10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial

OBJECTIVES: This study was designed to compare the long-term clinical outcome of coronary artery bypass grafting (CABG) with intracoronary stenting of patients with isolated proximal left anterior descending coronary artery. BACKGROUND: Although numerous trials have compared coronary angioplasty with bypass surgery, none assessed the clinical evaluation in the long term. METHODS: We evaluated the 10-year clinical outcome in the SIMA (Stent versus Internal Mammary Artery grafting) trial. Patients were randomly assigned to stent implantation versus CABG. RESULTS: Of 123 randomized patients, 59 underwent CABG and 62 received a stent (2 patients were excluded). Follow-up after 10 years was obtained for 98% of the randomized patients. Twenty-six patients (42%) in the percutaneous coronary intervention group and 10 patients (17%) in the CABG group reached an end point (p < 0.001). This difference was due to a higher need for additional revascularization. The incidences of death and myocardial infarction were identical at 10%. Progression of the disease requiring additional revascularization was rare (5%) and was similar for the 2 groups. Stent thrombosis occurred in 2 patients (3%). Angina functional class showed no significant differences between the 2 groups. CONCLUSIONS: Both stent implantation and CABG are safe and highly effective in relieving symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Stenting with bare-metal stents is associated with a higher need for repeat interventions. The long-term prognosis for these patients is excellent with either mode of revascularization.

Diagnostic accuracy of exercise electrocardiogram in patients with left anterior hemi-block

BACKGROUND: Left anterior hemiblock (LAHB) is the most frequent conduction abnormality, but its impact on the diagnostic accuracy of the exercise ECG has not been studied. The aim of our study was to determine the diagnostic accuracy of ST depression for predicting ischaemia in the presence of LAHB. PATIENTS: Consecutive patients with known or suspected coronary heart disease undergoing exercise ECG and 99mTc-sestamibi single photon emission computed tomography (SPECT) were included in the analysis. Patients with left bundle branch block, with changes in QRS morphology related to myocardial infarction, and patients who had undergone pharmacological stress testing were excluded. RESULTS: Of 1532 patients assessed, 567 patients qualified for the analysis. In 69 patients with LAHB, ECG stress testing had lower sensitivity (38% vs 86%) and lower negative predictive value (82% vs 92%) than in patients with normal baseline ECG. The reduction of sensitivity appeared to be similar in patients with isolated LAHB (n=43), in patients with right bundle branch block (n=39), and with bifascicular block (n=26). In contrast, the positive predictive value of the test was excellent. CONCLUSION: The diagnostic accuracy of the exercise ECG for prediction of ischaemia is reduced in patients with LAHB.

Unstable bicondylar tibial plateau fractures: a clinical investigation

OBJECTIVE: To evaluate fracture patterns in bicondylar tibial plateau fractures and their impact on treatment strategy. DESIGN: Prospective data analysis with documentation of initial injury and treatment strategy, computed tomography scans, conventional x-rays, long-term evaluation of radiographs, and functional assessments. SETTING: Level 1 regional trauma center. PATIENTS: Prospective data acquisition of 14 consecutive patients (10 male and 4 female) with a bicondylar tibial plateau fracture (AO Type C). INTERVENTION: Application of a stepwise reconstruction strategy of the tibial plateau starting with the reposition and fixation of the posteromedial split fragment using a 3.5 buttress plate, followed by reposition and grafting of the lateral compartment and lateral fixation with a 3.5 plate in 90 degree to the medial fixation device. MAIN OUTCOME MEASUREMENTS: All patients were evaluated with full-length standing film, standardized x-rays, Lysholm score for functional assessment, and patient's self-appraisal. RESULTS: Most of the complex bicondylar fractures follow a regular pattern in that the medial compartment is split in a mediolateral direction with a posteromedial main fragment, combined with various amounts of multifragmental lateral compartment depression. The technique introduced allows for accurate and stable reduction and fixation of this fracture type. The final Lysholm knee score showed an average of 83.5 points (range: 64.5-92). CONCLUSIONS: Complex bicondylar tibial plateau fractures follow a regular pattern, which is not represented in existing 2-dimensional fracture classifications. A 2-incision technique starting with the reduction of the posteromedial edge results in accurate fracture reduction with low complication rates and excellent knee function.

