Who lives in care homes in Greenland? A nationwide survey of demographics, functional level, medication use and comorbidities.

BACKGROUND: Greenland is facing an ageing population, and little is known about the characteristics of the elderly population in Greenland. This study offers both a comparison and a description of the demographics, causes of admission, comorbidities and medication of the residents in care homes in the capital, major and minor towns in four of the five administrative regions of Greenland. METHODS: The study was conducted from 2010 to 2016 as a descriptive questionnaire-based cross-sectional study. Data from eligible residents from eight care homes were collected from the regular care staff. Data were categorised into three groups based on town size for analysis. RESULTS: 244 (100 %) of eligible residents participated in the study. Nearly 100 % were of Greenlandic ethnicity based on parents' place of birth, and 62 % were women. The median age at admission/study was 69/71 years for men and 77/79 years for women (both p = 0.001). The median Body Mass Index was 25.6 kg/m2, more than half of the population were previous- or never-smokers and less than ten per cent consumed more than ten drinks of alcohol per week. The most common causes of admission were dementia (25.4 %), stroke (19.3 %) and social causes (11.1 %), while stroke (30.7 %), dementia (29.5 %) and musculoskeletal diseases (25.8 %) were the most common diagnoses at the time of the study. The Barthel Index was used to estimate the residents' level of independence, and residents in smaller towns were found to have a higher level of independence than residents in the capital. The median number of prescribed medications was five, and more residents in the capital were prescribed more than ten medications than elsewhere in Greenland. CONCLUSIONS: This study is the first to describe care home residents in Greenland. We found a population younger than residents in comparable Danish care homes and that women were older than men at admission. In addition, care home residents in the capital had a lower level of independence and a higher number of prescribed medications, which could relate to differences in morbidity, access to health care services and differences in social circumstances influencing the threshold for care home admission.

Radiological and pathological evaluation of the level of arterial division after colon cancer surgery.

AIM: In aiming to cure patients with colorectal cancer surgery, the surgeon must carefully dissect the mesocolon and mesorectum and divide the vascular pedicle near to its origin so as to include all local lymph nodes. This has been termed complete mesocolic excision. The distance from the distal vascular tie to the bowel wall in the fixed specimen is an indication as to the quality of surgery but this does not assess the length of the residual vascular pedicle and, by implication, residual lymph nodes. The aim of this study was to establish if our surgeons were carrying out complete mesocolic excision by assessing the length of the proximal arterial pedicle and relating this to arterial length in the fixed specimen. METHOD: This was a single centre prospective study of patients undergoing elective surgery for locally advanced colorectal cancer. An abdominal and pelvic CT scan was performed 2 days postoperatively and a radiologist blinded to the operative procedure measured the length of the residual arterial stump. Similarly, the length of the vessel in the fixed resected specimen and lymph node yield were also recorded. RESULTS: Fifty-two patients were recruited. The mean length of the residual arterial stump was 38 mm (95% CI: 33-43), which was significantly longer than the < 10 mm recommended in guidelines (P < 0.0001). The mean length was 31 mm (95% CI: 25-37) and 49 mm (95% CI: 40-57) for left and right sided resections respectively. There was no correlation between the residual arterial stump and the pathology. CONCLUSIONS: The residual arterial length was greater than suggested by guidelines and may indicate that our surgery is less radical than we planned. Caution should be taken when using pathological measurements of vascular ligation as it may not reflect the height of the pedicle division.

Structure-function-behavior relationship in estrogen-induced synaptic plasticity.

This article is part of a Special Issue "Estradiol and Cognition". In estrogen-induced synaptic plasticity, a correlation of structure, function and behavior in the hippocampus has been widely established. 17ß-estradiol has been shown to increase dendritic spine density on hippocampal neurons and is accompanied by enhanced long-term potentiation and improved performance of animals in hippocampus-dependent memory tests. After inhibition of aromatase, the final enzyme of estradiol synthesis, with letrozole we consistently found a strong and significant impairment of long-term potentiation (LTP) in female mice as early as after six hours of treatment. LTP impairment was followed by loss of hippocampal spine synapses in the hippocampal CA1 area. Interestingly, these effects were not found in male animals. In the Morris water maze test, chronic administration of letrozole did not alter spatial learning and memory in either female or male mice. In humans, analogous effects of estradiol on hippocampal morphology and physiology were observed using neuroimaging techniques. However, similar to our findings in mice, an effect of estradiol on memory performance has not been consistently observed.

