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Summary Purpose With increasing soft tissue clearance in pancreatic cancer surgery, postoperative chyle leak (CL) has become a more commonly observed complication. Recently, a new consensus definition was established by the International study group of pancreatic surgery (ISGPS). The aim of the present analysis was to evaluate risk factors and treatment options of patients with CL after pancreatic surgery. Methods Two hundred and twenty-eight patients with serous or chylous drainage after pancreatic surgery were included in this analysis of a prospectively collected database between 01/2014 and 12/2016. Risk factors for CL and treatment options were compared. A subgroup analysis on those patients, who had drain removal despite of persistent CL with respect to the need of subsequent percutaneous drainage or reoperation within three months postoperatively, was performed. Results Sixty patients with CL were identified. Of those, 41 patients were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. In patients with CL, the type of treatment had no effect on time to drain removal (P = 0.29) and morbidity (P = 0.15). Furthermore, morbidity was not increased in patients who had their drains removed despite persistent CL (P = 0.84). None of the latter patients had percutaneous drainage or reoperation for CL after removal of the surgical drains. Conclusions Dietary treatment may not be very effective in treating CL. Further research is warranted to explore the effect and necessity of CL treatment.

The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure.A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure.Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures.The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI.

Heinrich Muller was a nineteenth-century German retinal anatomist who, during his short career, was one of the discoverers of the rod photopigment rhodopsin and neuroglia in the retina, now known as Muller cells. He also described the ocular muscles and double foveae of some birds. An important, but largely neglected, insight by Muller was to combine careful psychophysical measurements and geometrical optics to find the location of the photosensitive layer of the retina in the living eye. Here, we provide translated passages from Muller's (1855) publication and compare his entoptic observations with retinal imaging using optical coherence tomography. Muller correctly deduced from his careful experiments that vision is initiated in the photoreceptors located in the back of the retina.

BACKGROUND Investigation was undertaken to determine the genetic relatedness of Neisseria gonorrhoeae (NG) isolates of young (

Die perkutane Koronarintervention (PCI) von chronischen Koronarverschlussen (CTO-PCI) hat sich in der letzten Dekade stetig weiterentwickelt und geht mittlerweile mit Erfolgsraten von uber 85 % einher. Die Ausbildung zum selbststandigen CTO-Operateur dauert oft mehrere Jahre und Bedarf neben institutionellen Voraussetzungen eines hohen Eigenengagements zur standigen Weiterbildung. Randomisierte Daten konnten zwar eine symptomatische Verbesserung, aber bisher keine Mortalitatssenkung nach erfolgreicher Koronarintervention zeigen. Umso entscheidender ist die richtige Patientenauswahl verbunden mit einer niedrigen periinterventionellen Komplikationsrate. Um dies zu gewahrleisten, hat sich die Deutsche Gesellschaft fur Kardiologie (DKG) entschieden, ein Positionspapier fur alle in Praxen und Krankenhausern tatigen Kardiologen, insbesondere aber auch fur alle interventionellen Kardiologen zu verfassen. Zielfuhrend erscheint eine bundesweite Etablierung von spezialisierten CTO-Zentren. Nur dadurch konnen diese hochkomplexen Prozeduren dem Patienten gegenuber mit einem niedrigen und somit vertretbaren Risiko angeboten werden.

Severe coronary calcification is a common cause for stent under-expansion, which is associated with an increased risk of stent thrombosis and restenosis. Presently the devices for treatment of under-expanded stent due to severe calcification are rotational atherectomy and high-pressure non-compliant balloons with the limitation of potential balloon rupture and perforation risk. We report on a series of seven successful treatments of chronically under-expanded stents due to severe calcification using shockwave coronary intravascular lithoplasty (IVL). Our report suggests that IVL is a feasible and safe tool for such chronically under-expanded stents.

The ending of the Phaedo is one of the most powerful and memorable moments in the entire Platonic corpus. It is not simply the end of a single dialogue, but a depiction of the end of the life of the man (Socrates) who is a looming presence in nearly everything that Plato wrote. In this article I offer an in-depth analysis of the final scene of the Phaedo. I argue that Plato very carefully constructs the scene for the sake of specific philosophical, dramatic, and political ends. Plato uses it to unify the Phaedo as a singular text, while also provoking us to reflect on the nature of our lives, our deaths, and the possibilities and limits of philosophy itself.

