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• The application of class I medical compression stockings seems to be safe in patients with peripheral arterial disease. • The transcutaneous tissue spectrometry device O2C allows quantitative evaluation of microperfusion of the lower limb. • Medical compression therapy should not be employed in patients with SO2 values below 10%. The use of medical compression stockings (MCS) in patients with peripheral arterial disease (PAD) and diabetes is the subject of an ongoing critical debate. While reducing leg edema of various origins by improving venous back flow, there is a concern about additional arterial flow obstruction when compression therapy is applied in pre-existing PAD. The aim of this study is to obtain further information on the use of class I MCS in patients with advanced PAD and to evaluate the framework conditions for a safe application. The total collective (n = 55) of this prospective, clinical cohort study consisted of 24 patients with PAD Fontaine stage IIb and higher studied before revascularization, of whom 16 patients were examined again after revascularization, and 15 healthy participants included for reference. The microperfusion of the lower extremity of all participants was examined in a supine, elevated, and sitting position using the oxygen to see (O2C) method. The results indicate that leg positioning had the strongest influence on microcirculation (SO2 and flow: p = 0.0001), whereas MCS had no significant effect on the perfusion parameters (SO2: p = 0.9936; flow: p = 0.4967) and did not lead to a deterioration of values into critical ranges. Mild medical compression therapy appears to be feasible even in patients with advanced PAD. Larger studies are warranted to observe any long-term effects, in particular for the treatment of reperfusion edema after revascularization. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: To analyze the impact of medication optimization according to the FORTA list on functional status in patients undergoing geriatric rehabilitation. Findings: An increase of at least 20 points of the BI was observed in 40% of patients in the intervention group and in 12% of patients in the control group (p< 0.001). Logistic regression analysis with an increase of at least 20 BI-points was significantly and independently associated with patient group (2.358, p< 0.02). Message: Medication optimization according to the FORTA rules has a significant additional improvement in activities of daily living in older adults hospitalized for geriatric rehabilitation. Introduction: Functional status is one of the most important issues of geriatric care. Polypharmacy seems to be a modifiable factor associated with functional decline in older adults. However, the impact of pharmacotherapy optimization on the activities of daily living in patients undergoing geriatric rehabilitation has not been investigated prospectively so far. Methods: This post hoc analysis of a subsample of the VALFORTA study included individuals only undergoing geriatric rehabilitation with a length of in-hospital stay of at least 14 days. Medication was modified according to the FORTA rules in the intervention group while in the control group standard drug treatment was applied. Both groups received comprehensive geriatric treatment. Results: The intervention and control groups consisted of 96 and 93 individuals respectively. They did not differ according to basic data except for age and Charlson Comorbidity Index (CCI) on admission. On discharge, activities of daily living (Barthel index, BI) were improved in both groups. An increase of at least 20 points of the BI was observed in 40% of patients in the intervention group and in 12% of patients in the control group (p< 0.001). Logistic regression analysis with an increase of at least 20 BI-points was significantly and independently associated with patient group (2.358, p< 0.02), BI on admission (0.957, p< 0.001), and the CCI (0.793, p< 0.041). Conclusion: This post hoc analysis of a subsample of older individuals hospitalized for geriatric rehabilitation demonstrates a significant additional improvement in activities of daily living by modification of medication according to FORTA. Registration: DRKS-ID: DRKS00000531. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: To determine the intracranial pathologies and treatment outcome after mild traumatic brain injury (mTBI) in patients aged ≥65 years referred to a clinic for oral and maxillofacial surgery. Findings: Acute and delayed intracranial hemorrhage and mortality rates are low in older patients after mTBI. Factors that increase the risk of intracranial complications are a decreasing Glasgow Coma Scale score, loss of consciousness, amnesia, cephalgia, somnolence, dizziness, and nausea. These findings may be useful for indicating a repeat CT scan. Message: Triage guidelines on screening and management of older patients with mTBI must be revised to improve patient outcomes. Purpose: The primary aim was to determine the incidence of intracranial