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The Broadly Rifted Zone (BRZ) of southern Ethiopia is a long‐lived and structurally complex segment of the East African Rift System. However, due to poor surface exposure of early synrift strata and a dearth of subsurface data, the evolution of the BRZ remains poorly understood. We present new apatite (U‐Th‐Sm)/He and augmented apatite fission track low‐temperature thermochronology data from the Beto and Galana basin boundary fault systems to constrain the tectonothermal evolution of the western and eastern BRZ, respectively. Time‐temperature reconstructions suggest that East African Rift System‐related extension began concurrently across the BRZ in the early Miocene (20–17 Ma), at least 6 Myr prior to faulting in the Main Ethiopian Rift further north. Increased time‐temperature resolution provided by multithermochronometer analyses reveals contrasting along‐strike spatiotemporal variations in Beto and Galana margin cooling histories, which appear to mirror the disparate structural geometries of their basin‐bounding normal fault arrays. Longitudinal contrasts in basin architecture and rift‐related cooling histories across the BRZ may reflect the region's heterogeneous distribution of preexisting basement fabrics, namely, the presence of a previously reported N‐NNE trending Neoproterozoic suture zone beneath the eastern BRZ. Its influence may explain both the development of long, curvilinear faults and the gradual basinward migration of strain exhibited by the easternmost BRZ, absent further west. The anomalous evolution of the BRZ compared to the greater Ethiopian Rift, both in its earlier onset and its wider deformation zone, likely results from its inheritance of preattenuated lithosphere, thermomechanically modified by earlier Cretaceous‐Paleogene Anza‐South Sudan rifting and/or Eocene plume impingement. Apatite (U‐Th‐Sm)/He and augmented fission track data constrain early Miocene onset of rift‐related cooling in Beto and Galana basin marginsContrasting along‐strike cooling histories of Beto and Galana margins appear to reflect disparate structural geometries of their basin‐bounding fault arraysLongitudinal contrasts in structural evolution of Broadly Rifted Zone may result from east‐west differences in preexisting lithospheric heterogeneities

Most countries exclude human immunodeficiency virus (HIV)‐positive patients from organ donation because of concerns regarding donor‐derived HIVtransmission. The Swiss Federal Act on Transplantation has allowed organ transplantation between HIV‐positive donors and recipients since 2007. We report the successful liver transplantation from an HIV‐positive donor to an HIV‐positive recipient. Both donor and recipient had been treated for many years with antiretroviral therapy and harbored multidrug‐resistant viruses. Five months after transplantation, HIVviremia remains undetectable. This observation supports the inclusion of appropriate HIV‐positive donors for transplants specifically allocated to HIV‐positive recipients. The authors report the first liver transplant from an HIV‐positive donor to an HIV‐positive recipient with a successful outcome at 6 months, and argue that the medical and social advances represented by this case call for legal and political progress. See the editorial from Fishman and Feng on page 2252.

We present the formalism and implementation of quasi-particle self-consistent GW(qsGW) and eigenvalue only quasi-particle self-consistent GW(evGW) adapted to standard quantum chemistry packages. Our implementation is benchmarked against high-level quantum chemistry computations (coupled-cluster theory) and experimental results using a representative set of molecules. Furthermore, we compare the qsGWapproach for five molecules relevant for organic photovoltaics to self-consistent GWresults (scGW) and analyze the effects of the self-consistency on the ground state density by comparing calculated dipole moments to their experimental values. We show that qsGWmakes a significant improvement over conventional G0W0and that partially self-consistent flavors (in particular evGW) can be excellent alternatives.

Die Zusammenfassung randomisierter kontrollierter und kontrollierter klinischer Studien (englisch: RCT und CCT) in systematischen Übersichtsarbeiten setzt die vollständige Erfassung aller Studien zu einer Fragestellung voraus. Ziel dieser Arbeit war die quantitative und qualitative Darstellung aller RCTs und CCTs in der Zeitschrift „Der Chirurg“.Es erfolgte eine Handdurchsuchung mit quantitativer und qualitativer Merkmalserfassung der Studien in „Der Chirurg“ von 1948 bis 2005 und ein Vergleich der Publikationshäufigkeiten (RCTs) mit führenden chirurgischen Zeitschriften.Es wurden 112 (90 RCTs, 22 CCTs) Studien identifiziert. Eine Fallzahlberechnung wurde in 12 (13%), eine Beschreibung der Randomisierungstechnik in 44 (49%) und eine Analyse nach „intention to treat“ in 5 (6%) RCTs angegeben. Ab dem Jahr 2000 nehmen die RCTs in „Der Chirurg“ im Gegensatz zum internationalen Trend ab.Verbesserte Rahmenbedingungen für Studien in der Chirurgie, die Umsetzung internationaler Standards (CONSORT Statement) und eine Änderung der Publikationsstrategie könnten die Quantität und Qualität deutschsprachiger RCTs und CCTs in „Der Chirurg“ steigern.Comprehensive identification of relevant literature is mandatory for valid assessment of the effectiveness of surgical interventions. Thus, electronic database searches are often complemented by handsearching of relevant surgical journals. The aim of this study was to assess the quantity and quality of randomized controlled (RCTs) and controlled clinical trials (CCTs) in the German surgical journalDer Chirurg.Quantitative and qualitative assessment was made after handsearching of studies published from 1948 to 2005 inDer Chirurg. Systematic database search (MEDLINE) was used for comparison of RCTs published inDer Chirurgand international surgical journals.Overall, 112 controlled clinical trials (90 RCTs, 22 CCTs) were identified by handsearching. The implementation of sample size calculation was reported in 12 of 90 (13%) RCTs. Forty-six (51%) did not specify the randomization process, and five (6%) incorporated the “intention to treat” principle in their analyses. After 2000, RCTs were published in declining frequency inDer Chirurg,whereas international surgical journals printed stable quantities of these studies.Improving the prerequisites of patient-centered clinical research in surgery, rigorous implementation of principles of the CONSORT statement, and modified publication strategies may improve the quality and quantity of reports on clinical studies in Germany.

