Four-Year Follow-up on Endovascular Radiofrequency Obliteration of Great Saphenous Reflux

BACKGROUND: Endovascular radiofrequency obliteration has been used since 1998 as an alternative to conventional vein stripping surgery for elimination of saphenous vein insufficiency. OBJECTIVE: To demonstrate the long-term efficacy of this treatment modality. METHODS: Data were prospectively collected in a multicenter ongoing registry. Only great saphenous vein above-knee treatments were included in this study. Eight hundred ninety patients (1,078 limbs) were treated prior to November 2003 at 32 centers. Clinical and duplex ultrasound follow-up was performed at 1 week, 6 months, and 1, 2, 3, and 4 years. RESULTS: Among 1,078 limbs treated, 858 were available for follow-up within 1 week, 446 at 6 months, 384 at 1 year, 210 at 2 years, 114 at 3 years, and 98 at 4 years. The vein occlusion rates were 91.0%, 88.8%, 86.2%, 84.2%, and 88.8%, respectively; the reflux-free rates were 91.0%, 89.3%, 86.2%, 86.0%, and 85.7%, respectively; and the varicose vein recurrence rates were 7.2%, 13.5%, 17.1%, 14.0%, and 21.4%, respectively, at each follow-up time point at 6 months, and 1, 2, 3, and 4 years. Patient symptom improvement persisted over 4 years. CONCLUSIONS: Endovascular temperature-controlled radiofrequency obliteration of saphenous vein reflux exhibits an enduring treatment efficacy clinically, anatomically, and hemodynamically up to 4 years following treatment.     

Auf dem Sprung . . .

Ohne Zusammenfassung     

Endoscopic transthoracic sympathectomy: current indications and techniques

Zusammenfassung GRUNDLAGEN: Die endoskopische thorakale Sympathektomie (ETS) existiert seit 60 Jahren als effektive Therapie der primären Hyperhidrose. Nach wie vor gibt es in der medizinischen Welt teils Vorbehalte, teils Unwissen über die Methode selbst, ihre Erfolgs- und Komplikationsraten sowie Nebenwirkungen. METHODIK: Nach Einführung in die Symptome und Behandlung der primären Hyperhidrose (konservativ und chirurgisch) werden Operationsmethoden und Langzeitergebnisse der ETS-Operation vorwiegend anhand der Daten aus der eigenen Abteilung präsentiert. ERGEBNISSE: Von 1965–2001 wurden 734 Sympathikotomien (ETS2–4) und bis 2003 weitere 103 Sympathikusblockaden (ESB4) bei Patienten mit primärer palmarer und axillärer Hyperhidrose durchgeführt. Die Konversionsrate betrug 0,1 %. Seit Einführung der Video-Thorakoskopie 1991 trat kein postoperatives Horner-Syndrom auf (zuvor 2,2 %), Drainage-pflichtige Pneumothoraces waren in 1,1 % zu verzeichnen. Nach einem medianen Follow-up von 16 Jahren waren 93 % der Extremitäten trocken, 5 % fast trocken und 2 % feucht. Nebenwirkungen traten in Form von kompensatorischem Schwitzen am Stamm (55 % insgesamt, davon 5 % stark) und gustatorischem Schwitzen (33 %) auf. Seit Einführung der limitierten Sympathikusblockade auf Höhe T4 (ESB4) konnte (bei naturgemäß kurzer Nachbeobachtungszeit) das kompensatorische Schwitzen auf 8,5 % und das gustatorische Schwitzen auf 2,1 % gesenkt werden. Mit dem postoperativen Ergebnis waren 100 % der Patienten nach ESB4 zufrieden, nach ETS2–4 waren 80 % zufrieden, 14 % teilweise zufrieden und 6 % unzufrieden (meist wegen starken kompensatorischen Schwitzens). SCHLUSSFOLGERUNGEN: Die ETS-Operation bietet hohe langfristige Erfolgsraten bei niedrigen Komplikationsraten. Patienten sollten über die zu erwartenden Nebenwirkungen genau aufgeklärt werden, für unzufriedene Patienten mit starkem kompensatorischem Schwitzen besteht nun die Möglichkeit der thorakoskopischen Klip-Entfernung.     

