Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

A vector-encoded bispecific killer engager to harness virus-activated NK cells as anti-tumor effectors

Treatment with oncolytic measles vaccines (MV) elicits activation of immune cells, including natural killer (NK) cells. However, we found that MV-activated NK cells show only modest direct cytotoxic activity against tumor cells. To specifically direct NK cells towards tumor cells, we developed oncolytic measles vaccines encoding bispecific killer engagers (MV-BiKE) targeting CD16A on NK cells and carcinoembryonic antigen (CEA) as a model tumor antigen. MV-BiKE are only slightly attenuated compared to parental MV and mediate secretion of functional BiKE from infected tumor cells. We tested MV-BiKE activity in cocultures of colorectal or pancreatic cancer cells with primary human NK cells. MV-BiKE mediate expression of effector cytokines, degranulation and specific anti-tumor cytotoxicity by NK cells. Experiments with patient-derived pancreatic cancer cultures indicate that efficacy of MV-BiKE may vary between individual tumors with differential virus permissiveness. Remarkably, we confirmed MV-BiKE activity in primaryhuman colorectal carcinoma specimens with autochthonous tumor and NK cells.This study provides proof-of-concept for MV-BiKE as a novel immunovirotherapy to harness virus-activated NK cells as anti-tumor effectors.

Risk factors for therapy failure after surgery for perianal abscess in children

Purpose

The role of surgery in managing perianal abscesses in the pediatric population is debatable, and data on recurrence risk is rare. This study aimed to evaluate the efficiency of surgery for a perianal abscess in children and identify parameters that predict recurrence.

Methods

We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018.

Results

Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease. Recurrences appeared after a median of 5 months (range: 1-18 months), in 12 cases as perianal abscess and 15 cases as fistula in ano. Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy. In univariate analysis, older age (p = 0.034), fistula probing (p = 0.006) and fistulotomy (p = 0.009) was associated with treatment success. History of perianal abscess, multilocal occurrence, and the presence of enteric flora in wound swabs was associated with treatment failure (p = 0.002, OR = 0.032). In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032).

Conclusion

Our study identified probing for fistula as a predictor of therapy success, while the history of perianal abscess was identified as a predictor of treatment failure. Therefore, in all children with perianal abscess, fistula probing and if present, fistulotomy should be performed.

Novel Group C Oncolytic Adenoviruses Carrying a miRNA Inhibitor Demonstrate Enhanced Oncolytic Activity In Vitro and In Vivo

Oncolytic adenoviruses (OAd) represent an attractive treatment option for cancer. Clinical efficacy of commonly utilized human adenovirus type 5 (Ad5)-based oncolytic viruses is limited by variable expression levels of the coxsackie- and adenovirus receptor (CAR) in tumor cells and high prevalence of neutralizing antibodies against human Ad5. However, previous studies have highlighted alternative human Ad types as promising candidates for oncolytic therapy. In this study, we generated novel OAds based on Ad1, -2, -5, and -6 derived from species C Ads. These OAds contain a 24-bp deletion in the early gene E1A for tumor selective replication and express the RNAi inhibitor P19. We examined these OAds for in vitro anticancer activity on various cancer cell lines derived from lung, colon, gynecologic, bone, and pancreatic carcinoma. In most surveyed cell lines, OAds based on Ad1, -2, and -6 demonstrated higher cell lysis capability compared with Ad5, suggesting enhanced oncolytic potential. Moreover, enhanced oncolytic activity was associated with P19 expression in a cell type-dependent manner. We further explored a A549 tumor xenograft mouse model to compare the novel OAds directly with Ad5 and H101, an oncolytic adenovirus used in clinical trials. These P19-containing OAds based on Ad1, -2, and -6 showed significantly decelerated tumor progression compared with H101, indicating better antitumor potency in vivo. Our studies provide a novel path for OAd development based on alternative Ad types with improved effectiveness by RNA interference suppression.

Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure

BACKGROUND

The optimal management of perianal abscess in children is controversial.

