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Upper gastrointestinal symptoms are among the most common reasons for medical consultation and represent a challenge for general practitioners in the outpatient care setting. History taking, symptom evaluation and physical examination are the crucial steps toward establishing an initial working diagnosis. The subsequent abdominal ultrasound and laboratory analyses are essential tools for the differential diagnosis.

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BACKGROUND: The quality of the donor heart and the individual risk of the recipient awaiting heart transplantation are difficult to assess. We investigated whether routinely used intensive care scoring systems can provide additional prognostic information on outcomes after heart transplantation. METHODS: A total of 114 consecutive patients who underwent heart transplantation were included. The Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Sequential Organ Failure Assessment (SOFA) scores were calculated for donors and recipients. Risk factors such as the donor's cause of death, donor's catecholamine use, dialysis status of the recipient, and smoking pattern of the donor and the recipient were assessed. The association of these parameters with mortality, length of stay on the intensive care unit, and need for invasive ventilation was investigated. RESULTS: The median APACHE II score of the donors was 20 (confidence interval [CI], 19-20), the median SAPS II score was 46 (CI, 45-48), and the median SOFA score was 10 (CI, 9-10). In contrast, the median scores of the recipients were as follows: APACHE II, 7 (CI, 6-8); SAPS II, 13 (CI, 12-14); and SOFA, 1 (CI, 1-2). None of the scores as calculated significantly predicted clinical outcome after transplantation. CONCLUSIONS: This study detected no prognostic impact of donor-related risk factors on outcome after heart transplantation. Our findings support the growing practice of also considering organs from donors with high-risk scores for heart transplantation.

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BACKGROUND: Takotsubo syndrome (TTS) is an acute cardiomyopathy associated with intense physical or emotional stress. The precise mechanisms of the disease remain unclear. The aim of this study was to study alterations in endothelial function, vascular compliance and structure and muscle sympathetic activity in the stable phase of the disease. METHODS: In this prospective observational study, patients with TTS and controls matched for age, sex, cardiovascular risk factors and medications were recruited. Flow-mediated vasodilatation (FMD) as a measure of endothelial dysfunction was the primary endpoint. Secondary endpoints included measurements of arterial stiffness, carotid atherosclerosis, quality of life and laboratory parameters. In a subset of patients, muscle sympathetic activity was measured before and after stress tests. RESULTS: The study included 22 TTS patients and 21 matched controls. A significant increase in endothelial dysfunction was seen in TTS compared to controls (FMD 3.4±2.4% vs. 4.8±1.9%, p=0.016). No significant differences in arterial stiffness, intima-media thickness, quality of life and laboratory markers including endothelin-1 were noted. TTS patients showed a reduced carotid total plaque area compared to controls (TPA 17.3±15.1 vs 24.7±12.8mm2, p=0.02). A trend of increased muscle sympathetic activity at rest was observed in TTS patients vs. controls (53.5±28.4 vs. 29.4±16.5 bursts/100 heart beats, p=0.09) with no significant differences in muscle sympathetic activity in response to stress. CONCLUSIONS: Our findings underscore the importance of endothelial dysfunction in patients with TTS which may be involved in the pathophysiology of this syndrome. CLINICALTRIALS. GOV IDENTIFIER: NCT01249599.

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BACKGROUND: Thrombogenicity is one of the main parameters tested in vitro to evaluate the hemocompatibility of artificial surfaces. While the influence of the temperature on platelet aggregation has been addressed by several studies, the temperature influence on the adherence of platelets to body foreign surfaces as an important aspect of biomedical device handling has not yet been explored. Therefore, we analyzed the influence of two typically applied incubation-temperatures (22°C and 37°C) on the adhesion of platelets to biomaterials. MATERIAL AND METHODS: Thrombogenicity of three different polymers - medical grade poly(dimethyl siloxane) (PDMS), polytetrafluoroethylene (PTFE) and polyethylene terephthalate (PET) - were studied in an in vitro static test. Platelet adhesion was studied with stringently characterized blood from apparently healthy subjects. Collection of whole blood and preparation of platelet rich plasma (PRP) was carried out at room temperature (22°C). PRP was incubated with the polymers either at 22°C or 37°C. Surface adherent platelets were fixed, fluorescently labelled and assessed by an image-based approach. RESULTS AND DISCUSSION: Differences in the density of adherent platelets after incubation at 22°C and 37°C occurred on PDMS and PET. Similar levels of adherent platelets were observed on the very thrombogenic PTFE. The covered surface areas per single platelet were analyzed to measure the state of platelet activation and revealed no differences between the two incubation temperatures for any of the analyzed polymers. Irrespective of the observed differences between the low and medium thrombogenic PDMS and PET and the higher variability at 22°C, the thrombogenicity of the three investigated polymers was evaluated being comparable at both incubation temperatures.