Correction of hallux valgus deformity with distal soft tissue realignment and proximal metatarsal osteotomy

Abstract Fifty moderate to severe hallux valgus deformities were corrected with a distal soft tissue realignment and proximal crescentic metatarsal osteotomy. With an average follow-up of 5.6 years, 40 feet (80%) were pain free and 42 (84%) caused no functional limitation. The average hallux valgus angle improved from 38.2° preoperatively to 12.4° at follow-up. The average intermetatarsal angle improved from 15.4° to 6.8°. The arch of motion of the first metatarsophalangeal joint was 75° preoperatively and 62° at follow-up. According to the AOFAS scoring system, 29 results (58%) were excellent, 14 (28%) good, 2 (4%) fair and 5 (10%) poor. The 5 poor results were attributed to recurrence of hallux valgus (2 cases), stiffness (1), hallux varus (1) and malunion of the osteotomy in dorsiflexion (1). The incidences of hallux varus and malunion in dorsiflexion were 8% and 14%, respectively. This technique is valuable in correction of moderate to severe hallux valgus deformities.     

Medizinische Beurteilungskriterien zu bandscheibenbedingten Berufskrankheiten der Lendenwirbelsäule (II)

The first part of this serial paper dealt with the medical criteria used in evaluation of the clinical picture caused by physical stress and the evaluation of other candidate causes and was published in issue no. 3/2005 (pp. 711–752) of Trauma and Berufskrankheit. This follow-up paper (II) presents criteria to be used in the evaluation of whether it is necessary to give up the occupations putting the spine at risk and in estimation of the degree of disability.     

Pharmacotherapy of ventricular fibrillation. A prospective study in an emergency medical service

This prospective study investigated the effects of standard pharmacotherapy in out-of-hospital ventricular fibrillation (VF) after i.v. or endobronchial (e.b.) administration of epinephrine and lidocaine. METHODS. Only patients presenting with out-of-hospital VF were included in this study, whereby VF of noncardiac origin was excluded. Cardiopulmonary resuscitation (CPR) was performed according to the guidelines of the American Heart Association. Basic life support was initiated by Emergency Medical Service (EMS) technicians. The first step of advanced life support was immediate defibrillation by the EMS physician. Epinephrine was given in doses of 2.5 mg e.b. or 1.0 mg i.v. If indicated, patients received 200-500 mg lidocaine e.b. or 100 mg i.v. The course of CPR was tape-recorded and 2-3 blood samples were taken from each patient for drug monitoring. Plasma levels of epinephrine and lidocaine were measured by high-pressure liquid and gas chromatography, respectively, and then correlated to the course of CPR. RESULTS. Forty-seven patients presented VF on arrival of the EMS physician. Restoration of spontaneous circulation was achieved in 64% (Table 3), and 30% of the patients were discharged from hospital without major neurologic deficits. Immediate defibrillation before initiation of pharmacotherapy produced a success rate of 15.8%, whereas defibrillation after drug therapy was successful in 61.5% of cases. Following e.b. instillation of 2.5 mg epinephrine (Fig. 1), median peak concentrations of epinephrine (40.2, range 4.0-79.8 ng/ml) were reached after 3-4 min and plasma levels greater than or equal to 10 ng/ml were seen for 20 min. After i.v. injection of 1.0 mg epinephrine (Fig. 2) maximum concentrations (71.6, range 4.7-104.2 ng/ml) were measured after 1-2 min and plasma levels decreased below 10 ng/ml after 10 min. Following e.b. instillation of 400-500 mg lidocaine mean lidocaine concentrations within the therapeutic range (2-5 micrograms/ml) were reached after 4-5 min and remained within these limits for 20-30 min. Peak concentrations were obtained after 12 min. Doses of 200-320 mg lidocaine e.b. failed to achieve therapeutic plasma levels (Fig. 3). Regarding the pharmacodynamic aspects of drug therapy, 22.5% of the initial survivors were resuscitated from VF without therapeutic epinephrine, presenting with mean endogenous epinephrine concentrations of 7.1 ng/ml, 51.6% of patients were resuscitated after epinephrine therapy with plasma concentrations greater than 20 ng/ml. In only 1 case could a relationship be demonstrated between the administration of lidocaine and resuscitation success. CONCLUSION. In CPR, the e.b. administration of epinephrine and lidocaine is a reliable alternative to the i.v. injection route of these drugs. Recommended doses are 2.5 mg for epinephrine and 400-500 mg for lidocaine. Resuscitation from VF requires immediate epinephrine therapy if initial defibrillation is not successful. Lidocaine has no effect on resuscitation from VF and therefore should be used specifically for antiarrhythmic therapy after restoration of spontaneous circulation.