Neural systems for choice and valuation with counterfactual learning signals.

The purpose of this experiment was to test a computational model of reinforcement learning with and without fictive prediction error (FPE) signals to investigate how counterfactual consequences contribute to acquired representations of action-specific expected value, and to determine the functional neuroanatomy and neuromodulator systems that are involved. 80 male participants underwent dietary depletion of either tryptophan or tyrosine/phenylalanine to manipulate serotonin (5HT) and dopamine (DA), respectively. They completed 80 rounds (240 trials) of a strategic sequential investment task that required accepting interim losses in order to access a lucrative state and maximize long-term gains, while being scanned. We extended the standard Q-learning model by incorporating both counterfactual gains and losses into separate error signals. The FPE model explained the participants' data significantly better than a model that did not include counterfactual learning signals. Expected value from the FPE model was significantly correlated with BOLD signal change in the ventromedial prefrontal cortex (vmPFC) and posterior orbitofrontal cortex (OFC), whereas expected value from the standard model did not predict changes in neural activity. The depletion procedure revealed significantly different neural responses to expected value in the vmPFC, caudate, and dopaminergic midbrain in the vicinity of the substantia nigra (SN). Differences in neural activity were not evident in the standard Q-learning computational model. These findings demonstrate that FPE signals are an important component of valuation for decision making, and that the neural representation of expected value incorporates cortical and subcortical structures via interactions among serotonergic and dopaminergic modulator systems.

Randomized controlled trial comparing Moviprep® and Phosphoral® as bowel cleansing agents in patients undergoing colonoscopy.

BACKGROUND: Introducing colonoscopy as part of colorectal cancer screening on a national level, we aimed at evaluating the efficacy of the two most common bowel cleansing agents, Moviprep(®) and Phosphoral(®). Secondly, we evaluated the benefit for the patient and society in terms of sick leave and discomfort. METHODS: In a single-blinded randomized equivalence trial, Phosphoral(®) (NaP) was compared with Moviprep(®) (2 l polyethylene glycol + ascorbic acid) in patients undergoing colonoscopy due to suspicion of cancer. Patients filled out questionnaires concerning stool consistency, discomfort and number of sick days due to bowel cleansing. Blinded colonoscopists estimated the efficiency of the cleansing using the validated Harefield Cleansing Scale. RESULTS: Two hundred and sixty-six patients were included 250 of whom underwent full colonoscopy. There was no difference in the percentage of acceptable bowel cleansings in the two groups; however, a significantly higher number of A scores were observed in the Moviprep(®) group (p = 0.028). We found no correlation between stool consistency and outcome of the cleansing and no difference in subjective discomfort during cleansing. Vomiting during cleansing occurred more often in the Phosphoral(®) group (p = 0.002). There was a trend toward a smaller number of sick days in patients who used Moviprep(®) compared with Phosphoral(®). CONCLUSIONS: Moviprep(®) and Phosphoral(®) provided equally efficient bowel cleansing in 90 % of patients, but Moviprep(®) provided a higher quality of cleansings graded as successful. The two agents were equally tolerated, and no difference was found in the related number of sick days.

Randomized clinical trial of self-gripping mesh versus sutured mesh for Lichtenstein hernia repair.

BACKGROUND: Many patients develop discomfort after open repair of a groin hernia. It was hypothesized that suture fixation of the mesh is a cause of these symptoms. METHODS: This patient- and assessor-blinded randomized multicentre clinical trial compared a self-gripping mesh (Parietene Progrip(®)) and sutured mesh for open primary repair of uncomplicated inguinal hernia by the Lichtenstein technique. Patients were assessed before surgery, on the day of operation, and at 1 and 12 months after surgery. The primary endpoint was moderate or severe symptoms after 12 months, including a combination of chronic pain, numbness and discomfort. RESULTS: The intention-to-treat population comprised 163 patients with self-gripping mesh and 171 with sutured mesh. The 12-month prevalence of moderate or severe symptoms was 17·4 and 20·2 per cent respectively (P = 0·573). There were no significant differences between the groups in postoperative complications (33·7 versus 40·4 per cent; P = 0·215), rate of recurrent hernia within 1 year (1·2 per cent in both groups) or quality of life. CONCLUSION: The avoidance of suture fixation using a self-gripping mesh was not accompanied by a reduction in chronic symptoms after inguinal hernia repair. REGISTRATION NUMBER: NCT00815698 (http://www.clinicaltrials.gov).

