The polymorphism of type 1 collagen (COL1A1) gene does not correlate with an increased risk of foot ulcers in patients with diabetes mellitus.

AIM: Diabetic foot syndrome (DFS) is a multifactorial debilitating complication of diabetes mellitus (DM). The identification of markers for predicting the risk of developing DFS could help and direct the efforts in the prevention to the highest risk patients. Type I collagen α1 (COL1A1) is the main component of type I collagen, the most abundant structural protein of the extracellular matrix of subcutaneous tissue. COL1A1 polymorphism has been previously investigated with regard to many clinical conditions affecting the bone or the skin. In this prospective study, we have assessed COL1A1 polymorphism in patients without and with DFS. PATIENTS AND METHODS: 202 DM patients without and 103 patients with DFS have been recruited. COL1A1 polymorphism, due to a mutation affecting the zinc-finger transcription factor specific protein, has been investigated. The most relevant clinical data (HbA1c, vascular risk factors, insulin treatment) have been collected and analyzed. RESULTS: No statistically significant difference in the distribution of the 3 genotypes constituting COL1A1 polymorphism between patients without and with DFS has been observed. Almost all DFS patients had at least one vascular risk factor, with a high rate of arterial hypertension and dyslipidemia. CONCLUSION: A multifaceted set of factors is involved in the development of DFS and only a combination of them may lead to such occurrence. In our DM patient population, COL1A1 polymorphism does not correlate with the occurrence of DFS, which appears to depend mostly on the presence of vascular risk factors. However, the impact of genetic factors affecting other components of the subcutaneous tissue cannot be excluded.

Prevention of type II endoleak using the AMPLATZER vascular plug before endovascular aneurysm repair.

OBJECTIVE: We evaluated the feasibility of visceral artery and lumbar artery (LA) embolization using AMPLATZER vascular plug (AVP) types 4 and 2 (AVP4, AVP2) prior to endovascular aneurysm repair (EVAR) to prevent the development of a type II endoleak. METHODS: Between January 2008 and April 2010, 45 arteries in 33 male patients were embolized with 44 AVP4 and one AVP2. Artery name and diameter; device number and size; and intervention, fluoroscopy, and deployment times for each procedure and each device were recorded. Computed tomography (CT) angiography was performed 2 days and 3, 6, 12, 18, 24, and 36 months after EVAR to confirm successful EVAR and embolotherapy, exclude endoleaks, and evaluate aneurysm shrinkage. RESULTS: AVP4 devices were implanted into the inferior mesenteric arteries in 33 cases, lumbar arteries in seven cases, and pelvic and renal arteries in two cases each. An AVP2 device was inserted into the gluteal artery in one case. The success rate was 100%, with total occlusion of all target vessels. No endoleaks were found in follow-up CT angiography. CONCLUSION: The use of AVP prior to EVAR is an efficient embolization technique that prevents the development of type II endoleaks.

[False aneurysm and bleeding caused by a secondary dislocated lesser trochanter fragment]. / Aneurysma spurium und verzögerte Blutungskomplikation durch ein sekundär disloziertes Trochanter-minor-Fragment bei pertrochantärer Femurfraktur.

A 92-year-old woman incurred an unstable pertrochanteric hip fracture with avulsion of the lesser trochanter (type 31-A2 according to the AO classification). The fracture was treated by gliding nail osteosynthesis, without fixing the minimally displaced lesser trochanter. No intra- or postoperative complications were detected. Suddenly, after 30 days, a swelling of the proximal femoral region, accompanied by signs of haemorrhage, occurred.CT-scans showed a false aneurysm of the deep femoral artery and a dorsal laceration of the artery proximal to the aneurysm. X-rays showed a further dislocation with rotation of the lesser trochanter fragment. Intraoperatively, the tip of the lesser trochanter fragment was identified to be responsible for the laceration of the artery. The false aneurysm was resected and the defect bridged by a vascular prosthesis while the fragment was removed. Follow-up showed no further complications. According to case reports from the literature, false aneurysms and laceration of the deep femoral artery caused by dislocated lesser trochanter fracture fragments are rare.

