Tricuspid valve Swan-Ganz catheter entrapment before cardiac surgery.

A Swan-Ganz catheter during cardiac surgery offers peri-operative haemodynamic monitoring, although insertion of these catheters is not without risk. We report a case of Swan-Ganz catheter entrapment within the tricuspid valve during elective off-pump coronary artery bypass surgery. The diagnosis was made immediately by transoesophageal echocardiography, thus preventing forced withdrawal of the catheter. Intra-operatively, the echocardiographically detected findings of complex entrapment was confirmed. The Swan-Ganz catheter was tightly wrapped around the subvalvular apparatus, requiring on-pump open surgical removal. This case illustrates the anatomical complexity of such a catheter entrapment around the tricuspid valve apparatus and the importance of rapid echocardiographic diagnosis to prevent iatrogenic damage.

Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases.

INTRODUCTION: Total ankle arthroplasty (TAA) has the objective to maintain the range of motion of the tibiotarsal joint and to preserve the nearby joints. However, the complication rate and failures remain quite high after TAA. The main objective of the study was to evaluate the improvement in the functional scores of the tibiotarsal arthrodesis after TAA failure. The secondary objective was to assess the specific complications. MATERIALS AND METHODS: This monocentric retrospective series includes 12 patients (nine men, three women, average age 52.5 years) operated between 2003 and 2018. An iliac graft was used in all cases. The arthrodesis was stabilized either by screws or by retrograde nailing. RESULTS: The reoperation was due to painful malleolar conflicts or loosening. The AOFAS score increased from 38/100 to 67/100 (51-86) post-operatively. The fusion was acquired at 3.7 months (3-6) except in two cases. DISCUSSION AND CONCLUSION: The 83% primary fusion rate is in the low average of the literature and 92% fusion rate in the high average after reoperation. All patients were improved even in two non-unions. The results of this study confirm that the arthrodesis after TAA failure is a reliable alternative to the TAA replacement. However, they are lower than those after a first-line arthrodesis.

[Genetic methods for analysis of autoinflammatory diseases]. / Genetische Methoden für die Analyse autoinflammatorischer Erkrankungen.

Over the past years the phenotypic and genetic spectrum of autoinflammatory diseases has continuously increased. Moreover, several monogenic autoinflammatory disorders have now been identified where febrile episodes are not among the leading symptoms and which can be accompanied by autoimmune phenomena and susceptibility to infections. Autoinflammatory conditions that are characterized by uncontrolled activity of cytokines, such as interleukin-1 beta (IL1ß), tumor necrosis factor alpha (TNF-α) and type 1 interferons (1-IFN), are amenable to specific therapeutic interventions. Thus, identification of the underlying genetic cause is important. During diagnostic work-up, genetic testing of a patient with autoinflammation should be carried out depending on the clinical presentation. If a distinct disorder is suspected, sequencing of the causative gene should be performed. Genetic tests using next generation sequencing (NGS), such as panel sequencing, exome sequencing and array comparative genomic hybridization (CGH) can be carried out if symptoms cannot be assigned to a specific disease entity.

[Importance of preoperative and intraoperative imaging for operative strategies]. / Bedeutung der prä- und intraoperativen Bildgebung für die operative Strategie.

Recent advances in preoperative and postoperative imaging have an increasing influence on surgical decision-making and make more complex surgical interventions possible. This improves the possibilities for frequently occurring challenges and promoting improved functional and oncological outcome. This manuscript reviews the role of preoperative and intraoperative imaging in surgery. Various techniques are explained based on examples from hepatobiliary surgery and neurosurgery, in particular real-time procedures, such as the online use of augmented reality and in vivo fluorescence, as well as new and promising optical techniques including imaging of intrinsic signals and vibrational spectroscopy.

Bridge to transplantation using paracorporeal biventricular assist devices or the syncardia temporary total artificial heart: is there a difference?