Perioperative music may reduce pain and fatigue in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Acute post-operative pain is a predictor in the development of chronic pain after laparoscopic cholecystectomy. Music has been shown to reduce surgical stress. In a randomized, clinical trial, we wanted to test the hypothesis that perioperative and post-operative soft music reduces pain, nausea, fatigue and surgical stress in patients undergoing laparoscopic cholecystectomy as day surgery. METHOD: The study was performed in otherwise healthy Danish patients eligible for day surgery. Ninety-three patients were included and randomized to either soft music or no music perioperatively and post-operatively. Using visual analog score pain, nausea and fatigue at baseline, 1 h, 3 h, 1 day and 7 days after surgery were recorded. C-reactive protein and cortisol were sampled before and after surgery. RESULTS: Music did not lower pain 3 h after surgery, which was the main outcome. The music group had less pain day 7 (P = 0.014). Nausea was low in both groups and was not affected by music. The music group experienced less fatigue at day 1 (P = 0.042) and day 7 (P = 0.015). Cortisol levels decreased during surgery in the music group (428.5-348.0 nmol/l), while it increased in the non-music group (443.5-512.0 nmol/l); still, the difference between the two groups were only significant using general linear models as post-hoc analysis. Soft music did not affect C-reactive protein levels. CONCLUSION: Soft music did not reduce pain 3 h after laparoscopic cholecystectomy. Soft music may reduce later post-operative pain and fatigue by decreasing the surgical stress response.

A regulatory link between ER-associated protein degradation and the unfolded-protein response.

Ubiquitin conjugation during endoplasmic-reticulum-associated degradation (ERAD) depends on the activity of Ubc7. Here we show that Ubc1 acts as a further ubiquitin-conjugating enzyme in this pathway. Absence of both enzymes results in marked stabilization of an ERAD substrate and induction of the unfolded-protein response (UPR). Furthermore, basic ERAD activity is sufficient to eliminate unfolded proteins under normal conditions. However, when stress is applied, the UPR is required to increase ERAD activity. We thus demonstrate, for the first time, a regulatory loop between ERAD and the UPR, which is essential for normal growth of yeast cells.

High-throughput screening of multifunctional nanocoatings based on combinations of polyphenols and catecholamines.

Biomimetic surface coatings based on plant polyphenols and catecholamines have been used broadly in a variety of applications. However, the lack of a rational cost-effective platform for screening these coatings and their properties limits the true potential of these functional materials to be unleashed. Here, we investigated the oxidation behavior and coating formation ability of a library consisting of 45 phenolic compounds and catecholamines. UV-vis spectroscopy demonstrated significant acceleration of oxidation and polymerization under UV irradiation. We discovered that several binary mixtures resulted in non-additive behavior (synergistic or antagonistic effect) yielding much thicker or thinner coatings than individual compounds measured by ellipsometry. To investigate the properties of coatings derived from new combinations, we used a miniaturized high-throughput strategy to screen 2,532 spots coated with single, binary, and ternary combinations of coating precursors in one run. We evaluated the use of machine learning models to learn the relation between the chemical structure of the precursors and the thickness of the nanocoatings. Formation and stability of nanocoatings were investigated in a high-throughput manner via discontinuous dewetting. 30 stable combinations (hits) were used to tune the surface wettability and to form water droplet microarray and spot size gradients of water droplets on the coated surface. No toxicity was observed against eukaryotic HeLa cells and Pseudomonas aeruginosa (strain PA30) bacteria after 24 h incubation at 37 °C. The strategy introduced here for high-throughput screening of nanocoatings derived from combinations of coating precursors enables the discovery of new functional materials for various applications in science and technology in a cost-effective miniaturized manner.

Laparoscopic repair of perforated ulcer in Western Denmark - a retrospective study.

