[Pilot study on drinking and voiding management in child day-care facilities in the district of Garmisch-Partenkirchen]. / Pilotstudie zum Trink- und Entleerungsmanagement in Kindertagesbetreuungseinrichtungen im Landkreis Garmisch-Partenkirchen.

BACKGROUND AND OBJECTIVES: The development of child day care is currently the focus of a public discussion. More and more very young children are cared for in a day-care facility rather than by the family. Therefore, key aspects of education are shifted into these institutions. The aim of this survey was to inquire about the current situation of drinking and voiding management in day-care facilities in the district of Garmisch-Partenkirchen. MATERIALS AND METHODS: In all, 322 questionnaires were sent to employees of 40 child day-care facilities. Organization of drinking and voiding behavior advices and personal assessments of continence education were queried. The evaluation was carried out anonymously. RESULTS: A total of 29 facilities (73%) replied. The average fluid intake was 260 ml (50-750 ml) at 12 o'clock in all day-care facilities included. The possibility to decide when to have breakfast and when to drink according to the individual thirst is practised in 43% (62/143) of the facilities. A fixed amount of fluid intake was offered by 11% (16/150) of the institutions. Of those responding, 92% (139/151) specifically send the children to the toilet, while 85% of the participants consider a continence education concept would be useful. CONCLUSION: According to a general trend, children attend day-care facilities earlier and spend more time there. This means that educational staff are taking care of children who are not yet continent. A verifiable continence educational concept does not exist in any of the institutions surveyed; however, most participants would favor such a concept. It would be desirable to establish an interprofessional health education program in which drinking and voiding training is integrated according to national recommendations.

Challenges in patient selection for the parachute device implantation.

BACKGROUND: A novel percutaneous ventricular restoration therapy (PVRT) has been recently proposed to treat patients with ischemic heart failure (IHF) and antero-apical regional wall motion abnormalities after myocardial infarction (MI). In this prospective, single center, non-randomized study, we herein propose safety and feasibility evaluation of the device, in which a different patient selection strategy was used. MATERIAL AND METHODS: A three-stage evaluation was adopted in a series of patients referred for a Parachute Ventricular Partitioning Device (Parachute™). After an initial clinical evaluation, a secondary screening step was performed according to echocardiographic functional (LVEF<40%, apical/anterior akinesia/dyskinesia) and anatomical criteria [diameter of LV-apex (LVAD) = 4.0 × 5.0 cm, left ventricular end diastolic diameter (LVEDD)>56 mm, left ventricular end systolic diameter (LVESD)>38 mm]. Patients encountering the echocardiographic criteria were selected for 3D cardiac CT (architecture, geometry, and trabeculation of the left ventricle) and eventually treated with the Parachute™. RESULTS: Fifty patients were screened according to the echocardiographic criteria. Twenty-seven of those that met the echo inclusion criteria underwent further cardiac CT imaging. After CT imaging, eight patients were scheduled for Parachute™ implantation. The device was successfully implanted in all eight patients with no in-hospital mortality. A 3-month follow-up echocardiography showed LV-volume reduction [95% CI; LVEDV: -76.5 (-116; -36.8), P = 0.002 and LVESV: -47.4 (-63.8; -30.9), P = 0.003] and improvement of global EF [95% CI; global EF: 6.87 (5.36; 8.39), P = 0.008]. CONCLUSION: Selection criteria for Parachute™ placement should include left ventricular functional and anatomical parameters. When preprocedural echocardiography and cardiac CT are adequately implemented, satisfactory periprocedural and short term follow-up results may be achieved after Parachute™ implantation.

Anastomotic stenting in a porcine aortoiliac graft model.

