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Lumbar spinal stenosis (LSS) is one of the most common indications for surgery in the USA. The addition of instrumented fusion to decompression for the treatment of LSS has become common, but recent randomized controlled trials (RCTs) have produced percieved conflicting results with unclear clinical implications. This review seeks clarity through an analysis of available RCTs. We performed a search of the PubMed database for RCTs that directly addressed decompression vs. decompression and fusion for the surgical treatment of LSS. RCTs were screened and reviewed to compare content such as patient selection, pathology, radiographic criteria, and operative technique. Five RCTs resulted from our search and were included in our analysis. Two studies yielded class I data while three yielded class III data due to study design related issues. Heterogeneity between these studies is emphasized with regard to patient selection, LSS definition, spondylolisthesis, instability, and surgical technique. Efforts to decipher which patients will truly benefit from instrumented fusion for the surgical treatment of LSS are still ongoing. Surgeon judgment will remain a crucial component for surgical decision making until future trials provide clarity. Instrumented fusion should be tailored to the individual patient rather than incorporated as a routine practice.

Background Resident applicants in neurosurgery often wonder what factors impact their chances of successfully matching. Using data published by the National Residency Match Program for 2009–2016, we examined which components of the Electronic Residency Application Service application correlated with successful residency matching. Methods Data were collected from the National Residency Match Program publication Charting Outcomes in the Match from all years it was available for neurosurgery (2009, 2011, 2014, 2016). Individual factors reported (number of contiguous ranks, research projects, publications and presentations, work experiences, volunteer experiences, United States Medical Licensing Examination Step 1 and 2 score deciles, categorical data about Alpha Omega Alpha status, Ph.D. degree, other degree, and strength of medical school National Institutes of Health funding) were aggregated for all 3 years. Categorical data were available only for U.S. seniors. Spearman correlation and χ2 were used for ranked data and categorical data, respectively. Separate analyses were run for U.S. seniors and independent applicants. Results For U.S. seniors applying to neurosurgery, number of contiguous ranks, United States Medical Licensing Examination Step 1 and 2 scores, research projects, Alpha Omega Alpha status, and medical school top 40 National Institutes of Health funding were significantly associated with successful matching of applicants. Number of volunteer experiences was nearly statistically significant. For independent applicants, only United States Medical Licensing Examination Step 1 and 2 scores and number of research projects were statistically significant. Conclusions This is the first study to analyze National Residency Match Program data for predictors of success in neurosurgical matching. Students applying to neurosurgery residency and their mentors should be aware of which baseline objective factors are associated with match success.

Network analysis based on graph theory depicts the brain as a complex network that allows inspection of overall brain connectivity pattern and calculation of quantifiable network metrics. To date, large-scale network analysis has not been applied to resting-state functional networks in complete spinal cord injury (SCI) patients. To characterize modular reorganization of whole brain into constituent nodes and compare network metrics between SCI and control subjects, fifteen subjects with chronic complete cervical SCI and 15 neurologically intact controls were scanned. The data were preprocessed followed by parcellation of the brain into 116 regions of interest (ROI). Correlation analysis was performed between every ROI pair to construct connectivity matrices and ROIs were categorized into distinct modules. Subsequently, local efficiency (LE) and global efficiency (GE) network metrics were calculated at incremental cost thresholds. The application of a modularity algorithm organized the whole-brain resting-state functional network of the SCI and the control subjects into nine and seven modules, respectively. The individual modules differed across groups in terms of the number and the composition of constituent nodes. LE demonstrated statistically significant decrease at multiple cost levels in SCI subjects. GE did not differ significantly between the two groups. The demonstration of modular architecture in both groups highlights the applicability of large-scale network analysis in studying complex brain networks. Comparing modules across groups revealed differences in number and membership of constituent nodes, indicating modular reorganization due to neural plasticity.

