Objective nasal airflow measures in relation to subjective nasal obstruction, trigeminal function, and olfaction in patients with chronic rhinosinusitis.

BACKGROUND: This study aimed to determine how nasal airflow measures and trigeminal function vary among patients with chronic rhinosinusitis (CRS) versus healthy controls and whether these measures are correlated with subjective nasal obstruction (SNO), olfactory function, and CRS control. METHODOLOGY: Participants included CRS patients and healthy controls. After a structured medical history, nasal airflow (peak nasal inspiratory flow [PNIF]; active anterior rhinomanometry [AAR]), trigeminal function (trigeminal lateralization test, CO2 sensitivity), and olfactory ("Sniffin' Sticks" odor identification test) tests were performed. SNO ratings were also obtained. RESULTS: Sixty-nine participants were included (37 men, 32 women, mean age 51 years). There was no significant difference for objective nasal airflow between patients and controls, but CRS patients had worse SNO, trigeminal function, and olfaction compared to controls. SNO, but not objective nasal airflow tests, was negatively correlated with CO2 sensitivity and odor identification. CONCLUSION: The perception of nasal obstruction does not only depend on nasal airflow, but may also be modulated by trigeminal function and other factors. Thus, the role of objective nasal airflow measures as a sole method of functional nasal obstruction assessment in CRS remains limited.

[Deep vein thrombosis as a primary symptom of abdominal aortic aneurysm : Bilateral deep vein thrombosis caused by infrarenal abdominal aortic aneurysm (15 cm in diameter) with complete compression of the inferior vena cava]. / Tiefe Venenthrombose als Primärsymptom eines abdominellen Aortenaneurysmas : Beidseitige 4-Etagen-TVT durch infrarenales Bauchaortenaneurysma (15 cm Durchmesser) mit vollständiger Kompression der V. cava inferior.

This article presents the case of a 70-year-old obese patient with severe bilateral leg pain due to deep vein thrombosis. After unsuccessful venous recanalization, computed tomography angiography revealed an abdominal aortic aneurysm 15 cm in diameter with total compression of the inferior vena cava. For venous decompression as well as rupture prophylaxis, conventional open surgical repair was performed.

Role of aorto(bi)femoral bypass in treatment of patients with critical limb threatening ischemia.

PURPOSE: To analyse the long-term outcome of open aortic procedures in patients with critical limb threatening ischemia. METHODS: Retrospective analysis of all patients with aortoiliac TransAtlantic Inter-Society Consensus II (TASC II), type D (TASC D) lesions extending to the femoral artery who underwent aortic bypass procedures for critical limb threatening ischemia (CLTI) or intermittent claudication (IC). RESULTS: Over a period of 10 years, 87 patients with IC and 45 patients with CLTI received a total of 56 aortounifemoral and 76 aorto-bi-femoral bypass procedures. After 7 years, overall primary patency (82.2% [CLTI] vs. 80.5% [IC], p = .918) and overall secondary patency (88.9% [CLTI] vs. 88.5% [IC], p = .851) were similar between patients with CLTI and those with IC. Long-term-survival (66.7% vs. 71.3%, p = .356) as well as limb salvage (86.7% vs. 94.3%, p = .104) was considerably lower in the CLTI-group, but the difference was not statistically significant. In the subgroup analysis, patients with CLTI and ischemic lesions (Rutherford class 5-6) had the poorest outcome after 84 months, in terms of secondary patency (92.1% vs. 73.7%, p = .015), limb salvage (97.4% vs. 73.7%, p = .000), and long-term survival (75.0% vs. 26.3%, p = .000) compared to patients with IC. Multivariate analysis revealed significant associations for patients with Rutherford class 5-6 in terms of secondary patency (p = .037) and limb salvage (p = .015). There was a significant difference in primary patency between graft limbs with superficial femoral artery occlusion and graft limbs with patent superficial femoral artery (84.6% vs. 93.0%, p = .017). CONCLUSIONS: Aortic bypass procedures can be used in the treatment of patients with CLTI. Moreover, results are satisfactory in patients with ischemic rest pain. However, less invasive treatments should be considered for patients with ischemic lesions.

