[The medical emergency department in a Swiss regional hospital: the important role of generalists]. / Die medizinische Notfallstation in der Schweiz am Beispiel des Spitals Lachen: Die entscheidende Rolle der Generalisten.

Patients not having a general practitioner will more likely use the emergency departments (ED) of hospitals for primary care. Crowding of the ED due to patients with minor health problems is a growing burden. The present work was aimed to analyze data of ED consultations at a Swiss regional hospital. Leading diagnoses of ED consultations covered a broad spectrum of internal medicine. The majority of patients seen in the ED are «walk-in¼ patients with minor problems that after initial evaluation and treatment in the ED could be managed as outpatients. Pediatric patients made a considerable part of the workload. Elderly patients (>65 years) were hospitalized more often.

Epidermodysplasia verruciformis in a HIV-positive patient homozygous for the c917A-->T polymorphism in the TMC8/EVER2 gene.

BACKGROUND: Epidermodysplasia verruciformis (EV) is a rare autosomal-recessive disorder characterized by widespread and persistent infection with human papilloma virus (HPV) and a risk of malignant degeneration. Most cases of EV are caused by mutations in the two EV genes, EVER1/TMC6 and EVER2/TMC8. The clinical presentation of EV takes two different forms, which coexist in most cases. Over a period of years, patients develop plane warts and pityriasis versicolor-like lesions. Sixteen cases of EV in HIV-positive patients have been clinically investigated and reported in the literature. However, different inherited susceptibilities towards HPV infection in immunodeficient patients, like HIV-positive patients, have only rarely been addressed. OBSERVATION: We describe a 22-year-old female patient with a congenital HIV infection, who presented with slowly progressing and confluent erythematous papules on her hands and hypopigmented macules on her extremities. The histopathology was typical for EV, and HPV5 was detected by PCR and reverse hybridization. The 44-year-old HIV-positive mother has no typical EV lesions. The patient is homozygous for an A to T single nucleotide polymorphism (SNP) at position 917 of the TMC8/EVER2 gene. The mother of the patient is heterozygous for this SNP. CONCLUSION: These results support the hypothesis that the combination of immunodeficiency and a susceptibility allele may contribute to the differences in occurrence of EV in HIV-positive patients.

Laser coagulation of placental anastomoses with a 30 degrees fetoscope in severe mid-trimester twin-twin transfusion syndrome with anterior placenta.

OBJECTIVE: To assess outcome after fetoscopic laser coagulation (FLC) of placental vascular anastomoses with the 30 degrees fetoscope in mid-trimester severe twin-to-twin transfusion syndrome (TTTS) with completely anterior placenta compared with the regular 0 degrees fetoscope in TTTS with other placental locations. METHODS: This was a prospective study of 176 consecutive monochorionic twin pregnancies undergoing FLC for severe TTTS. Of these, 51 patients required use of the 30 degrees fetoscope (study group) and 125 placental locations permitted use of the 0 degrees fetoscope (controls). RESULTS: The two groups had very similar outcomes. The median gestational age at FLC in the study group vs. control group was 21.0 (range, 17.4-24.6) weeks vs. 20.6 (range, 15.9-24.6) weeks. Both fetuses survived in 58.8% (30/51) of study patients vs. 66.4% (83/125) of controls. At least one fetus survived in 84.3% (43/51) of study patients and 88.8% (111/125) of controls (P = 0.45). Study patients delivered at a median of 34.1 (range, 25.0-38.4) weeks and controls at 34.0 (range, 25.0-40.3) weeks' gestation. CONCLUSIONS: Use of a 30 degrees fetoscope for FLC in cases of technically challenging extensive anterior placentation is associated with an outcome that is very similar to that achieved when a 0 degrees fetoscope is used in cases of more favorable placental location.

[Cutaneous infections due to atypical mycobacteria]. / Hautinfektionen durch atypische Mykobakterien.