Shell brace for stage II posterior tibial tendon insufficiency

BACKGROUND: The nonoperative treatment of posterior tibial tendon insufficiency (PTTI) can lead to unsatisfactory functional results. Short-term results are available but the impact on the evolution of the deformity is not known. To address these problems, a new brace for the flexible Stage II deformity was developed, and midterm followup was obtained. MATERIALS AND METHOD: In a prospective case series, eighteen patients (mean age 64.2 years; range, 31 to 82; four male, 14 female) with flexible Stage II PTTI were fitted with the new custom-molded foot orthosis. At latest followup of a mean of 61.4 (range, 20 to 87) months, functional results were assessed with the AOFAS ankle hindfoot score and clinical or radiographic progression was recorded. RESULTS: The score improved significantly from a mean of 56 points (range, 20 to 64) to a mean of 82 points (range, 64 to 100, p < 0.001). Three patients (3/18, 16%) had a clinical progression to a fixed deformity (Stage III) and a radiographic increase of their deformity. All the other patients were satisfied with the brace's comfort and noted an improvement in their mobility. Complications were seen in three patients (3/18, 16%), and consisted of the development of calluses. CONCLUSION: The "shell brace" is a valuable option for nonoperative treatment of the flexible Stage II PTTI. Hindfoot flexibility was conserved throughout the observation period in all but three patients. Functional outcome and patient acceptance was above average. Problems were few, and closely associated with a progression to a fixed, Stage III deformity.

A rare anomaly of the anterior communicating artery complex hidden by a large broad-neck aneurysm and disclosed by three-dimensional rotational angiography

Double fenestration of the anterior communicating artery (ACoA) complex associated with an aneurysm is a very rare finding and is usually caused by ACoA duplication and the presence of a median artery of the corpus callosum (MACC). We present a patient in whom double fenestration was not associated with ACoA duplication or even with MACC, representing therefore, a previously unreported anatomic variation. A 43 year old woman experienced sudden headache and the CT scans showed subarachnoid haemorrhage (SAH). On admission, her clinical condition was consistent with Hunt and Hess grade II. Conventional digital subtraction angiography (DSA) was performed and revealed multiple intracranial aneurysms arising from both middle cerebral arteries (MCA) and from the ACoA. Three-dimensional rotational angiography (3D-RA) disclosed a double fenestration of the ACoA complex which was missed by DSA. The patient underwent a classic pterional approach in order to achieve occlusion of both left MCA and ACoA aneurysms by surgical clipping. The post-operative period was uneventful. A rare anatomical variation characterised by a double fenestration not associated with ACoA duplication or MACC is described. The DSA images missed the double fenestration which was disclosed by 3D-RA, indicating the importance of 3D-RA in the diagnosis and surgical planning of intracranial aneurysms.

[Computer-aided surgery of the paranasal sinuses and the anterior skull base]

Endoscopic or microscopic surgery for chronic rhinosinusitis with or without nasal polyps is a routine intervention in daily practice. It is often a delicate and difficult minimally invasive intervention in a narrow space, with a tunnel view of 4 mm in the case of endoscopy and frequent bleeding in chronically inflamed tissue. Therefore, orientation in such a "labyrinth" is often difficult. In the case of polyp recurrence or tumors, the normal anatomical landmarks are often missing, which renders orientation even more difficult. In such cases, computer-aided navigation together with images such as those from computed tomography or magnetic resonance imaging can support the surgeon to make the operation more accurate and, in some cases, faster. Computer-aided surgery also has great potential for education.

Simultaneous, bilateral anterior ischemic optic neuropathy (AION) in polycythemia vera: a case report

BACKGROUND: Polycythemia vera (PV) is a hemopoetic disorder. Apparently, although thrombosis accounts for the majority of morbidity, AION has not been associated with PV so far. PATIENT AND FINDINGS: A 63 y-old woman with PV was hospitalized because of acute liver failure. She also experienced bilateral painless loss of vision. Bilateral, pale optic disc swelling with flame-like hemorrhages, more pronounced in the right eye, constricted visual fields, and relative afferent papillary defect (RAPD) on the right side were present. Computer tomography scan revealed no signs of intraorbital pathology, elevated intracranial pressure or hemorrhages. CLINICAL COURSE: We interpreted the findings as AION associated with the hyperviscosity syndrome. Liver transplantation had to be carried out in the next days. Three weeks later, vision improved slightly, but RAPD persisted, and disc pallor developed in both eyes. The patient died two months later. DISCUSSION: Central retinal artery and vein occlusions have been described as complications of Essential thrombocythemia, but not of PV. We observed a rare case of bilateral neuropathy suggestive of AION. This condition has so far not been associated with PV.

[Safety of treatment with tacrolimus ointment for anterior segment inflammatory diseases]

BACKGROUND: The off-label use of topical tacrolimus (Protopic) for inflammatory external eye diseases is gaining popularity. However, there are no reports on the safety profile of this new treatment option. PATIENTS AND METHODS: We treated six patients with different inflammatory eye diseases with topical tacrolimus (Protopic 0.03 %) as off-label use in addition to the conventional anti-inflammatory treatment. Patients were interviewed for side effects and serum drug concentrations were measured under steady state conditions one hour after topical application of tacrolimus ointment. RESULTS: Two patients reported a slight burning sensation immediately after application, in one patient we found a slight worsening of the dry eye problems. No patient abandoned the treatment due to side effects. Serum drug concentrations remained below the analytical threshold in all cases (< 1.5 ng/ml). CONCLUSIONS: Tacrolimus for the topical treatment of anterior segment inflammatory eye diseases is well tolerated without detectable systemic drug resorption.