Bordatella pertussis infection leads to a chronic, debilitating, and paroxysmal cough that can last for months to years. Incidence of B pertussis in the immunized adult population is rising nationwide, but many otolaryngologists are unfamiliar with the diagnosis and management of this disease. Adults often present late in the disease process when traditional diagnostic testing is ineffective and without the classic pediatric symptoms of whooping cough. As a result, B pertussis infections in adults are often overlooked or misdiagnosed as asthma exacerbations or viral bronchitis, leading to increased morbidity, unnecessary testing, and additional exposure of vulnerable populations to the pathogen. This commentary describes 3 adult cases of B pertussis confirmed with serum testing in the ambulatory population and describes varied presentations based on time from initial infection. Specific emphasis is presented on the physical manifestations of the disease in laryngeal structures, methods of diagnosis, and recommendations for treatment.

Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms. A retrospective chart review of 107 patients who underwent EVD placement within 24 h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48 h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation. Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p = 0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p = 0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p = 0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p = 0.59). No post-EVD hemorrhage had attributable neurologic morbidity. Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.

Anamnese und klinischer Befund: Bei einem 28-jahrigen Patienten mit Sichelzellerkrankung kam es nach einem Alkoholexzess zu einer vasookklusiven Krise mit akutem Thoraxsyndrom und Entwicklung eines schweren Lungenversagens. Therapie und Verlauf: Nach einer partiellen Austauschtransfusion konnte er erfolgreich mit einer venovenosen extrakorporalen Membranoxygenierung (ECMO) therapiert werden. 12 Tage nach Ubernahme wurde der Patient von der ECMO getrennt, 2 Tage spater konnte der tracheotomierte Patient dekanuliert werden. 19 Tage nach dem Ereignis erfolgte die Ruckverlegung des vollstandig genesenen Patienten in sein Heimatkrankenhaus nach Paris. Folgerung: Auch wenn es fur den Einsatz der ECMO zur Behandlung eines lebensbedrohlichen akuten Thoraxsyndroms bei Sichelzellerkrankung noch keine ausreichenden Daten gibt, scheint der Therapieansatz Erfolg versprechend und in dieser Situation eine bedenkenswerte Option zu sein.

Die aktuelle Leitlinie der ESC stellt ein hilfreiches und im klinischen Alltag praktikables Instrument in der Risikostratifizierung von Patienten im Kontext eines geplanten operativen Eingriffes als auch im perioperativen Management dar. Besonders wertvoll erscheinen die klare Strukturierung der Risikostratifizierung von Patienten und geplantem operativem Eingriff in den 3 Risikokategorien niedrig, mittel und hoch und die sich daraus ableitenden Konsequenzen im medikamentosen als auch diagnostischen und interventionellen pra-, peri- und postoperativen Management. Der grundlegende Algorithmus und Entscheidungsbaum wird auch in den parallel zu diesem Kommentar publizierten Pocket-Leitlinien der Deutschen Gesellschaft fur Kardiologie eine zentrale Stellung einnehmen.

Neben den klassischen kardiovaskularen Risikofaktoren werden prothrombogene Veranderungen des Gerinnungssystems als wichtige Marker fur ein erhohtes Atheroskleroserisiko angesehen. Erworbene Storungen der Hamostase sind haufig bei alteren Patienten anzutreffen und stehen im Zusammenhang mit der erhohten Pravalenz chronischer Erkrankungen in diesem Kollektiv. Pathophysiologisch ist eine Verknupfung von Krankheiten, die mit einer Hyperinsulinamie einhergehen, wie dem Diabetes mellitus, dem metabolischen Syndrom und der arteriellen Hypertonie, und einem veranderten Gleichgewicht der hamostaseologischen Faktoren gut belegt. Die Hyperinsulinamie ist als Indikator peripherer Insulinresistenz ein unabhangiger Risikofaktor der koronaren Herzkrankheit. Plasminogenaktivatorinhibitor wird als pathophysiologisches Bindeglied dieser Assoziation betrachtet. Chronische Entzundungsprozesse, die im Alter haufig sind, konnen uber eine Hyperfibrinogenamie weiter zur Storung des hamostaseologischen Gleichgewichts beitragen. Schlieslich ist denkbar, dass diese prothrombogenen Veranderungen die Progression der Atherosklerose im Alter beschleunigen und das Auftreten akuter Koronarsyndrome begunstigen. Diese Zusammenhange unterstreichen, dass die optimierte Behandlung von chronischen Begleiterkrankungen ein wichtiger Aspekt der Primar- und Sekundarpravention atherosklerotischer Manifestationen im Alter ist. Daruber hinaus bietet die prothrombogene Aktivierung des Gerinnungssystems einen vielversprechenden Ansatzpunkt fur spezifische Therapienkonzepte.