AIM: Biventricular support can be achieved using paracorporeal ventricular assist devices (p-BiVAD) or the Syncardia temporary total artificial heart (t-TAH). The purpose of the present study was to compare survival and morbidity between these devices. METHODS: Data from 2 French neighboring hospitals were reviewed. Between 1996 and 2009, 148 patients (67 p-BiVADs and 81 t-TAH) underwent primary, planned biventricular support. There were 128 (86%) males aged 44±13 years. RESULTS: Preoperatively, p-BiVAD recipients had significantly lower systolic and diastolic blood pressures, more severe hepatic cytolysis and higher white blood cell counts than t-TAH recipients. In contrast, t-TAH patients had significantly higher rates of pre-implant ECLS and hemofiltration. Mean support duration was 79±100 days for the p-BiVAD group and 71±92 for t-TAH group (P=0.6). Forty two (63%) p-BiVAD recipients were bridged to transplantation (39, 58%) or recovery (3, 5%), whereas 51 (63%) patients underwent transplantation in the t-TAH group. Death on support was similar between groups (p-BiVAD, 26 (39%); t-TAH, 30 (37%); P=0.87). Survival while on device was not significantly different between patient groups and multivariate analysis showed that only preimplant diastolic blood pressure and alanine amino-transferase levels were significant predictors of death. Post-transplant survival in the p-BiVAD group was 76±7%, 70±8%, and 58±9% at 1, 3, and 5 years after transplantation, respectively, and was similar to that of the t-TAH group (77±6%, 72±6%, and 70±7%, P=0.60). CONCLUSION: Survival while on support and up to 5 years after heart transplantation was not significantly different in patients supported by p-BiVADs or t-TAH. Multivariate analysis revealed that survival while on transplantation was not affected by the type of device implanted.

Differences in health behaviour between recipients of allogeneic haematopoietic SCT and the general population: a matched control study.

Little is known of health-relevant behaviour among long-term survivors of haematological disorders treated with haematopoietic SCT. This comparative cross-sectional multicentre study aimed (1) to explore the prevalence of selected behaviours in this group and (2) to compare them with those of the general population. Self-reported data of 376 survivors (mean age: 50.4 (s.d. = 12.8); median 7 years postallogeneic SCT (interquartile range (IQR) = 8.9; range 1-33) were compared with controls derived from the Swiss Health Survey 2007 by propensity score matching. Survivors were more physically inactive (26.8% vs 12.5%; P ⩽ 0.001) and consumed fewer portions of vegetables (⩾ 3 pieces: 10% vs 21.6%; P < 0.001), fruits (⩾ 3 pieces: 6.5% vs 10.6%; P < 0.001) and fish (31.2% vs 60.9% weekly fish dish; P < 0.001). More survivors consumed dairy products daily (92.5% vs 62.9%; P < 0.001), used sun protection regularly (94.5% vs 85.3%, P < 0.001) and had received influenza vaccinations in the past year (58.4% vs 21.5%; P < 0.001); fewer survivors smoked (13.4% vs 35.4%; P < 0.001). Survivors' weekly alcohol consumption was lower (median 1.5 servings (IQR 4) vs median 4.5 (IQR 10.3); P < 0.001). Of those taking immunosuppressants, 65.7% were non-adherent. Similar to the general population, survivors experience problems executing several health-enhancing behaviours, warranting corrective interventions.

Who gets a second heart? A current picture of cardiac retransplantation.

BACKGROUND: Heart retransplantation (HRT) accounts for 2.6% of heart transplantation (HT) indications. We performed a retrospective analysis of our recent HRT experience. METHODS: From January 2000 to June 2012, 820 HTs were performed; 798 (97.3%) were primary HTs and 21 (2.5%) 2nd HTs. Indications for HRT included: 57% cardiac allograft vasculopathy, 33% nonspecific graft failure, 5% primary graft failure (PGF), and 5% refractory acute rejection. The primary outcome was overall survival. Our results were compared with the most representative publications reporting HRT experiences before January 2000. RESULTS: Mean age at HRT was 39.9 ± 14.3 years, and there was a predominance of male patients (62%). Overall mortality was 52%; 30-day mortality was 19%. Eight patients (38%) developed PGF after HRT and 3 of them (38%) died within 30 days. Overall actuarial survivals at 1 month and 1, 3, and 5 years were 81.0%, 70.8%, 59.9%, and 53.3%, respectively. No significant risk factors for mortality could be identified. CONCLUSIONS: We observed improved short- and medium-term survival after HRT. This finding is probably related to changing recipient profiles, with less patients being retransplanted for PGF and more patients undergoing late retransplantation. Higher rates of PGF after HRT reflect our efforts to broaden the allograft pool by using marginal donors.