Patientenorientierte Forschung, insbesondere die Durchführung von randomisierten, kontrollierten, multizentrischen klinischen Studien ist eine Herausforderung für chirurgische Prüfärzte. Um das Hintergrundwissen und die notwendigen Kenntnisse zu vermitteln, sind die eher am Arzneimittelgesetz (AMG) orientierten Prüfarztkurse spezifisch für den chirurgischen Bereich fortzuentwickeln. Die Hauptunterschiede liegen im regulatorischen und inhaltlichen Bereich, insbesondere in der Erarbeitung und Sicherstellung der Struktur, in der Behandlungs- und Beobachtungsgleichheit durch spezielle Randomisierungstechniken sowie in der Standardisierung der Operationsverfahren.Im November 2005 veranstaltete das Studienzentrum der Deutschen Gesellschaft für Chirurgie (SDGC) in Kooperation mit dem Koordinierungszentrum für Klinische Studien Heidelberg (KKS-HD) einen chirurgischen Prüfarztkurs. Über drei Tage wurden 24 Teilnehmer durch 16 Dozenten systematisch in klinischen Studien (Planung, protokollgerechte Behandlung, Datenmanagement, Biometrie, Ethik, Recht) unterrichtet und die Veranstaltung evaluiert.Der Inhalt des Kurses wurde mit 1,60 (Mittelwerte), die Verständlichkeit mit 1,55 und der Lerneffekt mit 1,55 bewertet (1= sehr gut bis 6= ungenügend). Ergänzend zu der sehr positiven Bewertung wurden Redundanzen der Vorträge, Fehlen von Kleingruppenarbeit und zu knappe Kursunterlagen kritisch angemerkt.Die Evaluation unterstrich die Notwendigkeit und den Nutzen des Kurses. Weitere Veranstaltungen mit kontinuierlicher Evaluation sind notwendig und können auf dem vorgelegten Konzept aufbauen. Die alleinige Qualifizierung von Chirurgen als Prüfärzte ohne nachhaltige Verbesserung der unzureichenden Struktur und Finanzierung von Projekten wird jedoch nicht ausreichen, um eine grundlegende Verbesserung der patientenorientierten Forschung in Deutschland zu erreichen.Clinical research, especially the management of randomized controlled multicentre trials, is a challenge for surgical investigators. To provide the theoretical background and practical knowledge needed for surgical trials, it is necessary to revise standard training programmes, which focus on pharmacological research. The main differences concern regulatory aspects and content, especially in achieving and maintaining comparability, equal treatment, and outcome assessment using special randomisation techniques and standardised surgical procedures.In November 2005, in cooperation with the Coordinating Centre for Clinical Trials in Heidelberg, the Study Centre of the German Surgical Society Study Group (SDGC) hosted a clinical investigation course for surgeons. During 3 days, 24 participants were systematically instructed by 16 lecturers on clinical trials (planning, treatment by protocol, data management, biometrics, ethics, and law), followed by participants’ evaluation of the course.On a scale of 1 to 6 (excellent to insufficient, respectively) the mean grades for the course were 1.6 for content, 1.55 for clarity, and 1.55 for learning effect. Partial repetition, lack of work in small groups, and not enough materials to take home were the major criticisms.The evaluation emphasised the necessity and value of the course. Further courses with continued evaluation are necessary and can be based on the same underlying concept. However, the mere qualification of surgeons as clinical investigators without substantial additional improvements in structural problems and increased financial project support will not fundamentally improve clinical research in Germany.

Das Studienzentrum der Deutschen Gesellschaft für Chirurgie (SDGC) soll multizentrische randomisiert kontrollierte Studien in der Chirurgie planen, durchführen und auswerten. Das Ziel dieser Arbeit ist es, den Entscheidungsprozess des SDGC von einer Studienidee bis zum finalen Studienprotokoll transparent darzustellen.Der Prozess ist in 4 Stufen gegliedert. Studienideen können elektronisch über die Homepage des SDGC von Mitgliedern der Deutschen Gesellschaft für Chirurgie eingereicht werden. Die Ideen werden innerhalb von 4 Wochen vom SDGC bezüglich methodischer Aspekte und klinischer Relevanz bewertet. Durchführbare und neuartige Ideen werden anschließend in Kooperation mit dem Einreicher in eine Studienskizze überführt. Der Vorstand des SDGC entscheidet über die Annahme oder begründete Ablehnung der Studienidee anhand definierter Kriterien. In der 4. Stufe wird das SDGC zusammen mit dem Einreicher ein Studienprotokoll erstellen. Die Ideen und Entscheidungen werden auf der Homepage einsehbar sein.Der beschriebene Prozess kann helfen, relevante Projekte auszuwählen, finanzielle Unterstützung zu erhalten und den Ablauf von der Idee zum Studienprotokoll transparent darzustellen.The Study Centre of the German Surgical Society (SDGC) designs, conducts, and analyses multicentre randomised controlled surgical trials. The aim of this paper is to present the decision-making process and responsibilities of the SDGC from submission of a study idea to full protocol development in order to achieve transparency in trial selection.The process is divided into four steps. Study ideas can be submitted electronically by members of the German Surgical Society using a form via the homepage of the institution. Firstly, ideas are screened by staff members within 4 weeks for methodological and clinical relevance. Feasible and novel ideas are then converted to trial outlines in cooperation with the submitting surgeon. As a third step, the Steering Committee of the SDGC decides whether to accept the project using a list of defined criteria. Finally, the SDGC draws up a full protocol together with the submitting surgeon. All ideas and decisions are accessible via the SDGC homepage.The process described should help in the selection of relevant projects, acquisition of grants, and maintenance of transparency in trial selection and the protocol development process.