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We present the case of a 43-year-old man with the diagnosis of a posterior and anterior wall infarction who was taken to our institution after prolonged cardioplumonary resuscitation. Cardiac catheterization showed thrombotic occlusion of the LAD and a subtotal stenosis of the right coronary artery. Both lesions were revascularized by PCI. Despite catecholamine infusion, the patient developed severe cardiogenic shock with multiorgan dysfunction syndrome under therapeutic hypothermia. Thus, an Impella® CP, a percutaneous left ventricular assist device (LVAD), was implanted. Due to effective LVAD support, it was possible to wean and remove the device after 75 h of support. The impaired left ventricular ejection fraction and wall-motion abnormalities which were present on day 1 achieved complete recuperation on day 14. The patient was discharged without any neurological deficits.

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INTRODUCTION: There are conflicting reports on the posttransplantation morbidity and mortality of patients listed urgently and/or supported by a ventricular assist device (VAD). The aim of this study was to analyze the outcomes with regard to pretransplantation condition (elective, urgent, VAD). METHODS: All adult recipients between January 1, 2005, and October 31, 2012, were included. Demographics; preoperative, operative, and postoperative data; outpatient follow-up; and donor characteristics were collected and analyzed. RESULTS: Of a total of 74 patients, 19 were listed urgently, 20 had a Berlin Heart EXCOR BVAD (biventricular assist device) (Berlin Heart, Berlin, Germany) (8 urgent), 7 had a Berlin Heart INCOR left VAD (Berlin Heart, Berlin, Germany) (2 urgent), and 2 had a HeartWare left VAD (HeartWare International, Framingham, Mass, USA) (none urgent). Mean age was 52 ± 12years. The overall 30-day, 1-year, and 3-year survival was 90% ± 3%, 79% ± 5%, and 66% ± 7%. There was no difference in survival when comparing urgently listed (95% ± 5%, 84% ± 8%, 74% ± 12%) and elective patients (89% ± 4%, 77% ± 6%, 63% ± 8%; P = .4), and VAD patients (86% ± 6%, 76% ± 8%, 63% ± 11%) and those without mechanical support (93% ± 4%, 81% ± 6%, 69% ± 9%; P = .6). In-hospital outcomes and long-term complications were also comparable. CONCLUSIONS: Our series suggests that urgent patients and patients on a VAD have a posttransplantation outcome comparable to elective patients and patients without a VAD. These data support the effectiveness of the current practice of listing for heart transplantation.

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HISTORY AND ADMISSION FINDINGS: A 37-year-old man complained about a lack of strength, an unproductive cough and myalgia predominantly thigh-focused with subfebrile temperatures for days. INVESTIGATIONS: Laboratory investigations indicated rhabdomyolysis with acute kidney injury (AKI). Drug misuse was denied. Exertion and trauma could be excluded as well as rheumatologic or other infectious causes often responsible for rhabdomyolysis. PCR of a nasopharyngeal swab was positive for influenza A virus subtype H1N1. TREATMENT AND COURSE: Because of a progressive course of AKI haemodialysis was initiated. Levels of creatine kinase declined and urinary excretion rised. Hypocalcaemia due to secondary hyperparathyreoidism was substituted. During hospitalisation two seizures appeared. After performing a magnetic resonance imaging (MRI) the seizures could be attributed to a posterior reversible encephalopathy syndrome (PRES) secondary to influenza infection. A medication with valproic acid was initiated. CONCLUSION: Extrapulmonary manifestations of an influenza A (H1N1) virus infection are rare but have to be considered after exclusion of differential diagnosis in younger patients in particular. In addition to a therapy with neuraminidase inhibitors a symptomatic treatment is of paramount significance.

