Mitral valve replacement in patients under 65 years of age: mechanical or biological valves?

PURPOSE OF REVIEW There is controversy regarding the optimal choice of prosthetic valves in patients less than 65 years of age requiring mitral valve replacement (MVR). Recently, trends for valve replacement are moving towards biological prosthesis also in younger patients, which is justified by the fact that a later valve-in-valve procedure is feasible in the case of degeneration of the tissue valve. This strategy is increasingly recommended in aortic valve surgery but is questionable for MVR. The purpose of this review is to evaluate current guidelines and analyse evidence for biological MVR in patients under 65 years. RECENT FINDINGS There are differences between guidelines of the American Heart Association and those of the European Society of Cardiology concerning the choice of prostheses in patients undergoing MVR. Although the European Society of Cardiology recommends a mechanical mitral valve in patients under 65 years of age, the American Heart Association does not provide detailed advice for these patients. Mitral valve replacement with biological valves in patients under 65 years is associated with higher rates of reoperation due to structural valve deterioration. In addition, several studies showed a decreased survival after biological MVR. SUMMARY Evidence for biological MVR in patients less than 65 years without comorbidities or contraindication for oral anticoagulation does not exist. Recommendations for patients less than 65 years of age should not be blurred by current 'en-vogue' methods for promising but not yet proven valve-in-valve strategies.

15q26.1 microdeletion encompassing only CHD2 and RGMA in two adults with moderate intellectual disability, epilepsy and truncal obesity

We report two patients with microdeletions in chromosomal subdomain 15q26.1 encompassing only two genes, CHD2 and RGMA. Both patients present a distinct phenotype with intellectual disability, epilepsy, behavioral issues, truncal obesity, scoliosis and facial dysmorphism. CHD2 haploinsufficiency is known to cause intellectual disability and epilepsy, RGMA haploinsufficiency might explain truncal obesity with onset around puberty observed in our two patients.

Deep molecular response is reached by the majority of patients treated with imatinib, predicts survival, and is achieved more quickly by optimized high-dose imatinib: results from the randomized CML-study IV

PURPOSE Deep molecular response (MR(4.5)) defines a subgroup of patients with chronic myeloid leukemia (CML) who may stay in unmaintained remission after treatment discontinuation. It is unclear how many patients achieve MR(4.5) under different treatment modalities and whether MR(4.5) predicts survival. PATIENTS AND METHODS Patients from the randomized CML-Study IV were analyzed for confirmed MR(4.5) which was defined as ≥ 4.5 log reduction of BCR-ABL on the international scale (IS) and determined by reverse transcriptase polymerase chain reaction in two consecutive analyses. Landmark analyses were performed to assess the impact of MR(4.5) on survival. RESULTS Of 1,551 randomly assigned patients, 1,524 were assessable. After a median observation time of 67.5 months, 5-year overall survival (OS) was 90%, 5-year progression-free-survival was 87.5%, and 8-year OS was 86%. The cumulative incidence of MR(4.5) after 9 years was 70% (median, 4.9 years); confirmed MR(4.5) was 54%. MR(4.5) was reached more quickly with optimized high-dose imatinib than with imatinib 400 mg/day (P = .016). Independent of treatment approach, confirmed MR(4.5) at 4 years predicted significantly higher survival probabilities than 0.1% to 1% IS, which corresponds to complete cytogenetic remission (8-year OS, 92% v 83%; P = .047). High-dose imatinib and early major molecular remission predicted MR(4.5). No patient with confirmed MR(4.5) has experienced progression. CONCLUSION MR(4.5) is a new molecular predictor of long-term outcome, is reached by a majority of patients treated with imatinib, and is achieved more quickly with optimized high-dose imatinib, which may provide an improved therapeutic basis for treatment discontinuation in CML.

Lernzielkatalog für die studentische Lehre im Fachbereich „Geriatrie“ an Fakultäten für Humanmedizin.

Zusammenfassung Die Betreuung geriatrischer Patientinnen und Patienten setzt, nebst einer entsprechenden Haltung, fundierte Kenntnisse in Diagnostik und Behandlung praktisch aller medizinischen Fachgebiete voraus. Daher ist es wichtig, dass die Kompetenz von Studierenden der Humanmedizin im Bereich Geriatrie entsprechend gefördert wird. Bis heute hat jedoch die studentische Ausbildung im Fach Geriatrie an vielen europäischen Universitäten einen unklaren oder untergeordneten Stellenwert. Als ersten Schritt zur Förderung der Lehre in der Geriatrie hat die Europäische Facharztvereinigung Geriatrie (UEMS-GMS) in einem Delphi-Prozess einen Lernzielkatalog entwickelt. Dieser Katalog enthält die Mindestanforderungen mit spezifischen Lernzielen (Wissen, Fertigkeiten und Haltungen), welche die Studierenden der Humanmedizin bezüglich Geriatrie bis zum Abschluss des Medizinstudiums erwerben sollen. Zur Förderung der Implementierung dieses neuen, kompetenzbasierten Lernzielkatalogs an den deutschsprachigen Universitäten wurde eine an den Sprachgebrauch des „DACH-Raums“ (Deutschland, Österreich und Schweiz) angepasste deutsche Version erstellt. Im vorliegenden Beitrag wird diese Übersetzung vorgestellt. Die Fachgesellschaften für Geriatrie aus Deutschland, Österreich und der Schweiz empfehlen den medizinischen Fakultäten der jeweiligen Länder, diesen Katalog umzusetzen.