Zusammenfassung: Hintergrund: Die INSECT-Studie ist eine registrierte, dreiarmige, multizentrische, intraoperativ randomisierte Modellstudie des Studienzentrums der Deutschen Gesellschaft für Chirurgie (SDGC). Interventionen sind der Bauchwandverschluss in fortlaufender Nahttechnik mit unterschiedlich mittelfristig resorbierbarem, monofilem Nahtmaterial (PDS®vs. MonoPlus®) und mit kurzfristig resorbierbarem, geflochtenem Nahtmaterial (Vicryl®) in Einzelknopftechnik. Primärer Endpunkt ist die Rate der Narbenhernien nach einem Jahr.Material und Methoden: Evaluation des theoretischen und praktischen Teil eines chirurgischen Studientreffens durch 25 Teilnehmer aus 24 Kliniken unterschiedlicher Versorgungsstufen durch kategorielle Bewertung von insgesamt 25 Merkmalen zur Kursorganisation und -inhalt sowie Beurteilung der einzelnen Referenten auf einer Skala von 1 (ldquorsehr gutldquo) bis 6 (ldquorungenügendldquo).Ergebnisse: Die Verteilung der 625 Noten war wie folgt: sehr gut (n=367), gut (n=207), befriedigend (n=39), ausreichend (n=2) und keine Angabe (n=10). Für die Gesamtveranstaltung ergibt sich eine Durchschnittsnote von 1,5.Schlussfolgerung: Durch ein chirurgisches Studientreffen konnten die Teilnehmer aus eigener Wahrnehmung sowohl praktisch als auch theoretisch erfolgreich in den Studieninterventionen und -ablauf unterwiesen werden. Im Rahmen von chirurgischen randomisiert kontrollierten Studien sind die Maßnahmen zur Herstellung der Behandlungsgleichheit vor und während der Studie offen zu legen.

Transcranial contrast Doppler studies have shown an increased prevalence of right-to-left shunts in patients with migraine with aura compared with controls. The anatomy and size of these right-to-left shunts have never been directly assessed.

We describe the response of poly(methyl methacrylate) surfaces to localized mechanical stimulation by the tip of an atomic force microscope (AFM) in water, methanol, ethanol, and aqueous alcohol solutions. Simply pressing the AFM tip into the surface with no horizontal motion fails to produce visible features in subsequent low contact force images. A single small-area (40 × 40 nm²) high contact force scan has little effect in air but in water or in alcohol−water mixtures produces soft bumps (local volume increase) adjacent to the scanned area. These bumps typically have lateral dimensions of ~100 nm and rise tens of nanometers above the surrounding surface. Larger, micron-scale scans produce approximately parallel, raised ridges 50−150 nm apart. These structures are stable over time periods of hours or more in air and in solvent. We present evidence that these modifications are due primarily to stress-enhanced solvent uptake in material surrounding the area of tip−polymer contact.

ObjectiveTo evaluate recent changes in the spectrum and clinical presentation of infective endocarditis and to determine predictors of outcome.DesignA retrospective case study.MethodsDemographic, clinical, and echocardiographic characteristics were examined in 212 patients who fulfilled the Duke criteria for infective endocarditis between January 1980 and December 1995 to assess changes in clinical presentation and survival.ResultsClinical presentation and course did not change significantly during the study period despite the concurrent introduction of new diagnostic tools (for example, transoesophageal echocardiography). In-hospital mortality was 15% and remained unchanged. Neurological symptoms on admission, arthralgia, and weight loss were all independent risk factors for adverse outcome (odds ratios 26.1, 6.2, and 4.2, respectively). Age, prosthetic valve disease, previous antibiotic treatment, renal insufficiency, surgical treatment, and the type of valve involved were not predictive of mortality. In contrast to all other major reports, Streptococcus viridans was the most common causative organism in intravenous drug users (52%).ConclusionsDespite the introduction of new diagnostic tools, the course of infective endocarditis has remained unchanged over a period of 16 years. Evidence of early dissemination of the disease to other sites was associated with adverse outcome. Even in elderly patients, early aggressive treatment seems to be effective.

