoperative period, transient ischemic attack occurred in 2.8% of the patients and stroke in 1.6%, followed by one lethal outcome (0.3%). Stent thrombosis occurred in one patient (0.3%) several hours after the angioplasty, followed by urgent surgery and graft interposition. In the long-term follow-up, there were no transient ischemic attacks or strokes, non-neurologic mortality was 3.13%, and the recurrent restenosis rate was 4.4%. The rate of non-neurologic outcomes during the follow-up was significantly higher in asymptomatic patients than in symptomatic patients (4.54% vs 0%; P = .034). The statically highest rate of transient ischemic attack was verified in patients in whom Precise (Cordis Corporation, New Brunswick, NJ) stents was used (12.2%) and a Spider Fx (Covidien, Dublin, Ireland) cerebral protection device (12.5%) was used. Female gender, coronary artery disease, plaque calcifications, and smoking history were associated with an adverse outcome after angioplasty. CONCLUSIONS: Carotid artery stenting is safe and reliable procedure for CR after eversion endarterectomy treatment, with low rate of postprocedural complications. Type of stent and cerebral embolic protection device may influence the rate of postprocedural neurologic ischemic events.

Chemotherapy With Eribulin Following Potentially Curative Surgery in Patients With Localized Liposarcoma.

BACKGROUND/AIM: Soft tissue sarcomas are rare and heterogenous malignancies with high recurrence rates following resection and a poor prognosis in advanced stages. Eribulin is used in metastatic soft tissue sarcoma patients, who have failed first line chemotherapy and has been approved for patients with pretreated advanced liposarcoma (LPS) in the United States and Europe following the publication of data of a phase III trial. In addition, no data are available for eribulin as postoperative treatment after potentially curative surgery. We, thus, retrospectively evaluated efficacy and tolerability of adjuvant eribulin in patients with LPS not suitable for intensive chemotherapy in the routine clinical setting. PATIENTS AND METHODS: In this retrospective single center analysis, efficacy and safety of eribulin were retrospectively evaluated in five high risk LPS patients. RESULTS: Eribulin as treatment was administered to five patients with LPS following surgical resection. Median progression-free survival and overall survival were 12.3 months and 44.3 months, respectively. Toxicity was generally manageable, and grade 3+4 events were rare. CONCLUSION: Postoperative eribulin may be feasible in selected high risk LPS patients, who are not candidates for intensive chemotherapy regimens. Further prospective trials, however, are needed.

The more the merrier? Evidence and efficacy of immune checkpoint- and tyrosine kinase inhibitor combinations in advanced solid cancers.

Immune checkpoint inhibitors (ICI) and tyrosine kinase inhibitors (TKI) have gained therapeutical significance in cancer therapy over the last years. Due to the high efficacy of each substance group, additive or complementary effects are considered, and combinations are the subject of multiple prospective trials in different tumor entities. The majority of available data results from clinical phase I and II trials. Although regarded as well-tolerated therapies ICI-TKI combinations have higher toxicities compared to monotherapies of one of the substance classes and some combinations were shown to be excessively toxic leading to discontinuation of trials. So far, ICI-TKI combinations with nivolumab + cabozantinib, pembrolizumab + axitinib, avelumab + axitinib, pembrolizumab + lenvatinib have been approved in advanced renal cell (RCC), with pembrolizumab + lenvatinib in endometrial carcinoma and with camrelizumab + rivoceranib in hepatocellular carcinoma (HCC). Several ICI-TKI combinations are currently investigated in phase I to III trials in various other cancer entities. Further, the optimal sequence of ICI-TKI combinations is an important subject of investigation, as cross-resistances between the substance classes were observed. This review reports on clinical trials with ICI-TKI combinations in different cancer entities, their efficacy and toxicity.

Alternative schedule of temozolomide/capecitabine in neuroendocrine neoplasms.

