Electrophysiology lab efficiency comparison between cryoballoon and point-by-point radiofrequency ablation: a German sub-analysis of the FREEZE Cohort study

BACKGROUND

Pulmonary vein isolation (PVI) is recommended to treat paroxysmal and persistent atrial fibrillation (AF). This analysis aimed to assess the hospital efficiency of single-shot cryoballoon ablation (CBA) and point-by-point radiofrequency ablation (RFA).

METHODS

The discrete event simulation used PVI procedure times from the FREEZE Cohort study to establish the electrophysiology (EP) lab occupancy time. 1000 EP lab days were simulated according to an illustrative German hospital, including 3 PVI cases per day using CBA at one site and RFA at the other.

RESULTS

The analysis included 1560 CBA patients and 1344 RFA patients from the FREEZE Cohort. Some baseline patients' characteristics were different between groups (age, AF type, and some concomitant diseases), without being statistically associated to ablation procedure time. Mean procedure time was 122.2 ± 39.4 min for CBA and 160.3 ± 53.5 min for RFA (p < 0.0001). RFA was associated with a more than five-fold increase of cumulative overtime compared to CBA over the simulated period (1285 h with RFA and 253 h with CBA). 70.7% of RFA lab days included overtime versus 25.7% for CBA. CBA was associated with more days with an additional hour at the end of the EP lab shift compared to RFA (47.8% vs 11.5% days with one hour left, respectively).

CONCLUSION

CBA is faster and more predictable than point-by-point RFA, and enables improvements in EP lab efficiency, including: fewer cumulative overtime hours, more days where overtime is avoided and more days with remaining time for the staff or for any EP lab usage. Clinical trial registration NCT01360008 (first registration 25/05/2011).

Community variation in adolescent cannabis use in Australia and the Netherlands

BACKGROUND

While controversial, cannabis use is common, and often begins in adolescence. In Australia and the Netherlands, cannabis use is understood and legislated within a harm-minimisation framework. In Australia it is illegal to purchase or consume cannabis. Cannabis use in the Netherlands is illegal, except in licensed coffee shops where the sale and consumption of small amounts (5 g) are permitted.

METHODS

Secondary school aged children in Victoria, Australia and the Netherlands were surveyed using the same culturally adapted questionnaire, designed to measure community rates of substance use and risk factors. Youth cannabis use and predictors of use were compared between the two countries.

RESULTS

Similar levels of cannabis use in the last month were reported in Australia and the Netherlands (4.5%), with slightly lower use amongst girls, compared to boys. Common predictors of use were found in both the Australian and Netherlands sample.

CONCLUSIONS

The findings suggest that interventions that effectively target similar risk factors to reduce or prevent cannabis use may have applications cross-nationally.

Trial protocol: a clustered, randomised, longitudinal, type 2 translational trial of alcohol consumption and alcohol-related harm among adolescents in Australia

Background

This cluster randomised control trial is designed to evaluate whether the Communities That Care intervention (CTC) is effective in reducing the proportion of secondary school age adolescents who use alcohol before the Australian legal purchasing age of 18 years. Secondary outcomes are other substance use and antisocial behaviours. Long term economic benefits of reduced alcohol use by adolescents for the community will also be assessed.

Methods

Fourteen communities and 14 other non-contiguous communities will be matched on socioeconomic status (SES), location, and size. One of each pair will be randomly allocated to the intervention in three Australian states (Victoria, Queensland and Western Australia). A longitudinal survey will recruit grade 8 and 10 students (M = 15 years old, N = 3500) in 2017 and conduct follow-up surveys in 2019 and 2021 (M = 19 years old). Municipal youth populations will also be monitored for trends in alcohol-harms using hospital and police administrative data.

Discussion

Community-led interventions that systematically and strategically implement evidence-based programs have been shown to be effective in producing population-level behaviour change, including reduced alcohol and drug use. We expect that the study will be associated with significant effects on alcohol use amongst adolescents because interventions adopted within communities will be based on evidence-based practices and target specific problems identified from surveys conducted within each community.

Trial registration

The trial was retrospectively registered in September, 2017 (ACTRN12616001276448), as communities were selected prior to trial registration; however, participants were recruited after registration. Findings will be disseminated in peer-review journals and community fora.

Large reductions in child overweight and obesity in intervention and comparison communities 3 years after a community project

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Childhood obesity has been increasing over decades and scalable, population-wide solutions are urgently needed to reverse this trend. Evidence is emerging that community-based approaches can reduce unhealthy weight gain in children. In some countries, such as Australia, the prevalence of childhood obesity appears to be flattening, suggesting that some population-wide changes may be underway.

WHAT THIS STUDY ADDS

A community-based intervention project for obesity prevention in a rural town appears to have increasing effects 3 years after the end of the project, substantially reducing overweight and obesity by 6% points in new cohorts of children, 6 years after the original baseline. An apparent and unanticipated 'spillover' of effects into the surrounding region appeared to have occurred with 10%-point reductions in childhood overweight and obesity over the same time period. A 'viral-like' spread of obesity prevention efforts may be becoming possible and an increase in endogenous community activities appears to be surprisingly successful in reducing childhood obesity prevalence.

