Prospective ECG-gated High-Pitch Photon-Counting CT Angiography: Evaluation of measurement accuracy for aortic annulus sizing in TAVR planning.

PURPOSE: In planning transcatheter aortic valve replacement (TAVR), retrospective cardiac spiral-CT is recommended to measure aortic annulus with subsequent CT-angiography (CTA) to evaluate access routes. Photon-counting detector (PCD)-CT enables to assess the aortic annulus in desired cardiac phases, using prospective ECG-gated high-pitch CTA. The aim of this study was to evaluate the measurement accuracy of aortic annulus using prospective ECG-gated high-pitch CTA against retrospective spiral-CT reference. METHOD: Thirty patients underwent cardiac spiral-CT and prospective ECG-gated (30% R-R on aortic valve level) high-pitch CTA. Using propensity score matching, another 30 patients were identified whose CTA was performed using high-pitch mode without ECG-synchronization. Two investigators measured annular diameter, perimeter, and area on cardiac spiral-CT and high-pitch CTA. RESULTS: The aortic valve was imaged in systole in 90 % of prospective ECG-gated CTA cases but only 50 % of non-ECG-gated CTA cases (p = 0.002). There was a strong correlation (r ≥ 0.94) without significant differences (p ≥ 0.09) between cardiac spiral-CT and prospective ECG-gated high-pitch CTA for all annulus measurements. In contrast, significant differences were found in annular short-axis diameter and area between cardiac spiral-CT and non-ECG-gated high-pitch CTA (p ≤ 0.03). Furthermore, prospective ECG-gated high-pitch CTA showed significantly reduced radiation exposure compared with cardiac spiral-CT (CTDI 4.52 vs. 24.10 mGy; p < 0.001). CONCLUSION: PCD-CT-based prospective ECG-gated high-pitch scans with targeted systolic acquisition at the level of the aortic valve can simultaneously visualize TAVR access routes and accurately measure systolic annulus size. This approach could aid in optimizing protocols to achieve lower radiation doses in the growing population of younger, low-risk TAVR patients.

Patients', healthcare providers', and insurance company employees' preferences for knee and hip osteoarthritis care: a discrete choice experiment.

OBJECTIVE: To determine patients', healthcare providers', and insurance company employees' preferences for knee and hip osteoarthritis (KHOA) care. DESIGN: In a discrete choice experiment, patients with KHOA or a joint replacement, healthcare providers, and insurance company employees were repetitively asked to choose between KHOA care alternatives that differed in six attributes: waiting times, out of pocket costs, travel distance, involved healthcare providers, duration of consultation, and access to specialist equipment. A (panel latent class) conditional logit model was used to determine preference heterogeneity and relative importance of the attributes. RESULTS: Patients (n = 648) and healthcare providers (n = 76) valued low out of pocket costs most, while insurance company employees (n = 150) found a joint consultation by general practitioner (GP) and orthopaedist most important. Patients found the duration of consultation less important than healthcare providers and insurance company employees did. Patients without a joint replacement were likely to prefer healthcare with low out of pocket costs. Patients with a joint replacement and/or low disease-specific quality of life were likely to prefer healthcare from an orthopaedist. Patients who already received healthcare for knee/hip problems were likely to prefer a joint consultation by GP and orthopaedist, and direct access to specialist equipment. CONCLUSIONS: Patients, healthcare providers, and insurance company employees highly prefer a joint consultation by GP and orthopaedist with low out of pocket costs. Within patients, there is substantial preference heterogeneity. These results can be used by policy makers and healthcare providers to choose the most optimal combination of KHOA care aligned to patients' preferences.

CT-derived left ventricular global strain: a head-to-head comparison with speckle tracking echocardiography.

