Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study.

OBJECTIVE: To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. METHODS: Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. RESULTS: In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p=0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p=0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI]=0.02 [0.00, 0.59], p=0.03) and length of stay (HR [95% CI]=18.5 [4.39, 78.4], p<0.001). CONCLUSIONS: The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.

[Long and short QT syndromes : Emergency treatment and secondary prophylaxis]. / Long- und Short-QT-Syndrome : Notfalltherapie und Sekundärprophylaxe.

Long QT syndrome (LQTS) is a rare inherited or acquired channelopathy associated with a relevant mortality if left untreated. Therapy can reduce the sudden cardiac death (SCD) rate significantly. Of 17 subtypes, LQTS1-3 are the most common. Clinical presentation ranges from asymptomatic patients to torsade de pointes (TdP) and SCD. Emergency therapy includes defibrillation, administration of magnesium, betablockers and temporary pacing and sedation. Secondary prevention is based on betablocker therapy and implantation of an implantable cardioverter-defibrillator (ICD), if appropriate. Short QT syndrome (SQTS) is a rare channelopathy that manifests as SCD in 34%. So far 250 cases with mutations in 8 genes have been reported. ICDs are the only reliable protection against SCD. Drug therapy is based on hydroquinidine. Further therapeutic options exist for certain subtypes of both diseases. Patients should be referred to specialized centers.

Living the difference: alternative functional designs in five perennial herbs coexisting in a coastal dune environment.

Ecological theory suggests that in harsh environments major abiotic stress factors may act as environmental filters, thereby reducing the range of possible plant strategies through environmental trait selection. This would lead to functional similarity of species coexisting in hostile environments. To test this prediction, we evaluated six functional leaf traits at three different times of year in five species coexisting in a coastal dune ecosystem. The functional traits examined were associated with water status and light interception and use - two of the most limiting factors that lead to stress in dune systems. Species differed in traits associated with light absorption, namely chlorophyll content, the vigour index NDVI, and the proportion of the light absorbed that is used in photochemistry (as expressed by the effective and maximum quantum yield of PSII and the photochemical reflectance index). For most of the traits, the relative performance of species depended significantly on time. This research revealed a significant divergence in functional traits of coexisting species, which does not conform to findings in other harsh environments where species tend to functional convergence. The data provide experimental support for the hypothesis that there is no single combination of traits for a given environment, but that alternative functional designs of similar fitness may evolve in the same environment as a result of complex interactions and trade-offs among traits. This suggests that factors claimed to promote divergence, such as limiting similarity and disturbance processes, may play an important role in structuring the dune community under study. The high variability in functional traits suggests a significant degree of functional diversity and highlights the importance of preserving the species composition of threatened coastal dune habitats in order to preserve distinctive functional processes that may be unique to the systems.

[Short QT syndrome]. / Short-QT-Syndrom.

Short QT syndrome was first described in 2000. It is a sporadic or familial ion channel disease that is associated with abbreviation of the QT interval permanently or transiently. The time of first manifestation of symptoms such as atrial fibrillation or syncope or even sudden death is between the 2nd and 4th decade. Sudden death has also been described for newborns and adolescents. Therapy depends on the severity of the symptoms. The therapy of choice for secondary prevention of sudden death is the implantable cardioverter-defibrillator (ICD). Quinidine has been shown to be effective in preventing arrhythmias in a number of patients. It is mostly used as an adjunct to the ICD but has also been used with considerable success in children and individuals who refused ICD implantation.

[Catheter ablation of paroxysmal atrial fibrillation: extended recommendations considering safety improvements of pulmonary vein isolation with a cryoballoon--Case 11/2011]. / Katheterablation von paroxysmalem Vorhofflimmern: großzügigere Indikationsstellung durch verbesserte Sicherheit der Pulmonalvenenisolation mittels Cryoballon - Fall 11/2011.