hemorrhage (ICH) after mild traumatic brain injury (mTBI) in patients aged ≥ 65 years. The secondary aim was to identify risk factors for intracranial lesions and evaluate the need for in-hospital observation in this age group. Methods: This observational retrospective single-center study included all patients aged ≥ 65 years who were referred to our clinic for oral and plastic maxillofacial surgery following mTBI over a five-year period. Demographic and anamnesis data, clinical and radiological findings, and treatment were analyzed. Acute and delayed ICH and patient outcomes during hospitalization were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between CT findings and clinical data. Results: A total of 1,062 patients (55.7% male, 44.2% female) with a mean age of 86.3 years were included in the analysis. Ground-level fall was the most frequent cause of trauma (52.3%). Fifty-nine patients (5.5%) developed an acute traumatic ICH, and 73 intracerebral lesions were radiologically observed. No association was detected between ICH rate and antithrombotic medication (p = 0.4353). The delayed ICH rate was 0.09% and the mortality rate was 0.09%. Significant risk factors for increased ICH were a Glasgow Coma Scale score of < 15, loss of consciousness, amnesia, cephalgia, somnolence, dizziness, and nausea according to multivariable analysis. Conclusion: Our study showed a low prevalence of acute and delayed ICH in older adults with mTBI. The ICH risk factors identified here should be considered when revising guidelines and developing a valid screening tool. Repeat CT imaging is recommended in patients with secondary neurological deterioration. In-hospital observation should be based on an assessment of frailty and comorbidities and not on CT findings alone. [ABSTRACT FROM AUTHOR]

Objective: This study was designed to demonstrate the predictive ability of quantitative indocyanine green (ICG) fluorescence angiography for the short-term postoperative outcome, the occurrence of delayed graft function (DGF), and long-term graft survival. Summary Background Data: DGF is a relevant problem after kidney transplantation; sufficient microperfusion of the allograft is crucial for postoperative organ function. Fluorescence angiography with ICG can serve as an intraoperative quality control of microperfusion. Methods: This prospective diagnostic study, conducted in 2 German transplantation centers from November 2015 to October 2018, included 128 consecutive kidney transplantations. Intraoperative assessment of the allograft microperfusion was performed by near-infrared fluorescence angiography with ICG; a software was used for quantitative analysis. The associations between perfusion parameters (eg, ICG Ingress) and donor, recipient, peri-procedural, and postoperative characteristics were evaluated. Results: DGF occurred in 23 (24%) kidney recipients from deceased donors. ICG Ingress (P = 0.0027), donor age (P = 0.0452), recipient age (P = 0.0139), and recipient body mass index (P = 0.0017) were associated with DGF. ICG Ingress correlated significantly with recipient age (r = −0.27662, P = 0.0016), cold and warm ischemia time (r = −0.25204, P = 0.0082; r = −0.19778, P = 0.0283), operating time (r = −0.32208, P = 0.0002), eGFR on postoperative days 1 (r =+0.22674, P = 0.0104) and 7 (r = +0.33189, P = 0.0001). The cutoff value for ICG Ingress was 106.23 AU with sensitivity of 78.3% and specificity of 80.8% (P < 0.0001) for the prediction of DGF. Conclusion: Fluorescence angiography with ICG allows intraoperative quantitative assessment of microperfusion during kidney transplantation. The parameter ICG Ingress reflects recipient and procedure characteristics and is able to predict the incidence of DGF. Trial registration: Clinicaltrials.gov: NCT-02775838 [ABSTRACT FROM AUTHOR]

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) remains one of the most common gastrointestinal neonatal malformations. Even though postoperative management is standardized, it differs between hospitals and disease-associated clinical factors that may play a role in outcome have not yet been assessed in detail. In this monocentric retrospective study, data of 43 patients with EA between 2010 and 2018 were analyzed. Analysis includes assessment of the clinical background, surgical technique, postoperative management including application of continuous muscle relaxation (CMR), influence of coagulation parameters such as factor XIII and incidence of complications. 21 patients (49%) were preterm infants with birth weights between 490 and 2840 g (median 1893 g). Only 35% (n = 15) presented without any concomitant malformations. Within the entire study population, representing Vogt II, IIIb and IIIc, we observed an association between the development of a postoperative pneumothorax and anastomotic failure (AF) (p = 0.0013). Furthermore, pneumothorax was associated with anastomotic stenosis (AS) in Vogt IIIb patients (p = 0.0129). CMR (applied since March 2017 in 7 patients in an attempt to prevent anastomotic problems due to high complication rates) and coagulation factor XIII did not significantly correlate with postoperative outcome. Appearance of pneumothorax was correlated with postoperative complications. These children should be monitored carefully in closer scheduled gastroenterological follow-up esophago-gastro-duodenoscopies. CMR and factor XIII substitution did not reduce anastomotic leakage but should be tested within an enlarged study population. [ABSTRACT FROM AUTHOR]