Nurses' practice patterns in relation to adherence-enhancing interventions in stem cell transplant care: a survey from the Nurses Group of the European Group for Blood and Marrow Transplantation.

Recipients of stem cell transplants (SCT) must accurately manage multiple medications as non-adherence jeopardises treatment benefits. There is an evidence base for the efficacy of adherence-enhancing interventions; however, level of clinical implementation is unknown. This study aimed to identify patterns of practice in assessing medication adherence, screening for risk factors of non-adherence, interventions used in SCT to improve adherence and how nurses perceive the effectiveness of such interventions. A convenience sample of 143 European nurses completed a 29-item questionnaire measuring the frequency and perceived effectiveness of assessment/screening methods for adherence and three types of intervention (educational/cognitive, counselling/behavioural and psychological/affective). Questioning patients about adherence was the most regularly used assessment method (51.5%). Nurses used a median of seven interventions (interquartile range: six) 'frequently', the most popular being provision of reading materials (79%). The interventions perceived as most effective were; providing individual patient/family with teaching and reading materials. This is the first study exploring patterns of practice relating to adherence in SCT. Educational interventions were the most frequently employed style of intervention, which is at odds with recent data suggesting limited efficacy with this style of intervention. Combining educational, behavioural and psychological interventions would more accurately embrace current understanding.

Endovascular management of spinal dural arteriovenous fistulas in 78 patients.

INTRODUCTION: The purpose of this study was the evaluation of the safety and efficiency of the endovascular treatment of spinal dural arteriovenous fistulas (SDAVFs). METHODS: Between May 1992 and August 2012, 78 patients (59 men) with an angiographically proven SDAVF with pial venous drainage were treated by endovascular embolization (n = 61) and/or surgery (n = 31) at three German hospitals by a single team of physicians and according to a uniform therapeutic concept. RESULTS: Endovascular treatment resulted in a complete occlusion of the fistula in 47 cases (77 %). After failed embolization with residual shunt, 14 DAVFs were surgically cured (23 % failure rate). We had one permanent and two minor complications after endovascular therapy. Within a postoperative period of 2 weeks, 73.6 % of patients improved in gait disability, 51.1 % in micturition function, and 70.5 % in paresthesia of the lower extremities. Long-term follow-up data showed further improvement of clinical symptoms confirmed by normalization or resolution of spinal changes on MRI. CONCLUSIONS: An interdisciplinary approach to the management of SDAVFs is mandatory. Patients without a common origin of arteries supplying the spinal cord and the dural fistula, and without a stenosis or occlusion of the concerning segmental artery are potential candidates for endovascular treatment (diluted n-butyl-2-cyanoacrylate). Only occlusion of the "nidus" and the proximal segment of the draining vein can lead to clinical improvement.

Rocket fuel for the quantification of S-nitrosothiols. Highly specific reduction of S-nitrosothiols to thiols by methylhydrazine.

Reduction of S-nitrosothiols to the corresponding thiol function is the key step in analyzing S-nitrosocysteinyl residues in proteins. Though it has been shown to give low yields, ascorbate-dependent reduction is commonly performed in the frequently used biotin-switch technique. We demonstrate that the compound methylhydrazine can act as a specific and efficient reducing agent for S-nitrosothiols. The corresponding thiol function is exclusively generated from low molecular weight and proteinaceous S-nitrosothiols while methylhydrazine failed to reduce disulfides. It was possible to optimize the experimental conditions so that thiol autoxidation is excluded, and high reaction yields (>90%) are obtained for the thiol function. The biotin-switch technique performed with methylhydrazine-dependent reduction shows remarkably improved sensitivity compared to the ascorbate-dependent procedure.

The prognostic value of IDH mutations and MGMT promoter status in secondary high-grade gliomas.