The chemotherapy regimen capecitabine/temozolomide (CAPTEM) is routinely used in neuroendocrine tumors (NET), with antitumor activity particularly demonstrated in pancreatic or high-grade neuroendocrine neoplasms (NEN). However, different dosing regimens are used, and the optimal schedule remains to be defined. This single-center retrospective analysis assessed the efficacy and safety of CAPTEM in patients with NEN using a schedule starting both compounds simultaneously (temozolomide on days 1-5 and capecitabine on days 1-14 of a 28-day cycle) rather than sequentially. The primary parameters of interest were response rates, progression-free survival (PFS), and toxicities following this treatment regimen, hereinafter referred to as TEMCAP. The study population comprised 40 patients, half of whom (n = 20) had pancreatic NEN, and 9 patients (22.5%) had pulmonary or thymic NETs. The most common histology was NET G3 (n = 15, 37.5%), and 8 patients (20.0%) had a neuroendocrine carcinoma (NEC). Most patients (77.5%) had at least one prior systemic therapy, and 16 patients (40.0%) prior chemotherapy. The median number of TEMCAP cycles was 6 (range 1-16). Median PFS for the highly heterogeneous population was 13.3 months, while the median overall survival was 31.9 months. In total, 14/36 patients (38.9%) exhibited a partial response, and the disease control rate was 75.0%. The safety profile of TEMCAP (at a below-target mean temozolomide dose of 118.85 mg/m2) in our cohort was remarkably good with no toxicities of grade 3 or 4. Taken together, the results of this analysis further support the use of temozolomide/capecitabine in NEN and prompt further assessment of our modified TEMCAP schedule.

Clinical characteristics, treatment, and outcome of patients with large cell neuroendocrine carcinoma of the lung and brain metastases - data from a tertiary care center.

Large cell neuroendocrine carcinoma (LCNEC) of the lung is an aggressive malignancy, with brain metastases (BM) occurring in approximately 20% of cases. There are currently no therapy guidelines for this population as only few data on the management of LCNEC and BM have been published. For this retrospective single center study, patients with LCNEC and BM were identified from the Vienna Brain Metastasis Registry. Data on clinicopathological features, BM-specific characteristics, treatment, and outcome were extracted. In total, 52/6083 (0.09%) patients in the dataset had a diagnosis of LCNEC and radiologically verified BM. Median age at diagnosis of LCNEC and BM was 59.1 and 60.1 years, respectively. Twenty-seven (51.9%) presented with single BM, while 12 (23%) exhibited > 3 BM initially. Neurologic symptoms due to BM were present in n = 40 (76.9%), encompassing neurologic deficits (n = 24), increased intracranial pressure (n = 18), and seizures (n = 6). Initial treatment of BM was resection (n = 13), whole brain radiation therapy (n = 19), and/or stereotactic radiosurgery (n = 25). Median overall survival (mOS) from LCNEC diagnosis was 16 months, and mOS after BM diagnosis was 7 months. Patients with synchronous BM had reduced mOS from LCNEC diagnosis versus patients with metachronous BM (11 versus 27 months, p = 0.003). Median OS after BM diagnosis did not differ between LCNEC patients and a control group of small cell lung cancer patients with BM (7 versus 6 months, p = 0.17). Patients with LCNEC and BM have a poor prognosis, particularly when synchronous BM are present. Prospective trials are required to define optimal therapeutic algorithms.

Clinical characteristics, treatment, and long-term outcome of patients with brain metastases from thyroid cancer.

Brain metastases (BM) in patients with thyroid cancer (TC) are rare with an incidence of 1% for papillary and follicular, 3% for medullary and up to 10% for anaplastic TC (PTC, FTC, MTC and ATC). Little is known about the characteristics and management of BM from TC. Thus, we retrospectively analyzed patients with histologically verified TC and radiologically verified BM identified from the Vienna Brain Metastasis Registry. A total of 20/6074 patients included in the database since 1986 had BM from TC and 13/20 were female. Ten patients had FTC, 8 PTC, one MTC and one ATC. The median age at diagnosis of BM was 68 years. All but one had symptomatic BM and 13/20 patients had a singular BM. Synchronous BM at primary diagnosis were found in 6 patients, while the median time to BM diagnosis was 13 years for PTC (range 1.9-24), 4 years for FTC (range 2.1-41) and 22 years for the MTC patient. The overall survival from diagnosis of BM was 13 months for PTC (range 1.8-57), 26 months for FTC (range 3.9-188), 12 years for the MTC and 3 months for the ATC patient. In conclusion, development of BM from TC is exceedingly rare and the most common presentation is a symptomatic single lesion. While BM generally constitute a poor prognostic factor, individual patients experience long-term survival following local therapy.

Technical strategy in a patient with symptomatic thoracic aneurysm near the origin of the left subclavian artery and left internal thoracic artery coronary graft.

