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Abstract Background Deletions and partial losses of chromosome 7 (chr7) are frequent in acute myeloid leukemia (AML) and are linked to dismal outcome. However, the genomic landscape and prognostic impact of concomitant genetic aberrations remain incompletely understood. Methods To discover genetic lesions in adult AML patients with aberrations of chromosome 7 [abn(7)], 60 paired diagnostic/remission samples were investigated by whole-exome sequencing in the exploration cohort. Subsequently, a gene panel including 66 genes and a SNP backbone for copy-number variation detection was designed and applied to the remaining samples of the validation cohort. In total, 519 patients were investigated, of which 415 received intensive induction treatment, typically containing a combination of cytarabine and anthracyclines. Results In the exploration cohort, the most frequently mutated gene was TP53 (33%), followed by epigenetic regulators (DNMT3A, KMT2C, IDH2) and signaling genes (NRAS, PTPN11). Thirty percent of 519 patients harbored ≥ 1 mutation in genes located in commonly deleted regions of chr7—most frequently affecting KMT2C (16%) and EZH2 (10%). KMT2C mutations were often subclonal and enriched in patients with del(7q), de novo or core-binding factor AML (45%). Cancer cell fraction analysis and reconstruction of mutation acquisition identified TP53 mutations as mainly disease-initiating events, while del(7q) or −7 appeared as subclonal events in one-third of cases. Multivariable analysis identified five genetic lesions with significant prognostic impact in intensively treated AML patients with abn(7). Mutations in TP53 and PTPN11 (11%) showed the strongest association with worse overall survival (OS, TP53: hazard ratio [HR], 2.53 [95% CI 1.66–3.86]; P

Pulmonary edema and its association with low flow times has been observed in postcardiac arrest patients. However, diagnosis of distinct types of lung pathology is difficult.The aim of this study was to investigate pulmonary edema by transpulmonary thermodilution (TPTD) after out-of-hospital cardiac arrest (OHCA), and the correlation to downtimes. In this retrospective single-center study consecutive patients with return of spontaneous circulation (ROSC) following OHCA, age ≥ 18, and applied TPTD were enrolled. According to downtimes, patients were divided into a short and a long no-flow-time group, and data of TPTD were analysed. We identified 45 patients (n = 25 short no-flow time; n = 20 long no-flow time) who met the inclusion criteria. 24 h after ROSC, the extra vascular lung water index (EVLWI) was found to be lower in the group with short no-flow time compared to the group with long no-flow time (10.7 ± 3.5 ml/kg vs. 12.8 ± 3.9 ml/kg; p = 0.08) and remained at a similar level 48 h (10.9 ± 4.3 ml/kg vs. 12.9 ± 4.9 ml/kg; p = 0.25) and 72 h (11.1 ± 5.0 ml/kg vs. 13.9 ± 7.7 ml/kg; p = 0.27) post-ROSC. We found a statistically significant and moderate correlation between no-flow duration and EVLWI 48 h (r = 0.51; p = 0.002) and 72 h (r = 0.54; p = 0.004) post-ROSC. Pulmonary vascular permeability index (PVPI) was not correlated with downtimes. Our observation underlines the presence of cardiac arrest-related lung edema by determination of EVLWI. The duration of no-flow times is a relevant factor for increased extravascular lung water index., (© 2023. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background and Objective: Despite a measurable increase in recent years, the bystander resuscitation rate in Germany lags behind the European comparison. Special centers for the care of patients after cardiac arrest, so-called cardiac arrest centers (CAC), have been established. The aim of this work is to evaluate the role of CACs, in addition to in-hospital patient care, in improving the bystander resuscitation rate in Germany and what obstacles exist in the implementation of resuscitation training., Materials and Methods: Online survey by the working group cardiopulmonary resuscitation (AG42) of the German Society of Cardiology (DGK) and the German Resuscitation Council (GRC) RESULTS: Of the 74 participating clinics (78.4% certified as CAC), 23 (31.1%) conduct lay resuscitation training. These mainly take place within the framework of action days for resuscitation (82.6%) or in schools (39.1%). Permanent cooperation with at least one school existed in 52.2%. Basic life support (BLS) resuscitation dummies are available in 63.5% of these clinics and an automated external defibrillator (AED) demonstration device in 43.2%. According to the interviewees, the biggest obstacles to the consistent implementation of resuscitation courses in schools include lack of qualified instructors, lack of refinancing and difficulties with regard to coordinating activities between schools and providers., Conclusions: Direct training of lay rescuers by hospitals faces several obstacles. To increase the bystander resuscitation rate, focusing on targeted training of teachers as multipliers (train-the-trainer) can be a good approach for cardiac arrest centers., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Aims: While the number of patients with stable coronary artery disease (SCAD) is similar across European countries, Germany has the highest per capita volume of coronary angiographies (CA). This study evaluated the health economic consequences of guideline-non-adherent use of CA in patients with SCAD., Methods and Results: As part of the ENLIGHT-KHK trial, a prospective observational study, this microsimulation model compared the number of major adverse cardiac events (MACE) and the costs of real-world use of CA with those of (assumed) complete guideline-adherent use (according to the German National Disease Management Guideline 2019). The model considered non-invasive testing, CA, revascularization, MACE (30 days after CA), and medical costs. Model inputs were obtained from the ENLIGHT-KHK trial (i.e. patients' records, a patient questionnaire, and claims data). Incremental cost-effectiveness ratios were calculated by comparing the differences in costs and MACE avoided from the perspective of the Statutory Health Insurance (SHI). Independent on pre-test probability (PTP) of SCAD, complete guideline adherence for usage of CA would result in a slightly lower rate of MACE (-0.0017) and less cost (€-807) per person compared with real-world guideline adherence. While cost savings were shown for moderate and low PTP (€901 and €502, respectively), for a high PTP, a guideline-adherent process results in slightly higher costs (€78) compared with real-world guideline adherence. Sensitivity analyses confirmed the results., Conclusion: Our analysis indicates that improving guideline adherence in clinical practice by reducing the amount of CAs in patients with SCAD would lead to cost savings for the German SHI., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Pain that persists or recurs over a period of at least 3 months in childhood and adolescence is referred to as chronic pain. The primary localization of pain changes according to age: abdominal pain is more common at a younger age, headache is more common in adolescents and later back pain as well as muscle and joint pain. In the multimodal and interdisciplinary treatment of chronic pain, complementary procedures can expand the treatment spectrum. This article provides an overview of the existing evidence that for childhood and adolescence can at best be evaluated as readily understandable. In addition, the experiences of two children's hospitals show that complementary medicine can be used as a low-threshold and easily implemented therapy., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Chronic coronary syndrome (CCS) is a potentially progressive clinical presentation of coronary artery disease (CAD). Clinical practice guidelines (CPGs) are available for prevention, diagnosis, and treatment. Embedded in the "ENLIGHT-KHK" healthcare project, a qualitative study was conducted to identify factors that influence guideline adherence from the perspective of general practitioners (GPs) and cardiologists (CA) in the ambulatory care sector in Germany., Methods: GPs and CAs were surveyed via telephone using an interview guide. The respondents were first asked about their individual approach to caring for patients with suspected CCS. Subsequently, the accordance of their approach with guideline recommendations was addressed. Finally, potential measures for assisting with guideline adherence were discussed. The semi-structured interviews were transcribed verbatim and analysed using a qualitative content analysis in accordance with Kuckartz and Rädiker. Factors influencing adherence to CPGs were categorised by assessing whether they (i) inhibited or facilitated guideline adherence, (ii) played a role in patients at risk of CCS or with suspected or known CCS, (iii) were mentioned in implicit or explicit thematic reference to CPGs, and (iv) were declared a practical problem., Results: Based on interviews with ten GPs and five CAs, 35 potential influencing factors were identified. These emerged at four levels: patients, healthcare providers, CPGs, and the healthcare system. The most commonly cited barrier to guideline adherence among the respondents was structural aspects at the system level, including reachability of providers and services, waiting times, reimbursement through statutory health insurance (SHI) providers, and contract offers. There was a strong emphasis on interdependencies between factors acting at different levels. For instance, poor reachability of providers and services at the system level may result in inexpedience of guideline recommendations at the CPG level. Likewise, poor reachability of providers and services at the system level may be aggravated or alleviated by factors such as diagnostic preferences at the patient level or collaborations at the provider level., Conclusions: To assist with adherence to CPGs regarding CCS, promoting measures may be needed that account for interdependencies between barriers and facilitators at various healthcare levels. Respective measures should consider medically justified deviations from guideline recommendations in individual cases., Trial Registration: German Clinical Trials Register: DRKS00015638; Universal Trial Number (UTN): U1111-1227-8055., (© 2023. The Author(s).)