[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. / Diabetisches Fußsyndrom ­ Teil 2 : Revaskularisation, Behandlungsalternativen, Versorgungsstrukturen, Rezidivprophylaxe.

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

[Diabetic foot syndrome-Part 1 : Definition, pathophysiology, diagnostics and classification]. / Diabetisches Fußsyndrom ­ Teil 1 : Definition, Pathophysiologie, Diagnostik und Klassifikation.

There are ca. 8 million persons with diabetes mellitus living in Germany. A late sequelae of diabetes is the diabetic foot syndrome (DFS), the prevalence of which is greatly increasing. It comprises all alterations of the foot as a result of diabetic polyneuropathy as well as microvascular and macrovascular (peripheral arterial occlusive disease, PAOD) alterations. Many of the ca. 250,000 newly diagnosed diabetic foot ulcers per year become chronic wounds. Despite intensive efforts for prevention, early diagnosis and adequate wound care, ca. 13,000 persons with diabetes undergo major limb amputation in Germany every year. With consistent treatment in interdisciplinary centers and by exhausting all possible methods of wound treatment, pressure relief as well as arterial revascularization, the major amputation rate in patients with diabetic foot problems can be reduced by 80%. With a suitable strategy of prevention, the recurrence rate of foot ulcers would be reduced.

Biosynthetic vascular graft: a valuable alternative to traditional replacement materials for treatment of prosthetic aortic graft infection?

BACKGROUND AND AIMS: To report the experience of a tertiary vascular surgery center using Omniflow II® biosynthetic vascular grafts for treatment of prosthetic aortic graft infection. MATERIALS AND METHODS: Retrospective analysis of all patients with prosthetic graft infections who underwent in situ aortic reconstruction using Omniflow II® grafts or other conduits between March 2015 and May 2017. Early and late mortality, perioperative complications, and reinfection rate were analyzed. RESULTS: Sixteen patients (14 males, median age 68.5, range 57-89) with prosthetic aortic graft infection were treated at our center. Eight patients received an Omniflow II® biosynthetic graft, two patients silver-triclosan coated grafts, three patients bovine pericardial tube grafts, and three patients composite bovine pericardial tube grafts with Omniflow II® graft extensions. Perioperative complications occurred in seven patients (43.8%). Early mortality rate was 18.7% (n = 3). In addition, four patients died during follow-up after a median of 11 months (range 0-34 months). We did not observe any reinfections. Bypass grafts were patent in all patients. No major limb amputations were performed during follow-up. CONCLUSION: Treatment of prosthetic aortic graft infection with Omniflow II® vascular grafts is feasible. Graft material seems to have an excellent resistance to infection and might be a valuable alternative to traditional replacement materials. Especially long-term durability has to be continuously monitored and documented.

The Shape Effect on Polymer Nanoparticle Transport in a Blood Vessel.

Nanoparticle therapeutic delivery is influenced by many factors including physical, chemical, and biophysical properties along with local vascular conditions. In recent years, nanoparticles of various shapes have been fabricated and have shown significant impact on transport efficiency. Identification of which nanoparticle shape helps to improve the therapeutic delivery process allows for enhanced therapeutic effects, yet is hard to be quantified in vivo due to the complex nature of the in vivo environment. In this work, we turn to biological models as a guide for informing improved nanoparticle therapeutic delivery, and quantify the contribution of various factors on delivery efficiency. Here we show that with a mimetic blood vessel, improved therapeutic delivery is achieved using long filamentous rod nanoparticles under low pressure conditions. When considering medium pressure conditions, a combination of nanoparticle shapes presents improved therapeutic delivery over the treatment time-course starting with long filamentous rod nanoparticles, followed by short rod nanoparticles. Conditions of high pressure required a combination of short rod nanoparticles, followed by spherical nanoparticles to achieve enhanced therapeutic delivery. Overall, improvement of therapeutic delivery via nanoparticle carriers is likely to require a combination of nanoparticle shapes administered at different times over the treatment time-course, given patient specific conditions.