To evaluate the feasibility of a new acquisition protocol to reduce radiation exposure.Percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO) are characterized by the highest radiation exposure among PCI procedures.We analyzed 552 consecutive CTO procedures between January 2018 and October 2019. After 366 procedures (Group 1) a modified radiation acquisition protocol was implemented for the subsequent 186 procedures (Group 2). Besides a low fluoroscopy frame rate of 6/s and cine frame rate of 7.5/s for both groups, additional modifications consisted of increased copper filtering with lower entry dose in combination with a modified image postprocessing. Radiation exposure was assessed as air kerma (AK; mGy), and dose-area product (DAP; cGy*cmThere was no significant difference in lesion or procedural complexity between the study groups with 46 and 43% of the procedures done via the retrograde approach. While fluoroscopy time remained similar (median: 32.7 vs. 34.3 min), the protocol modifications resulted in a drastic reduction of AK by 68% from 2,040 (1,321-3,339) mGy to 655 (415-1,113) mGy (p .001) without affecting the procedural success rate. DAP was equally decreased by 71%. These considerable reductions were observed even in obese patients of BMI 30. In Group 2, not a single procedure exceeded the 5 Gy threshold as compared to 10.4% in Group 1.Radiation exposure decreased considerably with a new acquisition protocol without affecting procedure duration and success. These modifications were applicable also to patients with a high BMI.

Im aktuellen klinischen Alltag haben zystische Pankreaslasionen (PCNs) einen zunehmend relevanten Stellenwert, da sie aufgrund der sich stetig verbessernden Bildgebung haufig als Zufallsbefund diagnostiziert werden. Man unterscheidet zwischen nichtneoplastischen und neoplastischen Pankreaszysten, wobei letztere in unterschiedlicher Auspragung zur malignen Entartung neigen und damit als Vorlauferlasionen des duktalen Adenokarzinoms des Pankreas (PDAC) gelten. Zur Differenzialdiagnose werden neben einer genauen Anamnese und Untersuchung vor allem bildgebende Verfahren wie die Computertomographie (CT) und Magnetresonanztomographie (MRT) sowie der endoskopische Ultraschall mit Feinnadelaspiration herangezogen. Die Indikationen zur chirurgischen Resektion dieser Lasionen richten sich nach den aktuellen europaischen Leitlinien, deren Inhalte sind jedoch nicht evidenzbasiert, sondern stutzen sich auf Erkenntnisse und Empfehlungen von Experten. Gemas den Konsensusempfehlungen kann die asymptomatische seros-zystische Neoplasie (SCN) als serose Lasion mit niedriger Tendenz zur Entartung beobachtet werden. Im Gegensatz dazu sollten alle muzinos-zystischen Neoplasien (MCN) >4 cm sowie alle solid-pseudopapillaren Neoplasien (SPN) reseziert werden. Intraduktal papillar-muzinose Neoplasien (IPMNs), die aufgrund ihres Bezugs zum Pankreasgangsystem in Haupt(MD)- oder Seitengang(BD)-IPMNs unterteilt werden, sollten als MD-IPMN und als Mixed-type(MT)-IPMN reseziert werden. Das Entartungsrisiko der BD-IPMN ist variabler und abhangig von Risikofaktoren, die klinisch und bildmorphologisch definiert werden. Das therapeutische Management erfolgt daher individuell nach Risikoabschatzung. Um die Indikationsqualitat bei PCNs quantifizieren zu konnen und damit auch zu einer optimierten Versorgung beizutragen, werden dringend prospektive Langzeitstudien benotigt.

Die Implementierung technologischer Innovationen in der Chirurgie wie roboterassistierte Eingriffe, neuartige Implantate, Navigation oder moderne Visualisierungstechniken stellen fur Klinken eine okonomische Herausforderung dar, da sie selten per se kostendeckend sind. Im deutschen DRG(„diagnosis related groups“)-System sind die Kosten zahlreicher neuartiger Technologien und Innovation in der Chirurgie kurzfristig und auch oft mittel- und langfristig nicht oder nicht ausreichend gedeckt. Dieser Ubersichtsartikel beschreibt die okonomischen Aspekte chirurgischer Innovationen und zeigt mogliche Wege fur Kliniken auf, die Kosten zu decken. In einem simulierten Fallbeispiel wird veranschaulicht, inwieweit das aktuelle deutsche DRG-Tarifsystem die Kosten minimal-invasiver Techniken (laparoskopisch, roboterassistiert) im Rahmen einer elektiven Sigmaresektion bei benigner Indikation widerspiegelt.