In Germany approximately 70,000 patients with a renal insufficiency are treated by hemodialysis. The most frequent reasons for the need for dialysis are currently diabetic nephropathy and nephrosclerosis. Due to the increasing average age and the resulting multimorbidity of dialysis patients, the difficulties of medical care have also increased. Therefore, an interdisciplinary treatment of these patients is of great importance. An important point in the treatment is the choice of vascular access. This depends on the patient's concomitant diseases and on the urgency of hemodialysis. Vascular access is a prerequisite for dialysis and thus for the survival of the patient. A well-functioning dialysis access not only ensures the patient's survival but it is also important for the quality of life. The surgeon's task is therefore to create the optimal vascular access at the right time together with the treating nephrologist., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Patients with locally advanced esophageal or gastroesophageal adenocarcinoma benefit from multimodal therapy concepts including neoadjuvant chemoradiation (nCRT), respectively, perioperative chemotherapy (pCT). However, it remains unclear which treatment is superior concerning postoperative morbidity., Methods: In this study, we compared the postsurgical survival (30-day/90-day/1-year mortality) (primary endpoint), treatment response, and surgical complications (secondary endpoints) of patients who either received nCRT (CROSS protocol) or pCT (FLOT protocol) due to esophageal/gastroesophageal adenocarcinoma. Between January 2013 and December 2017, 873 patients underwent Ivor Lewis esophagectomy in our high-volume center. 339 patients received nCRT and 97 underwent pCT. After 1:1 propensity score matching (matching criteria: sex, age, BMI, ASA score, and Charlson score), 97 patients per subgroup were included for analysis., Results: After matching, tumor response (ypT/ypN) did not differ significantly between nCRT and pCT (p = 0.118, respectively, p = 0.174). Residual nodal metastasis occurred more often after pCT (p = 0.001). Postsurgical mortality was comparable within both groups. No patient died within 30 or 90 days after surgery while the 1-year survival rate was 72.2% for nCRT and 68.0% for pCT (p = 0.47). Only grade 3a complications according to Clavien-Dindo were increased after pCT (p = 0.04). There was a trend towards a higher rate of pylorospasm within the pCT group (nCRT: 23.7% versus pCT: 37.1%) (p = 0.061). Multivariate analysis identified pCT, younger age, and Charlson score as independent variables for pylorospasm., Conclusion: Both nCRT and pCT are safe and efficient within the multimodal treatment of esophageal/gastroesophageal adenocarcinoma. We did not observe differences in postoperative morbidity. However, functional aspects such as gastric emptying might be more frequent after pCT., (© 2021. The Author(s).)