Reports about the prognostic value of IDH mutations and the promoter region of the O6-Methyl-guanyl-methyl-transferase gene in secondary high-grade gliomas (sHGG) are few in number. We investigated the prognostic value of IDH mutations and methylation of the promoter region of the MGMT gene in 99 patients with sHGG and analyzed the clinical course of those tumors. Patients with sHGG were screened for IDH mutations by direct sequencing, and, for promoter status of MGMT gene, by the methylation-specific polymerase chain reaction. A total of 48 of 99 patients (48.5 %) had secondary anaplastic gliomas (Group 1), while 51 patients had secondary glioblastomas (Group 2). The median survival time after malignant progression of all patients with sHGG and with an IDH mutation was 4 years, which is significantly longer than in patients with wild-type IDH (1.2 years, p = 0.009). Patients' survival was not significantly influenced by the tumors' MGMT promoter status, both in Group 1- 9.7 years vs. 6.1 years, methylated vs. unmethylated promoter (p = 0.330)-as well as in Group 2-1.5 years vs. 1.6 years, methylated versus unmethylated promoter (p = 0.829). In our population, the IDH mutation status was not associated with increased PFS or median survival time in sGBM patients. However, patients with secondary anaplastic glioma and IDH mutation had a significantly improved outcome. In addition, IDH mutations are a more powerful prognostic marker concerning both PFS and MS than the MGMT promoter status in those patients.

Long-term follow-up of high-dose chemotherapy with autologous stem-cell transplantation and response-adapted whole-brain radiotherapy for newly diagnosed primary CNS lymphoma: results of the multicenter Ostdeutsche Studiengruppe Hamatologie und Onkologie OSHO-53 phase II study.

BACKGROUND: We previously reported the results of a phase II study for patients with newly diagnosed primary central nervous system lymphoma treated with autologous peripheral blood stem-cell transplantation (aPBSCT) and response-adapted whole-brain radiotherapy (WBRT). Now, we update the initial results. PATIENTS AND METHODS: From 1999 to 2004, 23 patients received high-dose methotrexate. In case of at least partial remission, high-dose busulfan/thiotepa (HD-BuTT) followed by aPBSCT was carried out. Patients refractory to induction or without complete remission after HD-BuTT received WBRT. Eight patients still alive in 2011 were contacted and Mini-Mental State Examination (MMSE) and the European Organisation for Research and Treatment of Cancer quality-of-life questionnaire (QLQ)-C30 were carried out. RESULTS: Of eight patients still alive, median follow-up is 116.9 months. Only one of nine irradiated patients is still alive with a severe neurologic deficit. In seven of eight patients treated with HD-BuTT, health condition and quality of life are excellent. MMSE and QLQ-C30 showed remarkably good results in patients who did not receive WBRT. All of them have a Karnofsky score of 90%-100%. CONCLUSIONS: Follow-up shows an overall survival of 35%. In six of seven patients where WBRT could be avoided, no long-term neurotoxicity has been observed and all patients have an excellent quality of life.

Centrosomal targeting of tyrosine kinase activity does not enhance oncogenicity in chronic myeloproliferative disorders.

Constitutive tyrosine kinase activation by reciprocal chromosomal translocation is a common pathogenetic mechanism in chronic myeloproliferative disorders. Since centrosomal proteins have been recurrently identified as translocation partners of tyrosine kinases FGFR1, JAK2, PDGFRα and PDGFRß in these diseases, a role for the centrosome in oncogenic transformation has been hypothesized. In this study, we addressed the functional role of centrosomally targeted tyrosine kinase activity. First, centrosomal localization was not routinely found for all chimeric fusion proteins tested. Second, targeting of tyrosine kinases to the centrosome by creating artificial chimeric fusion kinases with the centrosomal targeting domain of AKAP450 failed to enhance the oncogenic transforming potential in both Ba/F3 and U2OS cells, although phospho-tyrosine-mediated signal transduction pathways were initiated at the centrosome. We conclude that the centrosomal localization of constitutively activated tyrosine kinases does not contribute to disease pathogenesis in chronic myeloproliferative disorders.

Percutaneous balloon kyphoplasty with the patient under intravenous analgesia and sedation: a feasibility study.