BACKGROUND

The long-term evaluations of community-based childhood obesity prevention interventions are needed to determine their sustainability and scalability.

OBJECTIVES

To measure the impacts of the successful Be Active Eat Well (BAEW) programme in Victoria, Australia (2003-2006), 3 years after the programme finished (2009).

METHODS

A serial cross-sectional study of children in six intervention and 10 comparison primary schools in 2003 (n = 1674, response rate 47%) and 2009 (n = 1281, response rate 37%). Height, weight, lunch box audits, self-reported behaviours and economic investment in obesity prevention were measured.

RESULTS

Compared with 2003, the 2009 prevalence of overweight/obesity (World Health Organization criteria) was significantly lower (P < 0.001) in both intervention (39.2% vs. 32.8%) and comparison (39.6% vs. 29.1%) areas, as was the mean standardized body mass index (0.79 vs. 0.65, 0.77 vs. 0.57, respectively) with no significant differences between areas. Some behaviours improved and a few deteriorated with any group differences favouring the comparison area. In 2009, the investment in obesity prevention in intervention schools was about 30 000 Australian dollars (AUD) per school per year, less than half the amount during BAEW. By contrast, the comparison schools increased from a very low base to over 66 000 AUD per school per year in 2009.

CONCLUSIONS

The 8%-point reduction in overweight/obesity in both areas over 6 years from baseline to 3 years post-intervention was substantial. While the benefits of BAEW increased in the intervention community in the long term, the surrounding communities appeared to have more than caught up in programme investments and health gains, suggesting a possible 'viral spread' of obesity prevention actions across the wider region.

Inconsistent associations between sweet drink intake and 2-year change in BMI among Victorian children and adolescents

OBJECTIVE

The aim of this study was to examine whether baseline (T1) or 2-year change in sweet drink intake in children and adolescents was associated with age- and gender-standardized body mass index (BMIz) at time two (T2), 2 years later.

METHODS

Data on 1465 children and adolescents from the comparison groups of two quasi-experimental intervention studies from Victoria, Australia were analysed. At two time points between 2003 and 2008 (mean interval: 2.2 years) height and weight were measured and sweet drink consumption (soft drink and fruit juice/cordial) was assessed.

RESULTS

No association was observed between T1 sweet drink intake and BMIz at T2 among children or adolescents. Children from higher socioeconomic status families who reported an increased intake of sweet drinks at T2 compared with T1 had higher mean BMIz at T2 (β: 0.13, P = 0.05). There was no evidence of a dose-response relationship between sweet drink intake and BMIz. In supplementary analyses, we observed that more frequent usual consumption of fruit juice/cordial was associated with a higher BMIz at T2 among children.

CONCLUSION

This study showed limited evidence of an association between sweet drink intake and BMIz. However, the association is complex and may be confounded by both dietary and activity behaviours.

The appropriateness of opt-out consent for monitoring childhood obesity in Australia

Childhood obesity monitoring is a fundamental component of obesity prevention but is poorly done in Australia. Monitoring obesity prevalence in children provides important population health data that can be used to track trends over time, identify areas at greatest risk of obesity, determine the effectiveness of interventions and policies, raise awareness and stimulate action. High participation rates are essential for effective monitoring because these provide more representative data. Passive ('opt-out') consent has been shown to provide high participation rates in international childhood obesity monitoring programs and in a recent Australian federal initiative monitoring early child development. A federal initiative structured like existing child development monitoring programs, but with the authority to collect height and weight measurements using opt-out consent, is recommended to monitor rates of childhood obesity in Australia.

Reduction in overweight and obesity from a 3-year community-based intervention in Australia: the 'It's Your Move!' project

'It's Your Move!' was a 3-year intervention study implemented in secondary schools in Australia as part of the Pacific Obesity Prevention In Communities Project. This paper reports the outcome results of anthropometric indices and relevant obesity-related behaviours. The interventions focused on building the capacity of families, schools and communities to promote healthy eating and physical activity. Baseline response rates and follow-up rates were 53% and 69% respectively for the intervention group (n=5 schools) and 47% and 66% respectively for the comparison group (n=7 schools). Statistically significant relative reductions in the intervention versus comparison group were observed: weight (-0.74 kg, P < 0.04), and standardized body mass index (-0.07, P<0.03), and non-significant reductions in prevalence of overweight and obesity (0.75 odds ratio, P=0.12) and body mass index (-0.22, P=0.06). Obesity-related behavioural variables showed mixed results with no pattern of positive intervention outcomes. In conclusion, this is the first study to show that long-term, community-based interventions using a capacity-building approach can prevent unhealthy weight gain in adolescents. Obesity prevention efforts in this important transitional stage of life can be successful and these findings need to be translated to scale for a national effort to reverse the epidemic in children and adolescents.