From the Sea to Paris and back: On the interdependence of economic warfare, weather conditions and the submarine campaign 1916-1917

Starting of from Avner Offer’s comment that the First World War was not only a war of steel and gold, but also of bread and potatoes (1989: 1) and my own research on British as well as Australian preparations for economic warfare and based on sources from the entente as well as the central powers but also from the United States, Canada and Australia, may presentation will focus on the interdependence of the measures taken by entente as well as central power authorities in the second half of 1916. Already a year before both sides had become aware that this war would not only be decided on the battlefield, but that the issues of primary as well as secondary resources would be decisive. Accordingly measures that could strike the enemy in this field were discussed and put into place more and more and this at time, when weather conditions caused a reduction of harvest all over Europe, Northern America and Argentina.

Review of Clément Vidal, "The Beginning and the End. The Meaning of Life in a Cosmological Perspective"

No more ground control. Dissertations ideally always have been ambitious, and this one can’t claim to be too humble in these regards. Together the pieces of this work form a world view that the author confesses to finding ‘magnificent’. The story he tells is one in which intelligence and complexity are keys to unlock the universe’s mysteries. Vidal tackles questions like ‘What is philosophy?’, ‘Where does it all come from?’, Where are we going?’, ‘Are we alone in the universe?’ and even ‘What is good and what is evil?’. Questions which philosophers for ages have tried to answer.

Weather and War – Economic and social vulnerability in Switzerland at the end of the First World War

Neutral Switzerland – not embedded in the fighting forces – yet was involved in the Great War mainly in economical terms. Since Switzerland is a landlocked country especially agriculture became an important topic of war economy in regard to food security. Until 1916 national food supply was limited but could be maintained through barter trade. In 1916 a crisis on both supply and production level occurred and led to a decline in food availability and to immense price risings causing social turmoil. This paper aims to outline the factors of vulnerability in respect of food in Switzerland during the First World War and further it will show different coping strategies that were undertaken during that time. The paper takes the work of Mario Aeby and Christian Pfister (University of Bern) into consideration that pointed out to weather anomalies during the years 1916 and 1917 aggravating the already tense food situation. Arguing for an overlap of supply and production crisis the paper focuses on agricultural and economic history including environmental impacts. Further the paper addresses the question of what makes a food system resilient to such unforeseen impacts.

Low statin use in adults hospitalized with acute coronary syndrome.

OBJECTIVE To assess recommended and actual use of statins in primary prevention of cardiovascular disease (CVD) based on clinical prediction scores in adults who develop their first acute coronary syndrome (ACS). METHOD Cross-sectional study of 3172 adults without previous CVD hospitalized with ACS at 4 university centers in Switzerland. The number of participants eligible for statins before hospitalization was estimated based on the European Society of Cardiology (ESC) guidelines and compared to the observed number of participants on statins at hospital entry. RESULTS Overall, 1171 (37%) participants were classified as high-risk (10-year risk of cardiovascular mortality ≥5% or diabetes); 1025 (32%) as intermediate risk (10-year risk <5% but ≥1%); and 976 (31%) as low risk (10-year risk <1%). Before hospitalization, 516 (16%) were on statins; among high-risk participants, only 236 of 1171 (20%) were on statins. If ESC primary prevention guidelines had been fully implemented, an additional 845 high-risk adults (27% of the whole sample) would have been eligible for statins before hospitalization. CONCLUSION Although statins are recommended for primary prevention in high-risk adults, only one-fifth of them are on statins when hospitalized for a first ACS.

Unresolved Grief in a National Sample of Bereaved Parents: Impaired Mental and Physical Health 4 to 9 Years Later

PURPOSE: To assess unresolved parental grief, the associated long-term impact on mental and physical health, and health service use. PATIENTS AND METHODS: This anonymous, mail-in questionnaire study was performed as a population-based investigation in Sweden between August 2001 and October 2001. Four hundred forty-nine parents who lost a child as a result of cancer 4 to 9 years earlier completed the survey (response rate, 80%). One hundred ninety-one (43%) of the bereaved parents were fathers, and 251 (56%) were mothers. Bereaved parents were asked whether or not, and to what extent, they had worked through their grief. They were also asked about their physical and psychological well-being. For outcomes of interest, we report relative risk (RR) with 95% CIs as well as unadjusted odds ratios and adjusted odds ratios. RESULTS: Parents with unresolved grief reported significantly worsening psychological health (fathers: RR, 3.6; 95% CI, 2.0 to 6.4; mothers: RR, 2.9; 95% CI, 1.9 to 4.4) and physical health (fathers: RR, 2.8; 95% CI, 1.8 to 4.4; mothers: RR, 2.3; 95% CI, 1.6 to 3.3) compared with those who had worked through their grief. Fathers with unresolved grief also displayed a significantly higher risk of sleep difficulties (RR, 6.7; 95% CI, 2.5 to 17.8). Mothers, however, reported increased visits with physicians during the previous 5 years (RR, 1.7; 95% CI, 1.1 to 2.6) as well as a greater likelihood of taking sick leave when they had not worked through their grief (RR, 2.1; 95% CI, 1.2 to 3.5). CONCLUSION: Parents who have not worked through their grief are at increased risk of long-term mental and physical morbidity, increased health service use, and increased sick leave.