The purpose of the study was to evaluate the feasibility of anastomotic stent application in a porcine aortoiliac graft model. In a total of 10 pigs, a polytetrafluoroethylene aortobi-iliac graft was implanted through a midline abdominal incision. The lower edge of the iliac vessel was graft-inverted about 1 mm to produce irregularities at the downstream anastomosis. After transverse graft incision, six stainless-steel stents, six poly-L-lactic acid (PLLA) stents and four PLLA stents with 10% polycaprolactone (PCL) were implanted at the iliac anastomotic site using a 6 mm balloon dilatation catheter. Four anastomotic sites were left untreated. After two weeks, the patency of graft limbs was evaluated by contrast-enhanced computed tomography (CT). Both metal and polymeric stent designs provided adequate flexibility to manoeuvre across the anastomotic site for expansion in the chosen position. After deployment, the stent-arterial wall contact was complete on a macroscopic view. On CT scan, all metal and PLLA-stented graft limbs were free of stenosis, whereas all PLLA/PCL stents were occluded. The non-stented graft limbs showed a stenosis of 50-70%. In summary, this model is feasible to assess preclinically the deployment and patency rate of an anastomotic stent and to test future stent developments.

[The methodology and accuracy of MRI-based orbital volume calculations]. / Zur Methodik und Genauigkeit der MR-Volumetrie der Orbita.

OBJECTIVE: The aim of the present work was to establish a method for orbital volume calculation based on MR scanning data for the sake of better radiation hygiene. MATERIALS AND METHODS: The orbital volumes of 35 ophthalmologically healthy children were calculated on the basis of MRI scans. After data transfer to a separate workstation, volumetric analysis was carried out by two independent radiologists using semi-automated software. The accuracy of the calculated values was compared with orbital volumes measured by anatomic preparations and given in studies by various authors. RESULTS: Volume calculation was possible in all patients using MRI data. There is an acceptable agreement with the presented anatomic facts and the measured values of Bentheley. In the Wilcoxon test there was not a big difference between the courses of the values (p = 0.507). CONCLUSION: Even though we can obtain a better image of the bizarre structure of the bony orbits with CT, MR-based volumetry of the orbit is a reliable method and is not burdened by radiation exposure. It can thus be an important condition for the planning and the controlling of modern therapeutic concepts in treating anophthalmos and microphthalmos.

Microencapsulated cell-mediated treatment of inoperable pancreatic carcinoma.

Pancreatic cancer can seldom be resected, and chemotherapy has only a limited effect on survival or tumour load. We did a phase I/II trial in 14 patients with pancreatic cancer to assess the safety of local activation of low-dose ifosfamide. We encapsulated genetically modified allogeneic cells, which expressed a cytochrome P450 enzyme, in cellulose sulphate and delivered them by supraselective angiography to the tumour vasculature. These cells locally activated systemically administered ifosfamide. The tumours of four patients regressed after treatment, and those of the other ten individuals who completed the study remained stable. Median survival was doubled in the treatment group by comparison with historic controls, and 1-year survival rate was three times better. Further studies of this cell-therapy-based treatment combined with chemotherapy for inoperable pancreatic cancer are warranted.

Low frequency of p53 and ras mutations in bile of patients with hepato-biliary disease: a prospective study in more than 100 patients.