Experiences and challenges in implementing complex community-based research project: the Pacific Obesity Prevention in Communities project

Policy makers throughout the world are struggling to find effective ways to prevent the rising trend of obesity globally, particularly among children. The Pacific Obesity Prevention in Communities project was the first large-scale, intervention research project conducted in the Pacific aiming to prevent obesity in adolescents. The project spanned four countries: Australia, New Zealand, Fiji and Tonga. This paper reports on the strengths and challenges experienced from this complex study implemented from 2004 to 2009 across eight cultural groups in different community settings. The key strengths of the project were its holistic collaborative approach, participatory processes and capacity building. The challenges inherent in such a large complex project were underestimated during the project's development. These related to the scale, complexity, duration, low research capacity in some sites and overall coordination across four different countries. Our experiences included the need for a longer lead-in time prior to intervention for training and up-skilling of staff in Fiji and Tonga, investment in overall coordination, data quality management across all sites and the need for realistic capacity building requirements for research staff. The enhanced research capacity and skills across all sites include the development and strengthening of research centres, knowledge translation and new obesity prevention projects.

Reducing unhealthy weight gain in Fijian adolescents: results of the Healthy Youth Healthy Communities study

Obesity is a significant problem among adolescents in Pacific populations. This paper reports on the outcomes of a 3-year obesity prevention study, Healthy Youth Healthy Communities, which was part of the Pacific Obesity Prevention in Communities project, undertaken with Fijian adolescents. The intervention was developed with schools and comprised social marketing, nutrition and physical activity initiatives and capacity building designed to reduce unhealthy weight, and the individual exposure period was just over 2-year duration. The evaluation incorporated a quasi-experimental, longitudinal design in seven intervention secondary schools near Suva (n=874) and a matched sample of 11 comparison secondary schools from western Viti Levu (n=2,062). There were significant differences between groups at baseline; the intervention group was shorter, weighed less, had a higher proportion of underweight and lower proportion of overweight, and better quality of life (Pediatric Quality of Life Inventory only). At follow-up, the intervention group had lower percentage body fat (-1.17) but also a lower increase in quality of life (Assessment of Quality of Life instrument: -0.02; Pediatric Quality of Life Inventory: -1.94) than the comparison group. There were no other differences in anthropometry, and behaviours' changes showed a mixed pattern. In conclusion, this school-based health promotion programme lowered percentage body fat but did not reduce unhealthy weight gain or influence most obesity-promoting behaviours among Fijian adolescents. Despite growing evidence supporting the efficacy of community-based approaches to reduce obesity among children of European descent, findings from this study failed to demonstrate the efficacy of a community capacity-building approach among an adolescent sample drawn from a different sociocultural, economic and geographical context. Additional 'top-down' or other innovative approaches may be needed to reduce adolescent obesity in the Pacific.

Outcome results for the Ma'alahi Youth Project, a Tongan community-based obesity prevention programme for adolescents

Tonga has a very high prevalence of obesity with steep increases during youth, making adolescence a critical time for obesity prevention. The Ma'alahi Youth Project, the Tongan arm of the Pacific Obesity Prevention in Communities project, was a 3-year, quasi-experimental study of community-based interventions among adolescents in three districts on Tonga's main island (Tongatapu) compared to the island of Vava'u. Interventions focused mainly on capacity building, social marketing, education and activities promoting physical activity and local fruit and vegetables. The evaluation used a longitudinal design (mean follow-up duration 2.4 years). Both intervention and comparison groups showed similar large increases in overweight and obesity prevalence (10.1% points, n = 815; 12.6% points, n = 897 respectively). Apart from a small relative decrease in percentage body fat in the intervention group (-1.5%, P < 0.0001), there were no differences in outcomes for any anthropometric variables between groups and behavioural changes did not follow a clear positive pattern. In conclusion, the Ma'alahi Youth Project had no impact on the large increase in prevalence of overweight and obesity among Tongan adolescents. Community-based interventions in such populations with high obesity prevalence may require more intensive or longer interventions, as well as specific strategies targeting the substantial socio-cultural barriers to achieving a healthy weight.

The Pacific Obesity Prevention in Communities project: project overview and methods

Obesity is increasing worldwide with the Pacific region having the highest prevalence among adults. The most common precursor of adult obesity is adolescent obesity making this a critical period for prevention. The Pacific Obesity Prevention in Communities project was a four-country project (Fiji, Tonga, New Zealand and Australia) designed to prevent adolescent obesity. This paper overviews the project and the methods common to the four countries. Each country implemented a community-based intervention programme promoting healthy eating, physical activity and healthy weight in adolescents. A community capacity-building approach was used, with common processes employed but with contextualized interventions within each country. Changes in anthropometric, behavioural and perception outcomes were evaluated at the individual level and school environments and community capacity at the settings level. The evaluation tools common to each are described. Additional analytical studies included economic, socio-cultural and policy studies. The project pioneered many areas of obesity prevention research: using multi-country collaboration to build research capacity; testing a capacity-building approach in ethnic groups with very high obesity prevalence; costing complex, long-term community intervention programmes; systematically studying the powerful socio-cultural influences on weight gain; and undertaking a participatory, national, priority-setting process for policy interventions using simulation modelling of cost-effectiveness of interventions.

Obesity prevention in the family day care setting: impact of the Romp & Chomp intervention on opportunities for children's physical activity and healthy eating

BACKGROUND

The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments.

METHODS

The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n= 28) and comparison (n= 223) samples.

