Predictors of colonization with Staphylococcus species among patients scheduled for cardiac and orthopedic interventions at tertiary care hospitals in north-eastern Germany-a prevalence screening study.

As methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in humans are a global challenge. In Mecklenburg and Western Pomerania (Germany) 1,517 patients who underwent surgical interventions were systematically screened for MRSA and MSSA colonization on the day of hospital admission and discharge. Demographic data, risk factors and colonization status of the (i) nose, (ii) throat, (iii) groin, and (iv) thorax or site of surgical intervention were determined. Of the 1,433 patients who were included for further evaluation, 331 (23.1%) were colonized with MSSA, while only 17 (1.2%) were MRSA carriers on the day of hospital admission. A combination of nose, throat and groin swabs returned a detection rate of 98.3% for MSSA/MRSA. Trauma patients had lower prevalence of MRSA/MSSA (OR 0.524, 95% CI: 0.37-0.75; p < 0.001) than patients with intended orthopedic interventions. Males showed significantly higher nasal S. aureus carrier rates than females (odds ratio (OR) = 1.478; 95% CI: 1.14-1.92; p = 0.003). Nasal S. aureus colonization was less frequent among male smokers as compared to non-smokers (chi2 = 16.801; phi = 0.154; p < 0.001). Age, gender and smoking had a significant influence on S. aureus colonization. Combining at least three different swabbing sites should be considered for standard screening procedure to determine S. aureus colonization at patients scheduled for cardiac or orthopedic interventions at tertiary care hospitals.

[Therapy strategies for acute coronary syndrome and after coronary interventions. Antiplatelet agents and anticoagulants]. / Therapiestrategien beim akuten Koronarsyndrom und nach koronaren Interventionen. Antiaggregation und Antikoagulation.

There is ongoing development of new therapeutic regimens in the use of antithrombotic agents and anticoagulants focussing on acute coronary syndrome (ACS) with an increasing impact on current guidelines over the last years. This was especially accompanied by an increase in innovative percutaneous coronary interventional (PCI) methods in patients with ACS, non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI) with a need for therapeutics with more sufficient and effective antiplatelet action. On the other hand, newer direct and indirect thrombin inhibitors with primary use in prevention and therapy of thromboembolic events have been shown to have beneficial and even superior effects in ACS with or without PCI. The current review aims to report on the evidence-based use of approved antithrombotic agents and anticoagulants in ACS with special focus on PCI according to the actualized European guidelines.

Angiotensin II type 1 receptor blockade: high hopes sent back to reality?

Chronic activation of the renin-angiotensin system (RAS) plays a crucial role in the development of various cardiovascular diseases (CVD). Thus, effective RAS inhibition has been a major achievement to improve the treatment of patients at risk for CVDs, such as myocardial infarction, heart failure and stroke. Three substance classes that block RAS-activation are currently available, angiotensin converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor blockade (ARB) and renin inhibitors. Although the overall goal of these drugs remains the blockade of RAS activation, their individual targets in this system vary and may substantially influence the clinical benefit derived from the long term use of these substances. Here, we summarize the evidence available for the use of ARBs in different cardiovascular pathologies and the impact of this evidence on current treatment guidelines for patients at risk for CVD. Today, ARBs represent a good alternative in case of ACE-inhibitor intolerance due to their outstanding tolerability. ARBs in comparison to ACE-inhibitors have been proven to exert similar effective in the treatment of systolic heart failure, primary prevention of stroke, new onset of diabetes mellitus (DM) type 2 and DM type 2 dependent macroalbuminuria. ARBs should be considered as alternatives to ACE-inhibitors in subjects post-myocardial infarction. Overall however, there is no profound proof for a specific cardiovascular protection by blockade of the angiotensin II Type 1 (AT1) receptor that exceeds the impact of ACE-inhibition or synergises with ACE-blockade. In fact, combination of ARBs and ACE-inhibitor result in an increased rate of adverse effects and, therefore, this combination should not be encouraged. To summarize, the initial hope for a more specific impact on cardiovascular diseases by inhibition of the AT1-receptor in comparison to ACE-inhibition has not come true. However, ARBs have been proven to be equally effective as ACE-blockade in a large variety of clinical settings.

[Risk evaluation of type B aortic dissection: importance for treatment of acute aortic syndrome]. / Risikoevaluation der Aortendissektion Typ B: Bedeutung für die Behandlung des akuten Aortensyndroms.

Acute aortic syndrome (AAS) is a modern term used to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges including aortic dissection, intramural hematoma (IMH) and penetrating aortic ulcer (PAU). Population-based studies suggest that the incidence of aortic dissection ranges from 2.6 to 3.5 cases per 100,000 inhabitants per year; hypertension and a variety of genetic disorders with altered connective tissue are the most prevalent risk conditions. In general, open surgical repair is recommended when dissection involves the ascending aorta, whereas medical management and endovascular stent graft repair is the best option when the ascending aorta is spared. Pathological conditions involving the aortic arch may be treated using a hybrid approach combining debranching of supra-aortic vessels and stent graft placement. Stent graft-induced remodeling of a dissected aorta seems to have long-term benefits in complicated and so-called uncomplicated type B dissections as almost every case reveals a risk profile and one in eight patients diagnosed with acute type B aortic dissection has either an IMH or a PAU. Pain is the most commonly presenting symptom of AAS and should prompt immediate attention including diagnostic imaging modalities, such as multislice computed tomography, transesophageal ultrasound and magnetic resonance imaging. A specific therapeutic approach is necessary for IMH and PAU because without treatment they have a very poor outcome, are unpredictable in evolution and can be more severe than acute aortic dissection. All patients must receive the best medical treatment available at admission. High-risk but asymptomatic patients with IMH and PAU can probably be monitored without interventions. All symptomatic patients will need treatment. In many of these patients a direct surgical approach is often prohibitive due to age and multiple comorbidities. Endovascular treatment offers superior results and is becoming a recognized indication for such patients. Irrespective of the treatment modality close surveillance is mandatory in order to monitor disease progression.