More than 25 years ago it was demonstrated that an improvement in various parameters of blood flow in patients who have an hyperviscosity syndrome improves coronary blood flow. Hyperfibrinogenemia with resulting increase in plasma viscosity and erythrocyte aggregation has been demonstrated in patients with coronary heart disease. Poiseuille's law, which describes the interaction between vascular resistance, vessel geometry and blood viscosity, indicates--when applied to coronary artery disease--that an increase in the viscosity of blood, especially of plasma, can in the poststenotic microcirculation be a flow-limiting factor and a critical determinant of oxygen supply to myocardium that is at risk of ischaemia. An increased concentration of fibrinogen, which is the substance that causes the increase in plasma viscosity, has been shown to correlate prospectively with the risk of serious cardiovascular events. Patients with multiple-vessel coronary heart disease and treatment-refractory angina pectoris have clearly increased fibrinogen values. Chronic intermittent urokinase administrations--given with the aim of achieving fibrinogenolysis of the elevated fibrinogen concentration at a dose of 500 000 IU urokinase three times weekly -improves the rheological parameters and achieves an impressive decrease in symptoms. It is thus important in clinical practice to take into account that patients with atherosclerosis and a fibrinogen concentration of more than 300 mg may develop perfusion disorders and worsening of their symptoms.

The effect of fenofibrate (a clofibrate derivative) on fibrinogen concentration, blood viscosity and myocardial microcirculation was examined in 35 patients with coronary heart disease (n = 27) or hypertension (n = 8). After eight weeks' administration of 250 mg fenofibrate daily cholesterol and triglycerides levels decreased significantly, as did the fibrinogen concentration, from a mean of 300.7 +/- 75.1 mg/dl to 252.3 +/- 61.2 mg/dl (P less than 0.01). Plasma viscosity and erythrocyte aggregation were also significantly lowered (from 1.43 +/- 0.09 to 1.37 +/- 0.07 mPas and 15.0 +/- 3.1 to 13.5 +/- 2.2, respectively; P less than 0.01). In eight of twelve subjects selected from the whole group thallium myocardial scintigraphy demonstrated, after eight weeks of treatment with fenofibrate, a global (in two) or regional (in six) increase in blood flow. Reduction of fibrinogen concentration may in coronary heart disease achieve an improvement in myocardial microcirculation with decreased myocardial ischaemia.

Der rechte Ventrikel toleriert Volumenbelastungen durch Rekrutierung von Kapazitatsgefasen und Kapillaren des Lungenkreislaufs ohne wesentliche Drucksteigerung, besitzt aber nur geringe kontraktile Reserven und reagiert nichtadaptiert auf Druckbelastungen mit einer rechtsventrikularen Dysfunktion. Seine Grose und Druckbelastung sind prognoserelevant bei allen Formen pulmonaler Hypertonie und insbesondere bei Linksherzinsuffizienz. Von hoher Bedeutung ist die Differenzierung der pulmonalen Hypertonie nach der Venedig-Klassifikation. Ein insuffizienter rechter Ventrikel verschlechtert die linksventrikulare Hamodynamik infolge reduzierter Auswurfleistung, aber auch rechts-linksventrikularer Interaktionen mit Auslosung einer diastolischen linksventrikularen Dysfunktion bei noch intakter systolischer linksventrikularer Funktion. Eine rechtsventrikulare Ejektionsfraktion

Background: Syringomyelia results from obstruction of cerebrospinal fluid (CSF) flow due to a multitude of causes. Often symptoms of pain, weakness, and sensory disturbance are progressive and require surgical treatment. We present here a rare technique for syringosubarachnoid shunting. Case Description: We present the case of a 38-year-old male who suffered a traumatic cervical spinal cord injury due to a motor vehicle accident. With progressive pain and motor decline, a magnetic resonance imaging was obtained and showed a new syrinx extending cervical multiple segments. A unique surgical procedure using a myringotomy tube to shunt CSF into the subarachnoid space was employed in this case. The patient's examination stabilized postoperatively, and at 2 months and 6 months follow-up visits, his strength and sensation continued to improve. Conclusion: We used a myringotomy tube for syringosubarachnoid shunting for the surgical management of a posttraumatic syrinx with good results. This technique minimizes suturing and may minimize shunt-related complications.