RESULTS

Select results showed intervention children spent less time in screen-based activities (P= 0.03), organized active play (P < 0.001) and free inside play (P= 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children's positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P= 0.05), higher odds of staff being trained in nutrition (P= 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P= 0.01) active play, and of rewarding children with food (P < 0.001).

CONCLUSIONS

Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children's physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.

Comparison of a GE Lunar DPX-IQ and a Norland XR-26 dual energy X-ray absorptiometry scanner for body composition measurements in pigs – <i>in vivo</i>

Abstract. In the context of future growth and performance testing, this study compares corresponding body composition results measured by two dual energy X-ray absorptiometry systems. To test the capability of each device to detect differences among experimental groups widely varying in body composition, 77 pigs from 6 purebred/crossbred groups were used for the experiment. Each pig was scanned consecutively on a Norland XR-26 and on a GE Lunar DPX-IQ. Coefficients of determination were: R²=0.92 for bone mineral content (BMC), R²=0.90 for bone mineral density (BMD), R²=0.94 for lean mass (LEAN), R²=0.92 for fat mass (FAT), R²=0.88 for lean percentage (%LEAN) and fat percentage (%FAT). However, Norland yielded larger values for %FAT and smaller values for %LEAN, BMC, and BMD than Lunar (P<0.001) with the extent of deviation depending on the specific trait and on the breeding group. The deviation in BMC was greater than the deviation in BMD, suggesting different bone detecting algorithms. Both systems revealed similar differences among the breeding groups, and ranked them in the same order based on numerical values. Differences in calibration, bone detection, and software algorithms, however, require a prior crosscalibration to make the body composition data from both systems directly comparable. Finally, they can be used across research centres for the determination of relative and absolute body composition differences among animal groups and individuals.

Intramedullary subependymoma of the lower spinal cord

A 22-year-old woman developed an increasing distal paraparesis, which resulted in a severe ataxic gait. MRI demonstrated a very large intramedullary tumour mass from D11 to L2, which could not be identified as one of the common neoplastic diseases of the spinal cord. The tumour was removed completely and the diagnosis of subependymoma confirmed. With respect to our patient and to the limited reports in the literature, we describe some typical features that may help in the diagnostic and preoperative assessment of this very rare spinal cord tumour.

Successful vascular decompression in an 11-year-old patient with trigeminal neuralgia

CASE REPORT

We present the case of an 11-year-old boy who was suffering distinct trigeminal neuralgia. At the age of 3 years, the patient had contracted a severe Epstein-Barr virus infection and developed mild meningoencephalitis. Magnetic resonance imaging scans showed a slight enhancement in the pontomesencephalic cistern as well as a neurovascular conflict at the right trigeminal nerve. Intraoperatively, thickened fibrous tissue was found that was attached to both the trigeminal nerve and the superior cerebellar artery. Microvascular decompression using Gore Tex as tissue implant brought immediate relief.

DISCUSSION

Trigeminal neuralgia in pediatric patients is very rare. We present a case of typical trigeminal neuralgia in a child, demonstrating the pathogenesis of the neurovascular conflict due to subarachnoidal adhesions after meningoencephalitis.

Einfluss von elastischem Bodenbelag auf Milchmenge, Fett, Eiweiß und Zellgehalt bei Kühen in Laufstallhaltung

Abstract. Title of the paper: Effect of soft flooring in free stalls on milk yield, fat, protein and somatic cell counts in dairy cattle Research conducted at the Experimental Farm Oberschleißheim focused on comparing milk yield, fat, protein and somatic cell counts in dairy cattle housed in free stalls with concrete slatted floor and rubber mats covering the concrete slatted floor. Data were collected from 49 cows in 53 lactation periods, which were divided into experimental group (n = 26) on rubber matted floor (EBG) and control group (n = 27) on concrete slatted floor (BBG). Housing conditions of both groups differed in kind of cubicles. EBG had soft rubber mat mattresses, BBG had cubicles with straw manure mattresses. Data analysed originated from the official milk performance testing of the "Landeskuratorium der Erzeugerringe für tierische Veredelung in Bayern e.V." and from activity counters worn by the cows. Statistical analysis resulted in a significant higher activity level of the EBG versus BBG. Milk yield and protein showed no significant difference between both groups, fat was significant higher in BBG. Somatic cell counts were significant lower in EBG. Data analysed regarding activity level classes showed a trend of decreasing milk yield and milk constituents with increasing activity. No evidence was found that soft floor results in higher milk yield. But a higher activity level of EBG cows might indicate a higher cow comfort on elastic floor.

[Prehospital management of spinal cord injuries]

In both the United States and Europe about 10,000 patients suffer from spinal cord injury (SCI) each year and 20% die before being admitted to hospital. Prehospital management of SCI is very important since 25% of SCI damage may occur after the initial event. Emergency treatment includes examination of the patient, spinal immobilization, careful airway management, cardiovascular stabilization (maintenance of mean arterial blood pressure above 90 mmHg) and glucose levels within the normal range. From an evidence-based point of view, it is still not known whether additional specific therapy is useful and studies have not convincingly demonstrated that methylprednisolone (MPS) or other substances have clinically important benefits. Recently published statements from the US do not support the therapeutic use of MPS in patients suffering from SCI in the prehospital setting. Moreover, it is not known whether hypothermia or any other pharmacological interventions have beneficial effects. Networks for clinical studies in SCI patients should be established as a basic requirement for further improvement in outcome in these patients.

Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting residual adenoma

BACKGROUND AND PURPOSE

In clinically non-functional pituitary macroadenomas, prospective follow-up magnetic resonance imaging (MRI) was conducted after transsphenoidal surgery both to study the changes of the sellar contents at the post-operative site over time and to assess the amount of residual adenoma tissue.

METHODS

A total of 50 patients with clinically non-functional pituitary macroadenomas were treated by transsphenoidal tumour resection and were examined by MRI before and directly after surgery (early MR) and 3 months (intermediate MR) and 1 year after surgery (late MR). Changes in the sellar contents over time and the degree of tumour excision were studied on T1-weighted enhanced and unenhanced scans. All patients underwent complete neuro-ophthalmological and endocrinological assessments before and 3 months after surgery. For the interpretation of the post-operative images the results of the endocrinological examinations after surgery were also taken into account.

RESULTS

The maximum size of tumour extension on coronal T1-weighted images ranged from 1.2 cm to 5.0 cm (mean 2.3 cm). Despite tumour resection, early post-operative images still showed a persistent mass in the sella in 83% that was usually caused by post-operative haemorrhage, fluid collection and implanted fat material. However, rapid improvement in visual symptoms was noted in 89%. Changes in the sellar region at the early post-operative site markedly hindered the interpretation of MR images for detecting residual tumour tissue, which was suspected in half of the patients (1 intrasellar, 13 suprasellar, and 11 parasellar). Regression of the post-operative mass in the sella was present 3 months after surgery, resulting in a 50% change in the volume of the coronal sellar extension, which also improved the reliability in interpreting the post-operative MR images. On the intermediate MR images residual tumour tissue was detected in 30% of the patients (4 intrasellar, 2 suprasellar and 9 parasellar). Because the suprasellar mass descended over time, an increasing rate of tumour remnant within the sella was seen 3 months following surgery. Before surgery the pituitary gland was visible superiorly or posterosuperiorly to the macroadenomas in 35 patients. However, at the early post-operative site the remaining gland was only visible in 12 patients. Under the condition that endocrinological function tests confirmed adequate hormonal function, the remaining gland was detectable by MRI in 36 patients 3 months after surgery.

CONCLUSION

Delayed regression of the sellar contents after transsphenoidal surgery of pituitary macroadenomas was demonstrated by this prospective MR study. Owing to the changes at the post-operative site, it was difficult to interpret early post-operative images and detect residual adenoma tissue. With respect to the delayed regression of the sellar contents, the interpretation of post-operative images for detection of residual adenoma was improved 3 months after surgery. At this time, residual adenoma tissue was found in 30% of clinically non-functional macroadenomas, mostly at the parasellar and, after descent from the suprasellar space, at the intrasellar site.

Clinical outcome of patients with and without renal impairment undergoing a minimally invasive LIMA-to-LAD bypass operation

PURPOSE

Patients with renal impairment undergoing conventional coronary artery bypass grafting (CABG) have a significant risk of postoperative deterioration of kidney function. We investigated the outcome of patients with and without renal impairment treated by off-pump coronary artery surgery.

METHODS

From January 1997 until January 2000, 158 consecutive patients (mean age 63 +/- 9.8 years, 126 male, 32 female) underwent minimally LIMA-to-LAD bypass operations. The patients were divided into three groups: group I patients (n = 133) had a preoperative creatinine of < 1.3 mg/dL, group II patients (n = 21) had a creatinine of > 1.3 mg/dL, and patients of group III (n = 4) required chronic dialysis due to terminal kidney dysfunction. Monitoring of the blood creatinine was performed during the entire hospital stay. A postoperative angiogram was performed in 113 of the 158 patients.

RESULTS

All operations were performed without intraoperative complications. Postoperative angiograms revealed a patent LIMA-to-LAD bypass in all but one patient, who demonstrated a dissection of the left internal mammary artery (LIMA) graft. Mean creatinine value on admission was 1.0 +/- 0.1 mg/dL in group I and 2.7 +/- 1.9 mg/dL in group II. The maximal postoperative creatinine value was 1.1 +/- 0.4 mg/dL in group I and 2.9 +/- 2.7 mg/dL in group II. Neither hemofiltration nor hemodialysis was necessary in any patient of group I or group II during the postoperative course.

CONCLUSION

Minimally invasive LIMA-to-LAD bypass is a safe and effective procedure with low morbidity and no mortality in the first 158 patients. Preoperative renal impairment had no adverse effect on outcome or residual kidney function. Thus, higher doses of diuretics and hemofiltration/dialysis were not used, resulting in a cost reduction. Therefore, this approach may be worthwhile to consider in patients with significant renal impairment who have to undergo CABG.

