Exclusion of patients with arteriosclerosis reduces long-term recurrence rate of presumed arterial embolism after PFO closure

BACKGROUND: Percutaneous transcatheter closure of patent interatrial communications after presumed paradoxical embolism is used as an alternative to surgery or long-term anticoagulation for the treatment of patients who are at risk for recurrent thromboembolism. To avoid atherosclerotic events to be judged as recurrent paradoxical embolism, we prospectively excluded all patients with detectable arteriosclerosis from our series and investigated long-term results. METHODS AND RESULTS: We report the outcome of 180 patients who underwent percutaneous transcatheter closure of patent foramen ovale (PFO), PFO like atrial septal defect (ASD), or an ASD because of paradoxical embolism. One hundred four patients had cerebral embolism, 57 had transient ischemic attacks, 16 coronary embolism, and 3 had peripheral embolism. Twenty-three patients experienced multilocal arterial embolism. One hundred twenty-five patients had a PFO, 63 of them with an atrial septal aneurysm (ASA), 24 a PFO-like ASD (7 of them with an ASA), and 31 had an ASD. After 18 months, only 5 patients (2.8%) showed a trivial residual shunt. At a mean follow-up of 40 months (range 4 to 88), resulting in 602 observed patient-years, only 1 patient experienced a presumed paradoxical (coronary) embolism (calculated annual risk to suffer a recurrent thromboembolic event: 0.16%). CONCLUSIONS: Percutaneous transcatheter closure of PFO/ASD is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. It is associated with a high success rate, low incidence of hospital complications, and very low frequency of recurrent systemic embolic events.     

Clinical characteristics and treatment outcome in a representative sample of depressed inpatients - findings from the Munich Antidepressant Response Signature (MARS) project

Depression is a common and often difficult-to-treat clinical condition with a high rate of patients showing insufficient treatment response and persistence of symptoms. We report the characteristics of a representative sample of depressed inpatients participating in the Munich Antidepressant Response Signature (MARS) project. Eight hundred and forty-two inpatients admitted to a psychiatric hospital for treatment of a major depressive episode, recurrent or bipolar depression were thoroughly characterized with respect to demographic factors, clinical history, and the degree of HPA-axis dysregulation evaluated by means of combined dex/CRH tests, and the predictive value of these factors for treatment outcome is investigated. 80.8% of patients responded to treatment (i.e., improvement in symptom severity of at least 50%) and 57.9% reached remission (i.e., near absence of residual depressive symptoms) at discharge after a mean treatment period of 11.8 weeks. Regression analysis identified early partial response (within 2 weeks) as the most important positive predictor for achieving remission. Previous ineffective treatment trials in the current episode and presence of a migration background are potent negative predictors for treatment outcome. In addition, remitters were characterized by a more pronounced normalization of an initially dysregulated HPA-axis. We could show that a large majority of inpatients suffering from depression benefits from antidepressant treatment during hospitalization. However, a considerable number of patients failed to achieve remission. We demonstrated that this subgroup can be characterized by a set of demographic, clinical and neuroendocrine variables allowing to predict unfavorable outcome at an early stage of treatment.     

Incidence and predictors of atrioventricular conduction impairment after transcatheter aortic valve implantation

Atrioventricular (AV) conduction impairment is well described after surgical aortic valve replacement, but little is known in patients undergoing transcatheter aortic valve implantation (TAVI). We assessed AV conduction and need for a permanent pacemaker in patients undergoing TAVI with the Medtronic CoreValve Revalving System (MCRS) or the Edwards Sapien Valve (ESV). Sixty-seven patients without pre-existing permanent pacemaker were included in the study. Forty-one patients (61%) and 26 patients (39%) underwent successful TAVI with the MCRS and ESV, respectively. Complete AV block occurred in 15 patients (22%), second-degree AV block in 4 (6%), and new left bundle branch block in 15 (22%), respectively. A permanent pacemaker was implanted in 23 patients (34%). Overall PR interval and QRS width increased significantly after the procedure (p <0.001 for the 2 comparisons). Implantation of the MCRS compared to the ESV resulted in a trend toward a higher rate of new left bundle branch block and complete AV block (29% vs 12%, p = 0.09 for the 2 comparisons). During follow-up, complete AV block resolved in 64% of patients. In multivariable regression analysis pre-existing right bundle branch block was the only independent predictor of complete AV block after TAVI (relative risk 7.3, 95% confidence interval 2.4 to 22.2). In conclusion, TAVI is associated with impairment of AV conduction in a considerable portion of patients, patients with pre-existing right bundle branch block are at increased risk of complete AV block, and complete AV block resolves over time in most patients.     

Pesticides and farmer health in Nicaragua: a willingness-to-pay approach to evaluation

A contingent valuation approach to assess the health effects of chemical pesticides among Nicaraguan vegetable farmers is presented. Farmers’ valuation of health is measured as their willingness to pay (WTP) for low-toxicity pesticides. Results show that farmers are willing to spend an additional amount of about 28% of current pesticide expenditure for avoiding health risks. The validity of results is established in scope tests and with a two-step regression model. WTP depends on farmers’ experience with poisoning, income variables, and current exposure to pesticides. The results can help in designing rural health policies and in the formulation of programmes aiming to reduce the negative effects of pesticides.