Changes in blood flow velocity in the middle and anterior cerebral arteries evoked by walking

PURPOSE: Transcranial Doppler sonography (TCD) is an established method for assessing changes in blood flow velocity (BFV) coupled to brain activity. Our objective was to investigate whether walking induces measurable changes in BFV in healthy subjects. METHODS: Changes in BFV in both middle cerebral arteries (MCAs) of 40 healthy adult subjects during walking on a treadmill were measured using bilateral TCD. In 8 of the 40 subjects, 1 anterior cerebral artery (ACA) was monitored simultaneously with the contralateral MCA. The percentage increase in BFV (BFVI%) compared with the baseline velocity (V(0)), the percentage decrease in BFV (BFVD%) compared with the V(0), and the normalized ACA-MCA ratio were analyzed. RESULTS: The overall mean (+/- standard deviation [SD]) V(0) was 59.9 +/- 11.6 cm/second in the left MCA and 60.1 +/- 12.9 cm/second in the right MCA. Women had higher V(0) values than men had. Walking evoked an initial mean overall BFVI% in both left (8.4 +/- 5.1%) and right MCAs (9.1 +/- 5.1%), followed by a decrease to below baseline values in 38 of 40 subjects. A statistically significant increase of the normalized ACA-MCA ratio was measured, indicating that changes in BFV in the ACA territory were coupled to brain activation during walking. CONCLUSIONS: The use of functional TCD showed different changes in BFV in the ACAs and MCAs during walking. This method may be an interesting tool for monitoring progress in patients with motor deficits of the legs, such as paresis.

Accelerated hypertrophic chondrocyte kinetics in GDF-7 deficient murine tibial growth plates

The Growth/Differentiation Factors (GDFs) are a subgroup of the Bone Morphogenetic Proteins (BMPs) well known for their role in joint formation and chondrogenesis. Mice deficient in one of these signaling molecules, GDF-5, have recently been shown to exhibit a decreased rate of endochondral bone growth in the proximal tibia due to a significantly longer hypertrophic phase duration. GDF-7 is a related family member, which exhibits a high degree of sequence identity with GDF-5. The purpose of the present study was to determine whether GDF-7 deficiency also alters the endochondral bone growth rate in mice and, if so, how this is achieved. Stereologic and cell kinetic parameters in proximal tibial growth plates from 5-week-old female GDF-7 -/- mice and wild type control littermates were examined. GDF-7 deficiency resulted in a statistically significant increase in growth rate (+26%; p = 0.0084) and rate of cell loss at the chondrosseous junction (+25%; p = 0.0217). Cells from GDF-7 deficient mice also exhibited a significantly shorter hypertrophic phase duration compared to wild type controls (-27%; p = 0.0326). These data demonstrate that, in the absence of GDF-7, the rate of endochondral bone growth is affected through the modulation of hypertrophic phase duration in growth plate chondrocytes. These findings further support a growing body of evidence implicating the GDFs in the formation, maturation, and maintenance of healthy cartilage.

Tibial or hip BMD predict clinical fracture risk equally well: results from a prospective study in 700 elderly Swiss women

In a randomly selected cohort of Swiss community-dwelling elderly women prospectively followed up for 2.8 +/- 0.6 years, clinical fractures were assessed twice yearly. Bone mineral density (BMD) measured at tibial diaphysis (T-DIA) and tibial epiphysis (T-EPI) using dual-energy X-ray absorptiometry (DXA) was shown to be a valid alternative to lumbar spine or hip BMD in predicting fractures.

The mean anatomical shape of the tibial plateau at the knee arthroplasty resection level: an investigation using MRI

Clinical assessments after Total Knee Arthroplasty (TKA) show persisting pain after implantation in over 20% of patients. Impingement of soft tissue around the knee, due to imprecise geometry of the tibial implant, can be one reason for persisting ailment. Two hundred and thirty seven MRI scans were evaluated using an active contour detection algorithm (snake) to obtain a high-resolution mean anatomical shape of the tibial plateau. Differences between female and male, older and younger (40) and left and right averaged shapes were determined. The shapes obtained were asymmetric throughout. Absolute differences between the subgroups fell short of inter-individual variations represented by calculated one-sigma confidence intervals. Our results indicate that a differentiation in TKA tibial plateau design by gender, age, or side is of minor relevance.