Atypical mycobacteria are environmental saprophytes. Occasionally they may enter human skin through injuries and cause localized infection. Papules, nodules, plaques, ulcers and panniculitis-like lesions are common manifestations. Disseminated infection occurs in immunocompromised patients. Evidence of mycobacterial infection can be obtained by tissue specimens, culture being most important for diagnosis. Because many mycobacteria only grow on special media and at special temperatures it is crucial that clinical suspicion is raised so correct testing is performed. Buruli ulcer caused by M. ulcerans is the most prevalent atypical mycobacteriosis worldwide; its occurrence is restricted to tropical areas. In European countries fish tank granuloma caused by M. marinum is most commonly observed. M. avium-complex, M. kansasii und rapidly growing mycobacteria of M. fortuitum-complex are other atypical mycobacteria that can cause cutaneous infection. Treatment is difficult because many atypical mycobacteria are resistant to common antibiotics.

Detection of drug-resistant HIV minorities in clinical specimens and therapy failure.

OBJECTIVE: Particularly for therapy-experienced patients, resistance assessment by genotypic or phenotypic methods produces discordances. This study seeks proof that differences may arise from the fact that genotyping produces a single summary sequence whereas replicative phenotyping (rPhenotyping) functionally detects and assigns resistances in mixed HIV populations. METHODS: For validation, defined mixes of wild-type and M184V mutant were analysed by rPhenotyping or standard genotyping. Allele-specific and quantitative polymerase chain reaction (PCR) set detection and quantification limits for minor virus populations in vitro and in authentic clinical samples showing geno-/pheno-discrepant lamivudine resistance. RESULTS: Allele-specific and real-time PCR methods detected down to 0.3% of mutant M184V. The functional assessment was sensitive enough to reveal <1% of mutant M184V in mixed samples. Also in discordant samples from the diagnostic routine, in which rPhenotyping had identified drug resistance, real-time PCR confirmed minute amounts of mutant M184V. CONCLUSION: By utilizing the replication dynamics of HIV under drug pressure, a rPhenotyping format potently reveals relevant therapy-resistant minority species, even of HIV known to possess reduced replicative fitness. With its rapid turnaround of 8 days and its high sensitivity, our rPhenotyping system may be a valuable diagnostic tool for detecting the early emergence of therapy-threatening HIV minorities or the persistence of residual resistant virus.

Spinal epidural abscess in clinical practice.

Spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition. The major prognostic factor for a favourable outcome is early diagnosis, leading to appropriate treatment. In clinical practice, a diagnosis of SEA is often not considered, particularly in the early stages of the disease when neurological symptoms are not apparent. Knowledge of persons at risk, clinical features and the required diagnostic procedures may decrease the number of initially misdiagnosed cases. Clinical signs, duration of symptoms and the rate of neurological deterioration show a high inter-individual variability, and the classic triad (spinal pain, fever and neurological deficit) is often not found, especially not at first presentation to a physician. However, most patients complain of severe localized back pain. Inflammatory parameters in the blood are generally elevated, but not specific. Gadolinium-enhanced magnetic resonance imaging is the most sensitive, specific and accurate imaging method. Although neurosurgical decompression is still the treatment of choice in the majority of cases, less invasive procedures (e.g. computed tomography-guided needle aspiration) or antimicrobial treatment alone can be applied in selected cases. The choice of the most appropriate therapy should be discussed immediately after a confirmed diagnosis in consultation with infectious disease, radiology and spinal surgery specialists. The outcome of SEA is largely influenced by the severity and duration of neurological deficits prior to surgery, stressing the importance of early recognition.

Perinatal outcome in monochorionic twin pregnancies complicated by amniotic fluid discordance without severe twin-twin transfusion syndrome.