OBJECTIVE: to report the distribution and results of laparoscopic repair of perforated ulcer surgery in surgical departments in a major region in Denmark and compare it with the results from the national database regarding mortality and morbidity. METHOD: case charts from all patients who underwent laparoscopic repair of perforated ulcer in Western Denmark in the period 1 January 2003 - 1 July 2007 were collected. Demographical data, surgical details, morbidity, 30-day mortality, and length of stay were recorded. For comparison, data from the National Health Registry (NIP) describing all patients who had an operation due to perforated ulcer in this period was obtained. RESULTS: no more than 51 out of 818 patients undergoing operation for perforated ulcer in the region had a laparoscopic operation. Mortality in the laparoscopic group was 4% compared to 26% reported from the national database (NIP). The laparoscopic group had a higher reperforation rate but length of stay was equal. No formal criteria concerning surgeon or patients selection for laparoscopic surgery were met. CONCLUSION: laparoscopic repair of perforated ulcer was done without any selection criteria in few surgical departments in Western Denmark and was associated with a low mortality but a higher risk of reperforation.

Role of Cue1p in ubiquitination and degradation at the ER surface.

Endoplasmic reticulum (ER) degradation of aberrant proteins is mediated by the ubiquitin-proteasome pathway. Here, a membrane-bound component of the ubiquitin system, Cue1p, was identified. It was shown to recruit the soluble ubiquitin-conjugating enzyme Ubc7p to the ER membrane. In the absence of Cue1p, unassembled and thus cytosolically mislocalized Ubc7p was unable to participate in ER degradation or in the turnover of soluble non-ER proteins. Moreover, ubiquitination by Cue1p-assembled Ubc7p and Ubc6p was a prerequisite for retrograde transport of lumenal substrates out of the ER, which suggests that ubiquitination is mechanistically integrated into the ER degradation process.

Ubiquitin-conjugating enzymes: novel regulators of eukaryotic cells.

Covalent attachment of ubiquitin to cellular proteins is essential for cell viability and is catalysed by a set of distinct ubiquitin-conjugating enzymes. Individual members of this novel enzyme family mediate strikingly diverse functions, including DNA repair, cell cycle control, selective protein degradation and essential functions of the stress response.

Experimental pain impairs recognition memory irrespective of pain predictability.

BACKGROUND: Pain is hardwired to signal threat and tissue damage and therefore automatically attracts attention to initiate withdrawal or defensive behaviour. This well-known interruptive function of pain interferes with cognitive functioning and is modulated by bottom-up and top-down variables. Here, we applied predictable or unpredictable painful heat stimuli simultaneously to the presentation of neutral images to investigate (I) whether the predictability of pain modulated its effect on the encoding of images (episodic memory) and (II) whether subjects remember that certain images have been previously presented with pain (source memory). METHODS: Twenty-four healthy subjects performed a categorization task in which 80 images had to be categorized into living or non-living objects. We compared the processing and encoding of these images during cued and non-cued pain trials as well as cued and non-cued pain-free trials. Effects on recognition performance and source memory for pain were immediately tested using a surprise recognition task. RESULTS: Painful thermal stimulation impaired recognition accuracy (d', recollection, familiarity). This negative effect of pain was positively correlated with the individual expectation of pain interference and the attentional avoidance of pain-related words. However, the interruptive effect of pain was not modulated by the predictability of pain. Source memory for painful stimulation was at chance level, indicating that subjects did not explicitly remember that images had been paired with pain. CONCLUSIONS: Targeting negative expectations and a maladaptive attentional bias for pain-related material might help reducing frequently reported pain-induced cognitive impairments.

Membrane composition modulates thiopental partitioning in bilayers and biomembranes.

The nonspecific interaction of thiopental with erythrocyte ghosts, synaptic membranes, microsomes and mitochondria has been measured at 25 degrees C and pH 6.6. In cholesterol-depleted erythrocyte ghosts the partition coefficient decreases with increasing cholesterol content. In sonicated liposomes made from egg lecithin and cholesterol the partition coefficient also decreases with increasing cholesterol content. The dependence of the partition coefficient on cholesterol content in the biological membranes, on average, parallels that in the lipid bilayers. The partition coefficient in lipid bilayers made from lipids extracted from erythrocyte ghosts was comparable to that in the corresponding egg lecithin/cholesterol bilayer. The partition coefficients of all the biomembranes are consistently lower than those in the corresponding egg lecithin/cholesterol bilayer, the free energy of transfer between biomembrane and corresponding bilayer being -1 kcal/mol.

