Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment.

PURPOSE: This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population? METHODS: MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome. RESULTS: A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified. CONCLUSION: This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.

Biomechanical results of percutaneous calcaneal osteotomy using two different osteotomy designs.

BACKGROUND: Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V-osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature. We hypothesize that the V-osteotomy will result in a higher stiffness in biomechanical testing as the straight osteotomy using single screw for fixation. METHODS: The straight osteotomy (9 fresh-frozen specimens) and V-osteotomy (9 fresh-frozen specimens) was performed and the calcaneal tuberosity was moved 10mm medially and slightly rotated. One 6,5mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles. RESULTS: Despite the higher mean values of the group with V-osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A higher failure rate was observed in the group with straight osteotomy. CONCLUSION: The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies. LEVEL OF CLINICAL EVIDENCE: 5.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe.

BACKGROUND: Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance. METHODS: A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential. RESULTS: Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration. CONCLUSIONS: The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

A comparative analysis of psychological trauma experienced by children and young adults in two scenarios: evacuation after a natural disaster vs forced migration to escape armed conflict.

OBJECTIVES: Little is known about the psychological trauma experienced by children and young adults (CYAs) following displacement after natural disasters vs migration from conflict zones. In both instances, the decision to leave is usually cast by the family, and the life of CYAs is suddenly disrupted by external circumstances. STUDY DESIGN: An anonymous survey. METHODS: The same survey instrument, provided by the National Child Traumatic Stress Network (NCTSN), was used to survey self-reported health needs among CYAs during the aftermath of Hurricane Katrina (Health Survey for Children and Adolescents After Katrina) in October 2005-February 2006 and again during the peak of refugee arrivals in Berlin between October 2015 and March 2016. A weighted index to measure cumulative exposure to traumatic stresses during migration was developed along with an unweighted psychological impact score based on the 22-item NCTS psychological impact questionnaire. Spearman's correlation coefficient (rho) was used to assess the correlation between age and the two psychological impact indices. The two-tailed t-test was used to investigate differences in trauma experienced and psychological impact by gender. Logistic regression was used to investigate differences in types of traumatic stress experienced and psychological impact among CYAs displaced because of Hurricane Katrina and those seeking asylum in Berlin. RESULTS: The Katrina cohort included a total of 1133 CYAs, the Berlin cohort, a total of 405 CYAs. The median age in the Katrina cohort was 6.73 years (standard deviation [SD] 5.67, range 0-24; 50.13% males) compared with 17.64 years (SD, range 0-24; 83% males) in the Berlin cohort. Comparative analyses were adjusted to age and gender and revealed significant differences between the two cohorts, both with regards to the amount of trauma experienced and the psychological impact. A statistically significant and moderate positive correlation was observed between trauma experienced and psychological impact of migration in the refugee population (rho = 0.4955, P < 0.001); the correlation was less pronounced but still significant in the Katrina cohort (rho = 0.0942, P = 0.0015). Free-text responses revealed that in addition to common concerns about health, housing and safety, refugees were also pre-occupied with language acquisition and the adaptation to a new culture. CONCLUSIONS: The observed differences in the experience and the consequences of trauma in displaced CYAs warrant additional investigation. It was replicated that human-made disaster seems to show more traumatising potential than natural disaster. Stakeholders need to be aware of the potential medium and long-term consequences of migration/evacuation and allocate resources accordingly.

Advancements in quantum cascade laser-based infrared microscopy of aqueous media.

The large mid-infrared absorption coefficient of water frequently hampers the rapid, label-free infrared microscopy of biological objects in their natural aqueous environment. However, the high spectral power density of quantum cascade lasers is shifting this limitation such that mid-infrared absorbance images can be acquired in situ within signal-to-noise ratios of up to 100. Even at sample thicknesses well above 50 µm, signal-to-noise ratios above 10 are readily achieved. The quantum cascade laser-based microspectroscopy of aqueous media is exemplified by imaging an aqueous yeast solution and quantifying glucose consumption, ethanol generation as well as the production of carbon dioxide gas during fermentation.

Rapid identification of goblet cells in unstained colon thin sections by means of quantum cascade laser-based infrared microspectroscopy.