We assessed CT-derived left ventricular strain in a cohort of patients referred for transcatheter aortic valve implantation (TAVI) and validated it against 2 dimensional speckle tracking echocardiography as the gold standard. 65 consecutive patients with symptomatic aortic valve stenosis referred for CT imaging prior to TAVI were included in this analysis. For all patients, retrospectively ECG-gated multi-phase functional CT data sets acquired with identical reconstruction parameters were available. All data sets were acquired using a third generation dual source system. In all patients, multiphase reconstructions in increments of 10% of the cardiac cycle were rendered (slice thickness 0.75, increment 0.5 mm, medium smooth reconstruction kernel) and transferred to a dedicated workstation (Ziostation2, Ziosoft Inc., Tokyo, Japan). Additional functional reconstructions for dynamic assessment and quantification of strain were processed. Multiplanar reconstructions (MPR) of the left ventricle similar to standard echocardiographic 4, 2 and apical 3 chamber views were rendered in CT. Similar to echocardiographic longitudinal strain, the perimeter of the left ventricle was manually traced within the myocardium and peak maximal shortening as a parameter representing longitudinal strain was calculated for each view and averaged to obtain a marker for global longitudinal strain (CT perimeter-derived strain). Furthermore, for quantification of 3-dimensional strain, endocardial and epicardial borders of myocardium were marked in six short axis views and peak maximum 3- dimensional strain of the myocardium was calculated in standard six basal, six mid and four apical segments. 3-dimensional strain values of the 16 standard segments as well as perimeter-derived strain values in the three standard windows were averaged to obtain global strain. Echocardiography was performed in all patients before CT data acquisition. Digital loops were acquired from three apical views (four-, two-, and three chamber views). For assessment of 2 dimensional global longitudinal strain (GLS), recordings were processed with acoustic-tracking software allowing offline semiautomated speckle-based strain analyses. The mean age of all 65 patients was 81 ± 5 years. The mean echocardiographic ejection fraction and mean echocardiographic GLS were 50 ± 12% and -13.6 ± 4.5%, respectively. The mean CT-derived peak 3-dimensional global strain and mean peak strain derived by perimeter was 43.2 ± 13.5% and -11.2 ± 3.5%, respectively. Both CTderived global 3D-strain and perimeter derived strain showed a significant correlation to GLS derived by echocardiography (r = -0.8, p < 0.0001 for 3D strain and r = 0.71, p < 0.0001 for perimeter-derived strain). Bland-Altman analysis showed a systematic underestimation (i. e. worse strain values) of CT perimeter-derived strain compared to GLS by echocardiography (mean difference -2.4% with 95% limits of agreement between 4% to -9%). ROC Curve analysis assuming a normal GLS when less than -18% showed that a CT-derived peak 3-dimensional global strain cut-off-value of 45% has a sensitivity of 91% and a specificity of 60% for detecting normal left ventricular strain (AUC 0.81, p = 0.001). For CT perimeter-derived strain, a cut-off value of -12%-assuming a normal echocardiographic GLS when less than -18%-achieved a sensitivity of 82% and a specificity of 61% (AUC of 0.82, p = 0.001) for detecting abnormal left ventricular strain. Using dedicated software, assessment of CT-derived left ventricular strain is feasible and comparable to strain derived by echocardiographic 2 dimensional speckle tracking.

Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

SCOPE: Clostridium difficile infection (CDI) is the most important infective cause of healthcare-associated diarrhoea in high income countries and one of the most important healthcare-associated pathogens in both Europe and the United States. It is associated with high morbidity and mortality resulting in both societal and financial burden. A significant proportion of this burden is potentially preventable by a combination of targeted infection prevention and control measures and antimicrobial stewardship. The aim of this guidance document is to provide an update on recommendations for prevention of CDI in acute care settings to provide guidance to those responsible for institutional infection prevention and control programmes. METHODS: An expert group was set up by the European society of clinical microbiology and infectious diseases (ESCMID) Study Group for C. difficile (ESGCD), which performed a systematic review of the literature on prevention of CDI in adults hospitalized in acute care settings and derived respective recommendations according to the GRADE approach. Recommendations are stratified for both outbreak and endemic settings. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: This guidance document provides thirty-six statements on strategies to prevent CDI in acute care settings, including 18 strong recommendations. No recommendation was provided for three questions.

CT-derived left ventricular global strain in aortic valve stenosis patients: A comparative analysis pre and post transcatheter aortic valve implantation.