[CT coronary angiography in patients with atrial fibrillation]. / CT-Koronarangiographie bei Patienten mit Vorhofflimmern.

PURPOSE: Reliable visualization of the coronary arteries with multislice spiral CT angiography (MSCTA) in patients with atrial fibrillation (AF) remains a challenge despite retrospective ECG gating. A recently developed new algorithm automatically compensates dynamic changes in the heart rate during the scan, thus reducing misregistration and motion artifacts. The HeartBeat-RT algorithm combines a fixed-percent delay determined from the first R wave and the fixed offset delay based on the second R wave in the ECG cycle. The purpose of this study was to find out the optimal reconstruction window in MSCTA in patients with AF for each of the three major coronary arteries during the cardiac cycle. MATERIALS AND METHODS: 20 patients with permanent AF were imaged on a 16-slice scanner (slice collimation: 16 x 0.75 mm; rotation time 0.42 s; 140 kV; 380 mAs; 120 ml Ultravist 370 (R) i.v.). The patients had not received any previous drugs for heart frequency regulation. Acquisition was started after bolus tracking of a biphasic bolus of 120 ml Ultravist 370 injected intravenously. Each coronary segment was reconstructed at 0 % - 90 % of the cardiac cycle in increments of 10 %. For image analysis we used coronary segments as defined by the American Heart Association. Two blinded independent readers assessed the image quality in terms of visibility and artifacts (five-point rating scale 1 = very poor, 2 = poor, 3 = fair, 4 = good and 5 = excellent) and the degree of stenosis (five-point rating scale 1 = 0 %, 2 = 1 % - 49 %, 3 = 50 % - 74 %, 4 = 75 % - 99 %, 5 = 100 %) on axial slices, multiplanar reconstructions and three-dimensional volume-rendered images. RESULTS: The heart rate during examination ranged between 42 and 156 beats per minute, the average heart rate was 78 +/- 23. Each of the two readers evaluated 300 segments in 20 patients. Visualization of all coronary artery segments was superior at 40 % (mean score of the image quality 2.79) as compared to the standard diastolic reconstruction window at 80 % (image quality 2.33). The second best image quality (2.57) was acquired at 0 % of the cardiac cycle. CONCLUSION: The use of a frequency adapted delay algorithm with the choice of an end-systolic reconstruction window provided diagnostically valuable images in patients with AF.

[Radiologic features of inflammatory pseudotumors]. / Radiologische Befunde bei inflammatorischen Pseudotumoren.

Inflammatory pseudotumor is a rare benign tumor entity. Because inflammatory pseudotumors mimic malignant tumors both clinically and radiologically, the radiologist should be familiar with this entity. Inflammatory pseudotumor most commonly involves the lung and the orbit, but it has been reported to occur in nearly every site in the body. For making a definite diagnosis a biopsy is often essential. The treatment options are varied and consist of surgery, high-dose steroids, irradiation, and chemotherapeutics.

[Magnetic resonance imaging of the brain in patients with cardiac pacemakers. Experimental and clinical investigations at 1.5 Tesla]. / MRT-Untersuchungen des Hirns bei Patienten mit implantierten Herzschrittmachern. Experimentelle und klinische Untersuchungen an einem 1.5 Tesla-System.