Comparison of Long-term Outcomes of Heparin Bonded Polytetrafluoroethylene and Autologous Vein Below Knee Femoropopliteal Bypasses in Patients with Critical Limb Ischaemia.

OBJECTIVE/BACKGROUND: Endovascular first is the preferred therapy approach to critical limb ischaemia (CLI). However, in spite of new endovascular techniques, bypass surgery still plays an important role, especially in patients with complex anatomy in whom endovascular therapy is not considered feasible, or has failed. The goal of this study was to analyse the outcomes of prosthetic or autologous vein for femoropopliteal (P3) bypasses performed under the abovementioned conditions. METHODS: A retrospective analysis of patients who underwent a femoropopliteal (P3) bypass for CLI (March 2007-December 2015) was conducted. Endovascular therapy was not possible. Patency rates, limb salvage, major adverse limb event (MALE) free survival, and survival after 5 years were analysed. RESULTS: In total, 151 cases were included in the analysis (rest pain 35.8%, ulcer/gangrene 64.3%). The graft material was autologous vein in 76 cases (vein group) and heparin bonded expanded polytetrafluoroethylene (HePTFE) in 75 cases (HePTFE group). Indications, risk factors, previous revascularisation procedures, and runoff vessels were similar in both groups. Thirty day mortality was 6.6% in the vein group and 5.3% in the HePTFE group (p = .508), early graft occlusion (6.6% vs. 5.3%; p = .508) and 30 day major amputation rate (0% vs. 2.7%; p = .245) were similar between the two groups. Overall primary patency was 51.7% (55.5% [vein group] vs. 51.7% [HePTFE group]; p = .897) and overall secondary patency was 64.2% (74.6% [vein group] vs. 55.6% [HePTFE group]; p = .119), all without significance after 5 years. However, limb salvage (79.1%) was significantly different (90.0% [vein group] vs. 62.9% [HePTFE group]; p = .021). Survival was similar between the groups (47.3% vs. 42.9%; p = .582) as well as MALE free survival (69.4% vs. 55.0%; p = .348). CONCLUSION: Bypasses to the below knee popliteal artery show good results in patients with CLI unsuitable for endovascular therapy. Vein is still the first line graft material.

A comparison of tibial and peroneal venous and HePTFE bypasses in diabetics with critical limb ischemia.

OBJECTIVE: In this study we analyzed the outcome of tibial and peroneal venous and heparin-bonded expanded polytetrafluoroethylene (HePTFE) bypasses in diabetics with critical limb ischemia (CLI). We aimed to verify our hypothesis that HePTFE grafts will achieve acceptable 1-year patency and limb salvage results in patients who lack an adequate vein. METHODS: We conducted a retrospective analysis for all diabetics who underwent tibial bypass surgery in our department between October 2007 and October 2012. The study includes 97 grafts. All these patients were not suited for an endovascular therapy. We used autologous veins in 56 cases (Vein-Group) and HePTFE grafts in 41 cases (HePTFE-Group). Study endpoints were primary and secondary patency, limb salvage, and survival at 2 years postoperatively. RESULTS: Risk factors and indications were similar in both groups. The comparison between HePTFE- and Vein-Group showed significantly different patency rates. At 2 years, primary patency was 39.3% in HePTFE-Group vs. 78.5% in Vein-Group (P = .003) and secondary patency was 47.4% vs. 81.9% (P = .002). Limb salvage at 2 years was 79.3% vs. 87.4% (P = .073) and survival was 64.6% vs. 62.9% (P = .593) at the 2-year mark, with no significant differences. 30-days mortality, graft occlusion and major amputation rate showed no significant differences, either. CONCLUSIONS: This study shows that HePTFE bypasses are a viable option for diabetics undergoing tibial bypass surgery when no adequate vein is available.

Xenografts in septic vascular surgery.