PURPOSE

To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure.

METHODS

All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated.

RESULTS

Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant.

CONCLUSION

Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: protocol for a systematic review and meta-analysis

BACKGROUND

Surgical site infection describes an infectious complication of surgical wounds. This single complication is thought to occur in close to 20% of surgical cases. This complication has been described in all kinds of surgical procedure including minimally invasive procedures. Wound irrigation is frequently used as a means of reducing surgical site infection. However, there is lack of solid evidence to support routine wound irrigation. The aim of this review is to provide evidence for the efficacy of routine wound irrigation with normal saline in preventing surgical site infection. The rate of surgical site infection in cases with and without wound irrigation will be analyzed.

METHODS/DESIGN

Systematic literature searches will be conducted to identify all published and unpublished studies. The following databases will be searched for citations from inception to present: MEDLINE (via PubMed), Embase (via Embase), and CENTRAL (via the Cochrane library). The search strategy will be developed by the research team in collaboration with an experienced librarian and checked by a referee according to the Peer Review of Electronic Search Strategies (PRESS) guideline. A draft of the PubMed search strategy could be (irrigation[tiab] OR "Therapeutic Irrigation"[mesh] OR lavage[tiab]) AND (saline[tiab] OR "Sodium Chloride"[mesh] OR sodium chloride[tiab]) NOT ("Comment" [Publication Type] OR "Letter" [Publication Type] OR "Editorial" [Publication Type]). No time limits will be set. The reference lists of eligible articles will be hand searched. Relevant data will be extracted from eligible studies using a previously designed data extraction sheet. Relative risks will be calculated for binary outcomes and mean differences or standardized mean differences, if necessary, for continuous outcomes. For all measures, 95% confidence levels will be calculated. Both arms would be compared with regard to the rate of surgical site infection within 30 days following surgery. We will report the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DISCUSSION

This review aims at investigating the value of routine wound irrigation using normal saline in preventing surgical site infection.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42018082287.

The role of muscle strength on tendon adaptability in old age

PURPOSE

The purpose of the study was to determine: (1) the relationship between ankle plantarflexor muscle strength and Achilles tendon (AT) biomechanical properties in older female adults, and (2) whether muscle strength asymmetries between the individually dominant and non-dominant legs in the above subject group were accompanied by inter-limb AT size differences.

METHODS

The maximal generated AT force, AT stiffness, AT Young's modulus, and AT cross-sectional area (CSA) along its length were determined for both legs in 30 women (65 ± 7 years) using dynamometry, ultrasonography, and magnetic resonance imaging.

RESULTS

No between-leg differences in triceps surae muscle strength were identified between dominant (2798 ± 566 N) and non-dominant limb (2667 ± 512 N). The AT CSA increased gradually in the proximo-distal direction, with no differences between the legs. There was a significant correlation (P < 0.05) of maximal AT force with AT stiffness (r = 0.500) and Young's modulus (r = 0.414), but only a tendency with the mean AT CSA. However, region-specific analysis revealed a significant relationship between maximal AT force and the proximal part of the AT, indicating that this region is more likely to display morphological adaptations following an increase in muscle strength in older adults.

CONCLUSIONS

These findings demonstrate that maximal force-generation capabilities play a more important role in the variation of AT stiffness and material properties than in tendon CSA, suggesting that exercise-induced increases in muscle strength in older adults may lead to changes in tendon stiffness foremost due to alterations in material rather than in its size.

Assessment of arterially hyper-enhancing liver lesions using virtual monoenergetic images from spectral detector CT: phantom and patient experience

PURPOSE

To investigate a benefit from virtual monoenergetic reconstructions (VMIs) for assessment of arterially hyper-enhancing liver lesions in phantom and patients and to compare hybrid-iterative and spectral image reconstructions of conventional images (CI-IR and CI-SR).

