CT-Fluoroscopy: Tool or Gimmick?

Recent advances in CT scanner technology and computer hardware have led to the development of CT fluoroscopy (CTF), which allows real-time acquisition and display of cross-sectional images (with a rate of up to 8 frames per second). Since the introduction of the first CT fluoroscopy scanner in 1993, a variety of these scanners have been installed world-wide and many reports on the clinical use of this device have appeared recently. However, use of this new technology for the guidance of interventional radiologic procedures, such as percutaneous biopsy and percutaneous drainage, is not uniformly advocated by interventional radiologists. Concerns have been reported regarding radiation exposure and outcome of the procedures when compared with sequential CT guidance or other alternative guiding modalities. This article is intended to present an overview of CTF technology, to summarize the results of published papers on various interventional applications and to reflect on its specific advantages and disadvantages.     

The Bright Side of Grit in Burnout-Prevention: Exploring Grit in the Context of Demands-Resources Model among Chinese High School Students

This study contributes to understanding students’ emotional responses to academic stressors by integrating grit into the well-established Job Demands-Resources Model and by examining the relationship between academic demands, grit (consistency of interests, perseverance of effort), burnout, engagement, academic achievement, depression, and life satisfaction in Chinese students. We conducted a self-report study with N?=?1527 Chinese high school students (M_age?=?16.38 years, SD?=?1.04). The results of structural equation modeling showed that after controlling for gender, socio-economic status, and school types, demands positively related to burnout and negatively related to engagement. Both facets of grit negatively related to exhaustion, whereas only perseverance of effort positively related to engagement. Burnout positively related to depression and negatively related to life satisfaction, whereas engagement positively related to life satisfaction. However, neither burnout nor engagement was related to academic achievement. Our findings indicate that grit may be protective against school burnout.

     

Neutrophil Extracellular Trap-Related Extracellular Histones Cause Vascular Necrosis in Severe GN

Severe GN involves local neutrophil extracellular trap (NET) formation. We hypothesized a local cytotoxic effect of NET-related histone release in necrotizing GN. In vitro, histones from calf thymus or histones released by neutrophils undergoing NETosis killed glomerular endothelial cells, podocytes, and parietal epithelial cells in a dose-dependent manner. Histone-neutralizing agents such as antihistone IgG, activated protein C, or heparin prevented this effect. Histone toxicity on glomeruli ex vivo was Toll-like receptor 2/4 dependent, and lack of TLR2/4 attenuated histone-induced renal thrombotic microangiopathy and glomerular necrosis in mice. Anti–glomerular basement membrane GN involved NET formation and vascular necrosis, whereas blocking NET formation by peptidylarginine inhibition or preemptive anti-histone IgG injection significantly reduced all aspects of GN (i.e., vascular necrosis, podocyte loss, albuminuria, cytokine induction, recruitment or activation of glomerular leukocytes, and glomerular crescent formation). To evaluate histones as a therapeutic target, mice with established GN were treated with three different histone-neutralizing agents. Anti-histone IgG, recombinant activated protein C, and heparin were equally effective in abrogating severe GN, whereas combination therapy had no additive effects. Together, these results indicate that NET-related histone release during GN elicits cytotoxic and immunostimulatory effects. Furthermore, neutralizing extracellular histones is still therapeutic when initiated in established GN.     

Influence of different trigger techniques on twitch mouth pressure during bilateral anterior magnetic phrenic nerve stimulation

BACKGROUND: The trigger has a key role when assessing the twitch mouth pressure (Tw Pmo), since a "gentle" inspiratory or expiratory effort is needed for triggering to ensure an open glottis during twitch, but which also guarantees only very mild changes of transdiaphragmatic pressure following changes in lung volume. STUDY OBJECTIVES: To test if different trigger mechanisms cause different Tw Pmo values, if the predefined trigger criteria were accomplished, and if the breathing maneuver during triggering can influence the Tw Pmo. DESIGN: Experimental study. SETTING: Respiratory muscle and lung function laboratory of a university hospital. PARTICIPANTS: Twenty healthy men (mean age, 25.6 +/- 1.2 years [+/- SD]; mean FEV(1), 105.9 +/- 11.5% of predicted). MEASUREMENTS: Tw Pmo produced by bilateral anterior magnetic phrenic nerve stimulation was measured using an inspiratory flow trigger (40 mL/s), an inspiratory pressure trigger, and an expiratory pressure trigger (3.75 mm Hg). All trigger criteria were controlled. RESULTS: Unusable pressure-time curves occurred in 40% during expiratory triggering, but not during inspiratory triggering. For inspiratory pressure (flow) triggering, 10% (30%) of the predefined trigger criteria were exceeded by 50%, indicating that a "gentle" inspiratory effort was not warranted. The Tw Pmo was higher during inspiratory compared to expiratory triggering (analysis of variance, p < 0.05). The Tw Pmo during inspiratory pressure and flow triggering were comparable and significantly correlated (r = 0.70, p < 0.0001). The time between start of inspiration and trigger release, and the pressure-time product during that period ranged widely, but this could not predict the Tw Pmo (multiple linear regression). CONCLUSIONS: The trigger technique influences the Tw Pmo with higher values during inspiratory compared to expiratory triggering. Expiratory triggering more often produced unusable pressure-time curves. Inspiratory flow and pressure triggering is comparably useful in healthy subjects, but this might be different in patients. The trigger criteria need to be controlled to warrant a gentle breathing effort.     

Using Vascular Closure Devices Following Out-Of-Hospital Cardiac Arrest?

Objectives and Background: Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH).Methods: All victims from OHCA who received immediate coronary angiography after OHCA between January 1^st 2008 and December 31^st 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances.Results: 76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH.Conclusion: In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.     

13th St. Gallen International Breast Cancer Conference 2013: Primary Therapy of Early Breast Cancer Evidence,Controversies, Consensus – Opinion of a German Team of Experts (Zurich 2013)

Zusammenfassung

Alle zwei Jahre findet in St. Gallen (Schweiz) die internationale Konsensuskonferenz zur Behandlung des primären Mammakarzinoms statt. Da sich das internationale Panel in St. Gallen aus Experten unterschiedlicher Länder zusammensetzt, spiegelt der Konsensus ein internationales Meinungsbild wider. Vor diesem Hintergrund erscheint es aus deutscher Sicht sinnvoll, die Abstimmungsergebnisse für den Therapiealltag in Deutschland zu konkretisieren. Eine deutsche Arbeitsgruppe mit acht Brustkrebsexperten, von denen zwei Mitglieder des internationalen St. Gallen-Panels sind, hat daher die Abstimmungsergebnisse der St. Gallen-Konsensuskonferenz (2013) für den Klinikalltag in Deutschland kommentiert. Inhaltliche Schwerpunkte der diesjährigen St. Gallen-Konferenz waren operative Fragestellungen der Brust und der Axilla, strahlentherapeutische und systemische Therapieoptionen sowie die klinische Relevanz der Tumorbiologie. Intensiv diskutiert wurde der klinische Einsatz von Multigen-Assays, inkl. ihrer Bedeutung für die individuelle Therapieentscheidung.