Introduction: The diagnosis or exclusion of obstructive stable coronary artery disease (SCAD) in clinical practice is challenging and therefore clinical guidelines provide recommendations on the use of non-invasive and invasive testing. For Germany, data obtained from the OECD and health insurances indicate a potential non-adherence to guideline-recommended diagnostic pathways. However, there is a lack of prospective and reliable evidence for appropriate use of invasive coronary angiography (CA) in Germany., Objective: To provide evidence on the nature and extent of guideline non-adherence in patients undergoing CA with presumed obstructive SCAD in Germany and, to evaluate the clinical and economic consequences of potential deviations in guideline adherence., Methods: ENLIGHT-KHK is a multicentre, prospective observational study recruiting 1500 patients being admitted for CA with presumed obstructive SCAD and exclusion of acute myocardial infarction (DRKS00015638). The primary outcome measure is the adherence to clinical guidelines in the decision-making process for use of CA. Therefore, the patients' diagnostic pathways and adherence to German and European guidelines will be assessed using clinical data, health-claims data, and a patient questionnaire. The primary safety outcome is a composite of myocardial infarction, stroke and all-cause death. Secondary outcome measures are periprocedural complications and costs. Using a decision-analytic model, the clinical and economic impact of observed guideline adherence in clinical practice will be assessed. Potential barriers and facilitators of guideline-adherent decision-making will be evaluated via semi-structured interviews., Conclusions: ENLIGHT-KHK will give insights into the appropriateness of invasive CA in Germany and enable the development of concepts to improve guideline-adherence in the German health-care setting., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper!, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The incidence of recognized cardiopulmonary cement embolism in the context of percutaneous vertebroplasty varies between 0% and 23%. In most cases, only small fragments embolize in the pulmonary arteries or the right heart cavities. The latter can cause potential harm by right ventricular perforation., Case Summary: A 57-year-old patient was admitted to our department of cardiology due to exertional dyspnoea and chest pain. In the course of further diagnostic tests, a huge cement embolus was accidentally discovered in the right ventricle. The unusual size and length and the threat of ventricular perforation make this case so unique., Discussion: Large cement embolisms in kyphoplasty settings are possible and associated with the risk of fulminant complications., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The coronary subclavian steal syndrome (CSSS) is a rare complication after coronary arterial bypass graft operations (CABG) using the left or right internal mammary artery ((L/R)IMA). It results from a retrograde blood flow from the IMA into the subclavian artery (SA) due to a stenosis or occlusion of the SA proximal to the IMA origin. This "steal phenomenon" leads to a decreased blood flow in the IMA and may result in myocardial ischemia (MIS) and even myocardial infarction (MIN). Treatment options include interventional and surgical therapy., Case Presentation: We report the case of a 71-year old woman, who suffered from an acute non-ST elevation myocardial infarction (NSTEMI) 11 years after LIMA-CABG surgery and who was treated successfully with a carotid-subclavian bypass (CSB) after failed interventional therapy., Conclusion: CSB may be regarded as a viable treatment option for patients suffering CSSS in the case of MIS and even an acute MIN/NSTEMI, especially in the case of missing or failed interventional therapy attempts. Specialists in cardiothoracic and vascular surgery should be aware of possible CSSS conditions and know about appropriate diagnostic and therapeutic options., (© 2021. The Author(s).)

Aim: To find out differences in biomarkers between Japanese and German patients responsible for response after neoadjuvant radio/chemotherapy and survival for esophageal squamous cell carcinoma. Materials & methods: A total of 60 patients from Japan and 127 patients from Germany with esophageal squamous cell carcinoma were analyzed according to three SNPs by real-time PCR. Results: The distribution of the genotypes of ERCC1 rs16115 and ABCB1 C3435T rs1045642 was significantly different between both patients' groups. Japanese patients had significantly less good response to 5-fluorouracil/cisplatin chemotherapy. The influence of the three SNPs on response varied between patients from Japan and Germany. Conclusion: Different expressions of ERCC1 and ABCB1 SNPs of Japanese patients compared with the German patients partially explain the different response.

Background: This study compared the outcome between patients who had an open and those who had a hybrid esophagectomy for T1 or T3 esophageal adenocarcinoma (eAC). No clear data are available concerning this question based on T-category., Methods: Two groups of patients with esophagectomy and high intrathoracic esophagogastrostomy for eAC were analyzed: hybrid (laparoscopy + right thoracotomy) (n = 835) and open (laparotomy + right thoracotomy) (n = 188). Outcome criteria were 30- and 90-day mortality, R0-resection rate (R0), number of resected lymph nodes (rLNs), and 5-year survival rate (5y-SR). For each type of surgery, three patient groups were analyzed: pT1-carcinoma (group-1), cT3Nx and neoadjuvant chemoradiation (group-2), and pT3N0-3 without neoadjuvant therapy (group-3). The comparison was based on a propensity score matching in relation of 1:2 for open versus hybrid., Results: In group-1 (38 open vs 76 hybrid) R0-resection (100%), 30-day mortality (0%), 90-day mortality (2.6% vs 0%), and rLNs (median 29.5 vs 28.5) were not significantly different. The pN0-rate was 76% in the open and 92% in the hybrid group (p = 0.036). Accordingly, the 5y-SR was 69% and 87% (p = 0.016), but the prognosis of the subgroups pT1pN0 or pT1pN+ was not significantly different between open or hybrid. In group-2 (68 open vs 135 hybrid) R0-resection (97%), 30-day (0% vs 0.7%) and 90-day (4%) mortality, rLNs (28.5 vs 26), and 5y-SR (36% vs 41%) were not significantly different. In group-3 (37 open vs 75 hybrid) R0, postoperative mortality, rLNs, and 5y-SR were not significantly different., Conclusion: In a propensity score-matched comparison of patients with an open or hybrid esophagectomy for esophageal adenocarcinoma the quality of oncologic resection, postoperative mortality and prognosis are not different.

Mutated RAS onco-proteins are key drivers across many cancers. The distribution of somatic RAS mutations varies between cancer entities. Retrospective analyses have associated some RAS mutations with distinct clinical outcomes. However, the clinical impact of the full spectrum of RAS mutations in their disease contextuality remains to be defined. To improve upon this situation, we studied genomically and clinically annotated, prospectively recruited cohorts of patients with RAS-mutated metastatic lung cancer and colorectal cancer. Mutational spectra were compared with predictions derived from analyzing the mutagenic impact at the genome level for each entity. Interestingly, we found concordance of predicted signatures with those actually observed in our patients. Thus, composition of the functionally active RAS mutational subtypes is primarily determined by the mutagenic context. Most RAS mutations seemed dominant oncogenic drivers with entity-dependent clinical outcomes. RAS comutations were enriched in tumors harboring class 2/3 BRAF mutations, highlighting the functional dependency of some mutated BRAF isoforms on RAS. With our dataset, we established a probabilistic model for cross-entity comparison of the prognostic impact of specific RAS mutational subtypes. The resulting prognostic clusters showed largely consistent clinical categorizations in both entities. This suggests mutant subtype-specific functional properties leading to similar clinical effects. A notable exception is KRAS G12C, which imparted an adverse prognosis only in colorectal cancer. Our findings provide a framework for risk stratification of specific RAS mutations across several cancer entities, which is required to guide the analysis of clinical findings in patients treated with direct RAS inhibitors or agents targeting downstream pathways.