Die Pravention des plotzlichen Herztodes ist aufgrund der Haufigkeit dieses prognostisch gravierenden Ereignisses von hoher Bedeutung. Stand bisher die sekundare Pravention nach uberlebten, nahezu fatalen Arrhythmien im Vordergrund der Behandlung, so werden zunehmend Risikogruppen definiert, bei denen eine primare Prophylaxe sinnvoll ist. Die wichtigste therapeutische Masnahme ist die Behandlung der kardialen Grunderkrankung, wobei die medikamentose Herzinsuffizienztherapie und die Behandlung einer ischamischen Herzerkrankung entscheidend sind. Die medikamentose antiarrhythmische Therapie tritt wegen ihrer Wirkungslosigkeit und der Gefahr von proarrhythmogenen Effekten zunehmend in den Hintergrund. Eine weitere Therapieoption ist die Implantation von Cardioverter-Defibrillatoren (ICDs). Aufgrund der kostenintensiven Therapie muss hier jedoch insbesondere bei der primaren Prophylaxe die Indikation kritisch gestellt werden. Der wesentliche Risikofaktor fur das Auftreten einer fatalen Arrhythmie ist die Storung der linksventrikularen Funktion, die somit ein zentrales Kriterium zur Indikationsstellung einer ICD-Implantation ist. In view of the frequency of sudden cardiac death, prevention of this grave event is a high priority. While secondary prevention after survival of almost fatal arrhythmias previously constituted the core treatment, risk groups for whom primary prophylaxis makes good sense are now increasingly being defined. The major therapeutic measure is treatment of the underlying cardiac disease, with pharmacotherapy of cardiac insufficiency and treatment of ischaemic heart disease being of decisive importance. Antiarrhythmic drugs are now increasingly being abandoned as ineffective and potentially leading to proarrhythmogenic effects. A further therapeutic option is the use of implantable cadioverter defibrillators (ICDs). Owing to the high costs of this option, however, the indication must be strictly applied, in particular in the area of primary prophylaxis. The major risk factor for the occurrence of a fatal arrhythmia is disordered left ventricular function, which is thus a central criterion for establishing the indication for an ICD.

Besides classical, modifiable risk factors (hypercholesterolemia, hypertension, smoking) abnormalities of the glucose metabolism (diabetes mellitus, impaired glucose tolerance) are strong emerging cardiovascular risk factors. Epidemiological data indicate that 8 % of the population and up to 60 % of patients with coronary artery disease have abnormalities of glucose metabolism. The prevalence of these abnormalities will increase as the population ages and the mean body weight increases. An abnormal glucose concentration damages the endothelium in several ways: increased oxidative stress, inflammatory processes and an activation of procoagulant factors all impair endothelial function. A blood glucose normalising therapy is thought to decrease the incidence of cardiovascular events in these patients. In patients with an acute myocardial infarction and diabetes mellitus an early intensive insulin therapy improves the outcome of these patients. In summary, the early detection and treatment of abnormalities of glucose metabolism reduces cardiac events.

Zahlreiche Untersuchungen haben einen Zusammenhang zwischen rheologischen Determinanten und fortgeschrittenen Stadien der koronaren Herzkrankheit und arteriellen Verschlusskrankheit, aber auch der chronisch-obstruktiven Lungenerkrankung nachweisen konnen. Diese rheologischen Veranderungen konnen bei der koronaren Herzkrankheit in der poststenotischen Mikrozirkulation zur kritischen Sauerstoffversorgung des Myokards fuhren. Rheologische Therapieansatze zielen auf die Flussverbesserung mittels Reduktion des viskosen Widerstands durch Beeinflussung erhohter Fibrinogenwerte. So gelang die Etablierung der chronisch-intermittierenden Urokinasetherapie bei refraktarer Angina pectoris. Eine Verbesserung der Mikrozirkulation konnte auch unter Fibrattherapie in Folge einer verminderten hepatischen Fibrinogensynthese gezeigt werden. Ebenso konnen CSE-Hemmer durch Beeinflussung des Lipidprofils zu einer verbesserten Mikrozirkulation fuhren. Bei Patienten mit chronisch-obstruktiver Lungenerkrankung und Cor pulmonale, die haufig eine Polyglobulie, Hypoxie und pulmonale Mikrozirkulationsstorung aufweisen, kann eine isovolamische Hamodilutionstherapie zur Abnahme des pulmonal-arteriellen Mitteldrucks mit Steigerung des Herzzeitvolumens und der Belastungskapazitat einschlieslich Erhohung der Sauerstoffpartialdruckwerte fuhren.