INTRODUCTION: We assessed the potential of CT strain to detect changes in myocardial function in patients referred for TAVI pre and post intervention. PATIENTS AND METHODS: 25 consecutive patients with symptomatic aortic valve stenosis in whom TAVI had been performed were included in this analysis. Functional CT data sets acquired before and 3 to 6 months after TAVI were available. Multiphase reconstructions in increments of 10% of the cardiac cycle were rendered and transferred to a dedicated workstation (Ziostation2, Ziosoft Inc., Tokyo, Japan). For quantification of left ventricular strain, multiplanar reconstructions of the left ventricle in standard 4 chamber, 2 chamber as well as apical 3 chamber views were rendered. The perimeter of the left ventricle was traced dynamically through the cardiac cycle. Peak strain was calculated for each patient pre and post intervention. Furthermore, for quantification of 3-dimensional maximum principal strain, 2 volumetric regions of interests (VOI) were placed per each basal, mid and apical segment of the previously mentioned MPRs and peak maximal principal strain was calculated. Maximum principal strain as well as perimeter-derived longitudinal strain values in the three standard windows were averaged to obtain global strain. RESULTS: 25 patients were included in this analysis (mean age 78 ±â€¯9 years, 13 males). Peak global maximum principal strain was significantly higher at follow-up compared to baseline (0.46 ±â€¯0.19 vs. 0.59 ±â€¯0.18, respectively, p = 0.001). Similarly global longitudinal strain derived by perimeter was significantly lower - implying better contraction - compared to baseline (-8.6% ±â€¯2.8% vs. -9.8% ±â€¯2.6%, respectively, p = 0.006). CONCLUSION: Using dedicated software, assessment of CT derived left ventricular strain is feasible. In patients treated with transcatheter aortic valve replacement, CT-derived parameters of global myocardial strain improve onshort-term follow-up.

Hybridization of Subgap States in One-Dimensional Superconductor-Semiconductor Coulomb Islands.

We present measurements of one-dimensional superconductor-semiconductor Coulomb islands, fabricated by gate confinement of a two-dimensional InAs heterostructure with an epitaxial Al layer. When tuned via electrostatic side gates to regimes without subgap states, Coulomb blockade reveals Cooper-pair mediated transport. When subgap states are present, Coulomb peak positions and heights oscillate in a correlated way with magnetic field and gate voltage, as predicted theoretically, with (anti)crossings in (parallel) transverse magnetic field indicating Rashba-type spin-orbit coupling. Overall results are consistent with a picture of overlapping Majorana zero modes in finite wires.

Leaflet thrombosis following transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is increasingly being offered to high-risk patients with symptomatic aortic valve stenosis. Recent reports have suggested a high incidence of subclinical leaflet thrombosis following bioprosthestic aortic valve replacement. We report the frequency and clinical presentation of leaflet thrombosis identified by cardiac CT in patients referred for follow-up contrast enhanced CT angiography following TAVI. METHODS: 91 consecutive patients referred for follow-up contrast-enhanced CT angiography following TAVI were screened for inclusion in this analysis. Out of these, 13 patients were excluded. All CT examinations were performed using a 2nd or a 3rd generation dual-source system (Somatom Definition Flash/Force, Forchheim, Germany). In all patients, retrospectively ECG-gated spiral acquisition with tube modulation was performed to allow for assessment of leaflet motion. All prostheses were analyzed for presence of leaflet thrombosis defined as hypo-attenuated leaflet thickening with or without leaflet restriction. Post-procedural antithrombotic regimen as well as symptom status was documented in all patients. RESULTS: 78 consecutive patients (35 males, 81 ± 4 years) were analyzed. TAVI had been performed in all patients (76 transfemoral access, 2 transapical access) with either balloon-expandable prostheses (4 Sapien XT, 64 Sapien 3) or self-expandable prostheses (5 SJM Portico, 5 Symetis Acurate). Follow-up CT angiography was performed at a median of 4 months following index procedure (Interquartile range 1 month). Leaflet thrombosis was detected in 18 patients (23%, 14 Sapien 3, 1 Sapien XT, 2 SJM Portico, 1 Symetis Acurate). In patients with leaflet thickening on CT, only 11% were on either oral anticoagulation or new oral anticoagulants versus 50% for patients with no leaflet thickening (p 0.002). In patients with leaflet thrombosis, 3 leaflets were affected in 5 patients, 2 leaflets in 5 patients and in 8 patient only 1 leaflet was affected. Clinical symptoms (angina, dyspnea or both) were reported in 2/18 patients with leaflet thrombosis (11%) and in both patients a significant increase of the mean echocardiographic gradient over the prosthesis was documented. The peak and mean echocardiographic gradients obtained at the day of CT examination was significantly higher in symptomatic patients versus asymptomatic patients (peak 46 ± 7 vs. 23 ± 11 mmHg, mean 29 ± 7 vs. 12 ± 6 mmHg, p = 0.01 and 0.002, respectively). Follow-up CT was available for 4 patients with complete resolution of the hypo-attenuated leaflet thickening following treatment. CONCLUSION: Leaflet thrombosis following TAVI is a relatively frequent finding in patients referred for contrast enhanced CT angiography following TAVI. In the majority of patients it follows a subclinical course and is substantially more frequent in individuals who are not on oral anticoagulation. However, in patients with relevant increase in prosthetic gradients, symptomatic presentations are possible.