OBJECTIVES: To assess the natural history and perinatal outcome in monochorionic diamniotic twin pregnancies with discordant amniotic fluid volume without signs of severe twin-twin transfusion syndrome (TTTS). METHODS: This was an observational study of 84 consecutive monochorionic twin pregnancies which did not meet the criteria for severe TTTS and endoscopic laser coagulation of placental anastomoses at initial presentation. The population was subdivided into two groups. Group 1 consisted of 64 pregnancies (median gestational age, 20.1 (range, 15.6-24.7) weeks) with amniotic fluid discordance and no signs of congestive heart failure in the twin with the larger amniotic fluid volume (Twin 1) and positive end-diastolic flow in the umbilical artery of the twin with the smaller amniotic fluid volume (Twin 2). Group 2 (median gestational age, 19.1 (range, 16.0-24.4) weeks) consisted of 20 pregnancies with amniotic fluid discordance and intrauterine growth restriction (IUGR) (abdominal circumference < 5th percentile) in combination with absent or reversed end-diastolic (ARED) flow in the umbilical artery of Twin 2. After exclusion of one patient from Group 1, who opted for termination of pregnancy, nine patients in Group 1 and one in Group 2 developed severe TTTS, and laser coagulation was offered. The remaining 54 pregnancies of Group 1 were compared with the remaining 19 pregnancies of Group 2. RESULTS: Fetuses in Group 1 showed significantly higher survival rates (overall survival, 100/108 (92.6%) vs. 23/38 (60%), P < 0.0001; survival of both fetuses, 49/54 (90.7%) vs. 9/19 (47.4%), P = 0.0002) and median gestational age at delivery (33.6, (range, 27.6-37.8) weeks vs. 32.0 (range, 26.9-36.3) weeks, P = 0.0457). Overall, there was a significantly higher incidence of complications, defined as necessity for intrauterine intervention, fetal or neonatal death or delivery prior to 32 weeks, in Group 2 (Group 1: 30/63 (47.6%); Group 2: 16/20 (80%), P = 0.0188). CONCLUSIONS: Our data suggest that amniotic fluid discordance in monochorionic diamniotic twin pregnancies in combination with IUGR and umbilical artery ARED flow in one fetus represents an extremely high-risk constellation for adverse pregnancy outcome.

Starting or changing therapy - a prospective study exploring antiretroviral decision-making.

BACKGROUND: When to start or change antiretroviral treatment against HIV infection is of major importance. Patients' readiness is considered a major factor influencing such treatment decisions, in particular because no objective, absolute time point when to start antiretroviral therapy exists. We aimed at evaluating patients' readiness to start or change antiretroviral therapy (ART). PATIENTS AND METHODS: HIV-infected patients starting or changing ART between July 2002 and February 2003, treating physicians and nurses participated in this prospective, observational multicenter study. We assessed shared decision-making including qualitative aspects, expected treatment decisions and treatment status after 3 months. RESULTS: 75 patients were included. Of 34 patients for whom starting ART was considered, 27 (79%) indicated that they were willing to start treatment. After 3 months, 21 of 27 (78%) actually started therapy, six did not. Patients with depression were less likely to be ready for ART (p < 0.05). Of 41 patients for whom changing ART was considered, 35 (85%) indicated that they were willing to change treatment. Of the latter 35 patients, 33 (94%) finally changed ART within 3 months. Physicians and nurses were too optimistic in predicting the start or change of ART. The main reason to start or change ART was the sole recommendation of the physician (52% in those starting, 61% in those changing ART). Patients mainly judged the decision as shared and were very satisfied (71%) with the process. Qualitative findings revealed the importance of a dialectic decisionmaking, described with two categories: "dealing with oneself and others"' and "understanding and being understood." CONCLUSION: Patients mainly shared the decision made during consultation. Although physicians have an essential role concerning ART, patients, physicians, and nurses all contribute to the decision. Qualitative findings indicate the importance for health-care providers to include patients' expertise and contributions.

Pancreatic necrosis infection due to Lactobacillus paracasei in an immunocompetent patient.

An immunocompetent patient recovering from gallstone-induced pancreatitis had to be readmitted due to abdominal pain, fever, and rapid deterioration. Computed tomography guided needle aspiration established the diagnosis of pancreatic necrosis infection; microbiological investigations revealed monoinfection with Lactobacillus paracasei subspecies tolerans. To our knowledge, this is the first description of a pancreatic necrosis infection due to L. paracasei in an immunocompetent patient without any known risk factors for Lactobacillus infections.

CD45RA+ ICAM-3+ lymphocytes in interferon-beta1b-treated and -untreated patients with relapsing-remitting multiple sclerosis.