Aims: We sought to compare the efficiency of the novel EuroCTO (CASTLE) score with the commonly used Multicentre CTO registry in Japan (J-CTO) score in predicting procedural success of percutaneous recanalization (PCI) for coronary chronic total occlusions (CTOs). Methods and results: We evaluated 660 consecutive CTO PCIs (mean age: 66±11 years, 84% male). The mean J-CTO and EuroCTO (CASTLE) scores were 1.86 ± 1.2 and 1.74 ± 1.2, respectively. Antegrade wire escalation, antegrade dissection re-entry and retrograde approach were used in 82%, 14% and 37% of cases, respectively. Receiver-operator characteristic analysis demonstrated equal overall discriminatory capacity between the two scores (AUC: 0.698, 95%CI: 0.653-0.742 p

In vivo functional imaging of human photoreceptors is an emerging field, with compelling potential applications in basic science, translational research, and clinical management of ophthalmic disease. Measurements of light-evoked changes in the photoreceptors has been successfully demonstrated using adaptive optics (AO) coherent flood illumination (CFI), AO scanning light ophthalmoscopy (SLO), AO optical coherence tomography (OCT), and full-field OCT with digital AO (dAO). While the optical principles and data processing of these systems differ greatly, and while these differences manifest in the resulting measurements, we believe that the underlying physiological processes involved in each of those techniques are likely the same. AO-CFI and AO-SLO systems are more widely used than OCT systems. However, those systems produce only two-dimensional images and so, less can be said about the anatomical and physiological origins of the observed signal. OCT signal, on the other hand, provides 3D imaging but at a cost of high volume of data, making it impractical to clinical purposes. In light of this, we employed a combined AO-OCT-SLO system–with point-for-point correspondence between the OCT and SLO images–to measure functional responses simultaneously with both and investigate SLO retinal functional biomarkers based on OCT response. The resulting SLO images reveal reflectance changes in the cones which are consistent with those previously reported using AO-CFI and AO-SLO. The resulting OCT volumes show phase changes in the cone outer segment (OS) consistent with those previously reported by us and others. We recapitulate a model of the cone OS previously proposed to explain AO-CFI reflectance changes, and show how this model can be used to predict the signal in AO-SLO. The limitations of the model is also discussed in this manuscript.

Background Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We performed a study level pooled analysis from the five largest registries of percutaneous coronary intervention (PCI) of CTO. Research design and methods We conducted pooled analysis of 9500 patients in registries and data on procedural characteristics, technical success, and MACCE was collected. Results A total of 9500 patients were included in the analysis. Mean age was 65.4 years with previous CABG in 24.8%, reattempt procedure in 24.8% and mean JCTO score was 2.2. Final wiring strategy in hybrid algorithm-based registries was AWE in 40.8-58%, Retrograde in 24-35%, ADR in 16-25% and in Expert JCTO and EURO CTO was AWE in 72-75% and retrograde in 25-28%. Technical success was achieved in 87.8%. In hospital MACCE was 2.5 % (95% CI: 1.8 to 3.4%), mortality 0.44% (95% CI: 0.23 to 0.84%), stroke 0.2% (95% CI: 0.1 to 0.3%); myocardial infraction 1.6% (95% CI: 1.1 to 2.2%); and cardiac tamponade 0.8% (95% CI: 0.5 to 1.3 %). Conclusion CTO PCI is currently performed with high technical success rates and low complication rates in experienced hands utilizing various techniques.

Mapping highly dynamic cropping systems using satellite image time series is still challenging even when robust approaches are used. We assessed the potential of using high spatial and temporal resolution PlanetScope time series and deep neural networks (Convolutional Neural Networks (CNN) in one dimension - Conv1D, Long Short-Term Memory (LSTM), and Multi-Layer Perceptron (MLP)) for mapping integrated crop-livestock systems (ICLS) and different land covers in the western region of Sao Paulo State, Brazil. We used 10-day and 15-day composite EVI and NDVI time series (both individually and combined) as input data in the neural network classifiers. Conv1D using both EVI and NDVI 10 day-composite time series outperformed the other classifiers evaluated in this study (LSTM and MLP), allowing improved discrimination of land parcels with ICLS in our study area.

Die Leistenhernienchirurgie stellt fur Allgemein- und Viszeralchirurgen elektiv wie auch notfallmasig eine zentrale Aufgabe dar. Als Standardprozedur gilt sie im deutschen DRG-System als eher erlosschwach, was insbesondere im kostenintensiven universitaren Umfeld zu einem okonomischen Ungleichgewicht fuhren kann. Ziel dieser Analyse war neben der Untersuchung des Einflusses von klinischen Faktoren auf die Kosten und den Deckungsbeitrag auch die okonomische Gesamtevaluation der elektiven Leistenhernienchirurgie an einem Universitatskrankenhaus. Eingeschlossen in die Analyse wurden alle Patienten nach elektiver Leistenhernienoperation an 2 Standorten der Charite – Universitatsmedizin Berlin aus den Jahren 2014 und 2015. Ausgewertet wurde der Einfluss von klinischen Patienten- und Operationsfaktoren auf das okonomische Ergebnis der Falle. Insgesamt wurden 419 Patienten eingeschlossen, mehrheitlich nach Lichtenstein-Operation (44,9 %) und laparoskopischer Operation (53,9 %). Den grosten Einfluss auf das okonomische Ergebnis hat das Auftreten von postoperativen Komplikationen. Auch ein patientenbezogener Gesamtschweregrad (PCCL) von >1, mehr als 8 kodierte Nebendiagnosen sowie eine Verweildauer von unter 2 Tagen haben einen signifikant negativen Einfluss auf den Deckungsbeitrag. Insgesamt fuhrt die elektive Leistenhernienchirurgie zu einer Unterdeckung im Mittel von 651 € pro Fall. Bei der elektiven Leistenhernienchirurgie im universitaren Umfeld handelt es sich um einen hochgradig defizitaren Eingriff. Da jedoch eine vollstandige Einstellung dieser Therapie keine Alternative darstellt, bedarf es multifaktorieller Ansatzpunkte, um das okonomische Ergebnis zu verbessern.