ARCTIC CHANGE AND POSSIBLE INFLUENCE ON MID-LATITUDE CLIMATE AND WEATHER: A US CLIVAR White Paper.

The Arctic has warmed more than twice as fast as the global average since the mid 20th century, a phenomenon known as Arctic amplification (AA). These profound changes to the Arctic system have coincided with a period of ostensibly more frequent events of extreme weather across the Northern Hemisphere (NH) mid-latitudes, including extreme heat and rainfall events and recent severe winters. Though winter temperatures have generally warmed since 1960 over mid-to-high latitudes, the acceleration in the rate of warming at high-latitudes, relative to the rest of the NH, started approximately in 1990. Trends since 1990 show cooling over the NH continents, especially in Northern Eurasia. The possible link between Arctic change and mid-latitude climate and weather has spurred a rush of new observational and modeling studies. A number of workshops held during 2013-2014 have helped frame the problem and have called for continuing and enhancing efforts for improving our understanding of Arctic-mid-latitude linkages and its attribution to the occurrence of extreme climate and weather events. Although these workshops have outlined some of the major challenges and provided broad recommendations, further efforts are needed to synthesize the diversified research results to identify where community consensus and gaps exist. Building upon findings and recommendations of the previous workshops, the US CLIVAR Working Group on Arctic Change and Possible Influence on Mid-latitude Climate and Weather convened an international workshop at Georgetown University in Washington, DC, on February 1-3, 2017. Experts in the fields of atmosphere, ocean, and cryosphere sciences assembled to assess the rapidly evolving state of understanding, identify consensus on knowledge and gaps in research, and develop specific actions to accelerate progress within the research community. With more than 100 participants, the workshop was the largest and most comprehensive gathering of climate scientists to address the topic to date. In this white paper, we synthesize and discuss outcomes from this workshop and activities involving many of the working group members. WORKSHOP FINDINGS: Rapid Arctic change - Emergence of new forcing (external and internal) of atmospheric circulation: Rapid Arctic change is evident in the observations and is simulated and projected by global climate models. AA has been attributed to sea ice and snow decline (regionally and seasonally varying). However this cannot explain why AA is greatest in winter and weakest in summer. It was argued at the workshop that other factors can also greatly contribute to AA including: increased downwelling longwave radiation from greenhouse gases (including greater water vapor concentrations from local and remote sources); increasing ocean heat content, due to local and remote processes; regional and hemispheric atmospheric circulation changes; increased poleward heat transport in the atmosphere and ocean; and cloud radiative forcing. In particular, there is emerging observational evidence that an enhanced poleward transport of sensible and latent heat plays a very important role in the AA of the recent decades, and that this enhancement is mostly fueled by changes in the atmospheric circulation. We concluded that our understanding of AA is incomplete, especially the relative contributions from the different radiative, thermodynamic, and dynamic processes.Arctic mid-latitude linkages - Focusing on seasonal and regional linkages and addressing sources of inconsistency and uncertainty among studies: The topic of Arctic mid-latitude linkages is controversial and was vigorously debated at the workshop. However, we concluded that rapid Arctic change is contributing to changes in mid-latitude climate and weather, as well as the occurrence of extreme events. But how significant the contribution is and what mechanisms are responsible are less well understood. Based on the synthesis efforts of observational and modeling studies, we identified a list of proposed physical processes or mechanisms that may play important roles in linking Arctic change to mid-latitude climate and weather. The list, ordered from high to low confidence, includes: increasing geopotential thickness over the polar cap; weakening of the thermal wind; modulating stratosphere-troposphere coupling; exciting anomalous planetary waves or stationary Rossby wave trains in winter and modulating transient synoptic waves in summer; altering storm tracks and behavior of blockings; and increasing frequency of occurrence of summer wave resonance. The pathway considered most robust is the propagation of planetary/Rossby waves excited by the diminished Barents-Kara sea ice, contributing to a northwestward expansion and intensification of the Siberian high leading to cold Eurasian winters. OPPORTUNITIES AND RECOMMENDATIONS: An important goal of the workshop was achieved: to hasten progress towards consensus understanding and identification of knowledge gaps. Based on the workshop findings, we identify specific opportunities to utilize observations and models, particularly a combination of them, to enable and accelerate progress in determining the mechanisms of rapid Arctic change and its mid-latitude linkages.Observations: Due to the remoteness and harsh environmental conditions of the Arctic, in situ observational time series are highly limited spatially and temporally in the region.Six recommendations to expand approaches using observational datasets and analyses of Arctic change and mid-latitude linkages include: Synthesize new Arctic observations;Create physically-based sea ice-ocean surface forcing datasets;Systematically employ proven and new metrics;Analyze paleoclimate data and new longer observational datasets;Utilize new observational analysis methods that extend beyond correlative relationships; andConsider both established and new theories of atmospheric and oceanic dynamics to interpret and guide observational and modeling studies.Model experiments: We acknowledge that models provide the primary tool for gaining a mechanistic understanding of variability and change in the Arctic and at mid-latitudes. Coordinated modeling studies should include approaches using a hierarchy of models from conceptual, simple component, or coupled models to complex atmospheric climate models or fully coupled Earth system models. We further recommend to force dynamical models with consistent boundary forcings.Three recommendations to advance modeling and synthesis understanding of Arctic change and mid-latitude linkages include: Establish a Modeling Task Force to plan protocols, forcing, and output parameters for coordinated modeling experiments (Polar Amplification Model Intercomparison Project; PAMIP);Furnish experiment datasets to the community through open access (via Earth System Grid); andPromote analysis within the community of the coordinated modeling experiments to understand mechanisms for AA and to further understand pathways for Arctic mid-latitude linkages.