OBJECTIVES: Multiple sclerosis (MS) is believed to be an autoimmune disease of the human central nervous system mediated by autoreactive T cells. Interferon-beta1b (IFN-beta1b) has been shown to be effective in reducing disease activity defined by clinical and magnetic resonance imaging (MRI) criteria in relapsing-remitting MS (RRMS). Yet, the exact mechanisms by which these benefits are achieved remain unknown. CD45RA is a marker for naive T lymphocytes and intercellular adhesion molecule-3 (ICAM-3) is expressed on resting lymphocytes. MATERIAL AND METHODS: Forty-eight patients with RRMS, 24 of them treated with recombinant IFN-beta1b and 24 untreated, were enrolled in this prospective study over 18 months. We investigated the percentage of CD45RA+ ICAM-3+ cells within the total lymphocyte subset in the peripheral blood serially every 3 months and in CSF once at baseline. Detailed clinical examination including Expanded Disability Status Scale (EDSS) score was performed every 3 months and cranial MRI scans were assessed every 6 months. RESULTS: We found a temporary increase in the CD45RA+ ICAM-3+ lymphocyte ratio in peripheral blood of both untreated and IFN-beta1b-treated RRMS patients. Moreover, we determined a significant negative correlation (r = -0.5874; P < 0.01) between age as well as the EDSS score (r = -0.3629; P < 0.05) and the percentages of CD45RA+ ICAM-3+ lymphocytes in peripheral blood but a positive correlation between EDSS score and the CD45RA+ ICAM-3+ ratio (r = 0.3913; P < 0.05) in the CSF at baseline. CONCLUSION: CD45RA+ ICAM-3+ lymphocyte ratio in peripheral blood might indicate immunosenescence in MS. However, from our data it cannot be finally concluded whether it is also influenced by IFN-beta1b treatment.

[Outcome of long-term intensive therapy of surgery patients]. / Ergebnisse nach Langzeitintensivtherapie chirurgischer Patienten.

OBJECTIVE: The treatment of severely ill patients remains a medical and human challenge. The aim of the study was to determine the survival rate of patients with prolonged intensive care unit (ICU) treatment. Additionally, the somatic, psychological, and social sequelae of the survivors should be determined. METHODS: Data of all patients who stayed for at least 30 consecutive days on a surgical ICU were evaluated with respect to age, sex, diagnosis on admission, APACHE II-Score, ISS, pre-existing diseases, therapeutic procedures, complications, organ dysfunctions, and mortality. The survivors passed a follow-up examination after 35 +/- 14 months. This included somatic, psychological, and social parameters. RESULTS: Data of 101 patients were analysed (m/f: 78/23, mean age: 49.9 +/- 18.2 years, mean stay on ICU: 57 +/- 37 days, trauma patients: 46%). 31 subjects died on the ICU. Until the follow-up, another 24 patients deceased. Thus, the total mortality rose to 55%. Age, diagnosis on admission and severity of organ failure influenced the ICU mortality. Concerning the mortality after discharge, age, pre-existing morbidity and diagnosis on admission affected the outcome. 41 of the remaining 46 patients (89%) underwent the follow-up. Nearly half of them showed no or minor signs of impairment in any of the investigated areas. One third had severe handicaps. Trauma patients had the lowest mortality rates but showed worse results in rehabilitation. CONCLUSIONS: The mortality after prolonged ICU-treatment is substantially higher compared to average ICU patients. However, having survived the acute phase of the illness, successful rehabilitation in somatic, psychic as well as social terms could be performed to a considerable extent. This outcome is comparable to the one of other ICU populations. The results encourage to a consequent use of all medical options.

Primary cutaneous nocardiosis in an immune-competent patient.

We present a patient who was hospitalized due to a purulent skin lesion with a surrounding erythematous area in the region of the right paranasal crease accompanied by a swelling of the right eyelid. Initially the diagnosis of a carbuncle caused by an infection with Staphylococcus aureus was supposed. A surgical debridement was performed and an antibiotic therapy was started. Only special microbial investigations requested by the clinician led to the diagnosis of a cutaneous infection with Nocardia brasiliensis. The presented case is remarkable because the nocardia infection was in an immune-competent patient and the patient showed a primary cutaneous nocardiosis without dissemination.

Prognostic value of soluble tumor necrosis factor receptors 1 and 2 in multiple sclerosis patients treated with interferon beta-1b.