Adult hypophosphatasia. Current aspects

Hypophosphatasia is an inborn metabolic disorder in which abnormally low levels of the enzyme nonspecific alkaline phosphatase result in defective skeletal and dental mineralization (rickets, fractures, dental abnormalities) and in accumulation of the enzyme substrates (phosphoethanolamine, pyridoxal-5'phosphate and inorganic pyrophosphate). The build-up of inorganic pyrophosphate promotes the development of articular chondrocalcinosis. There are several forms of hypophosphatasia, with wide variations in severity. We report the case of a 53-year-old man with typical manifestations of moderate adulthood hypophosphatasia. Investigations in his family found the disease in a sister and two children. He had two autosomal mutations, which were transmitted recessively. Several mutations of the alkaline phosphatase gene have been identified. The genotype is correlated with the phenotype: some mutations are associated with milder forms and others with more severe forms of the disease.

Laser-induced fluorescence detection of malignant gliomas using fluorescein-labeled serum albumin: experimental and preliminary clinical results

To delineate the tumor margins of malignant gliomas laser-induced fluorescence detection technique was applied using 5-aminofluorescein-albumin as the fluorescent dye. The 5-aminofluorescein was linked to serum albumin (= AFlc-SA) as a cumulative protein label using residualizing markers. In a C6-glioma model the biodistribution and pharmacokinetics of the injected dye were investigated by labeling the protein conjugate with 111In-DTPA. Twenty-four hours after intravenous injection of the dye, fluorescence was activated by an argon laser and inspected in the C6-gliomas. Histological examinations were performed to compare the microscopic margins of the fluorescence-stained tumors with hematoxylin/eosin. The tumor uptake 24 h after dye injection was 23-fold higher than in the surrounding brain. Fluorescence inspection under laser activation demonstrated clearly stained and sharply demarcated tumors. The microscopic borders of the tumors corresponded exactly with the fluorescence, also demonstrating intracellular tumor uptake of the dye. In a preliminary study, three patients with malignant gliomas were operated using laser-induced fluorescence detection technique after injection of AFlc-SA. In all patients, the borders of the malignant gliomas were clearly stained by AFlc-SA during surgery. Laser-induced fluorescence imaging using the albumin conjugate AFlc-SA may be a promising method for delineating tumor margins which are hard to detect under the operating microscope alone.

The scientific history of hydrocephalus and its treatment

Hydrocephalus cases were regularly described by Hippocrates, Galen, and early and medieval Arabian physicians, who believed that this disease was caused by an extracerebral accumulation of water. Operative procedures used in ancient times are neither proven by skull findings today nor clearly reported in the literature. Evacuation of superficial intracranial fluid in hydrocephalic children was first described in detail in the tenth century by Abulkassim Al Zahrawi. In 1744, LeCat published findings on a ventricular puncture. Effective therapy required aseptic surgery as well as pathophysiological knowledge--both unavailable before the late nineteenth century. In 1881, a few years after the landmark study of Key and Retzius, Wernicke inaugurated sterile ventricular puncture and external CSF drainage. These were followed in 1891 by serial lumbar punctures (Quincke) and, in 1893, by the first permanent ventriculo-subarachnoid-subgaleal shunt (Mikulicz), which was simultaneously a ventriculostomy and a drainage into an extrathecal low pressure compartment. Between 1898 and 1925, lumboperitoneal, and ventriculoperitoneal, -venous, -pleural, and -ureteral shunts were invented, but these had a high failure rate due to insufficient implant materials in most cases. Ventriculostomy without implants (Anton 1908), with implants, and plexus coagulation initially had a very high operative mortality and were seldom successful in the long term, but gradually improved over the next decades. In 1949, Nulsen and Spitz implanted a shunt successfully into the caval vein with a ball valve. Between 1955 and 1960, four independent groups invented distal slit, proximal slit, and diaphragm valves almost simultaneously. Around 1960, the combined invention of artificial valves and silicone led to a worldwide therapeutic breakthrough. After the first generation of simple differential pressure valves, which are unable to drain physiologically in all body positions, a second generation of adjustable, autoregulating, antisiphon, and gravitational valves was developed, but their use is limited due to economical restrictions and still unsolved technical problems. At the moment, at least 127 different designs are available, with historical models and prototypes bringing the number to 190 valves, but most of these are only clones. In the 1990s, there has been a renaissance of endoscopic ventriculostomy, which is widely accepted as the method of first choice in adult patients with aquired or late-onset, occlusive hydrocephalus; in other cases the preference remains controversial. Both new methods, the second generation of valves as well as ventriculostomy, show massive deficits in evaluation. There is only one randomized study and no long-term evaluation.

Extradural spinal hemangioblastomas: report of two cases

Two cases of predominantly extraspinally extra- and intradural spinal cord hemangioblastomas in two patients each with and without von Hippel-Lindau-disease are reported. Preoperative MRI and angiographic findings are presented and the differential diagnosis is discussed. The surgical procedure is described and the literature of hemangioblastomas in this rare localization is reviewed. Improvements in both radiologic diagnosis and microsurgical techniques, and consequent screening programs will enhance life expectancy in patients afflicted with von Hippel-Lindau disease.

An argon-dye laser system for photodynamic therapy and diagnosis

An argon-dye laser system for the clinical application of photodynamic therapy and photodynamic diagnosis is presented. Two out-patient treatment rooms and three operating theaters are served by an argon-dye laser system which can be accessed by remote-control from each treatment room. The argon-dye laser offers a wide range of light wavelengths with sufficient energy for all kinds of photosensitizers and fluorescent substances. This report presents our experiences with the first remote-controlled laser configuration which is being used routinely in clinical practice for photodynamic therapy and photodynamic diagnosis.