Aims: To develop a psychometric measure of diabetes acceptance., Methods: An item pool was developed and pilot-tested using a sample of 220 people with diabetes; item selection resulted in the 20-item 'Diabetes Acceptance Scale (DAS)'. 606 people with diabetes were then cross-sectionally assessed with the DAS to evaluate its reliability, validity and clinical utility; concurrent measurements included diabetes-related coping (FQCI), diabetes distress (PAID-5), depressive symptoms (PHQ-9), quality of life (EQ-5D), self-management (DSMQ), glycaemic control (HbA 1c ) and complications., Results: Internal reliability was high (Cronbach's α = 0.96). Factorial and criterion-related results supported validity. Higher diabetes acceptance scores correlated with more functional coping styles, lower distress and depression levels, higher treatment adherence, better glycaemic control and better quality of life (all P < .001). Persons with low diabetes acceptance (22% of the sample) were four times more likely to have HbA 1c values over 9.0% (75 mmol/mol), two times more likely to be diagnosed with long-term complications and each over two times more likely to have had episodes of severe hypoglycaemia and ketoacidosis in the past year; the prevalence of major depression in this group was fivefold increased (all P < .05)., Conclusions: The DAS is a reliable and valid tool to measure diabetes acceptance. It may help identify patients with significant problems of accepting diabetes, a putative high-risk group in need of tailored care and support., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: Life-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear., Methods and Results: Incidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27 760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4 ± 6.3 years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality (<72 h) of TF-TAVI patients requiring ECS was 34.6%. Overall in-hospital mortality was 46.0%, and highest in case of annular rupture (62%). Independent predictors of in-hospital mortality following ECS were age > 85 years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02-3.45), P = 0.044], annular rupture [OR 1.96, 95% CI (0.94-4.10), P = 0.060], and immediate ECS [OR 3.12, 95% CI (1.07-9.11), P = 0.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%., Conclusion: Between 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS-nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Visceral artery aneurysms are rare with an incidence of only 0.01-0.1% of the population. Open surgical or endovascular elimination should be performed for aneurysms greater than 2 cm in size. The risk of aneurysm rupture is then approximately 25-40%. If the aneurysm ruptures the mortality can be as high as 76%. For mycotic aneurysms or spurious aneurysms there is no lower limit to the diameter size for the need of treatment. Sudden abdominal pain during pregnancy can be caused by visceral artery aneurysms and must be further clarified. The indications for surgery during pregnancy should be made generously. The clinical symptoms (abdominal complaints) of visceral artery aneurysms are manifold. The treatment can be either an open surgical approach or endovascular treatment. In the emergency setting, if endovascular treatment is no longer possible, an open surgical treatment needs to be performed. There are so far no randomized studies which could identify one of the procedures (open surgery vs. endovascular surgery) as clearly being superior. The prognosis after treatment is satisfactory with a 5-10 year survival rate of approximately 90%., Competing Interests: Compliance with ethical guidelinesB. Juntermanns, J. Bernheim, K. Karaindros, M. Walensi and J. N. Hoffmann declare that they have no competing interests. This article does not contain any studies with human participants or animals performed by any of the authors. The supplement containing this article is not sponsored by industry.

Aims: Although a true clinical challenge, high bleeding risk patients with an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) have never been specifically studied. Leaders Free ACS, a pre-specified Leaders Free sub-study, determined efficacy, and safety of a combination of 1-month dual anti-platelet therapy (DAPT) with implantation of either a polymer-free Biolimus-A9-coated stent (BA9-DCS) or a bare-metal stent (BMS) in these patients., Methods and Results: Leaders Free included 2466 patients undergoing PCI who had at least 1 of 13 pre-defined factors for an increased bleeding risk. Of these, 659 ACS patients were included in this analysis (BA9-DCS 330, BMS 329). At 12-month follow-up, treatment with the BA9-DCS was more effective (clinically driven target-lesion revascularization 3.9 vs. 9.0%, P = 0.009) and safer (cumulative incidence of cardiac death, myocardial infarction, or definite or probable stent thrombosis 9.3 vs. 18.5%, P = 0.001), driven by significantly lower rates of cardiac mortality (3.4 vs. 6.9%, P = 0.049) and myocardial infarction (6.9 vs. 13.8%, P = 0.005)., Conclusion: We believe that the results of this sub-analysis from the Leaders Free trial are likely to significantly impact clinical practice for high bleeding risk patients presenting with an ACS: the use of a BMS can, in our view, no longer be recommended, and, given the paucity of available data for second-generation DES with shortened DAPT in these patients, the BA9-DCS should currently be considered as the device with the strongest evidence to support its use for this indication., (© The Author 2016. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Removing boys' foreskins, even for medical reasons, is increasingly and critically discussed. The aim of this study is to retrospectively verify if the indication for the removal of boys' foreskins was justified. The study is based on the records of boys who underwent preputial operation in an outpatient medical office for pediatric surgery., Methods: Preoperative clinical findings, complaints, applied conservative and/or surgical procedures and histological results of the resected foreskins of boys, who underwent preputial operation between 2013-2015, were retrospectively analyzed., Results: A total of 176 boys (age 5 on average) underwent a preputial operation. In 85 % of the cases it was completely removed. Most frequent clinical findings (80 %) were that the prepuce was simply not retractable. 86 % of the boys were free of complaints. The most frequent histological findings were a discrete to moderately pronounced chronic fibrous posthitis (69 %) and subepithelial fibrosis (18 %), In the first case 78 % of the boys had been free of complaints, in the latter 72 %., Conclusion: The majority of the treated boys were free of complaints; however, most of them underwent a complete removal of their foreskin simply because it was nonretractable. The foreskin represents the most sensitive part of the male genital, preputiolysis is a natural process that can go on until early adolescence. Irreversible surgical procedures, such as a complete foreskin removal, should thus be restricted to a clear medical indication.

Robert Bartlett, emeritus Professor of surgery at the University of Michigan in Ann Arbor, USA, transformed classical works of world literature (Charles Dickens: A Christmas Carol, Lewis Carroll: Alice in Wonderland) into teaching aids for advanced training in intensive care medicine. He recently turned his hand to the well-known work of Ernest Hemingway: the Nobel Prize winning novel The Old Man and the Sea. Subsequent to Robert Bartlett's essay this article provides background information and comments on the current problems in modern intensive care medicine addressed in his essay.