Changes in the volume covered by mucin-secreting goblet cell regions within colon thin sections may serve as a means to differentiate between ulcerative colitis and infectious colitis. Here we show that rapid, quantum cascade laser-based mid-infrared microspectroscopy might be able to contribute to the differential diagnosis of colitis ulcerosa, an inflammatory bowel disease. Infrared hyperspectral images of mouse colon thin sections were obtained within 7.5 minutes per section with a pixel size of 3.65 × 3.65 µm(2) and a field of view of 2.8 × 3.1 mm(2). The spectra were processed by training a random decision forest classifier on the basis of k-means clustering on one thin section. The trained algorithm was then applied to 5 further thin sections for a blinded validation and it was able to identify goblet cells in all sections. The rapid identification of goblet cells within these unstained, paraffinized thin sections of colon tissue was enabled by the high content of glycopeptides within the goblet cells as revealed by the pronounced spectral signatures in the 7.6 µm-8.6 µm and the 9.2 µm-9.7 µm wavelength ranges of the electromagnetic spectrum. More so, the simple calculation of the ratio between the absorbance values at 9.29 µm and 8.47 µm provides the potential to further shorten the time for measurement and analysis of a thin section down to well below 1 minute.

Recidivism and characteristics of highly dangerous offenders being released from retrospectively imposed preventive detention: an empirical study.

This study examines the recidivism of offenders who are considered to be highly dangerous but who, as a result of a decision of the German Federal High Court, have not been in preventive detention because it was imposed retrospectively (Group II preventive detention cases; § 66b StGB). Taking into consideration the restrictions imposed by the study, the data were evaluated regarding their usefulness for predicting the likelihood of reoffending. The results of this study suggest that it could be useful to describe criteria for the not very severe reoffending group.

[Legal probation after deferred retrospective preventive detention: implications for the amended regulations on preventive detention]. / Legalbewährung nach nicht angeordneter nachträglicher Sicherungsverwahrung : Implikationen für die Neuregelung der Sicherungsverwahrung.

The study examines the legal probation of offenders who are considered to be highly dangerous but due to the decision of the Federal High Court were not in retrospective preventive detention (§ 66b StGB). In view of the current discussion, in anticipation of a detailed presentation of the study results the relevant criteria "probation behavior", "personality characteristics" and "prognosis quality" are picked out. The results are evaluated with respect to knowledge of the restrictions conditioned by the study regarding the usefulness for the prognosis of reoffending. The results of this study suggest that it might be useful to describe psychological criteria for the not seriously reoffending group of probands.

State of research, feasibility, safety, acceptability, and outcomes examined on remotely delivered exercises using technology for older adult with cancer: a scoping review.

INTRODUCTION: Technology-based exercise is gaining attention as a promising strategy for increasing physical activity (PA) in older adults with cancer (OACA). However, a comprehensive understanding of the interventions, their feasibility, outcomes, and safety is limited. This scoping review (1) assessed the prevalence and type of technology-based remotely delivered exercise interventions for OACA and (2) explored the feasibility, safety, acceptability, and outcomes in these interventions. METHODS: Studies with participant mean/median age ≥ 65 reporting at least one outcome measure were included. Databases searched included the following: PubMed, CINAHL, Embase, Cochrane Library Online, SPORTDiscus, and PsycINFO. Multiple independent reviewers completed screening and data abstractions of articles in English, French, and Spanish. RESULTS: The search yielded 2339 citations after removing duplicates. Following title and abstract screening, 96 full texts were review, and 15 were included. Study designs were heterogeneous, and sample sizes were diverse (range 14-478). The most common technologies used were website/web portal (n = 6), videos (n = 5), exergaming (n = 2), accelerometer/pedometer with video and/or website (n = 4), and live-videoconferencing (n = 2). Over half (9/15) of the studies examined feasibility using various definitions; feasibility outcomes were reached in all. Common outcomes examined include lower body function and quality of life. Adverse events were uncommon and minor were reported. Qualitative studies identified cost- and time-savings, healthcare professional support, and technology features that encourage engagement as facilitators. CONCLUSION: Remote exercise interventions using technology appear to be feasible and acceptable in OACA. IMPLICATIONS FOR CANCER SURVIVORS: Some remote exercise interventions may be a viable way to increase PA for OACA.

Chemoradiation in patients with unresectable extrahepatic and hilar cholangiocarcinoma or at high risk for disease recurrence after resection : Analysis of treatment efficacy and failure in patients receiving postoperative or primary chemoradiation.