[High-grade intimal sarcoma in an aneurysm of the infrarenal aorta]. / Hochmalignes Intimasarkom in einem Aneurysma der infrarenalen Bauchaorta.

Primary intimal sarcomas of the aorta are extremely rare and aggressive tumors metastasizing into bones and visceral organs including liver, kidneys, adrenal glands, and lung. The first symptoms are often nonspecific and often caused by arterial embolism. We report a case with an incidental finding of primary intimal sarcoma in an aneurysm of a patient with claudication due to tumor embolization.

[Radiological diagnosis and treatment of acute limb ischemia]. / Radiologische Diagnostik und Therapie bei akuter Extremitätenischämie.

Acute limb ischemia is associated with significant morbidity and mortality, despite diagnostic and therapeutic advances. Threatened limbs require immediate imaging in order to determine the subsequent therapeutic procedures. Conventional angiography in the DSA technique still has advantages over CT and MR angiography. In acute arterial occlusions below the femoral bifurcation, endovascular treatment with intra-arterial local thrombolysis or percutaneous thrombectomy is an alternative to open vascular surgical procedures. The following article describes diagnostic and therapeutic strategies for acute limb threat induced by arterial occlusion.

[Clinical guidelines as part of total quality management. Analysis of heterogenous treatment concepts of sepsis in various clinics with computer assisted generation, logical testing and complexity assessment of clinical algorithms]. / Klinische Leitlinien als Teil eines umfassenden Qualitätsmanagements. Analyse heterogener Behandlungskonzepte der Sepsis verschiedener Kliniken mit Hilfe computerunterstützter Erstellung, logischer Uberprüfung und Komplexitätsbewertung klinischer Algorithmen.

Generation, local tailoring, implementation and evaluation of clinical guidelines is an integral part of quality management. Clinical guidelines are intimately related to the independency of physicians' decisions. By this the physicians should be responsible for guideline development and guarantee the use of adequate methods of total quality management and outcome assessment. Formal consensus finding and transparency of evidence are necessary to guarantee the use of guidelines. Clinical algorithms are highly formalized and they are well suited for generation and analysis by the software ALGO. Determination of complexity and comparison of the clinical contents of algorithms is done by the scores CASA (Clinical Algorithm Structural Analysis) and CAPA (Clinical Algorithm Patient Abstraction). In a study of 22 clinical departments on treatment management concepts in sepsis following anastomotic insufFiciency in colorectal carcinoma a considerable heterogeneity was shown using this program.

Value of somatostatin receptor scintigraphy for preoperative localization of carcinoids.

Most carcinoid primary tumors are small and do not cause symptoms until complications (e.g. intestinal obstruction) or symptoms and signs of the carcinoid syndrome occur. Therefore in most cases an assessment of the primary tumor and its metastases must be performed. To determine the value of somatostatin receptor scintigraphy (SRS) for localizing carcinoid tumors, we compared the results of SRS with those obtained with computed tomography (CT) and ultrasonography (US) in 22 patients who had not undergone surgery for removal of the primary tumor. We could not find an advantage of SRS over CT and US for detecting the primary lesions. Tumors > 2 cm in diameter were regularly detected using all methods. SRS was not superior to CT or US for the detection of liver metastases. SRS showed the liver metastases in 16 of 18 patients, whereas CT and US detected liver metastases in all patients. For localization of extrahepatic abdominal and extraabdominal metastases (lymph nodes, bone), whole-body SRS showed an advantage over CT and US. We conclude that SRS is not superior to CT or US for localization of primary carcinoid tumors or liver metastases, although it did prove successful for visualizing extrahepatic and extraabdominal tumor spread. Additionally, SRS is useful for identifying receptor-positive metastases that may be treated by somatostatin analogs. Thus SRS should be performed in patients with a known carcinoid tumor, except those with an appendiceal carcinoid measuring < 1 cm in diameter.

Hydrodynamic investigation of mechanical bileaflet valves.