Purpose: To determine frequency of routine radiological staging of breast cancer patients diagnosed in a German Breast Cancer Screening Center from 2007 to 2014, the incidence and consequences of distant metastases detected and the resulting implications for clinical routine., Methods: Records of 896 patients with primary breast cancer diagnosed in the Screening Centre and treated in five participating hospitals were analyzed retrospectively. Evaluation included frequency and type of staging procedures and results with respect to distant metastasis and their consequences on clinical management., Results: 894/896 Patients (99.8 %) received staging for distant metastases by bone scintigraphy, chest X-ray and liver sonography and/or CT/MRT diagnostics. Distant metastasis was suggested In 6/894 patients but excluded in 3 by further diagnostics or clinical course. Thus, 3 (0.3 %) were clinically verified to have metastatic disease in bone (n = 2; both pT2) or in bone and lung (n = 1; cT4, cN3)., Conclusion: Due to the low incidence of verified metastatic disease, the high false positive rate of staging procedures and the unfavorable cost/benefit ratio routine radiological staging should be completely omitted in asymptomatic breast cancer patients diagnosed in a breast cancer screening programme.

Background: In clinically suspected fractures taking radiographs is the standard procedure but the indications should be strictly limited. Ultrasound offers a safe and radiation-free alternative for fracture diagnostics., Objectives: Sensitivity and specificity of sonographic fracture diagnostics and safety of sonographic algorithms for fracture evaluation., Methods: Presentation of useful applications for sonographic fracture evaluation and establishment of sonographic algorithms for safe fracture diagnosis., Results: In children distal forearm fractures can be diagnosed solely by ultrasound (sensitivity 96 % and specificity 97 %). The sonographic fat pad sign (SOFA) has been proven to be a useful primary screening tool for occult fractures of the pediatric elbow. A positive fat pad sign (SOFA+) is indicative of a fracture and radiographic diagnostics are necessary (sensitivity 97 % and specificity 91 %). Ultrasonography is also useful to exclude subcapital humeral fractures (sensitivity 94 % and specificity 100 %) and for correct estimation of displacement when present., Conclusions: Sonographic algorithms for fracture evaluation (SAFE) offer a safe diagnosis and guidance of the therapeutic course of certain pediatric fractures, thereby reducing unnecessary radiation exposure.

Background: Evidence that home telemonitoring for patients with chronic heart failure (CHF) offers clinical benefit over usual care is controversial as is evidence of a health economic advantage., Methods: Between January 2010 and June 2013, patients with a confirmed diagnosis of CHF were enrolled and randomly assigned to 2 study groups comprising usual care with and without an interactive bi-directional remote monitoring system (Motiva®). The primary endpoint in CardioBBEAT is the Incremental Cost-Effectiveness Ratio (ICER) established by the groups' difference in total cost and in the combined clinical endpoint "days alive and not in hospital nor inpatient care per potential days in study" within the follow-up of 12 months., Results: A total of 621 predominantly male patients were enrolled, whereof 302 patients were assigned to the intervention group and 319 to the control group. Ischemic cardiomyopathy was the leading cause of heart failure. Despite randomization, subjects of the control group were more often in NYHA functional class III-IV, and exhibited peripheral edema and renal dysfunction more often. Additionally, the control and intervention groups differed in heart rhythm disorders. No differences existed regarding risk factor profile, comorbidities, echocardiographic parameters, especially left ventricular and diastolic diameter and ejection fraction, as well as functional test results, medication and quality of life. While the observed baseline differences may well be a play of chance, they are of clinical relevance. Therefore, the statistical analysis plan was extended to include adjusted analyses with respect to the baseline imbalances., Conclusions: CardioBBEAT provides prospective outcome data on both, clinical and health economic impact of home telemonitoring in CHF. The study differs by the use of a high evidence level randomized controlled trial (RCT) design along with actual cost data obtained from health insurance companies. Its results are conducive to informed political and economic decision-making with regard to home telemonitoring solutions as an option for health care. Overall, it contributes to developing advanced health economic evaluation instruments to be deployed within the specific context of the German Health Care System., Trial Registration: ClinicalTrials.gov NCT02293252 ; date of registration: 10 November 2014.

Patron saints act as facilitators between God and humans. Humans appeal to patron saints for support in devastating, often futile situations in life. Patron saints may intercede for trade and professional guilds, every so often they hold a protective hand over objects. Saint Barbara is venerated as the patron saint of surgeons. In anesthesia she also oversees barbiturates, protects anesthetized patients, anesthetists and anesthesia nursing personnel. Within the Anglo-American language area Saint René is venerated by anesthetists and anesthesia nursing personnel. During anesthesia or critical care treatment patient safety and welfare are entirely in the hands of anesthetists and intensivists. Especially in the borderland of critical illness and imminent death, it may be reassuring for religiously or spiritually orientated physicians and nurses that they can turn to "their" patron saints to intercede so that upcoming anesthetic procedures or intensive care interventions will meet with success. Hereby, the heavy burden of responsibility may be borne more easily and equanimously.

Purpose: The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures., Patients and Methods: This is a prospective study of children under 14 years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis., Results: 38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5 %, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3 %. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2 %. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7 %, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5 %., Conclusion: The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.