Purpose This analysis of a consecutive series of bioresorbable vascular scaffolds (BVS) implanted for complex chronic total occlusions (CTOs) was done to evaluate the potential of this device to avoid a permanent full metal jacket with drug-eluting stents. Patients We analyzed 52 young patients (50.8 ± 8.3 years) for the BVS group, and additionally we followed a subgroup of 17 patients where DES were combined with BVS mainly because severe calcification at the lesion site (hybrid group). Results BVS were successfully implanted in 69 of 70 patients. An average of 3.17 BVS were used per lesion in the BVS group, with a CTO length of 28 ± 20 mm, and a reference diameter of 2.92 ± 0.34 mm, 69% were J-CTO ≥ 2. The retrograde approach was used in 38%. The device length was 79 ± 25 mm with 3.65 ± 0.34 mm final balloon diameter. In the hybrid group BVS was used to cover the distal segment beyond the actual occlusion predominantly in LAD lesions. Patients were discharged with dual antiplatelet therapy prescribed for 12 months. At 12 months, no patient had died or experienced an acute myocardial infarction. Angiography or MSCT follow-up available in 67% showed no reocclusion within 12 months. The target revascularization was 7% at 12 months. Two patients experienced a late non-acute reocclusion at 17 and 19 months. Conclusions The implantation of BVS for long complex CTOs was feasible with no stent thrombosis despite the high complexity of lesions and multiple BVS implanted. The lack of mechanical strength may lead to the need for focal reintervention, but still the long-term burden of full metal jacketed vessels could be avoided.

Objectives The aim was to establish a contemporary scoring system to predict the outcome of chronic total occlusion coronary angioplasty. Background Interventional treatment of chronic total coronary occlusions (CTOs) is a developing subspecialty. Predictors of technical success or failure have been derived from datasets of modest size. A robust scoring tool could facilitate case selection and inform decision making. Methods The study analyzed data from the EuroCTO registry. This prospective database was set up in 2008 and includes >20,000 cases submitted by CTO expert operators (>50 cases/year). Derivation (n = 14,882) and validation (n = 5,745) datasets were created to develop a risk score for predicting technical failure. Results There were 14,882 patients in the derivation dataset (with 2,356 [15.5%] failures) and 5,745 in the validation dataset (with 703 [12.2%] failures). A total of 20.2% of cases were done retrogradely, and dissection re-entry was performed in 9.3% of cases. We identified 6 predictors of technical failure, collectively forming the CASTLE score (Coronary artery bypass graft history, Age (≥70 years), Stump anatomy [blunt or invisible], Tortuosity degree [severe or unseen], Length of occlusion [≥20 mm], and Extent of calcification [severe]). When each parameter was assigned a value of 1, technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score ≥4. The area under the curve (AUC) was similar in both the derivation (AUC: 0.66) and validation (AUC: 0.68) datasets. Conclusions The EuroCTO (CASTLE) score is derived from the largest database of CTO cases to date and offers a useful tool for predicting procedural outcome.

OBJECTIVES The different mechanical and vasodilatory properties of arteries and veins may influence their flow profiles when used for coronary artery bypass grafting (CABG). This may be of significance when assessing the cut-off values for adequate flow. However, conduit-related flow differences are less examined. METHODS In a study of 268 patients, transit time flowmetry parameters of 336 arterial and 170 venous conduits all grafted to the left coronary territory were compared. With transit time flowmetry, the mean graft flow (MGF), pulsatility index, percentage of diastolic filling and percentage of backwards flow were measured. Conduit-related differences were further compared according to on- or off-pump CABG (ONCABG versus OPCABG) surgery. RESULTS Overall MGF and pulsatility index were comparable between arterial and venous grafts, but in arterial grafts, MGF was higher during ONCABG than during OPCABG (49.1 ± 35.3 ml/min vs 38.8 ± 26.6 ml/min; P = 0.003). Percentage of diastolic filling was higher in arterial grafts than in venous grafts (overall 71.0 ± 7.9% vs 63.7 ± 11.1%; ONCABG 69.9 ± 7.1% vs 63.9 ± 10.4%; OPCABG 71.9 ± 8.3% vs 63.4 ± 12.2%; all P CONCLUSIONS No statistically significant difference was observed for MGF and pulsatility index between arterial and venous conduits. However, arterial grafts have significantly higher diastolic filling and backwards flow than venous grafts. Furthermore, arterial grafts have a significantly higher MGF in ONCABG versus OPCABG.