BACKGROUND: The purpose of this work was to determine efficacy, toxicity, and patterns of recurrence after concurrent chemoradiation (CRT) in patients with extrahepatic bile duct cancer (EHBDC) and hilar cholangiocarcinoma (Klatskin tumours) in case of incomplete resection or unresectable disease. PATIENTS AND METHODS: From 2003-2010, 25 patients with nonmetastasized EHBDC and hilar cholangiocarcinoma were treated with radiotherapy and CRT at our institution in an postoperative setting (10 patients, 9 patients with R1 resections) or in case of unresectable disease (15 patients). Median age was 63 years (range 38-80 years) and there were 20 men and 5 women. Median applied dose was 45 Gy in both patient groups. RESULTS: Patients at high risk (9 times R1 resection, 1 pathologically confirmed lymphangiosis) for tumour recurrence after curative surgery had a median time to disease progression of 8.7 months and an estimated mean overall survival of 23.2 months (6 of 10 patients are still under observation). Patients undergoing combined chemoradiation in case of unresectable primary tumours are still having a poor prognosis with a progression-free survival of 7.1 months and a median overall survival of 12.0 months. The main site of progression was systemic (liver, peritoneum) in both patient groups. CONCLUSION: Chemoradiation with gemcitabine is safe and can be applied safely in either patients with EHBDC or Klatskin tumours at high risk for tumour recurrence after resection and patients with unresectable tumours. Escalation of systemic and local treatment should be investigated in future clinical trials.

Barriers and facilitators related to undertaking physical activities among men with prostate cancer: a scoping review.

BACKGROUND: Prostate cancer (PC) and its treatments lead to significant acute, chronic, or latent adverse effects that result in declines in patients' physical functions, quality of life and reduced sense of masculinities. Robust evidence shows that physical activity (PA) can improve many health outcomes in men with PC; however, less is known about the facilitators, preferences, and barriers to PA engagement in this population. The purpose of this scoping review is to document the nature and extent of literature related to these aspects of PA participation among men with PC. METHODS: We conducted a scoping review of PA among men with PC. Databases searched included Medline, CINAHL, Embase, Rehabilitation & Sports Medicine Source, and SportDiscus from inception to June 30, 2020. Multiple reviewers were used in all screening and data abstractions. RESULTS: The search yielded 2788 individual citations after duplicates were removed. Following title and abstract screening, 129 underwent full-text review, and 46 articles were included. Quantitative data related to our research question showed that structured group exercise was the most commonly reported facilitator/preference among men with PC, whereas treatment-related effects and lack of time are the most common barriers. In terms of qualitative data, the most prominent theme noted related to masculinities and gender-specific needs within the context of having PC. CONCLUSION: Men with PC have unique facilitators and barriers concerning PA. More work is needed from the research and clinical practice perspectives to enable this population to engage and remain in regular PA.

Rifting of the oceanic Azores Plateau with episodic volcanic activity.

Extension of the Azores Plateau along the Terceira Rift exposes a lava sequence on the steep northern flank of the Hirondelle Basin. Unlike typical tholeiitic basalts of oceanic plateaus, the 1.2 km vertical submarine stratigraphic profile reveals two successive compositionally distinct basanitic to alkali basaltic eruptive units. The lower unit is volumetrically more extensive with ~ 1060 m of the crustal profile forming between ~ 2.02 and ~ 1.66 Ma, followed by a second unit erupting the uppermost ~ 30 m of lavas in ~ 100 kyrs. The age of ~ 1.56 Ma of the youngest in-situ sample at the top of the profile implies that the 35 km-wide Hirondelle Basin opened after this time along normal faults. This rifting phase was followed by alkaline volcanism at D. João de Castro seamount in the basin center indicating episodic volcanic activity along the Terceira Rift. The mantle source compositions of the two lava units change towards less radiogenic Nd, Hf, and Pb isotope ratios. A change to less SiO2-undersaturated magmas may indicate increasing degrees of partial melting beneath D. João de Castro seamount, possibly caused by lithospheric thinning within the past 1.5 million years. Our results suggest that rifting of oceanic lithosphere alternates between magmatically and tectonically dominated phases.

The effects of monocytes on tumor cell extravasation in a 3D vascularized microfluidic model.