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Ethical problems as consequences of evidence-based medicine (EBM) have insufficiently been investigated and discussed. EBM--as initially intended--is usually interpreted as an attempt to treat patients individually with respect to their personal preferences and the present situation according to the best available clinical evidence. This practice is in line with accepted medical ethics. Therefore, it does not appear to be a relevant issue for discussion at first sight. However, between the theoretical concept and the practical use (or misuse) of this approach discrepancies exist which require some considerations. In particular the practical use of EBM generates a number of ethical problems: EBM is increasingly misused as an instrument of resource-allocation. Based on randomized controlled trials (RCTs) for very specific patient groups, the general access to medical supply is regulated and limited. The recurrence to general ("supra-individual") external evidence may additionally be in strong contrast to the individual patients' intentions and will and leads to conflicts for therapy decisions. If no longer the individual preferences and the patients' will are in the center of therapy decisions but a so called "general welfare", the mutual trust between patient and doctor is eroded. The utilitaristic approach of a primacy of this general welfare in opposition to the individual welfare is favored by the present interpretation and use of EBM. This conflicts with the perception of the doctor as a patient's advocate. However, the doctor being the patient's advocate is the basis of the traditional medical ethos. We should take care that we do not completely lose the basis of our medical ethos.

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OBJECTIVES: Primary objective of this meta-analysis was to produce a systematic and quantitative review of two independent clinical trials of 20 mg trospium chloride (TCI) twice daily (b.i.d.) in patients with detrusor overactivity [Alloussi et al. 1998, Cardozo et al. 2000]. PATIENTS AND METHODS: In two placebo-controlled, double-blind, multi-center studies, the effect of TCl on detrusor function was evaluated using urodynamic measurements. All 517 patients were randomized to receive TCl or placebo for 3 weeks. Urodynamic variables were measured at the beginning and at the end of the treatment. Safety was evaluated on the basis of adverse events (AEs), vital signs and laboratory tests. RESULTS: TCl produced significant improvements in 'maximum cystometric bladder capacity' (median treatment effect = 52 ml, 95% confidence interval 32-71 ml, p<0.0001) and 'urinary volume at first unstable contraction' (median treatment effect = 48 ml, 95% confidence interval 28 to 68 ml, p = 0.0001). The patients' assessment of efficacy also showed significantly greater clinical improvement in the TCl group than in the placebo group (p < 0.0001). The patients recorded a 'cure' or a 'marked improvement' more often in the TCl group than in the placebo group (47.9% and 19.7%, respectively). TCl was well tolerated, with similar frequencies of AEs reported in both groups (TCl: 35.7%, placebo group: 38.9%). CONCLUSIONS: Trospium chloride (20 mg twice daily) is an effective and safe medication for the treatment of detrusor overactivity.

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Therapy of detrusor hyperactivity with anticholinergic agents often is followed by adverse drug reactions. Intravesical application may be an interesting alternative. A randomised, single-blind, placebo-controlled, mono-centre clinical trial was carried out in 84 patients with urgency or urge incontinence. Due to intravesical administration of oxybutynin (CAS 5633-20-5) (n = 21) and trospium chloride (CAS 10405-02-4) (n = 21), respectively, a significant increase in maximum bladder capacity and decrease of detrusor pressure accompanied by an increase of residual urine were found in comparison to placebo in urodynamical investigations. Improvement of uninhibited bladder contractions occurred leading to higher filling volume. Under verapamil (CAS 152-11-4) (n = 21) no marked changes in the efficacy variables were found compared with placebo. All patients completed the study and were assessed with regard to efficacy and safety. No adverse events or marked changes in the vital signs were reported. The immediate onset of effect and the lack of adverse drug reactions suggest that treatment with topical oxybutynin or trospium chloride is an effective alternative in patients with intolerable side effects when orally treated. In addition, intravesical administration may be indicated in patients with bladder spasms due to indwelling catheter or in order to increase bladder capacity before percutaneous cystostomy.