Thoracic endovascular aortic repair (TEVAR) is a safe and reliable technique utilized in the treatment for aortic aneurysms. However, in up to 40% of patients, devices are typically placed over the left subclavian artery (LSA) origin. In this report, we present a case of a successful TEVAR procedure following the transposition of the LSA with protective carotico-axillary/carotid bypass in a patient with a patent left internal thoracic artery (LITA)-left anterior descending (LAD) coronary artery bypass graft and right internal carotid artery (ICA) occlusion.

Distribution of risk factors in patients with premature coronary, supra-aortic branches and peripheral atherosclerotic disease.

OBJECTIVE: The aim of this study was to determine the distribution of major risk factors among patients with atherosclerotic disease aged ≤50 years. SUBJECTS AND METHODS: The study population comprised 944 patients aged ≤50 years with clinically significant manifestations of atherosclerotic disease compared with 350 consecutive (control) older patients (age >50 years). RESULTS: The most significant risk factors for atherosclerotic disease of the supra-aortic branches were: smoking (87.5%, p < 0.001), family history of atherosclerosis (52.3%, p < 0.001), diabetes mellitus (28.5%) and being male (56.9%) (p < 0.05 for both). In patients with coronary artery disease, there was considerable disparity in the prevalence of smoking (85.4%), hyperlipoproteinemia (67.4%), and family history of atherosclerosis (68%) (p < 0.001). For peripheral artery disease, the most significant risk factors were smoking (97%, p < 0.001), hyperlipidemia (p < 0.01), and family history of atherosclerotic disease (p < 0.01). When compared to controls, patients with premature atherosclerosis smoked more frequently, had hyperlipidemia, had a family history of atherosclerosis, and were more frequently of male sex. CONCLUSION: Premature atherosclerosis was most frequently associated with smoking, hyperlipidemia, family history of atherosclerotic disease, and male sex.

Challenges in Palliative Care Nursing at a University Hospital: A Qualitative Interview Study.

We examined the perception of palliative care nurses regarding challenges, coping strategies, resources, and needs when working in a university hospital in Austria. A qualitative descriptive design was applied, using semistructured interviews with 8 female and 2 male nurses. All interviews were recorded as digital audio and transcribed verbatim. We used thematic analysis and MAXQDA. In our analysis, 6 themes emerged: Four themes related to challenges: ( a ) lack of a supporting structural framework, ( b ) conflict in interdisciplinary work, ( c ) conflict with caregivers, and ( d ) dealing with death in a highly specialized university environment. One theme related to ( e ) individual solutions and coping strategies, and 1 theme comprised ( f ) needs and suggestions for improvements. Taking care of the family of a dying person, handling threatening situation, and working with inexperienced physicians were among the most important challenges reported by nurses. A supportive team, professional counseling, and training related to communication skills and to culturally specific needs of families are perceived to be necessary to provide high-quality palliative care. Addressing the needs of nurses can substantially improve their working condition and has an impact not only on the nurses themselves but also on the quality of patient care.

Kidney Function Worsening Is Linked to Parenteral-Nutrition-Dependent Survival in Palliative Care Patients.

BACKGROUND: Parenteral nutrition (PN) is frequently administered in palliative care patients suffering from cachexia. The evidence regarding the use of PN in terminally ill patients is scarce. Routine laboratory parameters might help to decide whether to start or forgo PN, which could decrease overtreatment at the end of life. Kidney failure was frequently associated with survival. However, a relation between kidney function parameters and parenteral nutrition has not been observed thus far. The aim of this retrospective cohort study was to analyze kidney function parameters in palliative care patients under PN, as well as the relation between these parameters and overall survival. METHODS: Patients who were admitted to the Department of Palliative Medicine at the Medical University of Vienna were screened for PN treatment. Whether kidney function parameters at baseline or their dynamics over the course of two weeks were associated with survival was assessed with descriptive and interferential statistics. RESULTS: In total, 113 of 443 palliative care patients were administered parenteral nutrition for the first time. The overall survival (OS) for all patients with increased kidney function parameters at baseline was lower (creatinine: hazard ratio (HR) = 1.808, p < 0.001; urea: HR = 1.033, p < 0.001; uric acid HR = 1.055, p = 0.015). No significant increase in creatinine blood levels was observed in the first 2 weeks after the initiation of PN when compared to the non-PN group (p = 0.86). However, if creatinine blood levels increased within the PN group, lower overall survival was found (HR = 2.046, p = 0.007). CONCLUSION: Increased kidney function parameters, such as creatinine, urea and uric acid, might be used as negative prognostic markers in palliative care patients under PN. Moreover, an increase in creatinine during the administration of parenteral nutrition in the first 2 weeks is linked to worse outcomes. These findings may help future studies to establish objective markers for clinicians to determine whether to start or end PN in palliative cancer patients and decrease potential overtreatment at the end of life.

