Treatment of coronary de novo bifurcation lesions with DCB only strategy

Objectives

This observational study investigated the value of drug-coated balloons (DCB) only strategy in bifurcation lesions in a consecutive series of all comer percutaneous coronary intervention.

Background

Local application of paclitaxcel by DCB has clinical benefits in various settings including coronary bifurcations. While so far most bifurcation studies investigated sequential application of DCBs to the main (MB) and side branch (SB) with stenting of the MB, we report first results after DCB intervention without additional stenting of the MB or SB.

Methods

We performed 39 consecutive DCB only interventions in de novo bifurcation lesions with SB ≥2 mm and scheduled follow-up angiography after 4 months. Patients refusing angiography had telephone follow-up.

Results

Follow-up angiograms were obtained in 30 out of 39 DCB only interventions. 33.3 % were located in the left main (LM) bifurcation, 28.2 % in left anterior descending (LAD), 20.5 % in left circumflex (LCX) and 17.9 % in the right coronary artery. Four months after index procedure no patient had died, experienced myocardial infarction or stroke. Follow-up angiograms showed restenosis in 3 out of 30 interventions (10 %), 2 developing in the distal main (6.7 %) and 1 in the SB (3.3 %). All three patients had been treated for LM/LAD/LCX bifurcations and suffered from most severe coronary artery disease, but had not been eligible for CABG for various reasons. Target lesion revascularization was performed in 3 out of 39 patients consistent with a MACE rate of 7.7 %.

Conclusion

Treatment of de novo bifurcation lesions with DCB only intervention without additional stenting is a safe therapy with low rates of restenosis and TLR.     

Ligation versus propranolol for the primary prophylaxis of variceal bleeding in cirrhosis

In this randomized controlled multicenter trial, we compared endoscopic variceal banding ligation (VBL) with propranolol (PPL) for primary prophylaxis of variceal bleeding. One hundred fifty-two cirrhotic patients with 2 or more esophageal varices (diameter >5 mm) without prior bleeding were randomized to VBL (n = 75) or PPL (n = 77). The groups were well matched with respect to baseline characteristics (age 56 +/- 10 years, alcoholic etiology 51%, Child-Pugh score 7.2 +/- 1.8). The mean follow-up was 34 +/- 19 months. Data were analyzed on an intention-to-treat basis. Neither bleeding incidence nor mortality differed significantly between the 2 groups. Variceal bleeding occurred in 25% of the VBL group and in 29% of the PPL group. The actuarial risks of bleeding after 2 years were 20% (VBL) and 18% (PPL). Fatal bleeding was observed in 12% (VBL) and 10% (PPL). It was associated with the ligation procedure in 2 patients (2.6%). Overall mortality was 45% (VBL) and 43% (PPL) with the 2-year actuarial risks being 28% (VBL) and 22% (PPL). 25% of patients withdrew from PPL treatment, 16% due to side effects. In conclusion, VBL and PPL were similarly effective for primary prophylaxis of variceal bleeding. VBL should be offered to patients who are not candidates for long-term PPL treatment.     

The cross-talk between angiotensin and insulin differentially affects phosphatidylinositol 3-kinase- and mitogen-activated protein kinase-mediated signaling in rat heart: implications for insulin resistance

Insulin and angiotensin II (AngII) may act through overlapping intracellular pathways to promote cardiac myocyte growth. In this report insulin and AngII signaling, through the phosphatidylinositol 3-kinase (PI 3-kinase) and MAPK pathways, were compared in cardiac tissues of control and obese Zucker rats. AngII induced Janus kinase 2 tyrosine phosphorylation and coimmunoprecipitation with insulin receptor substrate 1 (IRS-1) and IRS-2 as well as an increase in tyrosine phosphorylation of IRS and its association with growth factor receptor-binding protein 2. Simultaneous treatment with both hormones led to marked increases in the associations of IRS-1 and -2 with growth factor receptor-binding protein 2 and in the dual phosphorylation of ERK1/2 compared with the administration of AngII or insulin alone. In contrast, an acute inhibition of both basal and insulin-stimulated PI 3-kinase activity was induced by both hormones. Insulin stimulated the phosphorylation of MAPK equally in lean and obese rats. Conversely, insulin-induced phosphorylation of Akt in heart was decreased in obese rats. Pretreatment with losartan did not change insulin-induced activation of ERK1/2 and attenuated the reduction of Akt phosphorylation in the heart of obese rats. Thus, the imbalance between PI 3-kinase-Akt and MAPK signaling pathways in the heart may play a role in the development of cardiovascular abnormalities observed in insulin-resistant states, such as in obese Zucker rats.     

Inhaled iloprost to treat severe pulmonary hypertension. An uncontrolled trial. German PPH Study Group