AimTo determine the relation between the extent and distribution of left ventricular hypertrophy and the degree of disturbance of regional relaxation and global left ventricular filling. MethodsRegional wall thickness (rWT) was measured in eight myocardial regions in 17 patients with hypertrophic cardiomyopathy, 12 patients with hypertensive heart disease, and 10 age matched normal subjects, and an asymmetry index calculated. Regional relaxation was assessed in these eight regions using regional isovolumetric relaxation time (rIVRT) and early to late peak filling velocity ratio (rE/A) derived from Doppler tissue imaging. Asynchrony of rIVRT was calculated. Doppler left ventricular filling indices were assessed using the isovolumetric relaxation time, the deceleration time of early diastolic filling (E-DT), and the E/A ratio. ResultsThere was a correlation between rWT and both rIVRT and rE/A in the two types of heart disease (hypertrophic cardiomyopathy: r = 0.47, p < 0.0001 for rIVRT; r = -0.20, p < 0.05 for rE/A; hypertensive heart disease: r = 0.21, p < 0.05 for rIVRT; r = -0.30, p = 0.003 for rE/A). The degree of left ventricular asymmetry was related to prolonged E-DT (r = 0.50, p = 0.001) and increased asynchrony (r = 0.42, p = 0.002) in all patients combined, but not within individual groups. Asynchrony itself was associated with decreased E/A (r = -0.39, p = 0.01) and protracted E-DT (r = 0.69, p < 0.0001) and isovolumetric relaxation time (r = 0.51, p = 0.001) in all patients. These correlations were still significant for E-DT in hypertrophic cardiomyopathy (r = 0.56, p = 0.02) and hypertensive heart disease (r = 0.59, p < 0.05) and for isovolumetric relaxation time in non-obstructive hypertrophic cardiomyopathy (n = 8, r = 0.87, p = 0.005). ConclusionsNon-invasive ultrasonographic examination of the left ventricle shows that in both hypertrophic cardiomyopathy and hypertensive heart disease, the local extent of left ventricular hypertrophy is associated with regional left ventricular relaxation abnormalities. Asymmetrical distribution of left ventricular hypertrophy is indirectly related to global left ventricular early filling abnormalities through regional asynchrony of left ventricular relaxation.

BackgroundThe severity of aortic regurgitation can be estimated using pressure half time (PHT) of the aortic regurgitation flow velocity, but the correlation between regurgitant fraction and PHT is weak. AimTo test the hypothesis that the association between PHT and regurgitant fraction is substantially influenced by left ventricular relaxation. MethodsIn 63 patients with aortic regurgitation, subdivided into a group without (n = 22) and a group with (n = 41) left ventricular hypertrophy, regurgitant fraction was calculated using the difference between right and left ventricular cardiac outputs. Left ventricular relaxation was assessed using the early to late diastolic Doppler tissue velocity ratio of the mitral annulus (E/ADTI), the E/A ratio of mitral inflow (E/AM), and the E deceleration time (E-DT). Left ventricular hypertrophy was assessed using the M mode derived left ventricular mass index. ResultsThe overall correlation between regurgitant fraction and PHT was weak (r = 0.36, p < 0.005). In patients without left ventricular hypertrophy, there was a significant correlation between regurgitant fraction and PHT (r = 0.62, p < 0.005), but not in patients with left ventricular hypertrophy. In patients with a left ventricular relaxation abnormality (defined as E/ADTI< 1, E/AM< age corrected lower limit, E-DT ≥ 220 ms), no associations between regurgitant fraction and PHT were found, whereas in patients without left ventricular relaxation abnormalities, the regurgitant fraction to PHT relations were significant (normal E/AM: r = 0.57, p = 0.02; E-DT< 220 ms: r = 0.50, p < 0.001; E/ADTI < 1: r = 0.57, p = 0.02). ConclusionsOnly normal left ventricular relaxation allows a significant decay of PHT with increasing aortic regurgitation severity. In abnormal relaxation, which is usually present in left ventricular hypertrophy, wide variation in prolonged backward left ventricular filling may cause dissociation between the regurgitant fraction and PHT. Thus the PHT method should only be used in the absence of left ventricular relaxation abnormalities.

Abstract: Background: Graft rejection and infection remain major problems following liver transplantation; both are heavily influenced by the immunosuppressive regimen. Despite the disparity in the primary disease leading to transplantation, all patients receive the same post-transplant immunosuppressive treatment in a given center. The aim of this study is to detect a possible effect of the underlying disease on the incidence of early acute rejection episodes after orthotopic liver transplantation (OLT). Patients and Methods: Retrospective analysis on all 101 consecutive liver transplants performed in 95 patients between 1983 and March 1998; five of these patients, surviving less than 30 days, were not included. The immunosuppressive regimen was based on conventional triple therapy during the whole study period. The diagnosis and treatment of acute rejection within the first 30 days post-OLT was uniform throughout the whole study period. Results: Though there were no differences with respect to patients' characteristics [age, child classification, number of HLA-mismatches or cytomegalovirus (CMV)-serocompatibility], patients with primary biliary cirrhosis (PBC) showed a significant increase of acute rejection after OLT compared with the other patients transplanted for other liver diseases (P = 0.024). The incidence of infection was not elevated in patients transplanted for PBC when compared with other diagnoses. Conclusion: Our results indicate that primary liver disease may be a determinant for acute graft rejection in PBC. Furthermore, these results suggest that immunosuppressive regimens based on the underlying disease should be considered.

Zusammenfassung.: Die cervicale Nahtinsuffizienz ist mit einer Frequenz von 20–50 % einer der wesentlichen Morbidittsfaktoren in der Chirurgie des Oesophaguscarcinoms. Wir berichten ber eine neue Technik der Gastroplastik, die Fundusrotationsgastroplastik, welche bei 53 Patienten angewandt wurde. Es handelte sich um 49 Patienten mit Oesophaguscarcinom und 4 Patienten mit gutartigen Erkrankungen. Die Klinikletalitt nach Oesophagektomie und Fundusrotationsgastroplastik betrug 5,7 % (3/53), die Nahtinsuffizienzrate 7,5 % (4/53). Vorteile der Fundusrotationsgastroplastik gegenber der konventionellen Magenplastik liegen in der besseren Durchblutung und der greren Lnge des Schlauchmagens. Klinische Vergleichsstudien werden belegen mssen, ob die Fundusrotationsgastroplastik der konventionellen Magenplastik berlegen ist.