BACKGROUND: In general, autologous veins are the optimal replacement material for an infected vascular graft in terms of handling, durability and resistance to reinfection. In the absence of suitable autologous material, several options are available, each of which has specific advantages and drawbacks with regard to these characteristics. METHODS: In recent years, xenogeneic materials (in particular pericardial patches from different species and biosynthetic grafts) have been increasingly used as replacement material in the setting of infections. Bovine and equine pericardial patches are applied in particular as self-made tube grafts in the aortic region and also in infections of iliacofemoral prosthetic grafts and shunt infections. RESULTS: The results of small clinical series on durability and resistance to reinfection are promising. CONCLUSION: It is feasible to use biosynthetic materials to replace infected intracavitary and extracavitary vascular grafts with remarkably low reinfection rates; however, the unique mechanical properties of the grafts as well as the initially increased thrombogenicity, need to be taken into consideration.

Interventional Removal of Intravascular Medical Devices: Methods and Technical Success.

PURPOSE: Evaluation of the technical success rate and complications when retrieving dislocated intravascular foreign bodies. MATERIAL AND METHODS: Between 1999 and 2015 38 patients (21 female; 17 male; Age: 17 - 92; Average 54.3 years) underwent an extraction of intravascular dislocated foreign bodies, which were not lost during a radiological intervention. The extracted material included 29 port catheters, 3 tips of tunneled dialysis catheters, 2 stents, 2 guide wires, 1 CVC tip and 1 AS occluder device. Various catheters for repositioning and extraction were used. The access was transarterial as well as transvenous. Technical success was defined as complete removal of the foreign body. RESULTS: The technical success rate was 92.1 % (35 of 38). In 17 patients an additional catheter was necessary to reposition the foreign body in order to make it accessible for the extraction catheter. In one case a stent was relocated and remodeled within the patient and was not extracted. In another case we experienced a dislocation of a small fragment of the port catheter into the distal parts of the pulmonary artery, which couldn't be extracted. A guide wire could not be extracted as it was already adhered with the vessel wall. Peri-interventional complications were not documented. CONCLUSION: The percutaneous extraction of dislocated intravascular foreign bodies is technically successful and poor of complications. Interventional therapy can avoid surgical removal. KEY POINTS: • The percutaneous extraction of dislocated intravascular foreign bodies is technically successful and safe.• In most cases surgical removal can be avoided.• The gooseneck-snare catheter was mainly used for the extraction of intravascular foreign bodies. Citation Format: • Ayx I, Goessmann H, Hubauer H et al. Interventional Removal of Intravascular Medical Devices: Methods and Technical Success. Fortschr Röntgenstr 2016; 188: 566 - 573.

The impact of infrainguinal endovascular interventions on the results of subsequent femoro-tibial bypass procedures: a retrospective cohort study.

BACKGROUND: Endovascular recanalization has become the accepted first-line treatment strategy for most lower extremity arterial occlusions, especially in patients with critical limb ischemia (Rutherford 4-6). Prior endovascular interventions have been described as risk factors for the outcome of subsequent lower extremity bypass surgery. The effect on subsequent tibial and peroneal bypasses is controversial. We analyzed the impact of prior endovascular lower extremity revascularization procedures on the short- and mid-term results of femoro-tibial and femoro-peroneal bypasses. METHODS: A retrospective analysis was conducted of all patients who had undergone tibial or peroneal bypass surgery after prior endovascular interventions (PEI-Group, n=40) of the same extremity in our department from October 2007 to October 2012. We compared this group with a group of patients who had received a tibial or peroneal bypass as primary revascularization procedure (BF-Group, n=93) during the same period of time because primary endovascular therapy had been deemed unfeasible in those cases. Indication in all cases was critical limb ischemia; the median age was 78 years (range 50-90 years), 45.1% were diabetics, and 42.9% were female. The graft material was autologous vein in 80 cases and HePTFE in 53 cases. Endpoints of the analysis were primary and secondary patency rates, limb salvage and survival at 2 years postoperatively. RESULTS: At 2 years overall primary patency was 68.4%, secondary patency was 69.5%, limb salvage was 83.6% and survival was 62.6%. Primary patency for the BF-Group was 74.3% vs. 55.1% for the PEI-Group (P=.310) at 2 years; secondary patency was 74.6% vs. 59.1% (P=.268). Prior endovascular intervention did not have any significant effects on limb salvage (83.7% vs. 83.6%; P=.470) or survival rates (61.0% vs. 65.0%; P=.258) at the 2-year mark, either. There were no significant differences in graft occlusion, death and major amputation rates within the first 30 postoperative days. Except for male gender, there were no significant differences in risk factors and indications between the two groups. CONCLUSIONS: Prior endovascular intervention of femoro-tibial vessels does not have a negative impact on the outcome of subsequent tibial or peroneal bypass surgery in patients with critical limb ischemia.