Systemic capillary leak syndrome is a rare idiopathic disorder characterized by recurrent episodes of hypotension and hemoconcentration due to sudden transient extravasation of up to 70% of plasma. Less than 40 cases have appeared in the literature. Mortality rates 5 years after diagnosis have been reported to be up to 75%. Clinical findings are generalized edema and intravasal fluid deficiency. Laboratory features include hypoalbuminemia and extreme hemoconcentration. A common finding is a monoclonal gammopathy. Rare manifestation of this syndrome is rhabdomyolysis due to increased compartment pressure and ischemic myonecrosis. Early diagnosis and exclusion of other clinical disorders like rheumatic myopathies and myositis are critical concerning prognosis and therapy. We describe a 46-year-old woman with rhabdomyolysis and systemic capillary leak syndrome whose condition is stable for a total of 30 months under a prophylactic regimen with oral terbutaline plus theophylline. A brief survey of the literature is given.

Functional magnetic resonance imaging (fMRI) studies have demonstrated alterations during task-induced brain activation in spinal cord injury (SCI) patients. The interruption to structural integrity of the spinal cord and the resultant disrupted flow of bidirectional communication between the brain and the spinal cord might contribute to the observed dynamic reorganization (neural plasticity). However, the effect of SCI on brain resting-state connectivity patterns remains unclear. We undertook a prospective resting-state fMRI (rs-fMRI) study to explore changes to cortical activation patterns following SCI. With institutional review board approval, rs-fMRI data was obtained in eleven patients with complete cervical SCI (>2 years post injury) and nine age-matched controls. The data was processed using the Analysis of Functional Neuroimages software. Region of interest (ROI) based analysis was performed to study changes in the sensorimotor network using pre- and post-central gyri as seed regions. Two-sampled t-test was carried out to check for significant differences between the two groups. SCI patients showed decreased functional connectivity in motor and sensory cortical regions when compared to controls. The decrease was noted in ipsilateral, contralateral, and interhemispheric regions for left and right precentral ROIs. Additionally, the left postcentral ROI demonstrated increased connectivity with the thalamus bilaterally in SCI patients. Our results suggest that cortical activation patterns in the sensorimotor network undergo dynamic reorganization following SCI. The presence of these changes in chronic spinal cord injury patients is suggestive of the inherent neural plasticity within the central nervous system.

Introduction Treatment of patients with small cell lung cancer (SCLC) is challenging due to the generally poor prognosis of the disease and the lack of new treatment options. There are few data on how delivered treatment has changed during the past decade in routine clinical practice and how this has effected overall survival. Methods We retrospectively analyzed all patients diagnosed with SCLC at our institution (lung cancer center certified by the German Cancer Society (DKG)) since 2002. Analysis included lines of treatment delivered, progression free survival (PFS) at each therapy line, use of radiotherapy, overall survival (OS), and use of PET-CT. Results Preliminary analysis included 102 patients, of which 41 % had limited disease (LD) and 59 % had extensive disease (ED). For all patients, platinum doublet with etoposide has remained standard first line therapy. For patients with LD, the use of simultaneous thoracic radiochemotherapy replaced sequential chemotherapy followed by thoracic radiotherapy. In order to achieve a smaller radiation field, simultaneous radiochemotherapy was usually preceded by 2 cycles of chemotherapy. For patients with extensive disease, the use of cisplatinum instead of carboplatin increased in good performance status patients due to improved antiemesis (apprepitant). As second line therapy, oral topotecan has largely replaced EpiCO (epirubicin, cyclophosphamide, vincristin). One patient with early recurrence of brain metastasis after radiotherapy and topotecan was treated successfully with oral temozolomide. Since August 2007, all ED patients responding to first line therapy received prophylactic cranial radiation. OS tended to increase throughout the study period (LD: from 14 to 17 months, ED: from 6.7 to 10.1 months). Conclusions New treatment options were successfully implemented in routine clinical practice and resulted in improved survival. However, survival remains unsatisfactory emphasizing the need for early detection and development of additional treatment strategies. Disclosure All authors have declared no conflicts of interest.