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The common treatment for patients with extensive damage to the ureter is complete ureteral replacement, combining Boari flap-psoas bladder hitch and downward mobilization of the involved kidney, with complete ideal replacement of the ureter, renal autotransplantation, of elective nephrectomy. Three case reports serve to describe two options of reconstructive treatment for complete ureteral replacement. The operative techniques, their limits, their postoperative results, and the treatment alternatives are discussed with due regard to recent literature. In the case of ileal replacement we have used a very short ileal segment to reduce the absorption surface of the ileal mucosa. Reflux prevention of the ileal segment was performed by creating an invaginated distal ileum nipple which was additionally fixed at the Boari flap by a third stapler row (auto suture TASS) to prevent potential nipple-gliding.

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A 77-year-old female patient presenting with recurrent pulmonary embolism and shock had a severe craniocerebral trauma after collapsing at home 2 days before admission. Since systemic thrombolytic therapy appeared hazardous in this patient, percutaneous fragmentation and distal dispersion of the proximal pulmonary emboli was performed using a pigtail catheter. This procedure improved cardiac output immediately by 15%, whereas the mean pulmonary artery pressure dropped only slightly from 48 to 46 mmHg. Thereafter, a streptokinase infusion of 100,000 IU during 1 h was instituted through the pigtail catheter into the pulmonary artery. 12 hours after the treatment was started, cardiac output was raised by 70% and mean pulmonary artery pressure was decreased from 48 to 25 mmHg. 14 days after admission, control ventilation-perfusion scan showed a markedly improved pulmonary perfusion, and right heart catheterization revealed normal right heart pressures. The patient recovered rapidly and there was no evidence of recurrent pulmonary embolism 18 months later. This report demonstrates that a percutaneous catheter fragmentation of proximal pulmonary emboli combined with local intermediate-dose infusion of streptokinase may be a helpful therapeutic option in patients with massive pulmonary embolism in whom systemic thrombolytic therapy is contraindicated.

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Traditionally, reconstruction of the scrotum has involved the use of split skin or pedicle flaps with often unsatisfactory aesthetic results. We present two cases with loss of the scrotum as a consequence of Fournier's gangrene. The use of tissue expanders for scrotal reconstruction involves the following advantages: excellent functional and cosmetic results, natural appearance of the neoscrotum, preservation of normal function and sensitivity of scrotal skin, no additional scars from skin grafting, and a simple surgical technique.

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A 31-year-old woman was admitted with recurrent pulmonary emboli. The patient subsequently developed right sided hemiplegia. A mobile left atrial mass attached to the interatrial septum was detected and paradoxical embolization was assumed to be the underlying cause of the cerebral event. Leg phlebography and B-mode ultrasonographic imaging showed that the most probable source of embolization was a right popliteal venous aneurysm containing thrombi adherent to the vein wall. The immediate treatment was restricted to full dose heparin therapy and supportive measures. Thirteen days after admission, the aneurysm was excised. Recovery was rapid and the patient was discharged for further rehabilitation with an only minimal neurological deficit 3 weeks after admission.

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The urethral protractor is a new device that helps push the urethral stump upwards together with the urogenital diaphragma. It facilitates suturing the anastomosis in radical prostatectomy and the intestino-urethral anastomosis after cystectomy. With the help of the urethral protractor, the urethral stump can be directed into various positions in order to simplify the localization and control of bleeding close to the urethra. By tilting the urethral protractor to one side, damage to the neurovascular bundles can be avoided when suturing. The urethral protractor consists of a rigid, reusable, suture guide made of stainless steel and a special, disposable balloon catheter.

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Treatment of patients with prostatic cancer with a combination of 1-2 mg depot-estrogen (ethinylestradiol sulfonate = Turisteron) per week and 1 mg dexamethasone per day suppressed the mean testosterone (T) level to 2.8% (0.53 nmol/l), the free T to 0.8% (1.9 pmol/l) and the adrenal androgens (AA) -- androstenedione (A), dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) -- to more than 40% of the initial values. Treatment with Turisteron alone (2 mg per week) did not change the DHEA and DHEAS levels but decreased plasma A concentration to 65% (2.96 nmol/l) of the initial values.

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