Primary epiploic appendagitis and fructose malabsorption.

Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made when computed tomography (CT) reveals a characteristic lesion. We report on contrast-enhanced CT images of a patient with PEA and regression of inflammation and the reduction in size of the inflamed appendage over the time period of 4 months. Patients with PEA usually recover without medication or surgical treatment within a few weeks. However, due to continuing bloating and irregular bowel movements we investigated carbohydrate malabsorption and diagnosed a fructose malabsorption. Bloating and irregular bowel movements in this patient with PEA were correlated to carbohydrate malabsorption and were treated successfully with a diet free of culprit carbohydrates.

The critical role of aprotinin in controlling haemostasis in conjunction with non-pharmacological blood-saving strategies during routine coronary artery bypass surgery.

OBJECTIVE: Aprotinin, a non-specific serine protease inhibitor, has been confirmed to be safe and effective in reducing intra- and postoperative blood drainage, transfusion requirements, and perioperative morbidity and mortality during coronary artery bypass surgery. It is the only one of the currently available haemo-static agents that is approved by the U.S. Food and Drug Administration (FDA) for use in cardiac surgery. However, one major weakness of currently available trials is the lack of information regarding the concomitant usage of aprotinin with blood-saving strategies that have been used more frequently in recent years. METHODS: Patients undergoing elective first-time coronary artery bypass grafting (n = 172) who were given systemic high-dose aprotinin (n = 85), combined systemic high-dose aprotinin and topical aprotinin (n = 27), or no aprotinin (n = 60) were reviewed retrospectively. The use of all blood-saving procedures was systematically taken in account. RESULTS: Postoperative blood drainage was significantly less in patients treated with aprotinin than controls (P < 0.0001). Concomitant use of topical aprotinin was accompanied by a postoperative blood loss reduction of 35% compared to systemic aprotinin use alone (P < 0.003). The intra- and postoperative donor blood requirements were dramatically reduced in both aprotinin-treated groups compared to controls, although patients received different blood saving strategies as appropriate (P < 0.0001). A trend of up to 20% lower postoperative blood drainage was noted in patients in whom intraoperative haemodilution and autologuos blood transfusions were used (P > 0.05). CONCLUSIONS: The present analysis demonstrates that the local and systemic administration of aprotinin is safe and effective in reducing intra- and postoperative blood drainage and transfusion requirements. In elective CABG procedures, aprotinin should still be used even if blood-saving strategies are employed.

[Clinical pathways: experiences, expectations, and perspectives]. / Behandlungspfade: Erfahrungen, Erwartungen, Perspektiven.

Due to economic necessities, existing reserves in clinical practice have to be used efficiently. The presentation of medical activity and systematic illustration of medical decisions in the form of clinical pathways constitute important tools to ensure the quality of patient care under fiscal pressure caused by the DRG system. To successfully establish clinical pathways, the architecture of the standard operating procedures developed specifically for a hospital must adequately reflect medical concerns and patient-related needs. The concept of necessity for the good of the patient applies in this instance rather than the principle of the complete depiction of all medical processes. Organizing the implementation into clinical practice should be assured and monitored. The standard operating procedures should be regularly adapted to suit medical developments. Success with the procedure should be reported and deviations from predetermined targets should be documented. A clinical pathway does not represent an administrative end in itself but rather a part of a higher control system that helps to improve the utilisation of the hospital's resources in terms of reliability and quality of patient care.

Which factors render cost-covering lump-sum charging difficult for the treatment of patients with acute leukemias?

BACKGROUND: Growing budget limitations and the planned charging subject to Diagnosis-Related Groups (DRG) points raise the question as to what costs are incurred by the induction therapy and early consolidation treatment of patients with acute myeloid leukemias (AML) and whether these can be compensated in a cost-covering manner by a system based on DRG points. PATIENTS AND METHODS: For 100 patients recruited within the framework of the "Kooperative AML-Studie 96" of the Süddeutsche Hämoblastosegruppe a process cost analysis was made between 1996 and 1999. All manpower and material costs incurred in the department itself and in the secondary services departments as well as the basic cost shares were recorded taking into due account the length of stay. The cost breakdown was effected based on a double induction therapy and one early consolidation treatment. RESULTS: It turns out that substantial differences exist between lower und upper limits of the length of stay and costs. For all three therapy blocks for patients up to 60 years the cost spread varies between 63 and 204 kDM with a median of 105 kDM, and for older patients between 55.6 and 146.6 kDM with a median of 87.6 kDM. On average, the costs subject to length of stay were roughly 70%. CONCLUSIONS: As the costs per case are subject to a spread and, for this relatively small group of patients, are extremely high, the fixing of a case-related lump sum is problematic, the more so as age of patient, comorbidity, type of therapy, ist outcome, and therapy-induced complications represent decisive influencing factors.