The reason for increased serum creatinine levels in preterm infants often remains unclear. We aimed to determine whether postnatal serum creatinine in preterm infants correlates with intake of amniotic fluid, represented by the amount of amniotic fluid after preterm premature rupture of membranes (PPROM). 74 preterm infants with PPROM > 48 h duration were retrospectively studied. Postnatal creatinine concentration was determined at day 2–5, 10–17 and 26–33 of life and compared between infants with normal intrauterine amniotic volumes, oligohydramnios and anhydramnios. Mean gestational age of included patients was 29.7 weeks (range: 24.0–36.1 weeks) and mean birth weight was 1452 g (range: 560–2940 g). Serum creatinine concentration was similar at day 2–5 and day 10–17 of life between the three groups. We observed a significant decrease in creatinine concentration from day 2–5 to day 26–33 in infants with normal amniotic fluid volume and oligohydramnios (p = 0.0001 and p = 0.0071, respectively), but not in anhydramnios. On day 26–33 of life, infants with anhydramnios showed significantly higher creatinine levels compared to infants with normal amniotic fluid volume and oligohydramnios (p = 0.0211). Postnatal serum creatinine of preterm infants at day 26–33 of life is elevated in infants with PPROM-induced anhydramnios, but not in oligohydramnios. [ABSTRACT FROM AUTHOR]

Objective: The study sought to assess the impact of ischemic (ICMP) compared to non-ischemic cardiomyopathy (NICMP) on recurrences of ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) recipients.Background: Data comparing recurrences of ventricular tachyarrhythmias in ICD recipients with ischemic or non-ischemic cardiomyopathy is limited.Methods: A large retrospective registry was used including all consecutive ICD recipients with first episodes of ventricular tachycardia (VT) or fibrillation (VF) from 2002 to 2016. Patients with ICMP were compared to patients with NICMP. The primary prognostic endpoint was first recurrences of ventricular tachyarrhythmias at one year. Secondary endpoints comprised ICD-related therapies, rehospitalization and all-cause mortality at one year. Statistics Kaplan-Meier survival and multivariable Cox regression analyses.Results: A total of 387 consecutive ICD recipients were included retrospectively (ICMP: 82%, NICMP: 18%). At one year of follow-up, freedom from first recurrences of ventricular tachyarrhythmias was lower in NICMP (81% vs. 71%, log-rank p = 0.063; HR = 1.760; 95% CI 0.985-3.002; p = 0.080), mainly attributed to higher rates of sustained VT (20% versus 12%, p = 0.054). Accordingly, freedom from first appropriate device therapies was lower in NICMP (74% vs. 85%, log rank p = 0.004; HR = 1.951; 95% CI 1.121-3.397; p = 0.028), especially in patients with sustained VT or VF at index. Both groups revealed comparable rates of rehospitalization and all-cause mortality at one year.Conclusion: NICMP was associated with higher rates of recurrent ventricular tachyarrhythmias and appropriate ICD therapies compared to ICMP at one year of follow-up, whereas rates of rehospitalization and all-cause mortality were comparable.Condensed Abstract: This study retrospectively compared the impact of cardiomyopathy types (ICMP versus NICMP) on recurrences of ventricular tachyarrhythmias in 387 ICD recipients. Freedom from first episodes of ventricular tachyarrhythmias and first appropriate device therapies were lower in patients with NICMP compared to ICMP. [ABSTRACT FROM AUTHOR]

Key Summary Points: Aim: The study sought to assess the impact of age on recurrent ventricular tachyarrhythmias, appropriate ICD therapies and all-cause mortality at 5 years in consecutive ICD recipients. Findings: Age ≥ 75 years was associated with higher rates of first recurrent ventricular tachyarrhythmias, appropriate ICD therapies and all-cause mortality at 5 years. Message: Elderly ICD recipients aged ≥ 75 years are at increased risk of recurrent ventricular tachyarrhythmias, appropriate ICD therapies and all-cause mortality at 5 years. Background: Data regarding the prognostic impact of age in implantable cardioverter defibrillator (ICD) recipients is limited. Objective: The study sought to assess the impact of age on recurrences of ventricular tachyarrhythmias in ICD recipients. Methods: This "secondary prevention" study is based on a large retrospective registry including consecutive ICD recipients with documented ventricular tachyarrhythmias from 2002 to 2016. Patients < 75 years of age were compared to patients ≥ 75 years. The primary endpoint was first recurrence of ventricular tachyarrhythmias