Second-look laparotomy is not always routinely performed after mesenteric infarction. Such operations are often not performed because of the high operative risk in aged patients and those with cardiovascular disease. We developed a minimally invasive technique, for second-look laparoscopy with the aim of decreasing the operative morbidity. With the patient under general anaesthesia, the old incision is opened at the umbilicus. The running suture in the abdominal wall is lifted with a clamp and the incision line is gently reopened. A trocar with a blunt tip designed for open laparoscopy is then inserted and fixed. Following insufflation of CO2 through the trocar it is possible to explore the entire small bowel and colon. We operated on five patients after bowel resection performed for mesenteric infarction. Second-look laparoscopy was diagnostic in all but one, in whom laparoscopy failed due to massive small bowel dilatation. The technique described here is very promising and deserves further evaluation.

We describe an apparatus measuring the cornealreflex stimulated pneumatically. The flow of preassurised air in the range of 0.1–1.5 bar is controlled by an electromagnetic switch. The time the valve is open, is variable. The air flow is directed to the cornea of the eye. The blink reflex is recorded by means of the surface electromyogramm and displayed on the screen of a storage scope.

Summary.: Surgical treatment of diffuse peritonitis is applied very variably. There is no question that source control is the most important treatment principle, but the role of additional treatment concepts such as continuous postoperative peritoneal lavage remains controversial. In a prospective survey (1993–1996) we analyzed the need for additional treatment concepts in our patient material. In 186 patients with diffuse peritonitis we applied the concept of source control and extensive (20–30 l) intraoperative lavage. Additional treatment principles such as continuous postoperative peritoneal lavage (n = 17) or staged lavage (n = 5) were applied only “on demand”, namely in 20 patients (11 %). In 166 patients (89 %) source control of diffuse peritonitis was possible. The mean severity of peritonitis (n = 186) was 28.5 (range 16–43) using the Mannheim Peritonitis Index. The primary cause of peritonitis in our patients was perforation or leakage in the lower GI tract (52 %). The hospital mortality rate was 12 % in the whole group, and the postoperative morbidity rate was 34 %. We conclude that nowadays, using high-quality intensive care as well as modern antiinfective treatment, only a few patients (ca. 10 %) need additional therapy measures such as postoperative lavage. Surgical source control in combination with intraoperative lavage is sufficient in most of the patients with diffuse peritonitis.

In a three-year period, 207 patients with cholecystolithiasis were referred to an interdisciplinary team at our hospital to evaluate the possibility of non-surgical treatment. Fifty-eight patients were found eligible for extracorporeal shock-wave lithotripsy (ESWL); 50 of them underwent ESWL on an outpatient basis with adjuvant bile acid therapy. Thirty patients (60%) had single stones, 14 (28%) had two or three stones, and 6 (12%) had five-ten stones. The mean total stone volume of all patients was 2,5 cm3, equivalent to a single stone of 1.7 cm diameter; 6 patients (12%) had slightly calcified stones. Successful stone fragmentation (fragments <- 4 mm) was achieved in 45 patients (90%). In the remaining 5 patients (10%) with residual fragments > 4 mm, ESWL was considered a failure and elective cholecystectomy was eventually performed or recommended. All patients received adjuvant oral bile acid therapy. The stone clearance rates after 3, 6, 12 and 18 months were 29%, 50%, 83% and 95% in patients with single stones and 22%, 40%, 64% and 88%, respectively, in all patients. The duration of treatment in 32 patients who have cleared all their gallstone fragments to date, was 8.5 months (range: 0.4–20.4 months); all of these patients are also free of their initial symptoms. Sideeffects and complications of ESWL included biliary colic in 17 patients (34%), mild acute pancreatitis in 1 patient (2%) and acute cholecystitis requiring emergency cholecystectomy in another patient (2%). The electromagnetic device and the protocol we used is well suited for ambulatory treatment of patients with a limited stone volume. A fragment size <- 4 mm was usually achieved with 2 treatment sessions and appears to be a reasonable endpoint of ESWL. Although laparoscopic cholecystectomy is now a routine procedure in our hospital, we believe that ESWL remains a valid treatment option in selected patients.

A steal phenomenon was detected by intravascular Doppler guidewire in a patient with a well collateralised coronary vascular area supplied by a reopened left circumflex coronary artery. This phenomenon accounted for the fall in blood flow velocity reserve during hyperaemic conditions to 50% of the baseline value. The collaterals must have been the cause of the steal phenomenon because complete revascularisation of the lesion barely reversed it.

Deposition of PrP amyloid in cerebral vessels in conjunction with neurofibrillary lesions is the neuropathologic hallmark of the dementia associated with a stop mutation at codon 145 of PRNP, the gene encoding the prion protein (PrP). In this disorder, the vascular amyloid in tissue sections and the approximately 7.5-kDa fragment extracted from amyloid are labeled by antibodies to epitopes located in the PrP sequence including amino acids 90-147. Amyloid-laden vessels are also labeled by antibodies against the C terminus, suggesting that PrP from the normal allele is involved in the pathologic process. Abundant neurofibrillary lesions are present in the cerebral gray matter. They are composed of paired helical filaments, are labeled with antibodies that recognize multiple phosphorylation sites in tau protein, and are similar to those observed in Alzheimer disease. A PrP cerebral amyloid angiopathy has not been reported in diseases caused by PRNP mutations or in human transmissible spongiform encephalopathies; we propose to name this phenotype PrP cerebral amyloid angiopathy (PrP-CAA).