For hydrodynamic comparison, 11 mechanical bileaflet valves have been perfused in a mock circulation system under pulsatile flow conditions. Six St. Jude Medical valves with different sizes from No. 21 to No. 31 and five Duromedics prostheses with corresponding sizes from No. 21 to No. 29 have been investigated. Flow, pressure, and orifice area were measured, while cardiac output was varied between 2 and 6 L/min. Insufficiency (I), maximal orifice area (Amax), mean orifice area (A), discharge coefficient (CD), performance index (PI), and efficiency index (EI) were determined. The St. Jude Medical valves show higher values of orifice area when compared with the Duromedics valves. For smaller valve sizes up to No. 25, the values of the orifice area are similar. The Duromedics valves show much lower values of insufficiency; thus, for small valve sizes, the Duromedics prosthesis seems to be superior. For larger valve sizes (No. 27, No. 29, and No. 31), a decision has to be made whether higher insufficiency and higher orifice area of the St. Jude Medical valve or lower insufficiency with lower orifice area is more acceptable.

[Comparative study of mechanical heart valves for implantation in mitral position]. / Vergleichende Untersuchung mechanischer Herzklappen zur Implantation in Mitralposition.

For hydrodynamic comparison of mechanical heart valves, three tilting disc valves (Björk-Shiley SD, Björk-Shiley CCD, Björk-Shiley Monostrut) and two bileaflet valves (St. Jude Medical, Duromedics) with annulus diameter dA = 31 mm were perfused in a mock circulation in mitral position. Flow, pressure, and orifice area were measured during pulsatile flow. Insufficiency, maximal orifice area, mean orifice area, performance index and efficiency index were calculated. The tilting disc valves show distinctly lower orifice areas than the bileaflet valves. The mean value of maximal orifice area Amax of the Björk-Shiley prostheses varies between 227.82 +/- 7.77 mm2 and 243.21 +/- 6.21 mm2. The mean value of Amax of the Duromedics prosthesis is 295.45 +/- 7.76 mm2 and that of the St. Jude Medical prosthesis is 477.43 +/- 11.32 mm2. The calculated mean orifice areas A of the bileaflet valves are also higher than those of the tilting disc valves. The mean values of A are: Björk-Shiley SD: 183.55 +/- 10.03 mm2; Björk-Shiley CCD: 206.30 +/- 8.62 mm2; Björk-Shiley Monostrut: 210.12 +/- 4.74 mm2; St. Jude Medical: 398.69 +/- 19.55 mm2; Duromedics: 262.90 +/- 6.84 mm2. The performance index PI is qualitatively identical with the values of the mean orifice area A because in this study only heart valves of the same size were investigated. For calculation of insufficiency I the entire reflux volume VR including closing volume VS and leakage volume VL was used, thus, insufficiency was also determined in intact prostheses. The values of insufficiency of the mechanical valves investigated are higher for the bileaflet valves than for the tilting disc valves.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of a comparative in vitro study of Duromedics and Björk-Shiley monostrut mitral heart valve prostheses.

Two different mechanical heart valves with annulus diameters 21-29 mm, (five Björk-Shiley monostrut tilting disc valves and five Duromedics bileaflet valves) have been tested in pulsatile flow in the mitral position of a mock circulation. Reflux, pressure, and orifice area have been measured while cardiac output was varied between 2 and 6 1 min-1. Insufficiency, mean orifice area, discharge coefficient, and performance and efficiency indices have been calculated. Mean values of insufficiency for the Björk-Shiley monostrut valves varied between 4.8 and 17.2% while the corresponding values for the Duromedics valves were in the range 6.1-17.3%. Mean values for orifice areas of the Björk-Shiley monostrut valves increased with the larger valve sizes from 101.1 to 210.2 mm2; for the Duromedics valves the area range was 134.5-262.9 mm2. Because of the larger orifice areas the values of discharge coefficient and performance index for the Duromedic valves were higher than those for the Björk-Shiley monostrut valves. As the insufficiency of the two mechanical valves was similar, and the orifice area of the bileaflet valves was greater than that of the tilting disc valves, Duromedics valves gave higher valves for the efficiency index, which varied between 0.31 and 0.39; for Björk-Shiley monostrut valves the index varied between 0.24 and 0.28 under the same test conditions. This hydrodynamic in vitro comparison of mechanical heart valves showed that the Duromedics bileaflet valves were superior to the Björk-Shiley tilting disc valves.