Banking of cryopreserved heart valves in Europe: assessment of a 10-year operation in the European Homograft Bank (EHB).

BACKGROUND AND AIM OF THE STUDY: The preparation, banking and distribution of cryopreserved heart valves has been carried out at the European Homograft Bank (EHB) in Brussels without interruption since January 1989. We present an assessment of the Bank's activities during this 10-year period. METHODS: Heart valve donors aged <62 years form three categories: multiorgan donors with non-transplantable hearts; recipients of cardiac transplantation; and non-beating heart cadavers with a warm ischemia time of less than 6 h. Past history and biology are checked for transmissible diseases. Dissection, incubation in antibiotics and cryopreservation in 10% dimethylsulfoxide with storage in liquid nitrogen vapors (about -150 degrees C), and quality control are according to the standards of the Belgian Ministry of Health. Cryopreserved valves are shipped to the implantation centers in a dry shipper at about -150 degrees C. RESULTS: Between January 30th 1989 and December 31st 1998, 1,817 non-transplantable hearts and 12 excised semilunar valves were obtained. In total, 2,077 valves (1,032 pulmonary, 931 aortic and 13 mitral) were decontaminated, cryopreserved and stored in liquid nitrogen vapor (six more valves were refrigerated). In total, 1,515 valves were discarded at different stages of the protocol, the main causes of rejection being significant macroscopic lesions (68.2% aortic and 26.67% pulmonary). Inadequate excision at procurement (10.37% pulmonary), persistent contamination after antibiotics (5.6%) and positive serology for hepatitis B and C and Q fever (5.4%) were other frequent causes for rejection. Among the 2,117 accepted valves, 1,398 were graded first and 719 second choice, mainly on the basis of morphology. In total, 2,090 cryopreserved valves and one refrigerated valve were implanted in 39 institutions between May 1989 and December 1998. Of requests, 10.02% could not be satisfied. In total, 967 pulmonary valves were implanted in the right ventricular outflow tract (RVOT); 424 during a Ross procedure, and 76 in the left ventricular outflow tract (LVOT). Of the aortic valves, 732 were implanted in the LVOT and 266 in the RVOT. Mitral homografts were used for tricuspid valve replacement in two cases, and in the mitral position in seven. Complications at distribution and thawing included 10 bag ruptures and 16 transversal conduit wall fractures. Of the valves shipped, 317 (13.16%) were not used and were returned safely in the dry shipper. Comparison of distribution rates in the first 5.5 and last 4.5 years of EHB activity shows: (i) a significant increase in pulmonary valve implantations in the RVOT (from 71.95% to 81.95%); and (ii) a marked increase (265%) in pulmonary homograft implantations as part of a Ross operation, and a significant decrease (28%) in aortic homograft implantation in the LVOT. CONCLUSION: While macroscopic lesions of procured aortic valves remain the most frequent and unavoidable cause of homograft rejection during quality control, the high percentage of inadequate surgical heart valve excision should be corrected. The rates of bacterial contamination and positive serology seem acceptable. Storage and shipping of cryopreserved homografts in liquid nitrogen vapor permits them to be spared very efficiently. The increasing use of pulmonary valves for RVOT reconstruction either in congenital heart disease or as part of the Ross procedure compensates for the limited availability of good quality aortic valves.