METHODS

All imaging was performed on a SDCT (Philips Healthcare, Best, The Netherlands). Images of a non-anthropomorphic phantom with a lesion-mimicking insert (containing iodine in water solution) and arterial-phase images from contrast-enhanced patient examinations were evaluated. VMIs (40-200 keV, 10 keV increment), CI-IR, and CI-SR were reconstructed using different strengths of image denoising. ROIs were placed in lesions, liver/matrix, muscle; signal-to-noise, contrast-to-noise, and lesion-to-liver ratios (SNR, CNR, and LLR) were calculated. Qualitatively, 40, 70, and 110 keV and CI images were assessed by two radiologists on five-point Likert scales regarding overall image quality, lesion assessment, and noise.

RESULTS

In phantoms, SNR was increased threefold by VMI_40keV compared with CI-IR/SR (5.8 ± 1.1 vs. 18.8 ± 2.2, p ≤ 0.001), while no difference was found between CI-IR and CI-SR (p = 1). Denoising was capable of noise reduction by 40%. In total, 20 patients exhibiting 51 liver lesions were assessed. Attenuation was the highest in VMI_40keV, while image noise was comparable to CI-IR resulting in a threefold increase of CNR/LLR (CI-IR 1.3 ± 0.8/4.4 ± 2.0, VMI_40keV: 3.8 ± 2.7/14.2 ± 7.5, p ≤ 0.001). Subjective lesion delineation was the best in VMI_40keV image (p ≤ 0.01), which also provided the lowest perceptible noise and the best overall image quality.

CONCLUSIONS

VMIs improve assessment of arterially hyper-enhancing liver lesions since they increase lesion contrast while maintaining low image noise throughout the entire keV spectrum. These data suggest that to consider VMI screening after arterially hyper-enhancing liver lesions.

Cardiovascular magnetic resonance assessment of acute cardiovascular effects of voluntary apnoea in elite divers

BACKGROUND

Prolonged breath holding results in hypoxemia and hypercapnia. Compensatory mechanisms help maintain adequate oxygen supply to hypoxia sensitive organs, but burden the cardiovascular system. The aim was to investigate human compensatory mechanisms and their effects on the cardiovascular system with regard to cardiac function and morphology, blood flow redistribution, serum biomarkers of the adrenergic system and myocardial injury markers following prolonged apnoea.

METHODS

Seventeen elite apnoea divers performed maximal breath-hold during cardiovascular magnetic resonance imaging (CMR). Two breath-hold sessions were performed to assess (1) cardiac function, myocardial tissue properties and (2) blood flow. In between CMR sessions, a head MRI was performed for the assessment of signs of silent brain ischemia. Urine and blood samples were analysed prior to and up to 4 h after the first breath-hold.

RESULTS

Mean breath-hold time was 297 ± 52 s. Left ventricular (LV) end-systolic, end-diastolic, and stroke volume increased significantly (p < 0.05). Peripheral oxygen saturation, LV ejection fraction, LV fractional shortening, and heart rate decreased significantly (p < 0.05). Blood distribution was diverted to cerebral regions with no significant changes in the descending aorta. Catecholamine levels, high-sensitivity cardiac troponin, and NT-pro-BNP levels increased significantly, but did not reach pathological levels.

CONCLUSION

Compensatory effects of prolonged apnoea substantially burden the cardiovascular system. CMR tissue characterisation did not reveal acute myocardial injury, indicating that the resulting cardiovascular stress does not exceed compensatory physiological limits in healthy subjects. However, these compensatory mechanisms could overly tax those limits in subjects with pre-existing cardiac disease. For divers interested in competetive apnoea diving, a comprehensive medical exam with a special focus on the cardiovascular system may be warranted.

TRIAL REGISTRATION

This prospective single-centre study was approved by the institutional ethics committee review board. It was retrospectively registered under ClinicalTrials.gov (Trial registration: NCT02280226 . Registered 29 October 2014).