Today, orthotopic liver transplantation is the treatment of choice for the end-stage of various liver diseases, and a 1-year survival rate of 80 % and a 5-year survival rate of 70 % in elective patients without tumor are reported in international surveys. The liver transplant programme of the Inselspital in Bern is small compared with international centres, which may raise questions about the results and the justification for such a programme. Over a period of 66 months, 62 liver transplantations were performed in 60 patients at the Inselspital. The hospital mortality was 3.3 %, and the 2.5-year overall survival rate was 92 % for elective cases without tumor. After a median follow-up of 30 months, 68 % of all patients were re-integrated in housework or full- or part-time in their profession, and 83 % were independent from the help of others. We conclude that a small liver transplant programme based only on routine resources can achieve results comparable to the international standards. Die orthotope Lebertransplantation ist heute zur Therapie der Wahl der Endstadien verschiedener Lebererkrankungen geworden. International beträgt das perioperative Überleben 80 % und die 5-Jahres-Überlebensrate liegt bei elektiv operierten nicht malignen Erkrankungen über 70 %. Das Lebertransplantationsprogramm in Bern ist im internationalen Vergleich klein und basiert auf dem Routinebetrieb einer Universitätsklinik. Es stellt sich daher die Frage nach den Resultaten und der Daseinsberechtigung eines solchen Programms. Im Zeitraum von 66 Monaten wurden am Inselspital in Bern 62 Lebertransplantationen bei 60 Patienten durchgeführt. Die perioperative Letalität betrug 3,3 %, die 30-Monats-Überlebensrate 92 % (elektive Patienten mit benignen Erkrankungen). 68 % der Patienten sind im Median 30 Monate nach der Transplantation arbeitsfähig und 83 % unabhängig von fremder Hilfe. Diese Resultate über einen 5-Jahres-Zeitraum sind vergleichbar mit den Ergebnissen internationaler Transplantationszentren. Aus unserer Sicht hat ein solches kleines Programm daher, wenn es interdisziplinär im Konzept einer Universitätsklinik eingepaßt ist, Daseinsberechtigung und Perspektive.

Background Sublingual nitroglycerin (glyceryltrinitrate, GTN) capsules or isosorbide dinitrate (ISDN) spray are routinely used to treat anginal attacks and to vasodilate maximally the epicardial coronary arteries during coronary angiography. Objective To compare the coronary vasodilatory effects of GTN capsules and ISDN spray with those induced by intracoronary GTN using quantitative coronary angiography. Design 96 patients (79 men and 17 women; median age 59 years) were randomised to four groups to receive either a sublingual capsule containing 0.8 mg GTN or two puffs of spray delivering 0.8 mg ISDN, followed or preceded by an intracoronary bolus of 0.2 mg GTN used as reference for maximal vasodilatation. Results There was a significant increase in the mean diameter of coronary arteries in angiographically normal segments in patients who received either intracoronary GTN (groups 1 and 2) or ISDN spray (group 4) as a first application (group 1, 0.46 mm, +17%, (baseline vessel diameter 100%), p &lt; 0.001; group 2, 0.45 mm, +13%, p &lt; 0.001; group 4, 0.47 mm, +13%, p &lt; 0.05). Patients who received a sublingual GTN capsule as the first application mode (group 3) had no significant change in epicardial vessel diameter (0.10 mm, +5%, p = 0.3). Conclusions Sublingual ISDN spray may be more efficacious than sublingual GTN capsules in certain patients with anginal attacks. ISDN spray should be preferred over capsules in coronary angiographic procedures.

Abstract—Among 215 patients referred for percutaneous closure of patent foramen ovale (PFO) after presumed paradoxical embolism, we assessed the prevalence of migraine. In the year prior to PFO closure, 48 (22) patients had migraine, twice the expected prevalence of 10 to 12 in the general European population. In patients with migraine with aura, percutaneous PFO closure reduced the frequency of migraine attacks by 54 (1.2 ± 0.8 vs 0.6 ± 0.8 per month; p 0.001) and in patients with migraine without aura by 62 (1.2 ± 0.7 vs 0.4 ± 0.4 per month; p 0.006). PFO closure did not have an effect on headache frequency in patients with nonmigraine headaches (1.4 ± 0.9 vs 1.0 ± 0.9 per month; p NS).

The long-term risk and risk factors for recurrent embolism after percutaneous closure of patent foramen ovale (PFO) were investigated in 152 consecutive patients with presumed paradoxical embolism. During follow-up, the actuarial freedom from recurrent embolism was 95.1 at 1 year, and 90.6 at 2 and 6 years. A residual shunt after percutaneous PFO closure was a predictor for recurrence (RR 5.3; 95 CI 1.3 to 21.0;p0.02). Randomized trials comparing medical treatment with percutaneous PFO closure in the prevention of recurrent embolism are in progress.

Introduction: The relationship between the appropriateness of the transthoracic echocardiography (TTE) and its clinical impact is still a matter of debate. Objective: The aim of this study was to assess the degree of adherence to the appropriate use criteria for echocardiography, in a tertiary public hospital in the United Kingdom, as well as the clinical impact of the exam on patient management. Methods: 859 TTE’s performed consecutively during January 2014 were reviewed to assess its appropriateness, and were classified as appropriate, uncertain or inappropriate using the 2011 guidelines. Subsequently, patient’s files were examined to determine the clinical impact of the TTE which was assigned to one of the following three categories: (1) active change in care, (2) continuation of current care, or (3) no change in care. Patients which files were not available were excluded (259). All classifications were evaluated by two independent cardiologists, with no direct relation to the study. Results: Our sample had a mean age of 63 ± 17 years with a gender balance. The majority of the exams were requested at the outpatient (81.4%) clinic, by cardiologists (50.3%) and general practitioners (13.4%). Regarding the main findings, in 7.6% of the studies there were moderate to severe systolic dysfunction; 4.0% showed severe valvular heart disease and 5.1% had significant pulmonary hypertension. Relatively to the appropriateness of the TTE requests, 76.5% were considered appropriate, 7.1% inappropriate and 12.6% uncertain. With respect to the clinical impact of the TTE’s, 42.7% of the exams led to an active change in care, 15.6% to a continuation of the care and 11.5% revealed no change in care. Age (β0.90, P=0.05) and outpatient setting (β4.4, P<0.01) were the most important predictors of an active change of care exam. On the contrary, the appropriateness of the TTE’s requests (β1.1, P=0.56) and the specialist ordering the exams (β0.81, P=0.26) were not independently associated. Conclusion: Our data showed that almost 8 out of 10 TTE were considered appropriate, and 4 out of 10 exams had an active clinical impact.