Effect of ochratoxin A on cell survival and collagen homeostasis in human mesangial cells in primary culture

Ochratoxin A (OTA) is a mycotoxin produced by several fungi growing on food source material. The main target of OTA is the kidney. So far, mainly cell lines of different origin have been used to study OTA toxicity. Yet all of them derived from tubule segments and therefore only limited information is available on glomerular effects of OTA. We exposed human mesangial cells in primary culture to OTA in nanomolar concentrations for up to 14 days. Necrotic and apoptotic cell death as well as fibrotic changes were studied. Protein content decreased only when unusual high OTA concentrations were used (1 μM). By contrast, an increase of caspase-3 activity or LDH release was observed after five days already at 10 nM OTA. A decrease of collagen I secretion was accompanied by a virtually unchanged collagen III and fibronectin secretion. Collagen IV secretion was slightly increased at low OTA concentrations (0.3–10 nM). We conclude that OTA has only a minor effect on human mesangial cells in primary culture. OTA did not influence collagen homeostasis substantially. Based on the data presented here, a risk of mesangial damage by OTA exposure is unlikely.     

Determinanten für die Bearbeitungszeit von zertifizierter Fortbildung in Printmedien

Zusammenfassung Hintergrund und Ziel:  Die Fortbildungsordnung für ?rzte definiert die Zeiteinheit einer akademischen Stunde (45 min) als die Grundlage für die Vergabe eines Fortbildungspunkts. Für die zertifizierte Fortbildung in Printmedien existieren keine Daten zur Bearbeitungsdauer solcher Artikel. Ziel der Arbeit ist die Analyse der Bearbeitungszeit und ihrer Determinanten anhand eines Jahrgangs von Fortbildungsartikeln für ein breites Spektrum von Fachrichtungen. Material und Methodik:  Ausgewertet wurden die Angaben in einem standardisierten Evaluationsbogen für den kompletten Jahrgang 2004 aller von einem deutschen Verlag herausgegebenen Facharztzeitschriften mit einem von der Nordrheinischen Akademie für ?rztliche Fort- und Weiterbildung zertifizierten Fortbildungsangebot. Ergebnisse:  Auf der Basis von 18 Zeitschriften und 12 587 Teilnehmern mit 65 393 Bearbeitungen von Fortbildungsartikeln einschlie?lich Fragen zur „Lernerfolgskontrolle“ zeigte sich, dass zwischen der Bearbeitungszeit und der Zeichenzahl (als Parameter für den Umfang der Artikel) nur eine schwache lineare Korrelation (r = 0,221) bestand. Dagegen fand sich eine st?rkere Abh?ngigkeit der Bearbeitungszeit von Parametern, die den Bezug des Lesers zum abgehandelten Thema charakterisieren (z.B. vorbestehende Strategie bezüglich des abgehandelten Problems, Berufsalter, H?ufigkeit des Krankheitsbilds im klinischen Alltag) und dem Ausma? des Wissenszuwachses. Sehr lange Bearbeitungszeiten wurden mit zunehmendem Alter h?ufiger angetroffen. Tageszeit und Wochentag hatten keinen nennenswerten Einfluss auf die Bearbeitungsdauer, die bei Bearbeitung mehrerer Fortbildungsartikel bis zur vierten Teilnahme zunahm und dann keine gerichteten Ver?nderungen mehr zeigte. Schlussfolgerung:  Die Bearbeitungszeit von Fortbildungsartikeln in Printmedien wird wesentlich durch den Bezug des Lesers zum abgehandelten klinischen Problem determiniert, der Umfang des Artikels ist von untergeordneter Bedeutung. Die Vergabe von Fortbildungspunkten im Rahmen des Fortbildungszertifikats der ?rztekammern sollte daher von einer Realerhebung der Bearbeitungszeiten abh?ngig gemacht werden. Nach l?ngerer Verschonung hat uns der Druckfehlerteufel wieder einmal aufgesucht und dabei kr?ftig zugeschlagen. Ausgerechnet in unserer Serie über zertifizierte Fortbildung wurde der Beitrag von Sch?fer et al., Determinanten für die Bearbeitungszeit von zertifizierter Fortbildung in Printmedien, Med Klin 2008;103:230-40 (Nr. 4), DOI befallen. Die letzte Seite dieses Beitrages (S. 240) fehlt. Obwohl dieser bedauerliche Fehler fernab von Herausgeberschaft und Verlag, n?mlich in der Druckerei, passierte, m?chten wir uns bei unseren Lesern entschuldigen. Die fehlende Seite des Artikels wird hiermit nachgedruckt.     

Functional urinary and fecal incontinence in neurologically normal children: symptoms of one 'functional elimination disorder'?

OBJECTIVE: To clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction (NNBSD) by comparing the prevalence of symptoms of disordered defecation in children with NNBSD before and after treatment for urinary incontinence (UI), and assessing the effect of such symptoms on the cure rate for UI. PATIENTS AND METHODS: In the European Bladder Dysfunction Study, a prospective multicentre study comparing treatment plans for children with NNBSD, 202 children completed questionnaires on voiding and on defecation, at entry and after treatment for UI. Four symptoms of disordered defecation were evaluated; low defecation frequency, painful defecation, fecal soiling, and encopresis. RESULTS: At entry, 17 of the 179 children with complete data sets had low defecation frequency and/or painful defecation (9%), classified as functional constipation (FC). Of the 179 children, 57 had either isolated fecal soiling or soiling with encopresis (32%), classified as functional fecal incontinence (FFI). After treatment for UI, FFI decreased to 38/179 (21%) (statistically significant, P = 0.035); for FC there were too few children for analysis. After treatment for UI, 19 of the 179 children (11%) reported de novo FFI. Symptoms of disordered defecation did not influence the cure rate of treatment for UI. CONCLUSIONS: FFI improved significantly after treatment for UI only, but not in relation to the outcome of such treatment. FFI did not influence the cure rate for UI. There was little to support a causal relation between disordered defecation and NNBDS ('functional elimination syndrome').