Die Versorgung psychischer Storungen stellt eine grose Herausforderung fur das deutsche Gesundheitssystem dar. Wenn Mehrfachdiagnosen vorliegen, leiden die Betroffenen unter einer besonders hohen Krankheitslast. Innovative Behandlungsmodelle fur eine integrierte und gestufte Versorgung (Collaborative Care und Stepped Care) sind bisher nur hinsichtlich ihrer Wirksamkeit fur singulare Storungsbilder untersucht worden. Das Projekt „Integrierte und gestufte Versorgung psychischer Erkrankungen durch Uberwindung sektoraler Behandlungsbarrieren“ (COMET), welches vom Hamburger Netzwerk fur Versorgungsforschung (HAM-NET) von 2017 bis 2020 durchgefuhrt wird, untersucht ein innovatives, leitlinienorientiertes Versorgungsmodell zur Verbesserung der Versorgung von Menschen mit psychischen Storungen unter Einbezug moglicher Komorbiditaten. Dieses neue Stepped- und Collaborative-Care-Modell fur Patienten der Primarversorgung, das Hausarzte, Psychiater und Psychotherapeuten sowie Kliniken vernetzt, wird im vorliegenden Beitrag vorgestellt. Zur Implementierung und Forderung des Modells wurden leitliniengerechte Behandlungspfade, ein tabletgestutztes Programm fur Screening, Diagnostik und leitliniengerechte Behandlungsempfehlungen sowie eine webbasierte Terminvergabeplattform entwickelt. Die aus dem Projekt gewonnenen Erkenntnisse zur Effektivitat und Effizienz des Modells konnen die Entscheidung, ob das Modell zukunftig in die Gesundheitsversorgung ubertragen wird, unterstutzen. Damit konnte ein entscheidender Fortschritt im Hinblick auf eine starker integrierte und sektorenubergreifende Versorgung von Patienten mit psychischen Storungen gelingen.

Objective Patients with Cushing’s syndrome (CS) have increased mortality. The aim of this study was to evaluate the causes and time of death in a large cohort of patients with CS and to establish factors associated with increased mortality. Methods In this cohort study, we analyzed 1564 patients included in the European Registry on CS (ERCUSYN); 1045 (67%) had pituitary-dependent CS, 385 (25%) adrenal-dependent CS, 89 (5%) had an ectopic source and 45 (3%) other causes. The median (IQR) overall follow-up time in ERCUSYN was 2.7 (1.2–5.5) years. Results Forty-nine patients had died at the time of the analysis; 23 (47%) with pituitary-dependent CS, 6 (12%) with adrenal-dependent CS, 18 (37%) with ectopic CS and two (4%) with CS due to other causes. Of 42 patients whose cause of death was known, 15 (36%) died due to progression of the underlying disease, 13 (31%) due to infections, 7 (17%) due to cardiovascular or cerebrovascular disease and 2 due to pulmonary embolism. The commonest cause of death in patients with pituitary-dependent CS and adrenal-dependent CS were infectious diseases (n = 8) and progression of the underlying tumor (n = 10) in patients with ectopic CS. Patients who had died were older and more often males, and had more frequently muscle weakness, diabetes mellitus and ectopic CS, compared to survivors. Of 49 deceased patients, 22 (45%) died within 90 days from start of treatment and 5 (10%) before any treatment was given. The commonest cause of deaths in these 27 patients were infections (n = 10; 37%). In a regression analysis, age, ectopic CS and active disease were independently associated with overall death before and within 90 days from the start of treatment. Conclusion Mortality rate was highest in patients with ectopic CS. Infectious diseases were the commonest cause of death soon after diagnosis, emphasizing the need for careful clinical vigilance at that time, especially in patients presenting with concomitant diabetes mellitus.