The objective of this study was to investigate the effect of interferon (IFN) beta-1b on the serum levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) and sTNF-R2 in patients with multiple sclerosis (MS) in correlation with clinical and magnetic resonance image (MRI) activity. Serum samples were obtained every 3 months from 24 patients treated with 8 x 10(6) U of IFN beta-1b every other day (treatment group) and from 21 patients without any immunomodulatory therapy (control group) over a 15-month observation period. The cytokine receptor levels were assessed by ELISA. Cranial MRI was performed every 6 months to determine the burden of disease. In the treatment group, the MRI responders had significantly larger mean values for the area under the concentration-time curve of sTNF-R1 (p = 0.04) and sTNF-R2 (p = 0.01) when compared to the MRI nonresponders during the 15-month observation period. With regard to an increase in sTNF-R1 and -2 of more than 20% during the first 3 months of treatment, we observed a sensitivity of 33 and 58%, respectively, a specificity of 90 and 60%, respectively, and a positive predictive value of 80 and 64%, respectively, for MRI response during the 15-month observation period. A decrease in sTNF-R1 and -2 of more than 20% during the first 3 months of treatment had a sensitivity of 40 and 20%, respectively, a specificity of 100 and 100%, respectively, and a positive predictive value of 100 and 100%, respectively, for further MRI nonresponse (during the 15-month observation period). The present data suggest that assessment of sTNF-Rs may contribute to the identification of subgroups of patients who are likely to respond better than others to treatment with IFN beta-1b. This could help to establish a cost-effective prescription pattern for this expensive treatment, which is of importance for the future management of patients with MS.

[Psychiatric emergencies in preclinical emergency service; incidence, treatment and evaluation by emergency physicians and staff]. / Der psychiatrische Notfall im Rettungsdienst. Häufigkeit, Versorgung und Beurteilung durch Notärzte und Rettungsdienstpersonal.

Preclinical psychiatric emergency situations (PES) rank third in frequency of calls in the German emergency medical system (EMS). However, few data exist concerning relevance and treatment of PES. The aim of this study was to investigate this relevance in preclinical EMS and its appraisal by emergency physicians and paramedics. The protocols filled in by EMS physicians on emergency duty in a German district were evaluated concerning PES. In addition, the emergency physicians and paramedics of the district were asked to complete a validated questionnaire concerning the importance, their own understanding of PES, and interest in training programs. With 9.2%, preclinical PES ranked third in frequency of all EMS calls. The most frequent case was substance abuse disorder (70%), followed by suicide attempts or ideation (33%). Specific therapy for psychiatric disorders is hardly ever performed. Emergency physicians and paramedics estimated the importance of knowledge about PES as high but rated their own knowledge as poor. Assessing five typical PES, emergency physicians gave the correct diagnoses in 71% of cases (paramedics 39%) and the correct therapy in 32% (paramedics 14%). The interest in training programs was significantly higher in experienced EMS physicians. Preclinical PES is a relevant diagnosis within EMS and correct treatment is hampered by limited knowledge. Sufficient training is not yet available, although programs are necessary and the willingness to participate in them is high.

Induction of sTNF-R1 and sTNF-R2 by interferon beta-1b in correlation with clinical and MRI activity.

OBJECTIVES: To investigate the influence of interferon (IFN) beta-1b on the serum levels of sTNF-R1, sTNF-R2 and TNF-beta in patients with multiple sclerosis (MS) in correlation with clinical and MRI activity. MATERIALS AND METHODS: Serum samples were obtained every 3 months from 24 patients treated with 8 x 10(6) U of IFN beta-lb every other day (treatment group) and from 21 patients without any immunomodulatory therapy (control group) over a 15-month observation period. The cytokine levels were measured by ELISA. Cranial MRI was performed every 6 months to determine the burden of disease of every patient. RESULTS: In the treatment group we found an obvious increase of sTNFR1 and sTNF-R2 (P < 0.001) and relatively stable serum levels of TNFbeta with no statistical significance (P = 0.56). In the control group, sTNF-R1 showed a significant decrease (P < 0.001) during the same observation period of 15 months. During the 15-month observation period, the MRI-responders group had significant larger mean AUC (area under the concentration-time curve) values of sTNF-R1 (P = 0.04) and sTNF-R2 (P = 0.01) when compared to the group of MRInonresponders. CONCLUSION: The present data suggest that IFN beta-1b induces the expression and shedding of TNF-R1 and TNF-R2. The magnitude of an increase of sTNF-Rs may be a marker for the effectiveness of treatment with IFN beta-1b.