Necrosis of the leg after intraarterial drug injection.

Inadvertent intraarterial injections in the context of drug abuse can cause damage to the vascular system. The clinical picture depends on the drug properties and ranges from partial ischemia to necrosis of the affected extremity. There are no current evidence-based guidelines regarding the management of intraarterial drug injections. In many cases the concept of solving vasospasm after injection is based on the use of intraarterial application of prostaglandins. We report a case in which a mixture of drugs was injected into the left femoral artery. The patient arrived 24 hours later with ischemia of the left leg at our emergency department. Angiography showed that there was no blood flowing in the leg. Despite intraarterial application of vasodilatators, regional neurolysis and thrombolyis with urokinase major amputation was unavoidable. The outcome after inadvertent injection depends on certain drug properties and the delay between injection and the beginning of therapy.

Efficacy of short term continuous subcutaneous insulin lispro versus continuous intravenous regular insulin in poorly controlled, hospitalized, type 2 diabetic patients.

UNLABELLED: Intravenous insulin infusion (IVII) is rapidly effective in improving glycaemia in uncontrolled hospitalized diabetic patients. This significantly improves their morbidity and mortality. Intravenous insulin infusion may lead to IV infusion complications and is a heavy burden for caregivers. AIM: The aim of our work was to compare the efficacy of IV regular insulin versus lispro Continuous Subcutaneous Insulin Infusion (CSII), in improving glycaemia in patients hospitalized for uncontrolled type 2 diabetes, the efficacy being assessed on the average blood glucose level observed. METHODS: The study was designed as a prospective randomized study. Thirty-three type 2 diabetic patients, hospitalized for uncontrolled diabetes by their usual practitioner were included. After acceptation, patients were randomly assigned to lispro CSII (group 1, n=20) or IVII regular insulin (group 2, n=13) for 5 days. Ten capillary blood glucose/day were performed. Pre-meal blood glucose targets were 4.4-6.6 mmol/l. Mann Whitney, Wilcoxon and Fischer exact tests were used. RESULTS: BG levels decreased significantly (-3.4+/-0.55 mmol/l in group 1 and -3.60+/-0.55 mmol/l in group 2, P<0.01) during the first 12 hours. Mean daily blood glucose at day 5 was statistically improved in both groups compared to day 1 (P<0.05 Wilcoxon) and comparable between the 2 groups. No severe hypoglycaemia was reported. No catheter complications occurred in group 1, 7 occurred in group 2. CONCLUSION: CSII and IVII infusion were comparable in rapidly improving hyperglycaemia in uncontrolled type 2 diabetic patients. CSII, being more convenient, could be preferred in medical and surgical settings.

A reproducible method for the enumeration of functional (cytokine producing) versus non-functional peptide-specific cytotoxic T lymphocytes in human peripheral blood.