Background Contrast-associated acute kidney injury (CA-AKI) is a potential risk associated with the percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO). This study should evaluate the incidence of CA-AKI in an era of advanced strategies of recanalization techniques and identify modifiable determinants. Methods We analysed 1924 consecutive CTO procedures in 1815 patients between 2012 and 2019. All patients were carefully monitored at least up to 48 h after a CTO procedure for changes in renal function. Results The incidence of CA-AKI was 5.6%, but there was no relation to the technical approach such as frequency of the retrograde technique, intravascular ultrasound or radial access. Procedures with CA-AKI had longer fluoroscopy times (37.6 vs 46.1 min; p = 0.005). The major determinants of CA-AKI were age, presence of diabetes and reduced ejection fraction, as well as chronic kidney disease stage ≥2, serum haemoglobin, and fluoroscopy time. Contrast volume or contrast volume/GFR ratio were not independent determinants of CA-AKI. Periprocedural perforations were more frequent in CA-AKI patients (11.3 vs 2.3%; p Conclusions CA-AKI was associated with the risk of in-hospital adverse events. Established patient-related risk factors for CA-AKI (age, diabetes, preexisting chronic kidney disease, low ejection fraction) were confirmed in this study. In addition, the length of the procedure, coronary perforations and low preprocedural serum haemoglobin were risk factors that might be preventable in patients at high risk for CA-AKI.

For infants, children, and adolescents with progressive advanced lung disease, lung transplantation represents the ultimate therapy option. Fortunately, outcomes after pediatric lung transplantation have improved in recent years now producing good long-term outcomes, no less than comparable to adult lung transplantation. The field of pediatric lung transplantation has rapidly advanced; thus, this review aims to update on important issues such as transplant referral and assessment, and extra-corporal life support as "bridge to transplantation". In view of the ongoing lack of donor organs limiting the success of pediatric lung transplantation, donor acceptability criteria and surgical options of lung allograft size reduction are discussed. Post-transplant, immunosuppression is vital for prevention of allograft rejection; however, evidence-based data on immunosuppression are scarce. Drug-related side effects are frequent, close therapeutic drug monitoring is highly advised with an individually tailored patient approach. Chronic lung allograft dysfunction (CLAD) remains the Achilles' heel of pediatric lung transplant limiting its long-term success. Unfortunately, therapy options for CLAD are still restricted. The last option for progressive CLAD would be consideration for lung re-transplant; however, numbers of pediatric patients undergoing lung re-transplantation are very small and its success depends highly on the optimal selection of the most suitable candidate.

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC By-NC-ND License (http://creativecommons.org/licenses/by-nc-nd/4), The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO-body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO-cap. This Euro-CTO consensus document describes current DLMCs and suggests a practical guide to anatomies and techniques in which these devices are applicable.

Introduction: We conducted a scoping review of dietary guidelines with the intent of developing a position paper by the “IUNS Task force on Dietary Fat Quality” tasked to summarize the available evidence and provide the basis for dietary recommendations. Methods: We systematically searched several databases and Web sites for relevant documents published between 2015 and 2019. Results: Twenty documents were included. Quantitative range intake recommendations for daily total fat intake included boundaries from 20 to 35% of total energy intake (TEI), for monounsaturated fat (MUFA) 10–25%, for polyunsaturated fat (PUFA) 6–11%, for saturated-fat (SFA) ≤11–≤7%, for industrial trans-fat (TFA) ≤2–0%, and Conclusion: Although the methodological approaches of the dietary guidelines were heterogeneous, most of them recommend total fat intakes of 30–≤35% of TEI, replacement of SFA with PUFA and MUFA, and avoidance of industrial TFA.

Background Development of different strategies and devices improved CTO revascularization. However, technical and procedural success might be influenced by several factors including geographical expertise. Methods A total of 4412 CTO coronary treated lesions (Japan 1531 Europe 2881) (mean age 64.5±10.7, male 85.2%, JCTO score 2.09±1.24) were analyzed in European and Japanese registries during the year 2016. The primary endpoint was to assess technical success rate of CTO-PCI cases and procedural outcomes. Results Primary Antegrade approach and success rate were 71.5% and 90.8% respectively in Japan while 77.0% and 94.1%, respectively in Europe, (p20mm. Conclusions Technical success rate was similar between Japan and Europe, but more retrograde approach was common in Japan. Unsuccessful retrograde crossing channel, severe lesion calcification and occlusion length>20mm were independent predictors of failed procedures for both countries. Procedural complications were higher in Japan probably because of longer procedural time and higher frequency of retrograde approach. Funding Acknowledgement Type of funding source: None