[Cervical tuberculous lymphadenopathy--a rare complication of myelodysplastic syndrome]. / Zervikale tuberkulöse Lymphadenopathie--Eine seltene Komplikation des Myelodysplastischen Syndroms.

Patients with myelodysplasia are susceptible to infections due to their compromised immunity. If presenting with a cervical lymphadenopathy patients must, in addition to other causes, be evaluated for tuberculosis, especially if they show a concurrent erythema nodosum.

[Quality of life after long-term surgical intensive care treatment]. / Lebensqualität nach chirurgischer Langzeit-intensivtherapie.

INTRODUCTION: Long-term treatment in surgical intensive care units (SICU) subjects the patient to a high degree of somatic, psychological, and social stress. The aim of this study was to determine their outcome in terms of quality of life and health status. METHODS: All patients from a 4-year period in a SICU with a length of stay (LOS) of 30 days or more were included. All survivors were interviewed and examined after 35 +/- 14 months; they also completed several questionnaires (Munich Inventory for Quality of Life and Health Status, POMS, and Spitzer Quality of Life Index). RESULTS: One hundred one patients fulfilled the inclusion criteria, and 46 survived until follow-up. Forty-one (89%) could be traced and examined. Male:female ratio was 31:10, age 42 +/- 17 years, and LOS 51 +/- 19 days, Diagnoses on admittance were multiple trauma (n = 32) and other (n = 9). When classifying patients according to physical impairment, one third each showed no, mediocre, or severe limitations. Subjective appraisal of quality of life and well-being was sufficient for about half the patients in every test. Trauma victims experienced more severe impairment of quality of life. There were no differences between sex, age, or time until follow-up. CONCLUSION: After prolonged SICU treatment, about half of the patients report limitations in their quality of life as a result of their illness and the subsequent treatment. Some patients, in particular after trauma, exhibit striking psychosocial problems despite satisfactory somatic treatment results. These problems can be positively addressed in rehabilitative efforts.

Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-twin transfusion syndrome.

OBJECTIVE: Severe twin-twin transfusion can be treated by either serial amniocenteses with removal of large volumes of amniotic fluid or by endoscopic laser coagulation of the communicating vessels. We investigated the benefit of laser surgery in comparison to serial amniocenteses in terms of pregnancy outcome. STUDY DESIGN: The data used in this comparative study were collected from 116 patients with severe twin-twin transfusion syndrome between 17 and 25 weeks' gestation. The patients were grouped according to the treatment center. The first group comprised 73 patients (median gestational age 20.7 weeks) treated in Hamburg by fetoscopic laser coagulation of the vascular placental anastomoses between January 1995 and May 1997. The second group comprised 43 patients (median gestational age 20.4 weeks), fulfilling identical diagnostic criteria and treated in Bonn by serial amniocenteses between 1992 and 1996. RESULTS: The overall fetal survival rate was not significantly different (61%, 89/146, vs 51%, 44/86; P =.239). There was a significantly higher proportion of pregnancies with >/=1 survivor in the laser-treated group (79%, 58/73, vs 60%, 26/43; P =.033). The number of cases with spontaneous intrauterine fetal death of both fetuses was significantly lower in the laser-treated group (3%, 2/73, vs 19%, 8/43; P =.003). The incidence of abnormal ultrasonographic findings in the brain was significantly lower among surviving neonates after laser surgery than after amniocenteses (6%, 5/89, vs 18%, 8/44; P =. 03). For pregnancies with >/=1 live-born baby, a significantly longer interval between first intervention and delivery (median 90 vs 72 days, P =.022) leading to a significantly higher gestational age at delivery (median 33.7 vs 30.7 weeks, P =.018) was observed for the laser-treated group. The birth weights of the donor fetuses were significantly higher in the laser-treated group (median 1750 vs 1145 g, P =.034), and a trend toward higher birth weight was also found for recipient fetuses (median 2000 vs 1560 g, P =.076). CONCLUSIONS: These findings indicate that endoscopic laser coagulation of placental vascular anastomoses offers a more effective alternative to serial amniocenteses as a treatment of severe second-trimester twin-twin transfusion syndrome.

Prognostic factors in severe twin-twin transfusion syndrome treated by endoscopic laser surgery.