One of the most difficult laboratory challenges in the field of therapeutic cancer vaccines has been the development of uncomplicated/reproducible methods for the quantification of vaccine immunization efficacy in peripheral blood of cancer patients. Existing methods are limited by lack of functional information (tetramers), difficulties with standardization/reproducibility [enzyme-linked immunosorbent spot (ELISPOT)] and reliance on endogenous (sample-specific) antigen presentation (cytokine flow cytometry). Herein we present a reproducible method utilizing an artificial antigen-presenting cell platform for flow cytometry-based quantification of the frequency and activation status of peptide-specific cytotoxic T lymphocytes. The methodology [currently presented for cytomegalovirus human leucocyte antigen (HLA)-A2 cognant peptide antigens] allows simultaneous ex vivo quantification of activated (cytokine-producing) and inactive tetramer-positive T cells following HLA class I/peptide/CD28 stimulation independent of endogenous antigen presentation. The simplicity and reliability of the assay provide for high-throughput applications and automation. The utility and application of this method are discussed.

Improvement of source localization by dynamical systems based modeling (DSBM).

Recently, we have proposed a new concept for analyzing EEG/MEG data (Uhl et al. 1998), which leads to a dynamical systems based modeling (DSBM) of neurophysiological data. We report the application of this approach to four different classes of simulated noisy data sets, to investigate the impact of DSBM-filtering on source localization. An improvement is demonstrated of up to above 50% of the distance between simulated and estimated dipole positions compared to principal component filtered and unfiltered data. On a noise level on which two underlying dipoles cannot be resolved from the unfiltered data, DSBM allows for an extraction of the two sources.

High antigenicity of intraperitoneal insulin infusion via implantable devices: preliminary rat studies.

Intraperitoneal insulin infusion of Genapol stabilized insulin via implantable devices significantly improves diabetes control and hypoglycemia frequency in type 1 diabetes while it increases insulin antibody levels. Causes for this particular antigenicity remain unknown. The role of insulin modifications occurring in the reservoir on the antigenicity observed was assessed by comparing the antigenicities of the insulin coming from the vial or from the pump reservoir. Rats were injected intraperitoneally with insulin sampled either from a vial (group 1) or from a pump reservoir during a refill of a clinical trial (group 2). Two control groups, one without insulin, the second one receiving a mixture of silicone and insulin were also studied. Human insulin antibody levels were assessed by RIA 10 days after 4 weekly immunizations. AIA levels were higher in group 1 compared to group 2 (P = 0.003 for the first experiment, P = 0.04 in the second experiment). The increased antigenicity of the insulin sampled from the implanted pump might be due to the insulin modifications occurring during the storage in the device. Insulin aggregates could be involved in this antigenicity since they are known to be antigenic and their concentration was shown to be related to the amplitude of the antigenic response.

Chromosomes of villadia and altamiranoa (crassulaceae).

Villadia, ranging from Texas to Peru with some 25 species, has a rather distinctive thyrsoid to spicate inflorescence, and we keep it as a genus separate from Sedum. Twenty species show every gametic chromosome number from 9 to 17 and also 20-22 and higher. Chromosome pairing in hybrids shows that the species differ by many translocations and that species with 21 or lower are effectively diploid. More specialized species tend to have fewer and larger chromosomes, suggesting that through time translocations have rearranged the ancestral genome into fewer units. We suspect that relocated genes may be programmed differently, affecting phenotype. Thus Villadia is like Echeveria in having a remarkably long descending series of evidently diploid chromosome numbers. Altamiranoa, often included in Villadia, with about 15 species from Mexico south, more closely resembles Sedum in its broadly cymose inflorescence. It appears polyphyletic, with no clear boundary from Sedum, and we disperse its species in Sedum. The ten species studied have gametic numbers from 20 to 29 that probably are effectively diploid, with a few higher and probably polyploid. Again, chromosome pairing in hybrids shows that the species differ by many translocations. Putative relatives in Sedum section Leptosedum have n = 26 to 31. Thus cytologically as well as morphologically Altamiranoa has remained more similar than Villadia to its Sedum relatives.

Analysis of spatiotemporal signals: a method based on perturbation theory.

We present a method of analyzing spatiotemporal signals with respect to its underlying dynamics. The algorithm aims at the determination of spatial modes and a criterion for the number of interacting modes. Simultaneously, a way of filtering of nonorthogonal noise is shown. The method is discussed by examples of simulated stable fixpoints and the Lorenz attractor.