Surgical Treatment of Proximal Segmental Occlusion of the Internal Carotid Artery.

PURPOSE: To present the feasibility, safety, and efficacy of carotid endarterectomy in patients with type II internal carotid artery occlusions, including the long-term outcomes. METHODS: From March 2008 to August 2015, 74 consecutive patients (48 men with a mean age of 65.1 ± 8.06 years) underwent carotid endarterectomy because of internal carotid artery (ICA) segmental occlusions. These were verified with preoperative carotid duplex scans (CDS) and CT angiography (CTA). Also, brain CT scanning was performed in all these patients. The indication for treatment was made jointly by a vascular surgeon, neurologist, and an interventional radiologist in a multidisciplinary team (MDT) context. After successful treatment, all the patients were followed-up at 1, 3, 6, and 12 months, then every 6 months thereafter. RESULTS: The most common symptom at presentation was transient ischaemic attack (TIA) in 49 patients (66.2%), followed by stroke in the past six months in the 17 remaining patients (23%). Revascularisation of the ICA with endarterectomy techniques was performed successfully in all the patients with an average clamp time of 11.9 min. All the procedures were performed under general anaesthesia in combination with a superficial cervical block. The early complication rate was 8.1% and included two cardiac events (2.7%) (one rhythm disorder and one acute coronary syndrome), three TIAs (4.1%), and one intracerebral hemorrhage (1.3%). Only one patient with the intracerebral hemorrhage died 5 days after surgery giving a postoperative mortality of 1.3% for this series. During the follow-up period (mean 50.4 ± 31.3 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 94.9%, 92.9%, and 82.9%, respectively. Likewise, the survival rates were 98.7%, 96.8%, 89%, and 77.6%, respectively. Ultrasound Doppler controls during follow-up detected 8 ICA restenoses; however, only 3 of these patients required further endovascular treatment. CONCLUSIONS: Carotid endarterectomy of internal carotid artery (ICA) segmental occlusion is a safe and effective procedure associated with acceptable risk and good long-term results. Therefore, the current guidelines which do not recommend carotid endarterectomy in this patient group should be reassessed, with the requirement for ongoing large-scale randomized controlled trials to compare CEA with best medical therapy in this patient cohort.

Vocal Cord Paralysis as the First Sign of Spontaneous Carotid Dissection in a Patient With Extracranial Internal Carotid Artery Aneurysm.

INTRODUCTION: Spontaneous dissection of supra-aortic arteries is an exceptionally rare cause of vocal cord dysfunction. We are reporting a case of spontaneous carotid dissection and internal carotid artery aneurysm presenting as vocal cord paralysis. CASE REPORT: A 44-year-old female was admitted with hoarseness and swallowing disorders. Diagnostic imaging revealed dissection and obliteration of the right internal carotid artery (ICA) 23 mm from the carotid bifurcation. Electromyography revealed unilateral paralysis/paresis of the right vocal cord. Genetic analyses for thrombophilia, methylenetetrahydrofolate reductase, and plasminogen activator inhibitor 1 were found to be at high risk. The patient was discharged after 5 days without any neurological findings, and control angiography revealed complete restitution of the flow in the right ICA one month later. However, a fusiform aneurysm of the distal part of the extracranial right ICA was detected and excluded with endovascular procedure. CONCLUSION: Connective tissue systemic disorders and even mild trauma could initiate the dissection process of neck arteries. Precise diagnosis might be difficult even for an experienced neurologist, however, the final outcome is favorable.

Treatment of stump complications after above-knee amputation using negative-pressure wound therapy.