PURPOSE: In-vitro and In-vivo evaluation of feasibility and safety of MRI of the brain at 1.5 T in patients with implanted pacemakers (PM). MATERIALS AND METHODS: 24 PM models and 45 PM electrodes were tested In-vitro with respect to translational forces, heating of PM leads, behaviour of reed switch (activated vs. deactivated) and function at a 1.5 T MRI-system (actively shielded, maximum field gradient: 30 mT/m; rise time: 150 T/m/s). Based on these results, 63 MRI examinations in 45 patients with implanted PM were performed. Prior to MRI the PM were re-programmed in an asynchronous mode. The maximum SAR of MRI-sequences was limited to 1.2 W/kg. Continuous monitoring of ECG and pulse oximetry was performed during MRI. PM inquiry was performed prior to MRI, immediately after MRI and -- to assess long-term damages -- three months after the MRI exams, including determination of stimulation thresholds to assess potential thermal myocardial injuries at the lead tips. RESULTS: Translational forces (F (max) < or = 560 mN) and temperature increase (DeltaT (max) < or = 2.98 degrees C) were in a range which does not represent a safety concern from a biophysical point of view. No changes to the programmed parameters of the PM or damage of PM components were observed neither In-vitro (n = 0/24) nor In-vivo (n = 0/63). Despite the strong magnetic field, the reed switch remained deactivated in 54 % (13/24) of the cases during In-vitro simulated MRI exams of the brain. All patient studies (n = 63/63) could be completed without any complications. Atrial and ventricular stimulation thresholds (expressed as pulse duration at 2-fold rheobase) did not change significantly immediately post-MRI nor in the 3 months follow-up (pre-MRI: 0.17 ms +/- 0.13 ms, post-MRI: 0.18 ms +/- 0.14 ms, 3 months follow-up: 0.17 ms +/- 0.12 ms). CONCLUSION: MRI of the brain at 1.5 Tesla can be safely performed in carefully selected clinical circumstances when appropriate strategies are used (re-programming the PM to an asynchronous mode, continuous monitoring of ECG and pulse oximetry, limiting the SAR value of the MRI sequences, cardiological stand-by). Based on these studies, implanted PM should not longer be regarded as an absolute contraindication for MRI at 1.5 T.

[3D motion adapted gating: a new navigator technique to shorten the acquisition time for coronary MRA]. / 3D Motion Adapted Gating: Eine neue Navigatortechnik zur Verkürzung der Messzeit bei der MR-Koronarangiographie.

PURPOSE: A major problem of free breathing coronary MR angiography (MRA) with respiratory navigator gating is low navigator efficiency and prolonged scan time due to irregular breathing patterns. 3D motion adapted gating (MAG) is a new adaptive navigator technique, which adapts in real time to changes of the end-expiratory position of diaphragm. This study evaluates the influence of 3D MAG on coronary MRA. METHODS AND MATERIALS: In 3D MAG, two additional gating windows are grouped around the conventional window. Additionally, each gating window is divided into three bands assigned to different portions of the k-space. The scan is terminated when three consecutive bands are filled and one complete image data set is collected. Free breathing navigator-gated coronary MRA was performed on 48 patients with suspected coronary artery disease. In random order, each patient underwent an ECG-gated, a 3D segmented k-space gradient echo sequence using 3D MAG and a conventional navigator technique. The coronary MRA was evaluated and compared using the following parameters: 1. navigator efficiency and scan time; 2. visualized coronary artery length; 3. qualitative assessment of image quality; and 4. detection of stenoses > 50 % in comparison with catheter angiography. RESULTS: Coronary MRA with 3D MAG had a significant increase in the average navigator efficiency (46 % +/- 12 % vs. 38 % +/- 12 %, p < 0.05), resulting in a significantly shorter scan time (mean: 18 % +/- 4 %, p < 0.05) for coronary MRA with 3D MAG compared to conventional navigator technique. Scans with and without 3D MAG had no significant differences in the continuously visualized vessel lengths, in the assessed image quality and in the sensitivity and specificity (83 % and 89 % vs. 83 % and 88 %, p > 0.05) of detecting coronary artery stenoses > 50 %. CONCLUSION: The 3D MAG technique improves the navigator efficiency and significantly (p < 0.05) shortens the scan time of navigator gated coronary MRA while maintaining image quality and diagnostic accuracy in the detection of coronary artery stenoses.

[Long-term fate of left atrial thrombi and incidence of cerebral embolism under continuous anticoagulation therapy]. / MR-tomographische Evaluation der Inzidenz zerebraler Embolien bei Patienten mit Vorhofflimmern und linksatrialen Thromben.