at 5 years. Secondary endpoints were ICD-related therapies, rehospitalization, and all-cause mortality at 5 years. Statistics comprised Kaplan–Meier survival curves, multivariable Cox regression analyses, and propensity-score matching. Results: A total of 592 consecutive ICD recipients with index ventricular tachyarrhythmias was included (< 75 years: 78%; ≥ 75 years 22%). Age ≥ 75 years was associated with the primary endpoint of first recurrence of ventricular tachyarrhythmias (49% vs. 43%, log-rank p = 0.015; HR 1.418; 95% CI 1.070–1.881; p = 0.015), and with the secondary endpoint of first appropriate ICD therapy (78% vs. 22%, log-rank p = 0.011) even within multivariable Cox regression analyses. After propensity-score matching, age ≥ 75 years was still associated with the primary endpoint of first recurrence of ventricular tachyarrhythmias (49% vs. 42%, log-rank p = 0.045; HR 1.482; 95% CI 1.007–2.182; p = 0.046). Conclusion: Elderly ICD recipients aged ≥ 75 years are at increased risk of recurrent ventricular tachyarrhythmias, appropriate ICD therapies, and all-cause mortality at 5 years. [ABSTRACT FROM AUTHOR]

Abstract The Gram-negative bacterium Haemophilus influenzae (H. influenzae) can commensally colonize the upper respiratory tract, but also cause life threatening disease including epiglottitis, sepsis and meningitis. The H. influenzae capsule protects the bacteria against both phagocytosis and opsonization. Encapsulated H. influenzae strains are classified into serotypes ranging from a to f dependent on their distinct polysaccharide capsule. Due to the implementation of vaccination the incidence of invasive H. influenzae type b (Hib) infections has strongly decreased and infections with other capsulated types, including H. influenzae type f (Hif), are emerging. The pathogenesis of H. influenzae meningitis is not clarified. To enter the central nervous system (CNS) the bacteria generally have to cross either the blood-brain barrier (BBB) or the blood-cerebrospinal fluid barrier (BSCFB). Using a cell culture model of the BCSFB based on human choroid plexus papilloma (HIBCPP) cells and different H. influenzae strains we investigated whether Hib and Hif invade the cells, and if invasion differs between encapsulated vs. capsular-deficient and fimbriated vs. non-fimbriated variants. We find that Hib can adhere to and invade into HIBCPP cells. Invasion occurs in a strongly polar fashion, since the bacteria enter the cells preferentially from the basolateral "blood "side. Fimbriae and capsule attenuate invasion into choroid plexus (CP) epithelial cells, and capsulation can influence the bacterial distribution pattern. Finally, analysis of clinical Hib and Hif isolates confirms the detected invasive properties of H. influenzae. Our data point to roles of capsule and fimbriae during invasion of CP epithelial cells. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to characterize the pathologic changes of the osteoarthritic humeral head. Methods The study included 55 patients with primary osteoarthritis who underwent anatomic shoulder arthroplasty. Several radiologic parameters (radiography, magnetic resonance imaging) were assessed. Humeral head deformity in the transverse plane and humeral cartilage erosion in the coronal plane were chosen for photographic measurements from the resected humeral heads. Results In the coronal plane, 82% of patients presented with an aspherical humeral head shape with a significantly longer caudal osteophyte. In the transverse plane, 50% of all patients showed a decentered apex. Patients with an aspherical humeral head shape in the transverse plane showed an aspherical humeral head shape in the coronal plane in 94% and a significantly longer osteophyte than patients with spherical humeral head shape, showing a 3-dimensional deformity of the humeral head during progression of primary osteoarthritis. Patients with an osteophyte length between 7 and 12 mm were associated with a glenoid type B2 in 30% and a decentered apex in the transverse plane in 38%. Patients with a humeral osteophyte longer than 13 mm were significantly more frequently associated with a type B2 glenoid (71%; P  < .0001) and a decentered apex in the transverse plane in 52%. Conclusion It seems that the progression of primary osteoarthritis of the glenohumeral joint is characterized by an increasing 3-dimensional deformity of the humeral head related to the glenoid morphology. We therefore propose an extended Samilson-Prieto classification with type A (spherical) and type B (aspherical) and grade I-IV osteophytes. [ABSTRACT FROM AUTHOR]