BACKGROUND: Inhaled aerosolized iloprost, a stable prostacyclin analogue, has been considered a selective pulmonary vasodilator in the management of pulmonary hypertension. OBJECTIVE: To assess the efficacy of inhaled iloprost in the treatment of life-threatening pulmonary hypertension. DESIGN: Open, uncontrolled, multicenter study. SETTING: Intensive care units and pulmonary hypertension clinics at six university hospitals in Germany. PATIENTS: 19 patients who had progressive right-heart failure despite receiving maximum conventional therapy (12 with primary pulmonary hypertension, 3 with pulmonary hypertension related to collagen vascular disease without lung fibrosis, and 4 with secondary pulmonary hypertension). INTERVENTION: Inhaled iloprost, 6 to 12 times daily (50 to 200 microg/d). MEASUREMENTS: Right-heart catheterization and distance walked in 6 minutes at baseline and after 3 months of therapy. RESULTS: During the first 3 months of therapy, New York Heart Association functional class improved in 8 patients and was unchanged in 7 patients. Four patients died, 3 of right-heart failure and 1 of sepsis. The acute hemodynamic response to inhaled iloprost was predominant pulmonary vasodilatation with little systemic effect at baseline and at 3 months (data available for 12 patients). Hemodynamic variables were improved at 3 months, and the distance walked in 6 minutes improved by 148 m (95% CI, 4.5 to 282 m; P = 0.048). Of the 15 patients who continued to use inhaled iloprost, 8 stopped: Four had lung transplantation, 1 switched to intravenous prostacyclin therapy, and 3 died. Seven patients are still receiving inhaled iloprost (mean +/-SD) duration of therapy, 536 +/- 309 days; mean dosage, 164 +/- 38 microg/d). CONCLUSIONS: Inhaled iloprost may offer a new therapeutic option for improvement of hemodynamics and physical function in patients with life-threatening pulmonary hypertension and progressive right-heart failure that is refractory to conventional therapy.     

Treatment of heroin addicts using buprenorphine.

Thirty-nine opioid-dependent outpatients were treated with the partial agonist buprenorphine at 2 to 6 mg/day for 1 month. Treatment retention was good (72%), and illicit opioid use decreased from 50% overall to 17% for those who remained in treatment. Precipitated withdrawal symptoms were mild and related to dose of buprenorphine. At the end of this month, 28 subjects were abruptly discontinued from buprenorphine and given the antagonist naltrexone. Withdrawal symptoms from buprenorphine were quite mild, and naltrexone was initiated in 20 patients (51% of total or 71% of those 28 completing 30 days on buprenorphine), but only 4 patients (10% overall) were successfully maintained on naltrexone for at least 2 weeks.     

Updates on the diagnosis and management of the most common hereditary porphyrias: AIP and EPP

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Koinzidenz der traumatischen Trachealruptur mit begleitendem ARDS

Treatment and diagnosis of a traumatic tracheal rupture is a challenge. Due to the rarity of such injuries and the subtle and delayed clinical presentation it is difficult to diagnose. We present for the first time the successful management of a 17-year-old multiply injured patient with coincidental tracheal rupture and ARDS (acute respiratory distress syndrome) after a fall. Besides the case report and pathogenesis the essential diagnostic and therapeutic measures are mentioned and discussed. The circumstances surrounding the accident have to be balanced with the severity of the trauma to also exclude rare injuries with certainty. Finally level 1 trauma centers specialized in ARDS provide the best clinical setting for successful treatment of these life-threatening injuries.     

Caudal bupivacaine supplemented with morphine or clonidine,or supplemented with morphine plus clonidine in children undergoing infra-umbilical urological and genital procedures: a prospective,randomized and double-blind study

Purpose  

We aimed to evaluate postoperative analgesia of morphine, or clonidine, or morphine plus clonidine, added to caudal bupivacaine in children undergoing infra-umbilical urological and genital procedures.     

Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology,management errors,and preventability of traumatic deaths in Berlin

Background

Despite continuous innovation in trauma care, fatal trauma remains a significant medical and socioeconomic problem. Traumatic cardiac arrest (tCA) is still considered a hopeless situation, whereas management errors and preventability of death are neglected. We analyzed clinical and autopsy data from tCA patients in an emergency-physician-based rescue system in order to reveal epidemiologic data and current problems in the successful treatment of tCA.

Material and methods

Epidemiological and autopsy data of all unsuccessful tCPR cases in a one-year-period in Berlin, Germany (n = 101, Group I) and clinical data of all cases of tCPR in a level 1 trauma centre in an 6-year period (n = 52, Group II) were evaluated. Preventability of traumatic deaths in autopsy cases (n = 22) and trauma-management failures were prospectively assessed.

Results

In 2010, 23% of all traumatic deaths in Berlin received tCPR. Death after tCPR occurred predominantly prehospital (PH;74%) and only 26% of these patients were hospitalized. Of 52 patients (Group II), 46% required tCPR already PH and 81% in the emergency department (ED). In 79% ROSC was established PH and 53% in the ED. The survival rate after tCPR was 29% with 27% good neurological outcome. Management errors occurred in 73% PH; 4 cases were judged as potentially or definitive preventable death.

Conclusion

Trauma CPR is beyond routine with the need for a tCPR-algorithm, including chest/pericardial decompression, external pelvic stabilization and external bleeding control. The prehospital trauma management has the highest potential to improve tCPR and survival. Therefore, we suggested a pilot prehospital tCPR-algorithm.     

Influence of the CCR-5/MIP-1 α Axis in the Pathogenesis of Rocio Virus Encephalitis in a Mouse Model

Rocio virus (ROCV) caused an outbreak of human encephalitis during the 1970s in Brazil and its immunopathogenesis remains poorly understood. CC-chemokine receptor 5 (CCR5) is a chemokine receptor that binds to macrophage inflammatory protein (MIP-1 α). Both molecules are associated with inflammatory cells migration during infections. In this study, we demonstrated the importance of the CCR5 and MIP-1 α, in the outcome of viral encephalitis of ROCV-infected mice. CCR5 and MIP-1 α knockout mice survived longer than wild-type (WT) ROCV-infected animals. In addition, knockout mice had reduced inflammation in the brain. Assessment of brain viral load showed mice virus detection five days post-infection in wild-type and CCR5−/− mice, while MIP-1 α−/− mice had lower viral loads seven days post-infection. Knockout mice required a higher lethal dose than wild-type mice as well. The CCR5/MIP-1 α axis may contribute to migration of infected cells to the brain and consequently affect the pathogenesis during ROCV infection.