Metastasis is the leading cause of cancer-related deaths. Recent developments in cancer immunotherapy have shown exciting therapeutic promise for metastatic patients. While most therapies target T cells, other immune cells, such as monocytes, hold great promise for therapeutic intervention. In our study, we provide primary evidence of direct engagement between human monocytes and tumor cells in a 3D vascularized microfluidic model. We first characterize the novel application of our model to investigate and visualize at high resolution the evolution of monocytes as they migrate from the intravascular to the extravascular micro-environment. We also demonstrate their differentiation into macrophages in our all-human model. Our model replicates physiological differences between different monocyte subsets. In particular, we report that inflammatory, but not patrolling, monocytes rely on actomyosin based motility. Finally, we exploit this platform to study the effect of monocytes, at different stages of their life cycle, on cancer cell extravasation. Our data demonstrates that monocytes can directly reduce cancer cell extravasation in a non-contact dependent manner. In contrast, we see little effect of monocytes on cancer cell extravasation once monocytes transmigrate through the vasculature and are macrophage-like. Taken together, our study brings novel insight into the role of monocytes in cancer cell extravasation, which is an important step in the metastatic cascade. These findings establish our microfluidic platform as a powerful tool to investigate the characteristics and function of monocytes and monocyte-derived macrophages in normal and diseased states. We propose that monocyte-cancer cell interactions could be targeted to potentiate the anti-metastatic effect we observe in vitro, possibly expanding the milieu of immunotherapies available to tame metastasis.

[Myxoma of the middle ear-a rare cause of facial palsy]. / Das Myxom des Mittelohrs als mögliche Ursache einer temporären Fazialisparese.

In case of the co-occurrence of facial palsy and inflammation-like symptoms of the same ear, the differential diagnosis is focused on viral (herpes zoster) or bacterial diseases. We report a patient for whom the surgical exploration of the middle ear revealed a benign tumor: a myxoma. These neoplasias are rare tumors in the head and neck region. The typical tumor site is the atrium of heart. In the ear, the tumor grows slowly and remains asymptomatic unless it irritates structures such as the facial nerve or the vestibular organ. Histologically, the tumor presents a "myxoid" matrix that is rich in acid mucopolysaccarides. The treatment of choice is complete surgical resection. Using the case presented, we discuss the causality between the tumor and the facial palsy, although during the operation the bony canal of the nerve was found to be intact. In any cases with clinically and radiologically unclear findings of the ear in connection with facial palsy, surgical exposure should be considered.

Effects of clofibrate treatment in laying hens.

Expression of peroxisome proliferator-activated receptor-alpha (PPARalpha) has been shown in liver of chicks, but effects of its activation have not yet been investigated. In this study, laying hens were treated with clofibrate, a synthetic PPARalpha agonist, to investigate the effects of PPARalpha activation on liver lipid metabolism. Hens receiving a diet containing 5 g of clofibrate/kg had a lower food intake and higher liver mRNA concentrations of typical PPARalpha target genes (carnitine palmitoyltransferase 1A, acyl-coenzyme A oxidase, bifunctional enzyme, lipoprotein lipase) involved in hepatic mitochondrial and peroxisomal beta-oxidation and plasma triglyceride clearance than control hens that received the same diet without clofibrate (P<0.05). Hens treated with clofibrate also had lower mRNA concentrations of fatty acid synthase, 3-hydroxy-3-methylglutaryl-coenzyme A reductase, and low-density lipoprotein receptor, proteins involved in fatty acid biosynthesis and cholesterol biosynthesis and uptake, than hens fed the control diet (P<0.05). These changes in clofibrate-treated hens were accompanied by reduced liver triglyceride concentrations, strongly diminished very low density triglyceride and cholesterol concentrations (P<0.05), a disturbed maturation of egg follicles, a complete stop of egg production, and a markedly reduced plasma 17-beta-estradiol concentration (P<0.05). In conclusion, it is shown that clofibrate has complex effects on hepatic lipid metabolism in laying hens that mimic PPARalpha activation in mammals, affect maturation of egg follicles, and lead to a stop of egg production. Because clofibrate treatment strongly reduced food intake in the hens, some of these effects (i.e., egg production) may have been due to a low energy and nutrient intake.

Environmental signatures and effects of an oil and gas wastewater spill in the Williston Basin, North Dakota.