Results of aortic valve replacement with pulmonary and aortic homografts.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement with cryopreserved human pulmonary or aortic valves (homografts) is an attractive alternative to the implantation of mechanical valves or bioprostheses, as anticoagulation can be avoided and a near-normal anatomy restored. However, few reports exist on the long-term follow up of patients with this type of valve. METHODS: Between 1990 and 1997, a total of 64 homografts were implanted in 62 adults (mean age 42 +/- 12 years) with non-endocarditic valve lesions (insufficiency, n = 16; stenosis, n = 20; combined lesions, n = 12; redo, n = 16). In total, 23 pulmonary grafts (PG) and 41 aortic grafts (AG) were used. Valves were obtained from the European Homograft Bank in Brussels. Two patients with aortic homografts were lost to follow up; the others were examined clinically and echocardiographically at yearly intervals (mean 3.6 +/- 2.0 years). Children aged less than 16 years (n = 21), and patients receiving a homograft due to endocarditis (n = 28) or during a Ross procedure (n = 16) were excluded from the study. RESULTS: Three patients (5%) died due to early postoperative complications (two with AG, one with PG). Three PG had to be explanted due to primary malfunction, and five (total 35%) during further follow up due to severe aortic insufficiency (at a mean of 3.3 +/- 1.8 years). In contrast, all AG were functioning at the end of the observation period (log rank test, p = 0.0001, chi-square test 13.9). The mean echocardiographic degree of regurgitation for PG was significantly higher than for AG (2.2 +/- 1 vs. 0.75 +/- 0.7, p <0.0001). The peak transvalvular gradient did not differ between groups (PG 12.3 +/- 9 mmHg vs. AG 16.7 +/- 10 mmHg, p = NS). In respect of perioperative parameters, patients with PG showed a significantly higher body temperature during the first seven postoperative days (37.3 +/- 0.6 degrees C vs. 36.8 +/- 0.3 degrees C, p = 0.003). All three patients with acute graft malfunction in long-term follow up had a perioperative febrile response without overt bacterial infection. CONCLUSION: In contrast to grafts of aortic origin, pulmonary homograft valves should not be used for aortic valve replacement because of their high rate of malfunction, both acutely and chronically. Higher postoperative body temperatures should lead to further investigations of possible enhanced immunoreactions against pulmonary homografts.

Are pulmonary homografts which were subjected to pulmonary hypertension more appropriate for aortic valve replacement than normal pulmonary homografts? A long-term multicentric echography study.

OBJECTIVE: To compare long-term results of the European Homograft Bank (LHB) cryopreserved pulmonary homograft in left ventricular outflow tract (LVOT) subjected to pulmonary hypertension with those subjected to normal pulmonary pressure. The mid-term study of this material published in 1997 showed different results. METHODS: Statistical analysis is calculated by the Kaplan-Meier survival curves, while differences in prevalence by the Log-Rank test. RESULTS: Follow-up (FU) was available in 69 cases (76.7%): 46 in group 1 and 23 in group 2. Five patients have been excluded from the study because of early homograft explantation (technical problems or early valve incompetence). Fourteen out of 43 cases of group 1 (32. 6%) and seven out of 21 cases of group 2 (33.3%) have been explanted after 2.5-88 months and 7-88 months, respectively. Significant echography changes have been found in 19 of 43 (44.18%) of group 1 and 11 of 21 cases (52.38%) of group 2 during the follow-up. Histology showed essentially wear and tear induced lesions. Mean FU was 36.9 (range, 6-88) and 41.3 months (range, 4-88) for group 1 and 2, respectively. No significant difference in the long-term outcome have been found between the two groups (P=0.38). CONCLUSION: Contrary to our previous echocardiography study of mid-term implants the long-term follow up of the PHGs implanted in the LVOT did not show better function of the pulmonary homografts subjected to pulmonary hypertension than those with normal pulmonary pressure. The high failure rate of the PHGs should discourage their use for LVOT reconstruction. Further echocardiography studies of remaining PHGs implanted in the LVOT, and gross and microscopic explant studies are required to judge on the definitive outcome of these grafts.

[Aortic valve replacement with homografts. An overview]. / Aortenklappenersatz mit Homografts. Eine Ubersicht.

The implantation of fresh or cryopreserved human heart valves (homografts) in aortic position is a tool in cardiac surgery since 30 years. Homografts are attractive alternatives to the implantation of mechanical or xenobiological prostheses, because anticoagulation can be avoided and a near normal anatomy can be restored. Physicians should know about the several kinds of grafts and operative techniques to adequately take care of the patients in follow-up. This overview on the literature covers methods of harvesting, preparation and conservation of homografts according to standard protocols of the European Homograft Bank in Brussels. Their use in the therapy of human valvular disease is discussed with special emphasis to operative techniques (subcoronary, root) and the Ross procedure and in pediatric surgery. Complications and aspects of postoperative care are discussed including immunologic phenomena. Homografts are useful tools for aortic valve replacement, especially in juveniles, in the presence of contraindications for anticoagulation and in endocarditis. Whereas aortic homografts have excellent long-term results, pulmonic homografts show a significant rate of malfunction. Further studies should be performed to clarify the role of the Ross operation or stentless xenografts compared to homografts in aortic position. In pediatric cardiac surgery homografts are of value especially for the reconstruction of the right ventricular outflow tract. Homografts in mitral position show disappointing results up to now. The major limitation in the use of homografts is the mismatch of availability and request, therefore homografts can only be used for the above mentioned special indications.