First experience with the 2005 modified Gore Helex ASD occluder system.

We report about our initial experience for the in 2005 modified Helex (Gore) device for closure of atrial septal defects (ASD) and persistent foramen ovale (PFO). Major changes were made at the delivery system for simplifying the Helex implantation procedure. We treated 11 patients, 8 children and 3 adults, with ages between 3 and 62 years. In 10 patients the diagnosis was a relevant ASD with volume overload of the right heart (Left to right shunts between 30 and 50%). One adult (age 58 years) have had a small left to right shunt with a PFO-like defect and the history of 2 neurologic embolic events. In 3 patients we found 2 defects. In all patients a Helex occluder was implanted successfully. The mean fluoroscopy time was 8,4 minutes. The immediate occlusion rate after 24 hours was 91%. In all cases there was a very good adaptation of the device to the anatomical structures. In this small series, the Helex occluder appears to offer a reliable system of occlusion for small and moderate ASDs and for PFO with minimal risk of major complications.

Clinical decision-making, ultrasonography, and scores for evaluation of suspected acute appendicitis.

Diagnosing acute appendicitis (aA) remains difficult. This study evaluated the utility of ultrasonography (US) compared to clinical decision-making alone and scoring systems to establish the indication for laparotomy in patients in whom aA was suspected. The prospectively documented data of 2209 patients admitted for suspicion of aA, who underwent US by one of 12 surgeons, formed a database in which the diagnostic and procedural performance of clinical decision-making, US, two scoring systems (Ohmann and Eskelinen scores), and clinical algorithms taking account of clinical and either US findings or score results, were retrospectively evaluated. The results of either modality were correlated with final diagnoses obtained by laparotomy in 696 patients, of whom 540 had aA (prevalence 24.45%) and follow-up data in the remainder. US had the highest specificity (97%, compared to 93% for the Ohmann and Eskelinen scores and 94% for the clinical evaluation and algorithms) and lowest overall rate of false-positive findings (negative laparotomy rate 7.6%). The scores were accurate in refuting the diagnosis of aA but otherwise not superior to US. The best overall diagnostic and procedural results were obtained with the algorithms that combined the results of either US or the Ohmann score with clinical evaluation, which produced the most favorable numbers of negative laparotomies, potential perforations, and missed cases of aA. US is the diagnostic standard of reference for patients with a possible diagnosis of aA. It yields diagnostic results superior to those of scoring systems and provisional clinical evaluation. However, the benefits of US by ultrasonographically trained surgeons are only fully appreciated within the context of clinical algorithms. The joint evaluation of score results and clinical evaluation may deliver information of similar accuracy.

[Validation of a diagnostic scoring system (Ohmann score) in acute appendicitis]. / Uberprüfung eines diagnostischen Scoresystems (Ohmann-Score) für die akute Appendicitis.

A diagnostic scoring system, recently published by Ohmann et al. in this journal, was validated by analyzing the clinicopathological data of a consecutive series of 2,359 patients, admitted for suspicion of acute appendicitis. The results of the scoring system were compared to the results of clinical evaluation by junior (provisional) and senior surgeons (final clinical diagnosis). To assess the diagnostic ability of the score, the accuracy and positive predictive value were defined as the major diagnostic performance parameters; the rate of theoretical negative laparotomies and that of diagnostic errors served as the major procedural performance parameters. Of 2,359 patients admitted for suspected acute appendicitis, 662 were proven to have acute appendicitis by histology, for a prevalence of 28%. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the provisional clinical diagnosis were 0.50, 0.94, 0.77, 0.83, and 0.82; 0.93, for the score 0.63, 0.93, 0.77, 0.86 and 0.84, and for the final clinical diagnosis 0.90, 0.94, 0.85, 0.96, and 0.93, respectively. Of the main diagnostic performance parameter, the accuracy of the score was significantly better than that of provisional clinical diagnosis (P < 0.05, chi 2 test). The score yielded a rate of negative appendecomies and laparotomies of 14.3 and 12.3%. With respect to the rate of overlooked cases of acute apendicitis, the score demonstrated a superior performance, with only 6 cases missed (0.9%). However, the number of patients with acute appendicitis, including those with perforated disease, who were not identified by the score, was almost four times that of the final clinical diagnosis (245 vs 63). With regard to the main procedural performance parameter, the score resulted in a significantly smaller number of diagnostic errors than the provisional clinical investigator (P < 0.05, chi 2 test). The results of this study indicate that the diagnostic scoring system might be helpful when experienced investigators or additional diagnostic modalities such as ultrasonography are not available. It may therefore be of value in the preclinical evaluation of patients with suspected acute appendicitis and may be instrumental as a quality control tool and in clinical guidelines.

[Can diagnostic scoring systems help decision making in primary care of patients with suspected acute appendicitis?]. / Können diagnostische Score-Systeme bei Patienten mit Verdacht auf akute Appendizitis eine Entscheidungshilfe in der Praxis sein?

BACKGROUND AND OBJECTIVE: To assess two recently developed scoring systems with respect to making or excluding the diagnosis of acute appendicitis. PATIENTS AND METHODS: Data on 2359 patients with typical signs of acute appendicitis (AA) were analysed, the results of two diagnostic scoring systems being compared with the diagnosis made by an experienced surgeon. RESULTS: AA was confirmed in 662 of the 22,359 patients (prevalence 28%). Sensitivity, specificity, positive and negative predictive values and overall accuracy for diagnosis with the Ohmann scoring system were 0.63, 0.93, 0.77, 0.86 and 0.84; with the Eskelinen score the values were 0.79, 0.85, 0.68, 0.81 and 0.835; and by the surgeon they were 0.90, 0.94, 0.85, 0.96 und 0.93. The negative appendectomy or laparotomy rate was 14.3 an 12.3 respectively with the Ohmann score, 29.5 and 26.6 with the Eskelinen score. The numbers of potential and of nondiagnosed perforations were 41% and 37% respectively with the Ohman score and 26.6% and 16.3% with the Eskelinen score. The number of missed cases of AA was lowest with the Ohman scoring system, compared with 1.8% for the surgeon. After excluding AA, both scoring systems had a specificity of -0.99, with a positive probability rate of at least 27 (Eskelinen score) up to 87 (Ohman score). CONCLUSION: Both diagnostic scoring systems are better for excluding than correctly diagnosing AA; the decision to exclude could be made with a high degree of accuracy. Either scoring system may therefore be used in primary care of patients suspected of AA to help decide on referral to hospital.

[30 years mitral valve prolapse--what has stayed the same?]. / 30 Jahre Mitralklappenprolaps--was ist geblieben?

As a Result of echocardiographic diagnostic criteria that took too little account of underlying pathology, mitral valve prolapse has, in the past, been diagnosed far too frequently, and has been associated with commonly occurring unspecific symptoms (mitral valve prolapse syndrome). The results of epidemiological studies have led to a new definition of diagnostic criteria. The diagnosis mitral valve prolapse is established in the first instance by auscultation. Echocardiography supports the diagnosis, provides information about the prognosis, and, with a high level of reliability, detects complications. Major complications of this condition are endocarditis and mitral valve insufficiency, as also--less well documented--cerebral embolism and sudden heart death. Particularly at risk of developing complications are those patients with a systolic murmur reflecting an already present mitral valve insufficiency. This patient group must be monitored for progressive mitral insufficiency and, in the presence of relevant exposure, requires endocarditis prophylaxis.