[Talus Fractures - an Update]. / Talusfrakturen ­ ein Update.

Background: Talus fractures are rare and often result from axial trauma. As most of the talus surface is covered by cartilage, the blood supply is limited. Thus talus fractures are seen as one of the most severe fractures and often lead to significant long-term complications. Several studies suggest that the initial fracture classification can lead to correct treatment and that this can influence the long-term outcome. The aim of the current study was to investigate the importance of the initial fracture classification in respect to the radiological outcome in a large patient cohort. Patients and Methods: Over a span of 12 years, 61 patients with talus fractures were treated at our institution. Overall 45 patients were available for a retrospective analysis. Correlation analysis was performed between the initial fracture severity and the radiological outcome. Results: The average follow-up was 17.3 months (range 6-68). Significant correlations were found between the Marti-Weber Classification and Bargon Score (rs = 0.78; p < 0.0001), as well as between the Hawkins Classification and the Bargon Score (rs = 0.80; p < 0.0001). Conclusions: Precise prediction of the expected radiological outcome of talar neck and body fractures is possible through the initial fracture classification alone. Computed tomography is the accepted standard to determine the exact diagnosis and extent of injury.

Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey.

We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.

[Molecular diagnosis of methicillin-resistent Staphylococcus aureus: Methods and efficacy]. / Molekulare Diagnostik von Methicillin-resistentem Staphylococcus aureus : Methoden und Effektivität.

Methicillin-resistant Staphylococcus aureus (MRSA) isolates are a serious public health problem whose ever-increasing rate is commensurate with the pressure it is exerting on the healthcare system. At present, more than 20% of clinical S. aureus isolates in German hospitals are methicillin-resistant, in Austria less than 10%. Strategies from low-prevalence countries show that this development is not necessarily inevitable. In the Scandinavian countries and the Netherlands, thanks to a rigorous prevention programme, MRSA prevalence has been kept at an acceptably low level (< 1-3%). Central to these search-and-destroy control strategies is an admission screening using several MRSA swabs taken from mucocutaneous colonisation sites of high-risk patients (MRSA surveillance). It has also been reported that the speed with which MRSA carriage is detected has an important role, as it is a key component of any effective strategy to prevent the pathogen from spreading. Since MRSA culturing involves a 2-3 day delay before the final results are available, rapid detection techniques (commonly referred to as MRSA rapid tests) using polymerase chain reaction (PCR) methods and, most recently, rapid culturing methods have been developed. The implementation of rapid tests reduces the time of detection of MRSA carriers from 48-72 to 2-5 h. Clinical evaluation data have shown that MRSA can thus be detected with very high sensitivity. Specificity, however, is sometimes impaired due to false-positive PCR signals occurring in mixed flora specimens. In order to rule out false-positive PCR results, a culture screen must always be carried out simultaneously. The data provide preliminary evidence that a PCR assay can reduce nosocomial MRSA transmission in high-risk patients or high-risk areas, whereas an approach that screens all patients admitted to the hospital is probably not effective. Information concerning the cost effectiveness of rapid MRSA tests is still sparse and thus the issue remains debated.