Background: For patients with malignant pleural mesothelioma (MPM), a multimodality treatment concept including neoadjuvant chemotherapy and radical surgery offers improved overall survival. While the lung-sparing extended pleurectomy and decortication (EPD) has become the preferential surgical approach, the more aggressive extrapleural pneumonectomy (EPP) remains reserved for a selected group of patients. Based on our experience from the past two decades, we aim to discuss and assess today’s role of EPP. Methods: Out of 523 MPM patients intended to be treated by induction chemotherapy followed by macroscopic complete resection between January 1999 and December 2019, we identified 151 consecutive patients who underwent EPP at our center. All patients were treated within a multimodality concept including neoadjuvant chemotherapy with platinum-based agents plus gemcitabine or pemetrexed. Clinical data were collected in an online database and analyzed retrospectively. Results: Of all patients, 57.6% were of IMIG stage IA or IB (n=87), 39.0% of all patients IMIG stage IIIA or IIIB (n=59). Mean tumor volume after induction chemotherapy was 294.6±315.0 cm3. Most patients were operated in the first decade between 1999 and 2009 [112 patients (74.2%)]. The overall 30- and 90-day mortality was 4.6% and 10.6%, respectively. The median overall survival was 18.5 months. Major postoperative morbidity was assessed as a composite outcome and occurred in 38.4% of all patients. Conclusions: Although EPD became the procedure of first choice, EPP is a reasonable approach in selected patients with high tumor burden and extensive involvement of the lung parenchyma, where parenchyma-sparing resection is technically not feasible or functionally not rational. All patients should be preoperatively assessed and informed about the eventuality of EPP, depending on intraoperative findings. Keywords: Extrapleural pneumonectomy (EPP); malignant pleural mesothelioma (MPM); surgical treatment; multimodality treatment; macroscopic complete resection

Background An increasing body of evidence suggests that microbiota may promote progression of pancreatic ductal adenocarcinoma (PDAC). It was hypothesized that gammaproteobacteria (such as Klebsiella pneumoniae) influence survival in PDAC, and that quinolone treatment may attenuate this effect. Methods This was a retrospective study of patients from the Massachusetts General Hospital (USA) and Ludwig-Maximilians-University (Germany) who underwent preoperative treatment and pancreatoduodenectomy for locally advanced or borderline resectable PDAC between January 2007 and December 2017, and for whom a bile culture was available. Associations between tumour characteristics, survival data, antibiotic use and results of intraoperative bile cultures were investigated. Survival was analysed using Kaplan-Meier curves and Cox regression analysis. Results Analysis of a total of 211 patients revealed that an increasing number of pathogen species found in intraoperative bile cultures was associated with a decrease in progression-free survival (PFS) (-1·9 (95 per cent c.i. -3·3 to -0·5) months per species; P = 0·009). Adjuvant treatment with gemcitabine improved PFS in patients who were negative for K. pneumoniae (26·2 versus 15·3 months; P = 0·039), but not in those who tested positive (19·5 versus 13·2 months; P = 0·137). Quinolone treatment was associated with improved median overall survival (OS) independent of K. pneumoniae status (48·8 versus 26·2 months; P = 0·006) and among those who tested positive for K. pneumoniae (median not reached versus 18·8 months; P = 0·028). Patients with quinolone-resistant K. pneumoniae had shorter PFS than those with quinolone-sensitive K. pneumoniae (9·1 versus 18·8 months; P = 0·001). Conclusion K. pneumoniae may promote chemoresistance to adjuvant gemcitabine, and quinolone treatment is associated with improved survival.

Noninvasive, objective measurement of rod function is as significant as that of cone function, and for retinal diseases such as retinitis pigmentosa and age-related macular degeneration, rod function may be a more sensitive biomarker of disease progression and efficacy of treatment than cone function. Functional imaging of single human rod photoreceptors, however, has proven difficult because their small size and rapid functional response pose challenges for the resolution and speed of the imaging system. Here, we describe light-evoked, functional responses of human rods and cones, measured noninvasively using a synchronized adaptive optics optical coherence tomography (OCT) and scanning light ophthalmoscopy (SLO) system. The higher lateral resolution of the SLO images made it possible to confirm the identity of rods in the corresponding OCT volumes.

Objective To identify and describe the use of the GRADE approach for rating the certainty of evidence in nutrition systematic reviews (SRs). Study design and setting We systematically searched for SRs using GRADE that were published between 2015 and 2019 in the 10 “nutrition” journals with the highest impact factor according to the JCR 2018. Results Out of 800 SRs, 55 SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Forty-seven SRs (5.9%) rated the outcome specific certainty of evidence (n = 36 in 2018/2019). We identified a total of 465 certainty of evidence outcome ratings (n = 335 RCT ratings), ranging from very-low (28.8%) to low (41%), moderate (26.5%), and high (3.7%). Very-low and high certainty of evidence ratings accounted for 61.4% and 0.8% of ratings in SRs of NRSs, compared to 16.1% and 4.8% in SRs of RCTs. Certainty of evidence was downgraded mostly for risk of bias (37.8%) and imprecision (33%) in SRs of RCTs and for imprecision (32.7%), risk of bias (29.4%) and inconsistency (29%) in SRs of NRSs. Conclusion Our study suggests a need for directing more attention toward strengthening acceptance of GRADE as well as building knowledge of the GRADE methodology in nutrition evidence synthesis.