The diagnosis of biliary disease, namely malignant disorders, is frequently hampered by the inconclusive cytology. We investigated prospectively the frequency of molecular changes in p53 and ras compared with cytology in patients with primary or secondary hepato-biliary disease. We investigated 118 consecutive patients, aged 24-89 with the following clinical diagnoses: choledocho/cholecystolithiasis (28), cholangiocellular carcinoma (21), gall bladder tumor (8), liver metastasis (3), autoimmune disease (8), chronic pancreatitis (16), pancreatic carcinoma (11), papillary disease (4), hepatic cirrhosis (6), cholangitis (2), anomalies (2), and normal (9). Bile was aspirated during routine endoscopic retrograde cholangio pancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). DNA was prepared freshly from a native aliquot. p53 mutations were detected by polymerase chain reaction (PCR) for exons 5 through 8 followed by TGGE. PCR for ras mutations was performed as RFLP-PCR with sequencing. In four cases, mutations in p53 could be found in exons 6 and 7. Twenty-two samples showed ras mutations; ras mutations were found in choledocholithiasis (4/28), bile duct (5/21), gall bladder (3/8) and pancreatic (1/11) carcinoma, liver metastasis (3/3), ulcerative colitis (2/3), PSC (1/2), and chronic pancreatitis (1/16). Cytology was clearly positive in seven cases, suspicious in three other, inconclusive in six, and negative in the rest. The molecular analysis resulted in a sensitivity of 33% and specificity of 87%, respectively, for the diagnosis of a malignant condition. PCR for p53 and ras mutations may aid the diagnosis of primary and secondary (metastatic) hepatobiliary disease if a malignant condition of the bile ducts and the liver is suspected and cytology is inconclusive or negative. However, the incidence of p53 and ras mutations in bile seems less frequent than in other malignant conditions of the gastrointestinal tract and the pancreas and lower than in tissue, leaving a poor sensitivity and specificity. Nevertheless, the presence of a p53 and/or ras mutation per se supports a clinical suspicion of malignancy, even when the conventional cytology is negative or inconclusive.

Mycotic aneurysm rupture of the descending aorta.

A 69-year-old diabetic male with salmonella bacteremia developed hypovolemic shock and swelling of the neck. A CT examination revealed massive mediastinal hemorrhage extending into the neck soft tissues caused by false aneurysm rupture of the descending thoracic aorta. Aortography showed continuous extravasation from a large leak at the medial side of the descending thoracic aorta. Although surgical intervention was immediately performed, the patient died 3 weeks later from multiple-organ failure. In this report, CT and angiographic findings of mycotic aneurysm rupture are presented and a review is given.

Transjugular intrahepatic portosystemic shunt (TIPS). Thrombogenicity in stents and its effect on shunt patency.

PURPOSE: To compare the thrombogenicity and patency of the Palmaz stent and the Wallstent, and to evaluate the effect of periprocedural heparin therapy in cirrhotic patients with maintained coagulation capacity who receive a transjugular intrahepatic portosystemic shunt (TIPS). MATERIAL AND METHODS: Twenty-four patients were randomized into 4 groups of 6 patients. Each received a Palmaz-stent or Wallstent TIPS with or without periprocedural heparin therapy. The groups receiving periprocedural heparin were given 24 U/kg b.w. just before stent placement, followed by 24 h therapeutic i.v. heparin. After 24 hours, all patients received i.v. heparin for 1 week followed by subcutaneous treatment with low-molecular-weight heparin (0.3 ml/day) for another 4 weeks. Stent thrombogenicity was determined scintigraphically after i.v. injection of 120-290 mBq of 99mTc-labeled platelets at the time of stent placement and expressed as the stent/heart ratio. Shunt patency was assessed by duplex sonography and confirmed radiologically. RESULTS: The aggregation ratio was highest 90 min after stent implantation. Wallstents showed a significantly higher ratio than Palmaz stents. Heparin reduced the ratio in patients with a Wallstent (-41%) but had no effect on Palmaz stents. Patients with a Wallstent without heparin had a higher rate of early shunt insufficiency (66.6%) than the other patients (0-16.6%). Primary assisted long-term patency was similar in the 4 groups. CONCLUSION: Wallstents were more thrombogenic than Palmaz stents and gave a significantly higher risk of early shunt insufficiency in cirrhotic patients with maintained coagulation capacity. Periprocedural heparin was effective in the prevention of shunt insufficiency and is therefore indicated in such patients.

Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding.