Effects of repetitive prolonged breath-hold in elite divers on myocardial fibrosis and cerebral morphology

BACKGROUND

Prolonged apnea by breath-hold (BH) divers leads to hypoxemia and compensatory mechanisms of the cardiovascular system (i.e. increase of total peripheral resistance, increase of systolic blood-pressure, left-ventricular enlargement) to maintain oxygen supply to oxygen sensitive organs such as the brain. All these changes may result in structural myocardial or subclinical brain alterations. Therefore, the aim of this study was to investigate mid-term effects of repetitive prolonged apnea using cardiac magnetic resonance imaging (CMR) and magnetic resonance imaging of the brain.

MATERIALS AND METHODS

17 elite BH divers (15 males) were investigated at baseline, from whom 9 (7 males) were investigated again at follow-up one year later. CMR included functional imaging and tissue characterization using T1- and T2-mapping as well as late gadolinium enhancement. Results were compared intra-individually and with 50 age matched controls.

RESULTS

Mean BH time were 297 ± 52 s (entire cohort) and 315 ± 56 s (sub-cohort) at initial, and 334 ± 104 s at follow-up examination. Apnea resulted in a progressive increase of the left ventricle and impaired function, whichfully resolved after cessation of apnea. At rest, no dilation of the left ventricle was notable (LV-EDV: 106.7 ± 28.8 ml; LV-EDV/BSA: 52.2 ± 12.7 ml/m²). Compared to controls, the apnea group showed significantly lower volumes (LV-EDV: 106.7 ± 28.8 ml vs. 140.9 ± 36.3 ml, p = .008; LV-EDV/BSA: 52.2 ± 12.7 ml/m² vs. 73.7 ± 12.8 ml/m²). In contrast, LV-EF showed no significant differences between both groups (61.0 ± 7.0% vs. 60.9 ± 3.6%). T1- and T2-mapping revealed no significant differences, neither intra-individually nor in comparison with age matched controls. (T1 pre-contrast: 974.1 ± 12.9 ms vs. 969.4 ± 29.0 ms, p = .2; T1 post-contrast: 368.9 ± 38.5 ms vs. 966.7 ± 40.5 ms, p = .4; ECV: 29.2 ± 1.5% vs. 29.8 ± 1.6%, p = .3; T2. 52 ± 2 ms vs. 52 ± 3 ms; p = .4). Except for one old embolic lesion no structural changes were found in brain imaging.

CONCLUSION

Although, prolonged apnea leads to impressive adaptions of the cardiovascular system (i.e. dilation of the left ventricle) and hypertension due to peripheral vasoconstriction no mid-term morphological changes could be observed in both, the myocardium and the brain. BH divers are suitable as a model to investigate acute physiological changes of prolonged apnea and hypoxemia, but not as a model for chronic alterations.

The sleeping beauty transposon vector system for treatment of rare genetic diseases: an unrealized hope?

Rare genetic diseases account for a considerable amount of fatalities and even their 'mild' or 'non-lethal' forms can produce drastic and undesirable discomfort to affected individuals. Various gene therapeutic approaches were tested for developing novel therapeutic concepts to treat these genetic diseases. Sleeping Beauty (SB) transposase represents one of these gene therapeutic systems which can be utilized for stable phenotypic correction. It is a transposable element which was resurrected and optimized for transposing genetic elements resulting in somatic integration of the transgene. Because of its versatile activity in many different organs, SB transposase has been explored for ex-vivo gene delivery and in vivo gene delivery including recently launched clinical trials based on engineered T-cells for tumor therapy and approaches to treat retinal degenerations. Here we will provide a state-of-the-art overview of preclinical studies for treatment of rare genetic diseases based on the SB transposase system for stable correction of the genetic defect. In this review, diseases affecting the blood system, the connective tissue, the immune system, the metabolism, and the nervous system and their treatment utilizing the SB transposase system will be discussed. Moreover, advantages and disadvantages of SB transposase-based gene therapeutic approaches will be mentioned. Although improvements of the SB transposase systems regarding genotoxicity and efficient delivery especially for applications in large mammals are desirable, the SB transposase system remains to hold great promise for curing rare genetic disease.