Background Standard therapy for refractory or resistant relapsed small-cell lung cancer (SCLC) has not yet been established. We conducted an open-label, multicenter, non-randomized phase II study to confirm the efficacy and safety of amrubicin, a topoisomerase inhibitor, in the treatment of refractory or resistant SCLC. Material and methods Patients with SCLC that is refractory or relapsed within 90 days of completing previous treatment received amrubicin at a dose of 40 mg/m2 for 3 consecutive days, every 21 days.The study treatment was repeated until disease progression or intolerable toxicity. The primary end point was overall response rate (ORR), and secondary end points were progression-free survival (PFS), overall survival (OS), and safety. Planned sample size was 80 patients to achieve power of at least 80% with one-sided alpha of 0.05, and expected and threshold value for primary endpoint as 20% and 10%. All patients were followed-up until one year after the last patient enrollment. Results Between November 2009 and February 2011, 82 patients were enrolled from 25 institutions. The median number of treatment cycles was four (range, one to 22 cycles).The ORR was 32.9% (p Conclusions Amrubicin demonstrated the favorable tumor response and survival with acceptable toxicity. Single-agent amrubicin could be considered as a standard regimen in the treatment of refractory or resistant relapsed SCLC. Disclosure All authors have declared no conflicts of interest.

In order to find out whether diet and drug therapy of hyperlipidemia changes the course and outcome of coronary artery desease, patients with angiographically proven coronary artery disease and hyperlipidemia were treated with diet, fenofibrate and colestipol. By reangiography after two to four years three groups of patients could be formed. Those which showed a progression, no change or a regression of coronary artery disease (CAD). These groups had different levels of lipoproteins under therapy. The regression group had lowest and the no change group had lower levels of total cholesterol and low density lipoprotein (LDL)-cholesterol as compared to the progression group. High density lipoprotein (HDL)- cholesterol had an inverse correlation. These results suggest that a lipid lowering therapy improves course and outcome of CAD.

Abstract 2489 Poster Board II-466 Elevated hospitalization rates for patients with sickle cell disease are largely a result of frequent vaso-occlusive crises. Recent hospital utilization concerns have placed increasing emphasis on rehospitalization as a cost saving and quality of care measure. For sickle cell disease, 30 day rehospitalization has become a benchmark for care quality. Previous reports have shown 30 day rehospitalization rates as high as 30-47% and propose outpatient follow-up as a preventive measure. However, these studies have been limited to single centers and have focused only on specific age groups. Our study sought to examine the efficacy of outpatient follow-up on 30 day rehospitalization prevention across all ages in a statewide Medicaid program. We hypothesized that a post-discharge outpatient visit is associated with lower rehospitalization rates for patients with sickle cell disease. The study is a retrospective cohort using Wisconsin Medicaid claims data for hospitalized children and adults with sickle cell disease from January 1, 2003 to December 31, 2007. Patients at risk for rehospitalization were identified using sickle cell disease-related ICD-9 diagnosis codes (28241, 28242, 28260-28269) at inpatient discharge. The first hospitalization with a sickle cell diagnosis for each individual was extracted and then only those hospitalizations with a diagnosis of sickle cell crisis (28242, 28262, 28264, 28269) were included. Each patient participated in the study only once. The main outcome measure was a rehospitalization within 30 days of discharge from the previous hospitalization. Individuals were considered to have had an outpatient follow-up visit based on a claim for an outpatient visit within 30 days of discharge or prior to a rehospitalization if the rehospitalization occurred in fewer than 30 days. Outpatient visits that occurred on the same day as the rehospitalization were not included. Outpatient visits were calculated as rates to avoid the bias of those not being rehospitalized having more time for an outpatient visit. Multiple logistic regression was performed to evaluate the association between having an outpatient visit, disease severity, and asthma on the outcome of rehospitalization. Severe cases were defined as individuals with 3 or more hospitalizations within 1 year beginning 2 months after the index hospitalization. Patients were excluded from our study if the index hospitalization resulted in death, as they were not at risk for rehospitalization. Four hundred and eight patients with a hospitalization for sickle cell crisis were included in the analysis. Of these 408 patients, 70 (17%) were rehospitalized within 30 days following discharge from the index hospitalization. Of the 70 re-hospitalized patients, 35 (50%) were re-hospitalized within 11 days, and 54 (77%) were rehospitalized within 22 days from discharge. Multiple regression revealed that severe disease was associated with rehospitalization (4.693, 95% CI (2.674, 8.236)), but neither the outpatient visit rate (OR 0.970, 95% CI (0.367, 2.560)) nor a diagnosis of asthma (OR 0.862, 95% CI (0.467, 1.592)) were associated with rehospitalization. Of note, when the unadjusted analysis using the simple existence of an outpatient visit prior to rehospitalization was used, outpatient visits did show an association with decreased rehospitalizations; however this association was no longer significant when adjusted for the increased time for an outpatient visit in those not rehospitalized within 30 days. Contrary to our hypothesis, outpatient follow-up was not associated with fewer rehospitalizations in our study, when the outpatient follow-up rate was used to correct for the increased time for outpatient visits in those not rehospitalized. Disease severity was found to be the only statistically significant predictor of rehospitalization for patients with sickle cell disease. Disclosures: No relevant conflicts of interest to declare.