Wastewaters from oil and gas development pose largely unknown risks to environmental resources. In January 2015, 11.4ML (million liters) of wastewater (300g/L TDS) from oil production in the Williston Basin was reported to have leaked from a pipeline, spilling into Blacktail Creek, North Dakota. Geochemical and biological samples were collected in February and June 2015 to identify geochemical signatures of spilled wastewaters as well as biological responses along a 44-km river reach. February water samples had elevated chloride (1030mg/L) and bromide (7.8mg/L) downstream from the spill, compared to upstream levels (11mg/L and <0.4mg/L, respectively). Lithium (0.25mg/L), boron (1.75mg/L) and strontium (7.1mg/L) were present downstream at 5-10 times upstream concentrations. Light hydrocarbon measurements indicated a persistent thermogenic source of methane in the stream. Semi-volatile hydrocarbons indicative of oil were not detected in filtered samples but low levels, including tetramethylbenzenes and di-methylnaphthalenes, were detected in unfiltered water samples downstream from the spill. Labile sediment-bound barium and strontium concentrations (June 2015) were higher downstream from the Spill Site. Radium activities in sediment downstream from the Spill Site were up to 15 times the upstream activities and, combined with Sr isotope ratios, suggest contributions from the pipeline fluid and support the conclusion that elevated concentrations in Blacktail Creek water are from the leaking pipeline. Results from June 2015 demonstrate the persistence of wastewater effects in Blacktail Creek several months after remediation efforts started. Aquatic health effects were observed in June 2015; fish bioassays showed only 2.5% survival at 7.1km downstream from the spill compared to 89% at the upstream reference site. Additional potential biological impacts were indicated by estrogenic inhibition in downstream waters. Our findings demonstrate that environmental signatures from wastewater spills are persistent and create the potential for long-term environmental health effects.

Smooth muscle cell proliferation and restenosis after stand alone coronary excimer laser angioplasty.

It has been shown that coronary excimer laser angioplasty can remove atherosclerotic intracoronary tissue. Stand alone coronary excimer laser angioplasty was successfully performed in a 53 year old white man with 90% stenosis of the left anterior descending coronary artery and exertional angina (Canadian Cardiovascular Society class III). The lesion was reduced to a 30% residual stenosis with use of a 1.2 mm and subsequently a 1.8 mm diameter laser catheter. Early follow-up angiography 24 h later revealed persistent patency and unchanged lesion diameter of the target vessel. The patient was free of symptoms during the 2 month follow-up period, but died suddenly while playing in a tennis tournament 63 days after the procedure. Postmortem histologic examination revealed 80% restenosis at the lesion site without plaque disruption or thrombosis. Specific staining of the histologic specimen for smooth muscle cells using alpha-actin revealed significant smooth muscle cell proliferation at the site of coronary excimer laser angioplasty. However, most of the vessel narrowing appeared to be due to underlying fibrotic plaque as a result of insufficient tissue ablation. This was probably related to the size of the currently available catheters, which are too small to create a large channel.

Effect of exercise on valvular resistance in patients with mitral stenosis.

OBJECTIVES: This exercise study assessed the relation between valvular resistance and flow in patients with mitral stenosis. BACKGROUND: Valvular resistance has been proposed as an alternative measure of stenotic valvular lesions, which is speculated to remain stable under changing hemodynamic conditions. METHODS: In 35 of 40 patients with pure or predominant mitral stenosis, continuous wave Doppler measurements of the mitral stenotic jet were possible at rest and during supine bicycle ergometry. Simultaneously, transvalvular flow was assessed by thermodilution technique. For calculation of valvular resistance, the mean mitral valve pressure gradient was determined according to the simplified Bernoulli equation and divided by transvalvular flow. Additionally, effective mitral valve area was calculated according to the continuity equation method, dividing flow by the mean diastolic flow velocity. RESULTS: Valvular resistance was 65 +/- 32 dynes.s.cm-5 at rest and increased to 82 +/- 43 dynes.s.cm-5 at 25 W (p < 0.001). The most prominent increase in valvular resistance (rest to 25 W 63 +/- 28 to 95 +/- 48 dynes.s.cm-5, p < 0.001) was found in those patients who had no or only a moderate (< 20%) change in effective mitral valve area. In contrast, valvular resistance remained constant (67 +/- 36 vs. 70 +/- 32 dynes.s.cm-5) in patients with a significant (> or = 20%) increase in mitral valve area with exercise. CONCLUSIONS: In patients with mitral stenosis, the exercise-induced changes in valvular resistance are heterogeneous. This is the result of the variable response of mitral valve area to an increase in flow. In the individual patient, mitral valve area can significantly increase, a factor that has to be taken into account when interpreting the hemodynamic relevance of the obstruction. Calculated valvular resistance is flow dependent and has no advantage over valve area calculations for quantifying mitral stenosis.