BACKGROUND: The transjugular-intrahepatic-portosystemic shunt is a new interventional treatment for portal hypertension. The aim of our study was to compare the transjugular shunt with endoscopic treatment for the prophylaxis of recurrent variceal bleeding. METHODS: Between March, 1993, and March, 1996, 126 patients with variceal bleeding were randomly assigned either transjugular shunt (n = 61) or endoscopic treatment (n = 65). Patients were followed up for a median of 14 (IQR 8-25) months and 13 (8-25) months, respectively. In 31 (51%) of the shunted patients, simultaneous transjugular-variceal embolisation was done at the time of shunt placement. Endoscopic treatment consisted of sclerotherapy and/or banding ligation and was combined with propranolol medication. FINDINGS: Technical success was achieved in all patients assigned to the shunt group. During follow-up, the cumulative 1-year variceal rebleeding rates in the shunted and endoscopically treated patients were 15% and 41% and the 2-year rates were 21% and 52% (p = 0.001), respectively. In nine (12%) patients from the endoscopic group treatment failed and the patients received the transjugular-shunt treatment. A total of 19 bleeding episodes from any source occurred in 15 patients in the shunt group compared with 100 episodes in 33 patients in the endoscopic group. There was no difference in survival with estimated 1-year survival rates for shunted and endoscopically treated patients of 90% and 89%, and 2-year survival rates of 79% and 82%, respectively. The incidence of clinically significant hepatic encephalopathy after 1 year was higher in the shunt group (36% vs 18%, p = 0.011). INTERPRETATION: These results suggest, that the transjugular shunt is more effective than endoscopic treatment in prevention of variceal rebleeding but has a considerable risk of hepatic encephalopathy. Survival is similar in the two groups.

[Recurrent bleeding from colonic varices in portal hypertension. The successful prevention of recurrence by the implantation of a transjugular intrahepatic stent-shunt (TIPS)]. / Rezidivierende Kolonvarizenblutung bei portaler Hypertonie. Erfolgreiche Rezidiv-Prophylaxe durch Implantation eines transjugulären intrahepatischen Stent-Shunts (TIPS).

HISTORY AND CLINICAL FINDINGS: Sclerotherapy was performed in a 52-year-old patient with alcoholic liver cirrhosis (Child-Pugh stage A) for recurrent bleeding from oesophageal varices. Half a year later he again was admitted to hospital because of recurrent passage of bloody stools. The cardiovascular status was stable; the liver was enlarged by 15 cm in the medioclavicular line. INVESTIGATIONS: Endoscopy revealed several varices in the colon near the right flexure. One of the varices had an ulcer of 5 mm size. Duplex sonography revealed portal hypertension with cirrhosis of the liver and partial thrombosis of the main trunk of the portal vein without any sign of cavernous transformation. TREATMENT AND COURSE: Because of the partial portal vein thrombosis it was decided to insert a transjugular intrahepatic portosystemic stent shunt. This obviated the thrombosis and lowered the portosystemic pressure gradient by 6.8%. With the shunt functioning well there were no further bleedings in the subsequent year. CONCLUSION: The only slightly invasive TIPS implantation is an effective therapeutic procedure for bleeding from colon varices caused by portal hypertension.

Budd-Chiari syndrome: technical, hemodynamic, and clinical results of treatment with transjugular intrahepatic portosystemic shunt.

PURPOSE: To evaluate use of the transjugular intrahepatic portosystemic shunt (TIPS) as a nonsurgical approach for the management of Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Twelve patients with fulminant (n = 2), subacute (n = 5), or chronic (n = 5) BCS underwent TIPS placement. Hepatic venous obstruction was demonstrated at computed tomography and color duplex sonography. BCS was confirmed histologically in all patients. Hemodynamic parameters and clinical characteristics were assessed. RESULTS: TIPS creation was successful in all patients. Treatment reduced the portal venous pressure gradient by 75% and resulted in a mean shunt flow of 2,300 mL/min +/- 650 (standard deviation). No serious procedure-related complications were observed. The two patients with fulminant BCS died of septicemia or progressive liver failure despite intervention. The other 10 patients showed clinical improvement with reduction or disappearance of ascites. During follow-up, shunt dysfunction occurred in five of 10 patients with recurrence of ascites requiring repeat intervention. CONCLUSION: TIPS placement is safe and effective in patients with portal hypertension caused by subacute or chronic BCS.