Purpose: The objective of our study was to evaluate the safety and accuracy of ultrasound (US) compared to standard radiographs in diagnosing supracondylar fractures (SCFs) of the humerus in children., Patients and Methods: A total of 106 children (aged between 1 and 13 years) with clinically suspected SCF of the humerus were primarily examined by US followed by standard two-plane radiographs of the elbow. US was conducted with a linear scanner viewing the distal humerus from seven standardized sectional planes. US fracture diagnosis was established either by a cortical bulging or cortical gap, or by a positive dorsal fat pad (dFP) sign. X-ray diagnosis was stated by an independent pediatric radiologist and, afterwards, compared to our US findings. Sonographic and radiographic findings were collected in a contingency table. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for US fracture diagnosis were calculated according to the radiographs. In addition, by identifying significant angulation and/or disrupture, SCFs were classified as non-operative/stable and operative/instable SCFs according to the AO Pediatric Fracture Classification System., Results: By US, a SCF could be excluded in 43 patients and in 63 patients, a fracture was diagnosed. In contrast, by radiographs, an SCF could be excluded in 46 patients and in 60 patients, a fracture was diagnosed. For US fracture diagnosis in comparison to radiographs, we calculated a sensitivity of 100 %, a specificity of 93.5 %, an NPV of 100 %, and a PPV of 95.2 %. Thirty-nine SCFs were sonographically classified as stable grades 1/2 SCFs and confirmed in 37 patients by X-rays. All four operative/instable SCFs were correctly identified by US., Conclusion: By identifying a positive dFP sign and/or cortical lesions of the distal humerus, SCFs can be detected very sensitively by US. Even the estimation of fracture displacement seems to be possible. We suggest US as an applicable alternative method in the primary evaluation of suspected SCF in children, guiding further diagnostics, where appropriate. After minor injuries, if clinical assessment for an elbow fracture is low and US examination is negative for fracture, additional radiographs are dispensable. Thereby, the amount of X-ray burden during childhood can be reduced, without loss of diagnostic safety.

X-rays are the standard imaging procedure for the diagnosis of pediatric long bone fractures. Recent studies show that ultrasound (US) imaging is also qualified to diagnose pediatric long bones fractures. Thus, the diagnosis and decision-making for the treatment of metaphyseal forearm fractures in children can be performed by solely using US. The sonographic fat pad sign has been proven to be a useful primary screening tool for pediatric elbow injuries. If there is a negative fat pad sign, a fracture is unlikely and taking additional radiographs is dispensable at this time. If there is a positive fat pad sign, a fracture is likely and radiographs should be taken. US is also useful to exclude subcapital humeral fractures and to estimate fracture displacement. If a fracture of the subcapital humerus is present, additional radiographs are necessary to avoid overlooking of pathologic fractures. For reliable sonographic fracture diagnosis in childhood, a detailed history und exact clinical examination are required.

Purpose: Elbow fractures are a common pathology in any pediatric emergency unit. X-ray of the elbow is the standard diagnostic procedure. Previous studies have shown that fractures can also be visualized by ultrasound (US). The aim of our study was to evaluate the diagnostic accuracy of US in comparison to X-rays in diagnosing pediatric elbow fractures., Methods: Sixty-seven patients aged 1-13 years with clinically suspected elbow fracture were first examined by US followed by standard two-plane radiographs. US examination was done with a 12-MHz linear probe from seven longitudinal positions across the distal humerus and additionally from longitudinal positions across the radial head and olecranon. The sonographic and radiological findings were compared in a contingency table, and sensitivity, specificity, and positive and negative predictive values of the US diagnostic procedure were calculated., Results: With X-ray, we found 48 patients with an elbow fracture and 19 patients with no fracture. With US, we found 46 patients with an elbow fracture and 21 patients with no fracture. In comparison to X-ray diagnosis, we calculated for US diagnosis a sensitivity of 97.9 %, a specificity of 95 %, a negative predictive value of 95 %, and a positive predictive value of 97.9 %., Conclusion: Typical elbow fractures in children could also be visualized by US. A positive fat pad sign, in particular, serves as a strong indicator for elbow joint fractures and can be identified very sensitively by US. We confirm US as a valuable primary screening tool for elbow injuries in children. In the absence of US signs of fracture and in sonographically confirmed non-displaced fractures, standard X-rays are dispensable, thereby minimizing the X-ray burden in children without loss of diagnostic safety.

Background. The use of transdermal fentanyl systems has increased over recent years, especially in patients with chronic pain. Large misuse potential and fatal outcomes have been described. Case Presentation. A 58-year-old patient presenting with clinical signs of opioid poisoning (hypoventilation, bradycardia, hypotension, and miosis) was admitted to our ICU. The first body check revealed a 75 mcg per hour fentanyl patch at the patient's right scapula. Some months ago, patient's aunt died after suffering from an oncological disease. During breaking up of her household, the patches were saved by the patient. Not knowing the risk of this drug, he mistook it as a heat plaster. Investigations. Laboratory test showed an impaired renal function and metabolic acidosis. Urine drug test was negative at admittance and 12 h later. CCT scan presented a global hypoxic brain disease. Treatment and Outcome. The patient was discharged 30 days after admittance in a hemodynamic stable condition but a vegetative state and transferred to a rehabilitation center. Learning Points. With the ongoing increase in fentanyl patch prescriptions for therapeutic reasons, it is likely that misuse cases will become more relevant. Conventional urine drug screening tests are not able to exclude the diagnosis fentanyl intoxication. History taking should include family member's drug prescriptions.

Intussusception of the appendix is a rare clinical entity and the preoperative diagnosis is challenging. We report the case of a 12-year-old girl with right-sided abdominal pain and concomitant peranal bleeding. Preoperative abdominal ultrasound showed partial appendicular intussusception which was confirmed by laparotomy. Appendectomy was carried out including a wide peripheral cecal ring. Peranal bleeding restarted 7 weeks after discharge and colonoscopy revealed ulcerative colitis. The etiology, clinical manifestations, diagnostic and therapeutic approaches for appendicular intussusception are discussed.

Background: Blood glucose level at admission in ST-segment elevation myocardial infarction (STEMI) is a predictor of heart failure and mortality. This study was performed to investigate the impact of hyperglycemia at admission in non-diabetic patients on infarct size, microvascular obstruction, and long-term outcome using contrast-enhanced magnetic resonance imaging (CMR) in patients with acute STEMI., Methods: One hundred and seven consecutive patients (84 males; mean age 59.4 years ± 11.3 years) with a first acute STEMI successfully treated by primary PCI were included. Admission hyperglycemia was defined as blood glucose above 7.8 mmol/l. CMR was performed 3.6 days ± 1.9 days after admission on a 1.5-tesla MR system. The imaging protocol included single-shot steady-state free precession (SSFP) cine sequences for assessing segmental and global left ventricular (LV) function and microvascular obstruction (MVO)/late gadolinium enhancement (LGE) imaging immediately and 10 min after the administration of 0.2 mmol gadodiamide/kg of body weight using an inversion-recovery SSFP (IR-SSFP) sequence. A receiver operating characteristics analysis was used to detect the best cut-off point of microvascular obstruction that predicted myocardial infarction and death during follow-up., Results: Of 107 patients, 37 (35%) had hyperglycemia on admission. Compared to normoglycemic patients, patients with admission hyperglycemia had a lower LV ejection fraction (38.6 ± 13.7% vs. 47.5 ± 12.2%, p < 0.001), greater ESV (88.8 ± 41.8 ml vs. 72.3 ml ± 35.1 ml, p = 0.01), greater infarct size (LGE% 21.1 ± 14.9% vs. 9.8 ± 8.7%, p < 0.001), and greater MVO (MVO% 9.6 ± 9.9% vs. 2.5 ± 4.3%, p < 0.001). Admission hyperglycemia was an independent predictor of the presence and extent of microvascular obstruction. Microvascular obstruction as a percentage of left ventricular mass was the only variable independently related to clinical outcome in a Cox proportional hazard model (Wald 18.78, HR 1.155, p < 0.001)., Conclusion: Hyperglycemia at admission in STEMI patients who are successfully treated by PCI is independently associated with the presence and extent of microvascular obstruction on contrast-enhanced CMR. Thus, microvascular obstruction as assessed by CMR may be a mechanism that relates admission hyperglycemia in acute STEMI to worse outcome.