Diagnostic value of stress echocardiography for the detection of restenosis after PTCA.

Stress echocardiography (SE) has become a widely accepted clinical tool for the non-invasive diagnosis of coronary artery disease (CAD). Previous studies have confirmed that SE has superior diagnostic value compared to exercise ECG testing. SE has also emerged as a cost-effective alternative to nuclear imaging techniques in patients where symptoms and/or conventional ECG stress testing have provided ambiguous results. Several studies have investigated the value of SE to detect significant restenosis after PTCA. However, in these studies, different methods have been used to induce cardiovascular stress such as physical exercise by bicycle or treadmill, pharmacologic stress testing (with dipyridamole or dobutamine) or transoesphageal atrial pacing. This review evaluates the published database of SE to detect restenosis in patients after successful PTCA. It includes 13 studies with a total of 989 patients performed at 3-6 months after the primary intervention. The diagnostic value, utility and limitations of SE is presented and discussed. The data show that SE has a high diagnostic value for detecting significant restenosis after PTCA. Mean sensitivity of SE was 74% (CI 69-79%), mean specificity was 87% (CI 84-89%). The positive predictive value (PPV) of SE was 83%, the overall negative predictive value (NPV) 97%. We conclude that, in the follow-up of patients after PTCA, SE has distinct advantages over other non-invasive methods and is a recommended method for the detection of those to be considered for repeat angiography.

Local and systemic delivery of low molecular weight heparin stimulates the reendothelialization after balloon angioplasty.

OBJECTIVE: Recent investigations revealed the importance of endothelial cell integrity and function in the pathogenesis of restenosis after angioplasty. Agents which stimulate reendothelialization may prevent restenosis after interventional procedures. The results of in vitro studies suggested that heparin and low molecular weight heparin administration may enhance the recovery of the endothelium. In this study the extent of endothelial denudation and the occurrence and time course of endothelial regeneration after experimental balloon angioplasty followed by subcutaneous or local delivery of low molecular weight heparin was investigated. METHODS: A total of 102 rabbits were included in the study. An atheromatous plaque was induced by electrical stimulation in the right carotid artery of the animals. All animals underwent balloon angioplasty. Thirty-two rabbits received no further medical treatment. Twenty-five rabbits received subcutaneous low molecular weight heparin reviparin (400 anti-Xa-units/day) during the following 7 days. In 25 animals the dilated arterial segments were treated locally with reviparin (1500 anti-Xa-units/4 ml, 2 atm) using a porous balloon (2.5 mm, 35 holes, diameter 75 microns). Twenty animals served as control group without intervention. The vessels were excised 3, 7, 14, 28 and 56 days following intervention. Sections were stained with an antibody against von Willebrand factor and PECAM 1 to confirm the endothelial origin of the lining cells. After bromodeoxyuridine labeling, the extent of proliferation was determined by using a monoclonal antibody. In addition, morphometric analysis of the intimal and medial area was performed. RESULTS: Three days after balloon angioplasty histomorphological analysis showed a reduction of about 60% of the preinterventional endothelial cell number in all three groups. Already one week after intervention there was a significantly higher number of endothelial cells in both groups of low molecular weight heparin treated animals compared to the untreated group (s.c. group 144 +/- 33, local group 142 +/- 32 versus untreated 79 +/- 17 endothelial cells, p < or = 0.05). This significant difference was maintained during the following four weeks and demonstrated a 2-fold increase in endothelial proliferation in the heparin treated animals compared with the untreated group. In addition, immunohistological examination showed a significant decrease in smooth muscle cell proliferation in the s.c. and local reviparin treated animals and a subsequent reduction of intimal thickening. CONCLUSION: Local delivery of low molecular weight heparin promotes reendothelialization and contributes to the inhibition of smooth muscle cell proliferation.