HISTORY AND ADMISSION FINDINGS: A 71-year-old, male patient was referred to our clinic for paroxysmal palpitations with dyspnoe and fatigue since four years despite pharmacological treatment with flecainide and bisoprolol. INVESTIGATIONS: A paroxysmal atrial fibrillation was documented in a 24-hour Holter recording. A bicycle ergometry showed a hypertensive reaction during exercise without any sign of coronary insufficiency. Intracardiac thrombi could by excluded by transesophageal echocardiography. DIAGNOSIS, TREATMENT AND COURSE: The diagnosos of a drug-refractory paroxysmal atrial fibrillation was made and cryoballoon pulmonary vein isolation was performed. A follow-up 3 months after the ablation disclosed a freedom from atrial fibrillation documented in 7-day Holter recording. CONCLUSIONS: Compared to pharmacological rhythm control, interventional treatment has been established as more effective therapy for paroxysmal atrial fibrillation. However, patients should be referred to the ablation early enough to avoid structural atrial remodeling and thus transition into persistent or permanent atrial fibrillation. New technical developments e.g. cryoballoon catheter-system simplifies the procedure and has been reported to be effective and safe to use for circumferential pulmonary vein isolation. Should the very promising preclinical data on efficacy and safety of cryothermal energy ablation be confirmed by results of ongoing, controlled trials, the catheter ablation may become the fist-line treatment for all patients with paroxysmal atrial fibrillation.

[Significance of diagnostic methods in the work-up of syncope]. / Stellenwert diagnostischer Methoden in der Synkopenabklärung.

After the initial evaluation including detailed history, physical examination, electrocardiogram, and orthostatic blood pressure measurements, risk stratification should follow, if the cause of syncope is still unclear in order to define the acuteness and extensiveness of the further diagnostic evaluation. The documentation of arrhythmia during syncope is the gold standard for diagnosis of arrhythmic syncope. The implantable loop recorder should be integrated early in the diagnostic work-up. In patients >40 years with otherwise unexplained syncope, carotid sinus massage is recommended. In suspected reflex-mediated syncope, the tilt test is able to confirm the diagnosis and gives information about the underlying pathomechanisms, while electrophysiological studies have still a proven indication in patients with previous myocardial infarction and preserved left ventricular function. The adenosine triphophate test has no clinical relevance in the diagnostics of syncope. Echocardiography plays an important role in the risk stratification by diagnosing structural cardiac disease. In patients experiencing syncope associated with exertion, exercise stress testing is indicated. Finally, a coronary angiogram should be performed, if ischemia triggered syncope is suspected. A routinely performed neurological evaluation is not recommended.

[Cardiac resynchronization therapy in non-ischemic cardiomyopathy]. / Resynchronisationstherapie bei nicht-ischämischer Kardiomyopathie.

Cardiac resynchronization therapy is recommended in patients with advanced heart failure (usually NYHA class III or IV) despite optimal pharmacologic therapy, severe systolic dysfunction (eg, left ventricular ejection fraction < 35 percent) and intraventricular conduction delay or echocardiographic indices of dyssynchrony and wide QRS complex (eg, QRS > or = 120 ms). Viral infection is the most common cause of myocarditis and has been implicated in the development of non-ischemic cardiomyopathy. We report on a patient who developed progressive congestive heart failure caused by non-ischemic cardiomyopathy after liver transplantation and reactivation of the underlying hepatitis C. Due to an insufficient response to optimized pharmacological therapy, the patient was successfully treated using cardiac resynchronization therapy.

[Recurrent transient ischaemic attacks in a patient with pansinusitis]. / Rezidivierende transitorische ischämische Attacken bei einer Patientin mit Pansinusitis.

A 31-year-old woman presented with neurological deficits after an operation for sinusitis. The cranial MRI revealed multiple ischaemic lesions. Laboratory results showed a hypereosinophilia as well as elevated creatine kinase and troponin levels. The ECG implied ST elevations, the left ventricular ejection fraction was highly reduced and the cardiac MRI was suspicious for endomyocarditis. The cardiac biopsy demonstrated the findings of Loeffler's endocarditis. In conclusion the diagnosis of hypereosinophilic syndrome was made and identified as the cause of the neurological deficits.

Experience with an ICD incorporating biventricular pacing.

Biventricular pacing for cardiac resynchronization is a promising therapy for symptomatic improvement in selected patients with underlying severe congestive heart failure. ICD treatment has been shown to prolong life in patients with life threatening ventricular tachyarrhythmias, but it does not improve quality of life. This review discusses current experience with ICD's incorporating biventricular pacing.