Standard free droplet digital polymerase chain reaction as a new tool for the quality control of high-capacity adenoviral vectors in small-scale preparations

High-capacity adenoviral vectors (HCAdVs) are promising tools for gene therapy as well as for genetic engineering. However, one limitation of the HCAdV vector system is the complex, time-consuming, and labor-intensive production process and the following quality control procedure. Since HCAdVs are deleted for all viral coding sequences, a helper virus (HV) is needed in the production process to provide the sequences for all viral proteins in trans. For the purification procedure of HCAdV, cesium chloride density gradient centrifugation is usually performed followed by buffer exchange using dialysis or comparable methods. However, performing these steps is technically difficult, potentially error-prone, and not scalable. Here, we establish a new protocol for small-scale production of HCAdV based on commercially available adenovirus purification systems and a standard method for the quality control of final HCAdV preparations. For titration of final vector preparations, we established a droplet digital polymerase chain reaction (ddPCR) that uses a standard free-end-point PCR in small droplets of defined volume. By using different probes, this method is capable of detecting and quantifying HCAdV and HV in one reaction independent of reference material, rendering this method attractive for accurately comparing viral titers between different laboratories. In summary, we demonstrate that it is possible to produce HCAdV in a small scale of sufficient quality and quantity to perform experiments in cell culture, and we established a reliable protocol for vector titration based on ddPCR. Our method significantly reduces time and required equipment to perform HCAdV production. In the future the ddPCR technology could be advantageous for titration of other viral vectors commonly used in gene therapy.

B7x/B7-H4 modulates the adaptive immune response and ameliorates renal injury in antibody-mediated nephritis

Kidney disease is one of the leading causes of death in patients with lupus and other autoimmune diseases affecting the kidney, and is associated with deposition of antibodies as well as infiltration of T lymphocytes and macrophages, which are responsible for initiation and/or exacerbation of inflammation and tissue injury. Current treatment options have relatively limited efficacy; therefore, novel targets need to be explored. The co-inhibitory molecule, B7x, a new member of the B7 family expressed predominantly by non-lymphoid tissues, has been shown to inhibit the proliferation, activation and functional responses of CD4 and CD8 T cells. In this study, we found that B7x was expressed by intrinsic renal cells, and was up-regulated upon stimulation with inflammatory triggers. After passive administration of antibodies against glomerular antigens, B7x(-/-) mice developed severe renal injury accompanied by a robust adaptive immune response and kidney up-regulation of inflammatory mediators, as well as local infiltration of T cells and macrophages. Furthermore, macrophages in the spleen of B7x(-/-) mice were polarized to an inflammatory phenotype. Finally, treatment with B7x-immunoglobulin (Ig) in this nephritis model decreased kidney damage and reduced local inflammation. We propose that B7x can modulate kidney damage in autoimmune diseases including lupus nephritis and anti-glomerular basement membrane disease. Thus, B7x mimetics may be a novel therapeutic option for treatment of immune-mediated kidney disease.

Comparison of magnetic resonance feature tracking with harmonic phase imaging analysis (CSPAMM) for assessment of global and regional diastolic function

AIMS

Complex post-processing is required for strain-derived assessment of diastolic dysfunction (DD) using CMR-tagging (TAG). Feature-tracking (FT), allows for rapid systolic strain assessment using conventional steady-state free precession (SSFP)-Cine sequences. Aim of this study was to investigate whether FT may be employed for the clinically applicable quantification of DD.

METHODS AND RESULTS

40 individuals (20 patients with DD I-III°, 20 controls) were investigated. CSPAMM and SSFP-Cine sequences were acquired in identical short-axis locations. Global and regional early diastolic strain rate (EDSR), peak diastolic strain rate (PDSR), twist, untwist and torsion were calculated from tagged and SSFP-Cine datasets. DD indices were compared, intra- as well inter-observer variability assessed.