Expanding DEMON Sidestream Deammonification Technology Towards Mainstream Application.

A cross-Atlantic R&D-cooperation involving three large utilities investigated the feasibility of mainstream deammonification-the application of partial nitritation/anammox for full-plant treatment of municipal wastewater at ambient temperatures. Two major process components have been implemented, 1) bioaugmentation of aerobic- and anaerobic ammonia oxidizers (AOB and AMX) from the DEMON-sidestream sludge liquor treatment to the mainstream and 2) implementation of hydrocyclones to select for anammox granules and retain them in the system. Different operation modes have been tested at laboratory- and pilot-scale in order to promote the short-cut (more direct anammox route) in nitrogen removal metabolism. At the full-scale installation at Strass WWTP, stable repression of nitrite oxidizing biomass (NOB) has been achieved for several months. Significant anammox enrichment in the mainstream has been monitored while high efficiency in the sidestream-process has been maintained (96% annual average ammonia removal).

[Aortic valve stenosis: computed tomography prior to transcatheter aortic valve implantation (TAVI). How can the outcome be improved?]. / Aortenklappenstenose: Computertomographie vor Transkatheteraortenklappenimplantation (TAVI). Wie erreicht man eine Verbesserung der Ergebnisse?

Computed tomography (CT) plays an important role in the preinterventional work-up of patients referred for transcatheter aortic valve implantation (TAVI). Contrast-enhanced CT allows a comprehensive examination with evaluation of both the vascular access route as well as aortic valve and aortic root geometry. Analysis of the minimum luminal vessel diameter, tortuosity and vascular calcification are important to determine the ability to perform the procedure via a transfemoral access. The size of the aortic annulus can be accurately measured by CT to aid selection of the appropriate prosthesis and the use of CT for prosthesis sizing has been associated with a decreased incidence of paravalvular leakage as compared to 2-dimensional echocardiography. In addition CT permits accurate assessment of aortic root anatomy, distance between coronary ostia and the annulus plane as well as the dimensions of the ascending aorta. Furthermore, suitable fluoroscopic projections that permit an exact orthogonal visualization of the aortic annulus plane by fluoroscopy during the procedure can be extracted from the CT data set. In summary, CT permits comprehensive imaging in TAVI candidates and optimizes procedural outcome.

Going for mainstream deammonification from bench to full scale for maximized resource efficiency.

A three-pronged coordinated research effort was undertaken by cooperating utilities at three different experimental scales investigating bioaugmentation, enrichment and performance of anammox organisms in mainstream treatment. Two major technological components were applied: density-based sludge wasting by a selective cyclone to retain anammox granules and intermittent aeration to repress nitrite oxidizers. This paper evaluates process conditions and operation modes to direct more nitrogen to the resource-saving metabolic route of deammonification.

Probiotics in Clostridium difficile infection: reviewing the need for a multistrain probiotic.

In the past two years an enormous amount of molecular, genetic, metabolomic and mechanistic data on the host-bacterium interaction, a healthy gut microbiota and a possible role for probiotics in Clostridium difficile infection (CDI) has been accumulated. Also, new hypervirulent strains of C. difficile have emerged. Yet, clinical trials in CDI have been less promising than in antibiotic associated diarrhoea in general, with more meta-analysis than primary papers on CDI-clinical-trials. The fact that C. difficile is a spore former, producing at least three different toxins has not yet been incorporated in the rational design of probiotics for (recurrent) CDI. Here we postulate that the plethora of effects of C. difficile and the vast amount of data on the role of commensal gut residents and probiotics point towards a multistrain mixture of probiotics to reduce CDI, but also to limit (nosocomial) transmission and/or endogenous reinfection. On the basis of a retrospective chart review of a series of ten CDI patients where recurrence was expected, all patients on adjunctive probiotic therapy with multistrain cocktail (Ecologic®AAD/OMNiBiOTiC® 10) showed complete clinical resolution. This result, and recent success in faecal transplants in CDI treatment, are supportive for the rational design of multistrain probiotics for CDI.