Beating heart operations including hybrid revascularization: initial experiences

BACKGROUND

The outcome of patients (n = 45) with coronary one- to three-vessel disease undergoing beating heart operations using a recently developed stabilizing device was investigated.

METHODS

Left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) revascularization was carried out alone (n = 31) or as hybrid procedure in combination with a balloon angioplasty (n = 14).

RESULTS

All 45 patients underwent a successful LIMA-to-LAD procedure without intraoperative complication during a 21 +/- 8-minute (range, 10 to 53 minutes) LAD occlusion time. In 14 hybrid procedures a total of 19 stenoses including 3 left main stenoses were treated successfully by percutaneous transluminal coronary angioplasty and stenting. The postoperative courses were uneventful with the exception of two surgical reexplorations necessitated by bleeding. No worsening of renal, neurologic, or respiratory functions occurred in any patient. In the group having a single LIMA-to-LAD procedure, early postoperative coronary angiograms (22 of 31) showed a patent LIMA graft and excellent anastomosis; this was also true in 4 patients 12 months after operation as shown in angiograms. All patients undergoing hybrid revascularization demonstrated a patent LIMA-to-LAD anastomosis; in 1 patient there was a dissection in the midlevel of the LIMA, which was stented successfully. The 6-month follow-up angiograms in 7 of 14 patients revealed open LIMA bypass grafts in all patients except 1, who was stented because of dissection.

CONCLUSIONS

These data indicate that a beating heart operation including hybrid revascularization is safe and effective in selected patients with coronary one- to three-vessel disease including left main stenosis. This approach may be especially advantageous in comparison with conventional coronary artery bypass grafting in patients with severe concomitant disease.

HLA DRB1* alleles in rheumatoid nodulosis: a comparative study with rheumatoid arthritis with and without nodules

Rheumatoid nodulosis (RN) is a rare condition associating rheumatoid nodules, episodes of arthritis, cystic bone lesions and, generally, positive rheumatoid factors (RF). It is considered a benign variant of rheumatoid arthritis (RA). In this study, we determined the HLA DRB1* alleles of our RN patients and compared the distribution of these alleles to those of 74 healthy controls and 104 RA patients with and without nodules. Four RN patients were observed. All had subcutaneous nodules and RF were negative in three patients. Of the 104 RA patients, 18 had nodules (nodRA). Systemic manifestation (including vasculitis, peripheral neuropathy or lung involvement) were found in seven of these nodRA cases (33.8%) and most had positive RF and erosive changes on X-rays. Only one RN patient had a RA-associated allele (DRB1*0101). The frequencies of the HLA DRB1* alleles encompassing the "rheumatoid" shared epitope were similar to those of other RA series: *0101, 34.6% (P = 0.03 compared with controls); *0401, 26.9% (P < 0.0001); *0404, 12.5% (P = 0.04); *0405, 4.8% (P = 0.8); *1001, 8.6% (P = 0.5). Of the nodRA and seronegative RA patients, 77.7% and 53.3%, respectively, presented the shared epitope. Thus, there was a tendency to decreased expression of the RA-associated alleles in RN (25%) compared with nodRA and seronegative RA patients. This study is restricted by the small number of tested RN patients, but the results suggest that the RA-associated alleles are poorly expressed in RN.

MR enhancement of the internal auditory canal induced by tissue implant after resection of acoustic neurinoma

PURPOSE

We studied intrameatal changes in MR enhancement induced by free-tissue implant over time after surgery for acoustic neurinoma.

METHODS

Twenty-one patients were examined by MR imaging after suboccipital resection of an acoustic neurinoma. Precontrast and postcontrast MR images were obtained within 3 days after surgery (early MR images), then 6 weeks (intermediate MR images) and 6 months (late MR images) after surgery. A muscle graft as a free-tissue implant was used within the internal auditory canal in 18 of the 21 patients to seal pneumatic cells of the petrosal bone inadvertently opened and to prevent leakage of cerebrospinal fluid.

RESULTS

On the early MR images, only minimal leptomeningeal or perineural enhancement was seen in 16 patients. There was no sign of residual tumor; however, enhancement increased and changed from linear to nodular on the intermediate MR images in 16 of the 18 cases in which a muscle graft had been used during surgery, mimicking a small intrameatal tumor. This nodular enhancement was still visible on the late MR images in 13 of the 16 cases.

CONCLUSION

Nodular MR enhancement within the internal auditory canal a few weeks to months after surgery for acoustic neurinoma may be induced by packing material and should be considered when interpreting postoperative MR images.