Purpose: To explore the use of 3D patient-specific cardiovascular models using rapid prototyping techniques to avoid unexpected findings and improve surgical planning in patients with complex congenital heart disease Methods: This European prospective multicenter (7 institutions) study included 21 patients with complex congenital heart diseases. Magnetic resonance imaging (MRI) and computed tomography (CT) were used to acquire 3D cardiovascular anatomy. Fused deposition technique using polylactic acid was used.A Bland-Altman analysis was used to evaluate the diameters measurement agreement between the 3D printed model and the patient's MRI and CT. 3D-models were used to plan the surgery.After the procedure, surgeons involved filled a questionnaire form to evaluate the usefulness of the 3D printed model. Results: The Bland-Altman analysis showed accurate agreement in the diameter between medical images and 3D-models (-0.20 ± 1.70 mm). 3D-models showed the spatial relationships between the VSD and great vessels in 10 patients with DORV and 3 patients with TGA and pulmonary stenosis, re-appraisal for biventricular repair in 2 cases, planning of lateral tunnel Fontan completion in 2 cases, re-opening of a restrictive VSD in 1 case, evaluation of MAPCA's in 1 case and evaluation of criss-cross heart anatomy in 2 cases. Surgeons found the 3D models to be very useful for surgical planning and avoiding complications with an overall level of satisfaction of 8.5 out of 10. Conclusions: 3D-printed cardiovascular models accurately replicate the patient's anatomy and are extremely helpful for planning surgery in complex congenital heart disease. They may potentially reduce operative time and morbi-mortality.

Background: Handheld ultrasound devices allow for a bedside screening although quantitative parameters are not easily obtained. We aim to assess the reliability of visual qualitative evaluation of left ventricle (LV) compared with standard quantitative evaluation with 2D transthoracic echocardiography (TTE). Methods: Two cardiologists have reviewed 135 consecutive standard TTE examinations. Both observers visually assessed LV size, hypertrophy (LVH) and ejection fraction (EF). LV diameter, volume, wall thickness and EF (Teichholz and Simpson) were also measured by both observers. Visual and quantitative agreement and inter and intraobserver variability were calculated. Results: Image quality allowed for evaluation of 130 examinations. Visually assessed EF compared with Simpson had better consistency (Intraclass correlation coefficient [ICC] 0,91 IC95% 0,88-0,94) than with Teichholz (ICC 0,75 IC95% 0,66-0,82). We have also observed good interobserver agreement regarding visually assessed EF (ICC 0,81 IC95% 0,71-0,87) and Simpson EF (ICC 0,80 IC95% 0,70-0,89) as well as good intraobserver agreement (visual EF: ICC 0,81 IC95% 0,74-0,86; Simpson: ICC 0,89 IC95% 0,84-0,93). Regarding LVH we found moderate agreement between visual and quantitative assessment (weighted Kappa [wK] 0,44 (IC95% 0,32-0,56)), moderate interobserver agreement for quantitative assessment (ICC 0,59 IC95% 0,44-0,71) and poor interobserver agreement for visual assessment (wK 0,19 IC95% 0,08-0,30). Intraobserver variability regarding LVH visual estimation was moderate (wK 0,40 IC95% 0,29-0,52) and regarding LVH quantification was good (ICC 0,78 IC95% 0,70-0,84). LVH was visually overestimated in 25% of examinations. Regarding LV size, we found poor agreement between visual assessment and its quantification with end-diastolic diameter (wK 0,22 IC95% 0,06-0,39) and moderate agreement between visual assessment and end-systolic LV volume (wK 0,62 IC95% 0,47-0,77). Interobserver agreement regarding quantitative volume assessment was good (ICC 0,90 IC95% 0,85-0,94) and regarding visual assessment was moderate (wK 0,43 IC95% 0,26-0,70). We found good intraobserver variability of volume measurement (wK 0,64 IC95% 0,50-0,78) and of visual size assessment (ICC 0,96 IC95% 0,94-0,97). Conclusions: Visual LVEF assessment is consistent with quantitative assessment and should be regarded as a reliable parameter that can be obtained from bedside examination with a handheld device. Visual assessment of LV size and wall thickness is less reliable than its quantification and should be confirmed with standard measurements.

Intention of paedaudiology is to detect and to evaluate hearing loss in children.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare form of congenital heart disease characterised by atrioventricular as well as ventriculoarterial discordance. It is usually associated with a variety of severe intracardiac defects. Few patients with this abnormality survive past 50 years. An 80 year old woman was admitted to the hospital because of mild congestive heart failure. Cardiac examination revealed a 4/6 holosystolic and a 2/6 decrescendo diastolic murmur at the left sternal border. Radiography, echocardiography, and computed tomography confirmed newly diagnosed CCTGA without associated intracardiac defects.