BACKGROUND AND PURPOSE: Kyphoplasty is a minimally invasive procedure for the treatment of malignant or osteoporotic vertebral compression fractures, normally performed with the patient under general anesthesia. This may cause a therapeutic dilemma because these patients often have a very high risk for general anesthesia due to concomitant diseases. The aim of this study was to evaluate the safety and feasibility of percutaneous kyphoplasty by using IV anesthesia and sedation with midazolam and piritramide. MATERIALS AND METHODS: From June 2007 to June 2009, we prospectively included 133 patients (77 women, 56 men; mean age, 69.18 ± 11.45 years) who were referred for BKP. Kyphoplasty was always performed under fluoroscopic guidance with a biplane angiographic system by using a transpedicular or extrapedicular approach. The individual anesthesia risk was assessed by using the ASA criteria. All procedures were performed with the patient under IV anesthesia and sedation with fractionated administration of midazolam and piritramide. Pain was assessed before and after treatment by using a VAS. RESULTS: Ninety-nine patients (74.4%) had a significantly increased risk for general anesthesia (ASA score, ≥ 3). A total of 162 kyphoplasty procedures were performed. The mean amounts of midazolam and piritramide used were 11.3 ± 4.38 mg and 11.8 ± 3.98 mg, respectively. No complications related to IV anesthesia and sedation occurred. Periprocedural pain management was rated as sufficient, and all patients would undergo the procedure again. CONCLUSIONS: Percutaneous BKP with the patient under IV anesthesia and sedation with midazolam and piritramide is a safe and feasible method for treating vertebral compression fractures in patients with an increased risk for general anesthesia.

Training microneurosurgery - four years experiences with an in vivo model.

OBJECTIVE: Enquiries among surgical trainees revealed an increasing discontent regarding their quality of training. 40 % of young surgical trainees judge their training as inadequate and 70% are offered no structured training programme. Working time restrictions and economic pressure may be strong factors hindering residents from becoming skillful surgeons. Therefore, additional forms of training seem to be needed. METHOD: An in vivo swine model was evaluated for its practical use in training neurosurgical residents. Surgical procedures included craniotomy, dural opening, brain surgery and excision of an artificial tumour created by injection of coloured fibrin glue. Microscopy and bleeding management with bipolar cautery and haemostyptics were an integrated part of training. Supervision by experienced neurosurgeons with up to 3 trainees in a 2-day course was warranted. Standardised questionnairies before and after training were used to assess the quality and utility of the programme. RESULTS: 24 residents have participated in the course (1 (st)-5 (th) year of training). Minor experience with less than 100 conducting surgeries was seen in 59% of trainees. 14 residents had participated in more than 100 surgeries as first assistant. Spinal surgery was the predominant common experience. All participants judged their surgical training as insufficient. 77% had no microsurgical lab at their clinics. Expectations for the course were met for all trainees and the tutorials judged as excellent (65%) or good (35%). Positive evaluations of the in vivo model (97%), a realistic laboratory setup (94%), the working environment (94%) and close supervision (94%) showed that these were the most favourable aspects of the course. CONCLUSION: Educational training in surgical specialities is becoming a major problem in our daily practice and requires additional training facilities. In this context, in vivo models are an ideal opportunity for young neurosurgeons to train bleeding management and surgical complications in particular. This educational form is thought to be a unique training model which is now added by spinal and neurovascular courses.

Comparison between two intraoperative intravenous loading doses of paracetamol on pain after minor hand surgery: two grams versus one gram.

BACKGROUND: Paracetamol (acetaminophen) is widely used for postoperative analgesia at a recommended dose of 1 g every six hours in adult patients. Increasing the loading dose to 2 g was suggested to improve immediate postoperative analgesia without increased toxicity in healthy adult patients. We tested the hypothesis that a loading dose of 2 g of intravenous paracetamol results in better postoperative analgesia after surgery as compared with a dose of 1 g. METHODS: Sixty adult patients scheduled for minor hand surgery under intravenous regional anaesthesia were randomized into two groups. The first group received 1 g of intravenous paracetamol before surgery while the second group received 2 g. Verbal numeric pain score, analgesic consumption, first night sleep quality, and patient's satisfaction were recorded during the first 24 hours. RESULTS: Verbal numeric pain scores during the first 24 hours after surgery were significantly lower in the 2 g paracetamol group as compared to the 1 g paracetamol group. No differences were found between the two groups with regard to rescue analgesic consumption, sleep quality and patient's satisfaction. CONCLUSIONS: An intraoperative loading dose of 2 g paracetamol improves postoperative analgesia after minor hand surgery as compared to 1 g paracetamol.