Nearly 20% of all patients admitted to an intensive-care unit are obese. Their excess weight puts them at risk for several problems and complications during their intensive-care unit stay. Especially, pulmonary problems need particular attention, and comprehensive knowledge of the specific pathophysiologic changes of the respiratory system is important. Lung protective ventilation strategies, supplemented by lung-recruiting manoeuvres, may be feasible in critically ill obese patients with lung injury. Careful positioning of the obese is essential to optimise ventilation and facilitate weaning from mechanical ventilation. Optimal hypocaloric nutrition with a high proportion of proteins is advised to control hyperglycaemia. Because mortality in obese patients is similar to or lower than in non-obese ones, it is conceivable that obesity has a protective effect in the critically ill.

Purpose: Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure is an X-ray of the forearm and wrist. Former studies have shown that these fractures can be visualized by ultrasound. The intention of this study was to evaluate the safety and reliability of the ultrasound diagnostic procedure in comparison with X-ray diagnosis., Methods: Patients aged 0-12 years with tentative diagnosis of forearm fracture in a physical examination were then examined, from six positions, with a 7.5-MHz linear array transducer. The diagnosis and the recommended treatment were noted, after which standard X-rays were taken. Finally, differences between diagnoses, the extent and direction of the deformity, and the treatment recommended after both diagnostic procedures were analysed., Results: From January 2007 to May 2008, 93 patients were examined. We found 77 fractures in 64 patients (48 radius, 2 physeal fractures of the radius, 1 ulna, and 13 radius and ulna). The sensitivity of ultrasound in diagnosing forearm fractures was 94%, and the specificity was 99%. Difference between the means of the deformities were 1.6° (radius anterior-posterior direction), 1.6° (radius medial-lateral direction), 0.2° (ulna anterior-posterior direction), and 0.2° (ulna medial-lateral direction)., Conclusion: Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis.

Objective: The purpose of this study was to investigate the prevalence and prognostic importance of the cardiac MRI finding of right ventricular involvement in patients with acute ST-segment elevation myocardial infarction (MI)., Subjects and Methods: Fifty patients (41 men, nine women; mean age, 58 +/- 11 years) with first-ST-segment elevation MI underwent 1.5-T cardiac MRI immediately after successful percutaneous coronary intervention. The cardiac MRI protocol included steady-state free precession cine sequences for functional assessment of the left, right, and both ventricles and inversion recovery FLASH delayed enhancement sequences after contrast administration for the quantification of myocardial damage. The prevalence of right ventricular involvement detected with ECG and echocardiography was compared with the prevalence detected with cardiac MRI, which was the reference standard. Patients underwent follow-up for 32 +/- 8 months., Results: Right ventricular involvement was diagnosed with cardiac MRI in 27 patients (54%): 14 of 30 patients (47%) with inferior ST-segment elevation MI and 13 of 20 patients (65%) with anterior ST-segment elevation MI. ECG and echocardiographic findings showed only moderate agreement with cardiac MRI findings in the detection of right ventricular involvement in inferior acute MI (kappa = 0.38). Patients with right ventricular involvement in anterior ST-segment elevation MI had larger infarcts (delayed enhancement, 25.9% +/- 14.5% vs 11.4% +/- 10.1%; p = 0.030), lower left ventricular ejection fraction (34.3% +/- 8.2% vs 45.2% +/- 9.5%; p < 0.015), and lower right ventricular ejection fraction (39.8% +/- 6.6% vs 54.9% +/- 8.8%; p < 0.001) than those without right ventricular involvement. In a multivariate logistic regression model, right ventricular involvement was a strong independent predictor (odds ratio, 15.8; 95% CI, 4-63%) of major cardiac adverse events., Conclusion: Right ventricular involvement in ST-segment elevation MI is detected more frequently with cardiac MRI than with ECG and echocardiography and is an independent prognostic indicator.

Implantable cardioverter-defibrillator (ICD) therapy is effective in primary and secondary prevention for patients who are at high risk of sudden cardiac death. However, the current risk stratification of patients who may benefit from this therapy is unsatisfactory. Single nucleotide polymorphisms (SNPs) are DNA sequence variations occurring when a single nucleotide in the genome differs among members of a species. A novel concept has emerged being that these common genetic variations might modify the susceptibility of a certain population to specific diseases. Thus, genetic factors may also modulate the risk for arrhythmias and sudden cardiac death, and identification of common variants could help to better identify patients at risk. The DISCOVERY study is an interventional, longitudinal, prospective, multi-centre diagnostic study that will enrol 1287 patients in approximately 80 European centres. In the genetic part of the DISCOVERY study, candidate gene polymorphisms involved in coding of the G-protein subunits will be correlated with the occurrence of ventricular arrhythmias in patients receiving an ICD for primary prevention. Furthermore, in order to search for additional sequence variants contributing to ventricular arrhythmias, a genome-wide association study will be conducted if sufficient a priori evidence can be gathered. In the second part of the study, associations of SNPs with ventricular arrhythmias will be sought and a search for potential new biological arrhythmic pathways will be investigated. As it is a diagnostic study, DISCOVERY will also investigate the impact of long-term device diagnostic data on the management of patients suffering from chronic cardiac disease as well as medical decisions made regarding their treatment.