Purpose: Chronic pressure overload as in hypertension leads to regional LV remodelling, primarily affecting the basal iv. septum (IVS) which hypertrophies and shows reduced longitudinal function. This can be compensated by increased radial function, particularly in early disease. Measurement of systolic upstroke and diastolic downstroke of LV wall motion by M-mode might provide similar radial data. We have tested these easily obtainable measurements on our closed chest/closed pericardium pig model, pertaining as close to physiology as possible. In this model, we aimed to study LV wall systolic thickening and diastolic thinning velocities in acute pressure overload. Methods: 7 anesthetised, closed chest/closed pericardium pigs were instrumented with a descending aorta balloon, partially inflated during 5-10 heartbeats creating an 30% LV pressure increase. Echocardiographic LV LAX B-mode cine-loops were acquired (5 pre-, 5-10 inflation, 10 postinflation beats). The velocity of systolic thickening upstroke and diastolic thinning downstroke of the IVS and the LV posterior wall (LVPW) were measured from anatomic M-mode images of the LV base, mid and apex. Results: During balloon inflation, a reduction in the upstroke and downstroke velocities occurred in the basal LVPW, mid and apical IVS and LVPW, recovering after balloon deflation. However, the basal IVS showed the opposite-increased thickening and thinning velocities in response to afterload (Table 1). Conclusions: The basal LV septum differs from the remaining LV as the segment with the highest wall stress. In this model, we have demonstrated the increase in radial thickening and relaxation of the basal IVS with acute afterload, as opposed to the other LV segments where these parameters acutely decrease. These findings provide better insight into LV functional remodelling in acute afterload and, due to the selected animal model, might provide better translational data for the clinical setting. Table. Preinflation BasePreinflation MidPreinflation ApexInflation BaseInflation MidInflation ApexPostinflation BasePostinflation MidPostinflation ApexIVS S-slope15.3±10.8*28.9±14.5*27.0±14.2*23.6±13.720.9±12.619.6±8.418.4±14.8*28.3±23.426.4±10.4*IVS D-slope27.6±10.0*54.9±18.0*67.9±40.745.4±31.742.0±22.952.4±27.026.4±16.566.4±33.962.9±42.1LVPW S-slope48.7±10.2*43.3±16.0*36.3±16.5*35.6±11.422.0±13.022.4±12.443.4±15.9*39.6±16.3*39.4±19.3*LVPW D-slope75.7±49.7*76.4±22.985.0±51.0*37.3±27.758.7±57.138.0±25.365.9±30.0*70.4±33.466.9±27.4* Regional LV wall upstroke and downstroke velocities (mm/s) before, during and after acute pressure overload. * P<0.05 vs. inflation

Pulmonary vascular dysfunction is claimed to be a contributor to the development of pulmonary hypertension (PH). Impaired systemic vascular reactivity is one of the essential factors in the pathogenesis of cardiovascular disease. The aim of the investigation was to study whether there is any association between systemic vascular function and pulmonary artery pressure (PAP) in patients who have associated causes for PH development, such as coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Methods: The brachial artery vasodilator responses were measured by the ultrasound technique in twenty patients with mild to moderate COPD (group I) and twenty age–matched and COPD stage-matched patients who had past history of myocardial infarction (NYHA II) (group II).Conventional echocardiographic variables were measured in the said patients too. Results: Both flow-mediated dilatation (FMD) and nitrate-mediated dilatation (NMD) were significantly lower, and PAP was significantly higher in the group II patients compared to the same parameters of group I patients. NMD was inversely correlated with PAP (r=-0.7, p=0.02) in group I patients. There was no interrelation between FMD and PAP in patients from group I. Neither FMD nor NMD were correlated with PAP in group II patients. A significant positive correlation between PAP and left ventricular mass index (r=0.8, p=0.003) was revealed in the said patients as well. Conclusions: Attenuated vasodilator response of brachial artery to nitroglycerine is associated with PAP elevation in COPD patients. PH is closely related to cardiac remodeling in COPD patients in whom CHD developed. These data suggest different "stages" of vascular and cardiac remodeling in patients with COPD alone and in coexistence with CHD. The obtained data can be useful in the selection of treatment as regards these patient categories.

Background: Systemic sclerosis (SSc) is a rare connective tissue disease that can lead to severe heart complications, i.e. congestive heart failure, arrhythmia and sudden cardiac death. The latter are associated with poor prognosis in SSc. The aim of this study was to test whether infra-clinical myocardial dysfunction can be detected in patients with SSc free from cardiovascular symptoms. Methods: Global LV, and segmental right ventricular longitudinal strain (2D-speckle tracking strain) were quantified by transthoracic echocardiography to assess ventricular deformations in 48 patients suffering from SSc and 40 matched control subjects. Results: Despite normal LVEF, patients presenting SSc had significantly impaired LV GLS in compared to controls (17.9 +/- 3.04 % vs -19.4+/- 2.3 %; p= 0.01). By contrast, there was no significant difference on lateral and inferior RV strain between patients and controls. Decreased LV deformation was detected in patients regardless of pulmonary injury, i.e. restrictive syndrome and pulmonary arterial hypertension (PAH). Patients with diffuse cutaneous SSc had impaired (GLV?) LV and RV strains in 4 and 2 chamber views compared to those presenting a limited form of cutaneous SSc, with respectively, -18.9 +/- 3.47% vs -16.6+/- 3.70%, p=0.039 and -19.7+/- 2.93% versus -17.6+/- 3.40% p=0.047. Conclusion: Speckle-tracking strain analysis can detect infra-clinical impairment of LV myocardial function in patients with SSc who are free from any cardiovascular symptoms regardless of SSc impact on pulmonary function. Right and Left ventricular strain in Ssc