RESULTS

for global EDSR correlated strongly (r=0.94), revealed good agreement and no significant differences between both methods. Correlation for regional EDSR was lower, results differed significantly in the anterior wall (p<0.05). Correlation for PDSR was moderate (r=0.63), results in the healthy control group differed significantly (p<0.05). FT derived rotational indices correlated poorly with TAG (twist: r=0.28; untwist: r=0.02; torsion: r=0.26), subgroup analysis revealed significant differences (p<0.05). Intra- and inter-observer variability for FT derived global EDSR and PDSR were comparable to TAG, but significantly higher for regional EDSR and rotational indices.

CONCLUSION

FT derived global EDSR allows for rapid clinical determination of diastolic dysfunction, revealing good agreement with TAG and low intra- as well as interobserver variability. However, TAG analysis not only yields higher accuracy and reproducibility of global- and regional diastolic strain, but also delivers reliable information about diastolic rotational and untwisting dynamics.

Renal denervation: results of a single-center cohort study

PURPOSE

To investigate the effect of renal denervation on office-based and 24-h ambulatory blood pressure measurements (ABPM) in a highly selective patient population with drug-resistant hypertension.

MATERIALS AND METHODS

Patients with drug resistant hypertension eligible for renal denervation were included in the study population. Office blood pressure and ABPM were assessed prior to and after renal denervation. To detect procedure related renal or renal artery damage, magnetic resonance imaging (MRI) and angiography (MRA) were performed pre-interventional, one day post-interventional, and one month after renal denervation.

RESULTS

Mean follow-up time between renal denervation and blood pressure re-assessment was 9.5 ± 3.9 months. Between August 2011 and March 2013, 17 patients prospectively underwent renal denervation. Pre-interventional mean office blood pressure and ABPM were 177.3 ± 20.3/103.8 ± 20.4 mmHg and 155.2 ± 20.5/93.7 ± 14.5 mmHg, respectively. Post-interventional, office blood pressure was significantly reduced to 144.7 ± 14.9/89.5 ± 12.1 (p < 0.05). ABPM values remained unchanged (147.9 ± 20.3/90.3 ± 15.6, p > 0.05). The number of prescribed antihypertensive drugs was unchanged after renal denervation (4.7 ± 2.0 vs. 4.2 ± 1.2, p = 0.18). No renovascular complications were detected in follow-up MRI.

CONCLUSION

After renal denervation, no significant decrease in ABPM was observed. These results may indicate a limited impact of renal denervation for drug resistant hypertension.

KEY POINTS

• Renal denervation showed no significant effects on 24-h ambulatory blood pressure measurements. • A significant decrease in office blood pressure measurements may be explained by a potential detection bias. • Renal artery alterations were not observed on follow-up MRI scans.

Mechanisms of circumduction and axial rotation of the carpometacarpal joint of the thumb

Osteoarthritis of the carpometacarpal joint of the thumb (CMCJ) is a frequent clinical problem. The aim of the study was to discuss the mechanisms of circumduction and axial rotation of the CMCJ considering geometrical properties of the articulating surfaces and the configuration of the muscle system acting over the CMCJ. 28 CMCJ from 7 female and 7 male corpses (age: 81 yrs (median), 53-91 yrs (interval), which did not show any sign of arthrosis, were investigated. Contours in flexion/extension: in saddle point O, the contour of the proximal surface is stronger curved. For 23 of the 28 joints the contours showed an eye-catching difference. Contours in ab-/adduction: all 28 joints showed the respective incongruity. Straight lines and their included angles: in both articulating surfaces, the angles between the straight lines through the saddle point showed values which were close to 90 degrees. Out of neutral position a small axial rotation (maximal range: 3.5 degrees) is possible without that the contact at the saddle points is changed. But, when one of the straight lines of the proximal surface meets a respective straight line of the distal surface, the contact "point" is enlarged to a contact "line". When the axial rotation is further increased, the contact "line" splits into two contacts "points", which are located at outer areas of the articulating surfaces.