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Malignant pleural mesothelioma (MPM) is a rare tumor of the visceral and parietal pleura that is most commonly associated with occupational exposure to asbestos. Since tumor biology is both aggressive and highly heterogeneous at histopathological and molecular level, prediction of prognosis and treatment effect remains challenging. Up to date, the best outcome in primary treatment is achieved by a multimodality approach that includes chemotherapy, followed by macroscopic complete resection (MCR). However, due to the morbidity associated with radical surgery and the limited life expectancy, a deliberate allocation to MCR is crucial. While MCR can be accomplished by extrapleural pneumonectomy (EPP) or extended pleurectomy and decortication (EPD), the current preferential treatment is EPD due to its lower morbidity and mortality. The present article describes the surgical perspective of MPM treatment starting off with correct allocation to MCR by applying a multimodality prognostic score (MMPS), followed by a step-wise description of the EPD with resection and reconstruction of pericardium and hemidiaphragm. We highlight the importance of repeated intraoperative biopsies and frozen section of the chest wall, the diaphragm and the pericardium to allow an accurate intraoperative staging and to adapt the surgical procedure in case of multifocal infiltration. Additionally, the prevention of possible pitfalls associated with EPD such as esophageal obstruction by the reconstructed hemidiaphragm or prolonged hospital stay due to persisting air leak are going to be discussed.

The improved success rate of recanalization of occluded coronary arteries is partly due to the development of the retrograde approach via collateral pathways. The proper application of this technique requires a thorough knowledge of the anatomy of the coronary collateral system, and its functional capacity. Furthermore, proper angiographic technique is required to highlight the collateral pathways and understand the challenges when trying to pass wires through these channels.

Guidelines advocate transit time flowmetry (TTFM) for intraoperative graft patency verification during coronary artery bypass graft surgery (CABG), but studies on accuracy and precision of the TTFM technique are few. In an observational study of CABG patients, we analyzed covariation of left internal mammary artery (LIMA) blood flow with TTFM and free flow measurements.Covariation of TTFM and free blood flows was evaluated in 60 patients undergoing CABG using the LIMA as one of the conduits. With LIMA flow measurements routinely performed before and after vasodilation, results are based on 120 paired intraoperative measurements.As demonstrated by a combined approach of regression and Bland-Altman analysis for the two flow situations, TTFM was higher than free flow in 64% of measurements, with an overestimation by TTFM of 7.1% ± 16.3% in the overall cohort (prevasodilation), statistically carried by measurements with 4-mm probes (overestimation by 13.3% ± 15.4%, both p0.01). In a multiregression analysis, oversizing of the TTFM probe (odds ratio 9.56, 95% confidence interval: 2.03 to 45.10, p = 0.004) and high flows (odds ratio 1.02, 95% confidence interval: 1.01 to 1.04, p0.001) were independent determinants of flow overestimation by TTFM, although in the Bland-Altman analysis no systematic overestimation was seen in the postvasodilation situation. In a receiver-operating characteristics analysis, optimal cutoff value as determined from Youden's index for assuming flow overestimation was 68 mL/min.Overall, with slight overall overestimation of 7.1%, TTFM is an accurate indicator of LIMA blood flow during CABG, with a clinically acceptable precision. Overestimation may be expected with flows greater than 68 mL/min, but most importantly, in situations with oversized TTFM probes.

Neuroendocrine tumors (NETs) are rare neoplasms, which represent complex challenges in diagnosis and treatment. Even in the metastatic stage there are important differences in the type of tumor in comparison to gastrointestinal and pancreatic adenocarcinomas. Therefore, the disease courses are substantially different depending on the grade of differentiation. Even in the metastatic stage the 5‑year survival rates of G1 tumors is up to 83%. Approximately 20% of small intestine NETs additionally show hormone activity, which can compromise survival and the quality of life. For individual treatment decisions the special tumor biology of these tumors must be taken into consideration more so than for other tumor entities. Surgery always becomes important for these tumors when a R0 resection appears possible. Oligometastasis of the liver and the lymph drainage system can be meaningfully approached by surgical treatment. In selected patients with an isolated liver involvement, a liver transplantation can be considered; however, even tumor debulking can lead to improvement in the quality of life and survival, especially for hormone active tumors with a carcinoid syndrome which cannot be conservatively controlled. The aim of this review is to present the value of surgical treatment options in the case of (oligo)metastasized NETs.

Aims The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability. Methods and results Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P