PURPOSE: Patients (pts.) with atrial fibrillation (AF) and atrial thrombi are known to have an increased risk for cerebral embolism. However, little is known about the clinical course of atrial thrombi and the incidence of cerebral embolism in those patients during anticoagulation therapy. The high sensitivity of MR imaging (MRI) including diffusion-weighted imaging (DWI) suggests that this technique could provide an improved estimate of cerebral embolism associated with the presence of left atrial thrombi. The aims of this prospective study were to evaluate 1) the prevalence of clinically silent and apparent cerebral embolism in pts. with newly diagnosed AF and atrial thrombi using MRI/DWI, 2) the long-term fate of atrial thrombi under continues anticoagulation therapy and 3) the incidence of cerebral embolism during a follow-up period of 12 months with continuous anticoagulation therapy. MATERIALS AND METHODS: The study group consisted of 32 pts. with 1) newly diagnosed AF and evidence of left atrial (LA) thrombi detected by TEE and 2) a new start of anticoagulation therapy [International Normalized Ratio (INR) 2.0 - 3.0]. 19 pts. with 1) newly diagnosed AF and no evidence of atrial thrombi and 2) an equivalent anticoagulation regimen served as the control group. In both groups a) MRI/DWI studies of the brain (weeks 0, 4, 8, 12, 20, 28, 36, 44, and 52), b) transesophageal echocardiographic studies (TEE) for assessment of LA-Thrombi (weeks 0 and 52) and c) clinical neurological assessments (weeks 0, 20 and 52) were performed. RESULTS: In the study group (AF and LA-Thrombi) 11 out of 32 pts. (34 %) displayed signs of acute (n = 8) or chronic (n = 3) cerebral embolism in the initial MRI studies. In 4 out of 32 pts. (13 %), MRI/DWI depicted new or additional cerebral emboli (n = 12) during the follow-up period despite continuous anticoagulation therapy. 2 (n = 2/4; 50 %) of these patients had clinically apparent neurological deficits. In the control group 1 out of 19 pts. (5 %) showed evidence of chronic cerebral embolism as assessed by MRI/DWI at the beginning of the study (week 0). No embolic cerebral lesions were detected during the 12-month follow-up. Within 12 months only 63 % (n = 20/32) of LA thrombi in the study group resolved completely under anticoagulation. CONCLUSION: 1. The incidence of clinically inapparent cerebral emboli in pts. with newly diagnosed AF and atrial thrombi is much higher than the incidence of clinically apparent emboli and has been underestimated in the past. 2. New cerebral embolism may occur even with continued effective anticoagulation therapy in 13 % of pts. 3. Only 63 % of atrial thrombi resolve completely within 12 months under anticoagulation therapy.

German Roentgen Society Statement on MR Imaging of Patients with Cardiac Pacemakers.

UNLABELLED: The aim of this paper is to inform physicians, especially radiologists and cardiologists, about the technical and electrophysiological background of MR imaging of patients with implanted cardiac pacemakers (PM) and to provide dedicated clinical practice guidelines how to perform MR exams in this patient group. The presence of a conventional PM system is not any more considered an absolute contraindication for MR imaging. The prerequisites for MR imaging on pacemaker patients include the assessment of the individual risk/benefit ratio as well as to obtain full informed consent about the off label character of the procedure and all associated risks. Furthermore the use of special PM-related (e.g. re-programming of the PM) and MRI-related (e.g. limitation of whole body SAR to 2 W/kg) precautions is required and needs to be combined with adequate monitoring during MR imaging using continuous pulsoximetry. MR conditional PM devices are tested and approved for the use in the MR environment under certain conditions, including the field strength and gradient slew rate of the MR system, the maximum whole body SAR value and the presence of MR imaging exclusion zones. Safe MR imaging of patients with MR conditional PM requires the knowledge of the specific conditions of each PM system. If MR imaging within these specific conditions cannot be guaranteed in a given patient, the procedure guidelines for conventional PM should be used. The complexity of MR imaging of PM patients requires close cooperation of radiologists and cardiologists. KEY POINTS: Conventional pacemaker systems are no longer an absolute but rather a relative contraindication for performing an MR examination. The procedural management of conventional pacemaker includes the assessment of the individual risk/benefit ratio, comprehensive patient informed consent about specific related risks and "off label" use, extensive PM- and MRI-related safety precautions as well as adequate monitoring techniques during the MR exam. Decisive for patient safety are precise understanding of, and compliance with, the terms of use for the specific MR-conditional pacemaker system. If the electrophysiological and MRI-specific conditions for use of MR-conditional pacemakers are not met or compliance with these conditions for use cannot be guaranteed, the device must be treated like a conventional pacemaker.