[Septic portal vein thrombosis. Its successful therapy by local fibrinolysis and a transjugular portasystemic stent-shunt (TIPS)]. / Septische Pfortaderthrombose. Erfolgreiche Therapie durch lokale Fibrinolyse und transjugulären portosystemischen Stent-Shunt (TIPS).

HISTORY AND FINDINGS: A 68-year-old man, without any preceding hepatic or abdominal disease, suddenly developed a severe septic illness with consumptive coagulopathy and upper abdominal pain. B-mode and duplex ultrasonography revealed fresh portal vein thrombosis. Despite extensive conservative measures there was no significant improvement after one week and further thrombus extension with threatened acute mesenteric vein occlusion. TREATMENT AND COURSE: Local fibrinolysis with recombinant plasminogen activator and urokinase via percutaneous transjugular intrahepatic catheterization of the portal vein achieved almost complete dissolution of the thrombus within 3 days. Subsequently the portal vein catheter was changed into a transjugular portosystemic stent shunt (TIPS). CONCLUSIONS: While local or systemic fibrinolysis has been practised in previously reported cases of acute portal vein thrombosis, the described use of TIPS introduces a new element. The shunt between hepatic and portal veins assures therapeutic access to the portal venous bed. It lowers portal vein pressure and can diminish the danger of recurrent thrombosis by raising portal flow. This minimally invasive procedure may be a nearly ideal treatment even in the course of portal vein thrombosis which has a high complication rate.

The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites.

BACKGROUND: Previous studies have suggested that the transjugular placement of an intrahepatic stent to establish a portosystemic shunt is an effective treatment of uncomplicated ascites accompanying variceal bleeding. We studied the stent shunt for use in patients with liver cirrhosis and ascites refractory to medical treatment. METHODS: Fifty of 62 consecutive patients with cirrhosis and refractory ascites (18 with Child-Pugh class B liver disease and 32 with class C) were treated with the stent shunt--an expandable stent of metallic mesh placed between a major branch of the portal vein and one of the hepatic veins. Patients were followed for a mean (+/- SD) of 426 +/- 333 days. Those with advanced cancer, severe heart failure, or severe liver failure were excluded. RESULTS: The stent shunt was successfully placed in all patients and reduced the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) had complete responses (total remission of ascites within three months), and nine patients (18 percent) had partial responses (ascites detected by ultrasound but with no need for paracentesis). Four patients did not respond, including two who died within two weeks of shunt placement. After the procedure, 25 patients had hepatic encephalopathy, as compared with 20 patients before the procedure; although encephalopathy improved in 3 patients, new encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who were evaluated, the mean serum creatinine concentration was 1.5 +/- 0.09 mg per deciliter (133 +/- 8 mumol per liter) before placement of the stent shunt, 1.5 +/- 1.6 mg per deciliter (133 +/- 141 mumol per liter) one week after the procedure, and 0.9 +/- 0.3 mg per deciliter (80 +/- 27 mumol per liter) after six months (P = 0.008 for the comparison of concentrations before and six months after the procedure). Renal function did not improve in the six patients with organic kidney disease. Procedure-related complications developed in 16 patients, including intraabdominal bleeding requiring blood transfusions in 2 patients. Thrombotic occlusion of the stent shunt occurred within two weeks in 5 patients, and later insufficiency of the shunt occurred in 16 patients, including 12 with recurrence of ascites after complete remission. During followup, an additional 29 patients died--10 of progressive liver disease and 19 of other causes. Survival for at least one year was associated with a patient's being under 60 years of age, having a serum bilirubin level before placement of the stent shunt of less than 1.3 mg per deciliter (22 mumol per liter), and having a complete response. CONCLUSIONS: Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic stent-shunt procedure was an effective treatment for many patients with liver cirrhosis and refractory ascites, but mortality from underlying diseases was substantial.