Purpose: Overactive bladder (OAB) is a common condition affecting approximately 11% of individuals worldwide. One of the newest treatment options for OAB symptoms is mirabegron. The objective of this network meta-analysis is to evaluate the extent of the efficacy and tolerability of mirabegron compared both to placebo and first-line anticholinergic pharmacotherapies. Methods: Articles were identified through the MEDLINE, EMBASE, and Cochrane databases using the search term ‘mirabegron’. All original, prospective, randomised, controlled, double-blind clinical trials studying mirabegron in adults receiving initial treatment for OAB were included. Efficacy was assessed based on outcome variables and responder data. Tolerability was evaluated for reported adverse events. Results: Thirteen studies including a total of 13,333 individuals were included. Mirabegron demonstrated better efficacy compared to placebo and tolterodine extended release 4 mg. Compared to placebo, the incidence of tachycardia and nasopharyngitis was greater with mirabegron 50 mg, and the incidence of cardiac arrhythmia was greater in 100 mg treatment groups. Mirabegron 100 mg also demonstrated a lower incidence of cardiac arrhythmia compared to tolterodine. Conclusions: The current study presents new information that may affect patient-centred strategies for the management of OAB, with a particular concern for cardiovascular safety. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this prospective study was to investigate absolute radiation exposure values and factors that influence radiation exposure of interventionists during CT-guided interventions (CTGIs). To our knowledge, no data exist regarding the radiation dose to which the interventionist is exposed during these procedures. Methods Absolute radiation dose values from a total of 131 CTGIs were analyzed. Radiation dose values were collected by thermoluminescent dosimeters that were positioned above the lead protection being worn, on the forehead, thyroid, chest, gonads, and right and left hand and foot. The radiation doses were analyzed with respect to the experience level of the person performing the procedure, the degree of difficulty measured on a 4-point Likert scale, the lesion size measured on a 3-point Likert scale, and the CT system used. Results Median whole-body dose was 12 μSv. With the exception of the forehead, all whole-body radiation doses were statistically significantly lower in CTGIs performed using the modern dual-source CT system compared with the 16-slice multi-detector CT. For CTGIs rated as more complex, the radiation exposure of the radiologist performing the procedure was statistically significantly higher, with the exception of the left hand. A statistically significantly lower median whole-body dose was measured for inexperienced compared with experienced radiologists. However, a few dose measurements of more than 1 mSv were found at the right hand. Conclusions Radiation exposure measured during CTGIs is low (<50 μSv). Because the radiation dose was higher in more-complex interventions and for 16-slice multi-detector row CT, inexperienced radiologists should focus on less-complex procedures. [ABSTRACT FROM AUTHOR]

Purpose We separately evaluated the lymphatic and blood vascular systems to assess the diagnostic accuracy of microvascular invasion and identify predictive markers for occult metastasis of testicular nonseminomatous germ cell tumors. Materials and Methods Tissue samples of 86 patients treated for testicular nonseminomatous germ cell tumors (stage 1 in 48 and stage greater than 1 in 38) were stained using the lymphatic endothelial cell specific marker LYVE-1 and the blood vessel endothelial cell marker von Willebrand factor. We assessed lymph vessel density in LYVE-1 stained sections and blood vessel density in von Willebrand factor stained sections. Lymphovascular invasion in LYVE-1 stained sections and blood vascular invasion in von Willebrand factor stained sections were documented. Parameters were correlated with standard clinicopathological data. Results Blood vessel density in von Willebrand factor sections was significantly greater than lymphatic vessel density in LYVE-1 sections (p <0.001). Peritumor and nontumor lymphatic vessel density in LYVE-1 sections was associated with metastasis at diagnosis (OR 1.277/U, p = 0.020 and OR 1.113/U, p = 0.095). Lymphovascular invasion in LYVE-1 sections was significantly associated with metastasis (OR = 4.517, p = 0.002) but blood vascular invasion in von Willebrand factor sections was only slightly significant (OR 2.261, p = 0.071). Only lymphovascular invasion in LYVE-1 stained sections was significantly associated with metastasis in a multiple logistic regression model. Microvascular invasion in hematoxylin and eosin stained sections was not associated with metastasis but microvascular invasion evaluated in LYVE-1 and von Willebrand factor stained sections was associated with metastasis (OR 3.506, p = 0.016). Conclusions Lymphovascular invasion in LYVE-1 stained sections was the most important predictive parameter for metastasis at diagnosis, suggesting greater relevance of the lymphatic system in metastatic dissemination of testicular nonseminomatous germ cell tumors. Vascular endothelial cell specific markers provide higher diagnostic accuracy for microvascular invasion. Our results may impact the current concept of microvascular invasion used for risk stratification of clinical stage 1 testicular nonseminomatous germ cell tumors. [ABSTRACT FROM AUTHOR]