Purpose: To assess myocardial salvage in acute ST segment elevation myocardial infarction (STEMI) by using contrast-enhanced CMR., Methods: Forty-four consecutive patients (38 male; mean age 59 +/- 10 years) with a first acute STEMI underwent acute percutaneous coronary intervention with successful restoration of TIMI grade 3 flow. CMR was performed 2 +/- 1 days after reperfusion on a standard 1.5 T MR Scanner that included a steady-state free precession cine imaging for LV function and an inversion-recovery fast low angle shot (TR 8 ms, TE 4 ms, FA 25 degrees ) sequences for late gadolinium enhancement (LGE) following the injection of 0.2 mmol/kg BW gadodiamide. The myocardium at risk (MR) was approximated by the volume of myocardium exhibiting LGE and/or impaired wall motion. The myocardial salvage index (MSI) was calculated as the volume of the MR minus the volume of LGE divided by the volume of the MR. Reperfusion therapy was rated successful with an ST elevation resolution (STR) > or =70% and was considered inadequate below 70%., Results: Infarct size (LGE) was 17 +/- 13% of LV mass, the mean STR was 53.4 +/- 28.3%, and the MSI was 10.9 +/- 6.2%. There was a good correlation between the MSI and the STR (r = 0.695, P < 0.0001). Thirty patients had an STR below 70%, and 14 patients had an STR greater than 70%. The MSI was greater in patients with a STE resolution of more than 70% (12 +/- 11 vs. 6 +/- 3%, P < 0.0001)., Conclusion: A simple MR algorithm based upon the relationship of functional impairment, which includes myocardial stunning, to the extent of LGE (infarct necrosis) is in accordance with STR as a clinical marker of successful reperfusion in acute myocardial infarction.

Background: Aortic valve stenosis is the most common type of valve lesion in Europe and North America. Patient treatment is based on disease severity, which is classified by determining the aortic valve area (AVA)., Purpose: To compare dual-source computed tomography (DSCT) with magnetic resonance (MR) imaging for quantifying AVA., Material and Methods: Thirty-two patients, 28 with normal aortic valve function and four with aortic valve stenosis, who underwent DSCT coronary angiography (Somatom Definition; Siemens, Erlangen, Germany), were included in this study. Retrospective ECG-gated contrast-enhanced DSCT scans with dose-reducing tube current modulation were performed, and data sets were reconstructed in 3% steps of the R-R interval (slice thickness 0.75 mm, increment 0.6 mm). Planimetry of the AVA in systole was assessed on cross-sectional images by multiplanar reformations. Within 48 hours, MR was performed with a 1.5T scanner (Magnetom Sonata; Siemens, Erlangen, Germany) using a balanced steady-state free-precession cine sequence (repetition/echo time 3/1.5 ms, flip angle 60 degrees, spatial resolution 1.4 x 1.4 mm(2)). Cine sequences of the left ventricular outflow tract (LVOT) were obtained in two orthogonal planes, and MR planimetry was performed on cross-sectional images of the aortic valve perpendicular to the LVOT images., Results: AVA assessment by DSCT and MR was feasible in all 32 patients. Mean AVA values determined by DSCT and MR were 4.73+/-1.5 cm(2) and 4.69+/-1.4 cm(2), respectively. A strong positive correlation was found between both imaging modalities (R=0.98, P<0.001). Bland-Altman analysis demonstrated an excellent intermodality agreement, with a slight underestimation of AVA by DSCT. The mean difference was -0.04 cm(2), with a standard deviation of 0.32 cm(2)., Conclusion: Retrospective ECG-gated contrast-enhanced DSCT with tube current modulation provides an accurate imaging technique for the assessment of the AVA. Further studies are required to determine whether DSCT also allows for AVA quantification in patients with aortic valve stenosis.

Sculptures from the Stone Age hint at the possibility that morbidly obese humans have always existed. Today, obesity represents a global epidemic with far-reaching consequences affecting health systems worldwide. Increasingly often, anaesthetists and intensivists are challenged with the treatment of extremely obese patients perioperatively. In addition to insufficient logistics and inappropriate technical equipment, the large number of obesity-related diseases, combined with the distinct pathophysiological changes of the respiratory system, put the morbidly obese patient at a significantly increased risk of perioperative complications. If, however, elaborate logistics and adequate airway management--followed by lung protective mechanical ventilation--are combined with appropriately conducted anaesthesia and intensive care, the morbidly obese patients' intensive care survival rates and hospital survival rates can be similar to those of patients of normal weight.

Background: Thromboendarterectomy (TEA) and stenting are in competition for treatment of carotid artery lesions. Both treatment modalities have to improve significantly. The goal of the study was to evaluate the influence of routine intraoperative duplex ultrasound examination., Methods: In a continuous prospective study, 575 patients underwent 620 carotid operations. Intraoperative duplex ultrasound examination was performed prior to wound closure: 9.5% had significant contralateral ICA stenoses and 6.7% ICA occlusion; 8.5% presented special lesions. An eversion TEA was performed in 20.5% while 78.5% underwent conventional TEA with patch plasty and graft interposition in 1%. Intraoperative quality control revealed unexpected lesions in 10% requiring immediate repair., Results: The combined morbidity/mortality rate (MMR) of the total series was 2.6%. Women had an elevated risk (4.2%) in comparison to men (1.9%). The risk of elder patients (>75 years, n=151) was remarkably low. The neurological complication rate of the total series was 1.6% and the incidence of major strokes 1.1%., Conclusions: Routine intraoperative duplex ultrasound examination of the carotid reconstruction allows early diagnosis and immediate correction of morphologic as well as hemodynamic lesions. Competing with stent placement a further reduction of complications of carotid TEA seems to be possible and necessary.

The German "GKV-Modernisierungsgesetz" offers new opportunities for patient care. The concept of "integrated care" provides organizational structures for an standardized treatment of myocardial infarction by bridging the different sectors of the German health care system. Apart from guideline-based therapy, innovative diagnostic (cardiac MRI) and therapeutic (drug-eluting stents) techniques are implemented in the "integrated care" model as well. The "Herzinfarktverbund Essen" is the first national real world experience of the integrated care concept in the treatment of myocardial infarction.