OBJECTIVE: The aim of this study was to investigate clinical and sonographic parameters, in particular Doppler blood flow measurements, in severe second-trimester twin-twin transfusion syndrome before and after endoscopic laser coagulation of the placental vascular anastomoses, to correlate these data with fetal outcome and to determine whether fetal blood flow measurements could help to estimate the probability of fetal survival. METHODS: In 121 cases of severe twin-twin transfusion syndrome examined between 17 and 26 weeks of gestation, the following investigations were performed: fetal biometry, placental location, deepest pool of amniotic fluid, echocardiography and Doppler sonography of the umbilical arteries and the ductus venosus of both twins before and after fetoscopic laser ablation of the placental anastomoses. RESULTS: The overall survival rate was 64% (156/242). Both fetuses survived in 48% (58/121) and one fetus survived in 33% (40/121), resulting in 81% (98/121) of pregnancies with at least one survivor. Gestational age at the time of the procedure and placental location had no significant influence on fetal survival. The amniotic fluid volume drained after laser coagulation correlated significantly (p = 0.038) with the risk of miscarriage or extremely premature delivery within 4 weeks of the procedure. Intertwin discrepancy in abdominal circumference showed a significant negative correlation (p = 0.004) with the probability for survival of donor fetuses. Before the procedure, 19% (23/121) of donor twins and 5% (6/121) of recipient twins showed absent or reversed end-diastolic flow in the umbilical artery (p = 0.001). This finding had no significant influence on the survival rate of donors. An increase of waveform indices in the umbilical artery 1 day after the procedure compared to immediately after the procedure correlated significantly with a lower probability for survival of donors (p = 0.042) and recipients (p = 0.018). Before the procedure, 37% (45/121) of recipient twins and 9% (10/113) of donor twins showed absent or reversed flow during atrial contraction in the ductus venosus (p < 0.0001). This finding had a significant negative influence on the survival rate of recipient fetuses (p = 0.02). Furthermore, an increase of waveform indices in the ductus venosus 1 day after the procedure compared to immediately after the procedure correlated significantly with a lower probability of survival in recipients (p = 0.005). CONCLUSIONS: Fetoscopic laser coagulation of the placental vascular anastomoses in severe mid-trimester twin-twin transfusion is a potentially corrective and effective, minimally invasive procedure. Doppler investigation of the umbilical and fetal circulations provides important information on the fetal condition, prognosis and therapeutic effects of the intervention. Signs of congestive heart failure in the recipient may reduce the probability of survival, whereas increased placental resistance in the donor before the procedure is not necessarily associated with a reduction in the probability of survival after laser coagulation.

[Aortic valve replacement as an independent predictive factor for later development of aortic dissection]. / Der Aortenklappenersatz als unabhängiger prädiktiver Faktor für die Entstehung einer späteren Aortendissektion.

Dissection of the ascending aorta (type A) following later after aortic valve replacement has been described with increasing frequency. This study analyzes the role of aortic valve replacement for the evolution of late dissection. In a series of 80 consecutive patients with type A dissection, a previous aortic valve replacement had been performed in 12 cases (15%). In addition to arterial hypertension (p < 0.001) and Marfan syndrome (p < 0.01), multivariate analysis identified previous aortic valve replacement (p < 0.01) as an independent predisposing factor for type A dissection. Dissection occurred 3 +/- 4 years after aortic valve replacement with a clinical and anatomical profile similar to classic dissection as proven by comparison to a group of 62 patients with classic dissection associated with arterial hypertension or Marfan syndrome. With 75% and 66%, respectively, 30 day and 1 year survival of patients with dissection following later after aortic valve replacement was similar to patients with classic type A dissection. Extensive thinning and/or fragility (p < 0.05) of the aortic wall in the presence of a mildly dilated aorta (45 +/- 5 mm) at the time of aortic valve replacement was associated with a high risk for late dissection; this finding was substantiated by comparison to a control group of 10 consecutive patients with a similarly dilated aortic root but no dissection. Type and diameter of valve prostheses, cross-clamp time, NYHA functional class, and left ventricular ejection fraction were unrelated to late dissection. Previous aortic valve replacement is an independent predisposing factor for a dissection of the ascending aorta later. At the time of aortic valve replacement, prophylactic replacement or wrapping of the ascending aorta should be considered in patients with a thinned/fragile aortic wall even without a markedly dilated aortic root.