Austrian clinical practice with anidulafungin in 2008: a multicenter survey.

Anidulafungin had demonstrated favorable efficacy versus fluconazole in a randomized trial on invasive Candida infections. Since patient characteristics in the post-approval use of antifungals likely deviate from clinical trials, we surveyed the use of anidulafungin in clinical routine. We performed a retrospective survey of the post-approval use of anidulafungin in 9 Austrian clinical centers. Anidulafungin was used in 129 critically ill patients with severe comorbidities and multiple risk factors. Indications were suspected invasive fungal infections (IFI) (61%), proven candidemia (19%), and at risk for IFI (prophylaxis, 20%). Candida colonization in conjunction with other risk factors prompted treatment in many patients. predominant pathogens were C. albicans, C. glabrata and C. krusei. Anidulafungin was mostly used for pre-emptive (69%) and first-line treatment (17%) of invasive candidiasis. Treatment response, i.e. complete response/stabilization as determined by investigators (89% in the overall population; 87% for documented candidemia) and survival rates (81% and 75%, respectively) were similar to previous trial data. No breakthrough IFI and few adverse events were reported. Overall, favorable clinical experiences were documented with anidulafungin in the clinical routine setting.

Clostridium difficile infection: monoclonal or polyclonal genesis?

Clostridium difficile is considered to be a leading cause of hospital-acquired diarrhea. C. difficile (CDI) infection shows a high rate of recurrence. There would have to be a predominantly monoclonal mechanism of CDI within individual patients in order for molecular epidemiologic tools such as polymerase chain reaction (PCR) ribotyping to be useful in outbreak investigation or differentiation between infection relapse versus re-infection. It was the aim of our study to determine whether CDI is of monoclonal or of polyclonal genesis. Between December 2009 and June 2010, 11 patients with nosocomial CDI were chosen arbitrarily. Five individual colonies of C. difficile were picked from each of the primary culture plates. Of 55 isolates gained, 47 were available for PCR ribotyping (eight isolates failed attempts to re-culture). Among these 47 isolates, eight different PCR ribotypes were identified. Only one of the 11 patients had a stool sample that yielded more than one ribotype (PCR ribotypes 438 and 232); this 67-year-old female cancer patient was already suffering from recurring diarrhea prior to the fatal episode of colitis which was subsequently investigated. We conclude that polyclonal infections may occasionally occur in patients with CDI. Our findings of predominantly monoclonal origin of CDI within patients suggest that molecular epidemiologic investigations can be used reliably for outbreak investigations or discrimination between relapse and re-infection.

Clinical aspects of 2009 pandemic influenza A (H1N1) virus infection in Austria.

PURPOSE: To describe the clinical features, risk factors for severe disease and effectiveness of oseltamivir in patients with 2009 pandemic influenza A (H1N1) virus infection. METHODS: In a prospective, cross-sectional, multicentre study, data on 540 patients with confirmed 2009 H1N1 infection from seven Austrian hospitals were collected using a standardised online case-history form. RESULTS: The median age of the patients was 19.3 years (range 26 days-90.8 years); point-of-care testing yielded false-negative results in 60.2% of the 176 cases tested. The most common symptoms were fever, cough, fatigue and headache. Overall, 343 patients (63.5%) were hospitalised, 49 (9.1%) were admitted to an intensive care unit (ICU) and 14 (4.1%) died. Case fatality rates were highest (9.1%) in those aged 65 years or older. Factors significantly associated with a higher risk for ICU admission included age, neurological disease, adipositas, and both interstitial pathology and lobular pathology on chest X-ray. No association with pregnancy, malignancy or immunosuppressive therapy was detected. Antiviral treatment significantly reduced the duration of fever by 0.66 days and lowered the risk of ICU admission, but had no significant benefit on survival. CONCLUSIONS: During the 2009 H1N1 influenza pandemic, elderly or obese patients and those with neurological disease had an increased risk for severe H1N1 infection in Austria. Pregnancy was not associated with a higher risk for severe disease in the later phase of the 2009 H1N1 pandemic. Antiviral treatment provided a minimal effect on the symptoms of influenza but reduced the risk of admission to an ICU.