Introduction: The stump wound complications after above-knee amputation lead to other problems, such as prolonged rehabilitation, delayed prosthetic restoration, the increase in total treatment cost and high mortality rates. Objective: To evaluate the safety and outcomes of negative-pressure wound therapy (NPWT) using Vacuum-Assisted Closure (VAC®) therapy in patients with stump complication after above-knee amputation (AKA). Methods: From January 2011 to July 2014, AKA was performed in 137 patients at the University Cardiovascular Clinic. Nineteen (12.4%) of these patients (mean age 69.3 ± 9.2 years) were treated with NPWT. The following variables were recorded: wound healing and hospitalization time, rate of NPWT treatment failure, and mortality. Results: AKA was performed in 17 (89.5%) patients after the vascular or endovascular procedures had been exhausted, while urgent AKA was performed in two (10.5%) patients due to uncontrolled infection. The time before NPWT application was 3.1 ± 1.9 days and the duration of the NPWT use ranged from 15 to 54 days (mean 27.95 ± 12.1 days). During NPWT treatment, operative debridement was performed in 12 patients. All the patients were kept on culture-directed intravenous antibiotics. The average hospital length of stay was 34.7 days (range 21­77 days). There were four (20.9%) failures during the treatment which required secondary amputation. During the treatment, one (5.3%) patient died due to multi-organ failure after 27 days. Conclusions: The use of NPWT therapy in the treatment of AKA stump complication is a safe and effective procedure associated with low risk and positive outcome in terms of wound healing time and further complications.

Massive necrotizing fasciitis following bellow-knee arterial surgery - A therapeutic challenge.

INTRODUCTION: Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method. CASE REPORT: A 61-year-old patient was admitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile. CONCLUSION: In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons' experience are of great significance in rapid reaction to this rare surgical complication.

Decomposition of aqueous diphenyloxide by ozonolysis and by combined gamma-ray-ozone processing.

Diphenyloxide (DPO) is one of many, rather toxic pollutants produced by combustion of fossil fuels, which are emitted to the atmosphere with flue gases and brought to ground water by rain and snow. Its decomposition is investigated by ozonolysis at room temperature and the major products like phenol, resorcinol, hydroquinone, dihydroxy-benzoic acid as well as the total yield of aldehydes and carboxylic acids were determined as a function of applied ozone concentration. In addition, the DPO-degradation was studied by a combined action of gamma-ray under continuous bubbling of a known ozone concentration. In this case the formation of the same products is observed, but their yields differ from the above ones. Based on the synergistic action of ozone and gamma-ray the DPO-radiolysis is rather efficient, leading to an initial-G-value of 11.3. Some probable reaction mechanisms are presented for explanation of the degradation process.

["Blue-toe" syndrome as a possible complication of the abdominal aortic aneurysm: a report of two cases].

INTRODUCTION: Severe extremity ischemia and the presence of the"blue-toe"syndrome are rarely the first complications of the present abdominal aortic aneurysm.We report two interesting cases of this rare entity. OUTLINE OF CASES: A 61-year-old man presented with the rest pain of his toes accompanied with digital ischemia of both feet. Physical examination confirmed regular arterial pulses at lower extremities accompanied with palpable pulsate mass in the abdomen. Vascular ultrasound and multidetector tomography (MDCT) of blood vessels revealed small abdominal aortic aneurysm (37 mm in diameter), filled with the irregular, ulcerated, heterogeneous thrombotic masses. Aneurysm sac resection was performed with an aorto-bi-iliac bypass reconstruction. A week later, it was mandatory to amputate the fifth toe on the left foot because of the advanced gangrenous process.The second case was a 77-year-old woman with 7-day history of severe feet pain. Abdominal examination revealed pulsatile mass paraumbilical to the left. Performed abdominal ultrasonography and MDCT angiography confirmed coexistence of the infrarenal aortic aneurysm, 40.5 mm in diameter, covered by significant mobile mural thrombus and ulcerations. Surgical reconstruction was mandatory and patient underwent aneurysm sac resection and aortobifemoral reconstruction. CONCLUSION: Embolic phenomenon and peripheral embolic occlusion from the mural thrombus within the abdominal aortic aneurysm are relatively rare events, but associated with tissue loss.Thorough diagnostic examinations and prompt management are required regardless of the aneurysm size once these signs occurred.

[Persistent descending mesocolon: case report].

INTRODUCTION: Positional anomalies of the right half of the colon are quite common whereas positional anomalies of the left half of the colon are much less common because of embryological disorders during the period of the embryological development of that part of the bowel. The process of the fixation of the descending colon to the posterior abdominal wall can be absent. In that case, when the descending colon has a free descending mesocolon, it shows some degree of mobility. CASE OUTLINE: We are presenting an example of one of the anomalies, which is characterized by the persistent descending mesocolon, which extends from the splenic flexure or just below it to the sigmoid colon. The persistent descending mesocolon in our case contains or surrounds almost complete small bowel in a recess which is located laterally to the left of the midline. The content of this hernial sac simulates the symptoms of an internal hernia followed by clinical symptoms and roendgenographical signs. CONCLUSION: We are of the opinion that this anomaly is more common than some surveys of literature would suggest.