Sarcoidosis and spondylarthropathy. Three case-reports

Coexistent sarcoidosis and seronegative spondylarthropathy have rarely been reported. We add three new cases to the nine previously published. Two men and one woman with sarcoidosis met Amor's criteria for spondylarthropathy. The diagnosis of sarcoidosis was based on histologic findings in two cases and on roentgenographic and laboratory test findings in one case. The features of each of the two diseases were unremarkable. The two diagnoses were confirmed at about the same time. Osteoarticular manifestations of sarcoidosis are reviewed. Our case-reports illustrate the diagnostic difficulties raised by discovery of sacroiliitis in a patient with sarcoidosis: sarcoid osteitis, infection, or a spondyloarthropathy can be the cause of the sacroiliac lesions. Moreover, the pelvic and spinal manifestations of sarcoidosis can mimick a spondylarthropathy. Coexistence of sarcoidosis and spondylarthropathy is probably due to chance, since there are no shared predisposing genetic factors and the number of reported cases is small.

Proximal paraparesis following spinal anesthesia

A 70-year-old man with prostatic cancer extending to the urinary bladder underwent transurethral resection of the bladder neck under spinal anesthesia and developed weakness of the proximal lower limbs a few hours after the procedure. The weakness persisted for several months. Because there were no local surgical complications (hematoma, infectious epiduritis, abscess) or bone metastases responsible for nerve root or spinal cord compression, a causal relation between the neurologic deficit and the spinal anesthesia was considered likely. Neurologic deficits are uncommon after spinal anesthesia and can be produced by complications of the surgical procedure (direct nerve injury, hematoma, abscess), arachnoiditis, neurotoxicity of disinfectants or of preservatives added to solutions of anesthetic drugs, or spinal cord ischemia. Precipitating factors for spinal cord ischemia include faulty patient position during the procedure, intraoperative arterial hypotension and injection of vasoconstricting agents.

MR imaging of residual tumor tissue after transsphenoidal surgery of hormone-inactive pituitary macroadenomas: a prospective study

22 patients were examined by magnetic resonance (MR) imaging before and after transsphenoidal surgery of hormone-inactive pituitary macroadenomas to evaluate for tumor removal. MR imaging was performed without and with gadolinium-DTPA before the operation and 3 months after. In all cases a suprasellar tumor extension was found preoperatively, in 9 cases with an additional parasellar, in 2 cases with an additional retrosellar extension (average diameter 2.5 cm). In 7 cases complete tumor removal was shown by postoperative MR, but in 11 cases residual tumor tissue was found (4 x suprasellar, 5 x parasellar, 2 x retrosellar). In 4 patients postoperative MR could not clearly differentiate residual tumor from scar formation. Although in cases of residual tumor follow-up MR imaging was performed over a period of two years, residual tumor volumes did not appear to change. This study demonstrates that MR imaging is highly sensitive for evaluating residual tumor tissue after transsphenoidal surgery of hormone-inactive macroadenomas.

Spontaneous fracture of the odontoid process in a patient with ankylosing spondylitis. Nonunion responsible for compression of the upper cervical cord

Tetraparesis due to a spontaneous fracture of the base of the odontoid process occurred in a patient with undiagnosed, advanced ankylosing spondylitis. Few cases of insufficiency fractures of the proximal cervical spine in patients with loss of spinal mobility have been reported in the literature. The pathologic lesions that can cause severe neurologic compromise are reviewed. Because functional impairment and neurologic loss are common even after surgical decompression and stabilization, these lesions should be looked for during a careful physical evaluation followed by appropriate investigations.

Overdrainage and shunt technology. A critical comparison of programmable, hydrostatic and variable-resistance valves and flow-reducing devices

When vertical body position is simulated, conventional differential pressure valves show an absolutely unphysiological flow, which is 2-170 times the normal liquor production rate. Although this is compensated in part by the resistance of the silicon tubes, which may produce up to 94% of the resistance of the complete shunt system, a negative intracranial pressure (ICP) of up to 30-44 cmH2O is an unavoidable consequence, which can be followed by subdural hematomas, slit ventricles, and other well-known complications. Modern shunt technology offers programmable, hydrostatic, and "flow-controlled" valves and anti-siphon devices; we have tested 13 different designs from 7 manufacturers (56 specimens), using the "Heidelberg Valve Test Inventory" with 16 subtests. "Programmable" valves reduce, but cannot exclude, unphysiological flow rates: even in the highest position and in combination with a standard catheter typical programmable Medos-Hakim valves allow a flow of 93-232 ml/h, Sophy SU-8-valves 86-168 ml/h with 30 cmH2O. The effect of hydrostatic valves (Hakim-Lumbar, Chhabra) can be inactivated by movements of daily life. The weight of the metal balls in most valves was too low for adequate flow reduction. Antisiphon devices are highly dependent on external, i.e. subcutaneous, pressure which has unpredictable influences on shunt function, and clinically is sometimes followed by shunt insufficiency. Two new Orbis-Sigma valves showed relatively physiological flow rates even when the vertical position (30 cmH2O) was simulated. One showed an insufficient flow (5.7 ml/h), and one was primarily obstructed. These have by far the smallest outlet of all valves. Additionally, the ruby pin tends to stick. Therefore, a high susceptibility to obliterations and blockade is unavoidable. Encouraging results obtained in pediatric patients contrast with disappointing experiences in some German and Swedish hospitals, which suggests that our laboratory findings are confirmed by clinical results. The concept of strict flow limitation seems to be inadaequate for adult patients, who need a relatively high flow during (nocturnal) ICP crises. The problem of shunt overdrainage remains unsolved.