Fifteen hemodialysis patients suffering from stable anemia were treated with recombinant human erythropoietin (r-HuEPO). Within 16 weeks, hematocrit values increased from 23.7 +/- 1.2 to 35.7 +/- 0.2%. Simultaneously, mean predialytic blood pressure rose significantly from 131/79 to 139/85 mm Hg. Three out of 15 patients developed frank hypertension and had to be put on antihypertensive therapy. When the hematocrit was lowered again from 36.3 +/- 1.8 to 30.5 +/- 1.2% in these 3 patients, blood pressure was attenuated and the antihypertensive medication could be reduced or abolished. With rising hematocrit values, whole blood viscosity increased at both low (+42%) and high shear rates (+33%) without reaching the values seen in healthy subjects. By contrast, plasma viscosity was already elevated in hemodialysis patients prior to r-HuEPO treatment and showed only a slight, but insignificant increase during r-HuEPO treatment. Since whole blood viscosity is one factor that determines vascular resistance, it is conceivable that the development of hypertension during correction of the renal anemia is, at least partly, due to an increment of blood viscosity.

In 22 patients with suspected pulmonary embolism and 19 patients with suspected deep vein thrombosis, thrombin-antithrombin III complex (TAT) as an indicator of thrombin activation was measured using a newly developed ELISA. For comparison fibrinopeptide A (FPA), as a marker of an activated coagulation, as well as platelet factor 4 (PF4), and β-thromboglobulin (β-TG), as markers of platelet activation, were determined. In all patients in whom pulmonary embolism was confirmed by perfusion lung scan and in 15 of 16 patients in whom deep vein thrombosis was confirmed by phlebography, TAT exceeded the upper limit of normal (3.0 ng/ml). FPA was increased in 71% of the pulmonary embolism patients, PF 4 in 53%, and β-TG in 59%. The data for the patients with deep vein thrombosis were comparable. PF 4 and β-TG were increased in more than 25% of the normal controls, FPA in 17%, and TAT in 9%. TAT is very sensitive in detecting an activation of the coagulation system in patients with suspected thromboembolic events. The test, however, is not specific for thrombembolism; it only indicates an activation of the coagulation system. Acute pulmonary embolism or deep vein thrombosis would appear to be unlikely if TAT is normal. The measurement of TAT is easier and less susceptible to disturbances than that of FPA, PF4, and β-TG.

With the advent of recombinant human erythropoietin (r-HuEPO) effective treatment of renal anemia has become possible (1–3). However, with the increase of hematocrit levels some of the patients treated developed hypertension. Since blood viscosity determines vascular resistance (4, 5) and thereby blood pressure (6, 7), we investigated blood pressure behaviour and blood viscosity in long-term dialysis patients during treatment with r-HuEPO.