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Modern liver surgery has improved the percentage of potentially resectable malignant tumors. However, if the future liver remnant is small, patients remain at risk of developing postoperative liver failure. Thus, the future liver remnant must be increased, while at the same time, the primary tumor may have to be controlled by chemotherapy. To address this conflict, we retrospectively analyzed the changes in hypertrophy before and after Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) or Portal Vein Embolization (PVE), with or without parallel systemic chemotherapy. We retrospectively analysed 172 patients (54 female and 118 male), treated with ALPPS in 90 patients (median age 61 years [Q1, Q3: 52,71]) and with PVE in 82 patients (median age 66 years [Q1, Q3: 56,73]). The median control interval was 4.9 [Q1, Q3: 4.0, 6.0] weeks after the PVE, and 2.6 [Q1, Q3: 1.6, 5.8] weeks after ALPPS step 1. The overall kinetic growth rate (median) for the entire group was 0.02 (2%) per week. When systemic chemotherapy was administered prior to intervention, the kinetic growth rate of these treated patients (vs. untreated) exhibited a median of 0.020 [Q1, Q3: 0.011, 0.067] compared to 0.024 [Q1, Q3: 0.013, 0.041] (p = 0.949). When chemotherapy was administered after the PVE/ ALPPS treatment, the kinetic growth rate declined from a median of 0.025 [Q1, Q3: 0.013, 0.053] to 0.011 [Q1, Q3: 0.007, 0.021] (p = 0.005). Subgroup analysis showed statistically significant effects only in the PVE group (median ALPPS -45% (p = 0.157), PVE -47% (p = 0.005)). This retrospective analysis indicated that systemic chemotherapy given after PVE/ the first step of the ALPPS procedure, i.e., the growth phase, has a negative effect on the kinetic growth rate.

After one year of the pandemic and hints of seasonal patterns, temporal variations of in-hospital mortality in COVID-19 are widely unknown. Additionally, heterogeneous data regarding clinical indicators predicting disease severity has been published. However, there is a need for a risk stratification model integrating the effects on disease severity and mortality to support clinical decision-making. We conducted a multicenter, observational, prospective, epidemiological cohort study at 45 hospitals in Germany. Until 1 January 2021, all hospitalized SARS CoV-2 positive patients were included. A comprehensive data set was collected in a cohort of seven hospitals. The primary objective was disease severity and prediction of mild, severe, and fatal cases. Ancillary analyses included a temporal analysis of all hospitalized COVID-19 patients for the entire year 2020. A total of 4704 COVID-19 patients were hospitalized with a mortality rate of 19% (890/4704). Rates of mortality, need for ventilation, pneumonia, and respiratory insufficiency showed temporal variations, whereas age had a strong influence on the course of mortality. In cohort conducting analyses, prognostic factors for fatal/severe disease were: age (odds ratio (OR) 1.704, CI:[1.221-2.377]), respiratory rate (OR 1.688, CI:[1.222-2.333]), lactate dehydrogenase (LDH) (OR 1.312, CI:[1.015-1.695]), C-reactive protein (CRP) (OR 2.132, CI:[1.533-2.965]), and creatinine values (OR 2.573, CI:[1.593-4.154]. Age, respiratory rate, LDH, CRP, and creatinine at baseline are associated with all cause death, and need for ventilation/ICU treatment in a nationwide series of COVID 19 hospitalized patients. Especially age plays an important prognostic role. In-hospital mortality showed temporal variation during the year 2020, influenced by age.

With the emergence of new subvariants, the disease severity of Severe Acute Respiratory Syndrome Coronavirus-2 has attenuated. This study aimed to compare the disease severity in patients hospitalized with omicron variant infection to those with influenza infection. We compared data from the multicenter observational, prospective, epidemiological \"CORONA Germany\" (Clinical Outcome and Risk in hospitalized COVID-19 patients) study on patients infected with Severe Acute Respiratory Syndrome Coronavirus-2 to retrospective data on influenza infection cases from November 2016 to August 2022. Severe Acute Respiratory Syndrome Coronavirus-2 cases were classified as wild-type/delta variant before January 2022, or omicron variant from January 2022 onward. The primary outcome was in-hospital mortality, adjusted for age, gender, and comorbidities. The study included 35,806 patients from 53 hospitals in Germany, including 4,916 patients (13.7%) with influenza infection, 16,654 patients (46.5%) with wild-type/delta variant infection, and 14,236 patients (39.8%) with omicron variant infection. In-hospital mortality was highest in patients with wild-type/delta variant infection (16.8%), followed by patients with omicron variant infection (8.4%) and patients with influenza infection (4.7%). In the adjusted analysis, higher age was the strongest predictor for in-hospital mortality (age 80 years vs. age 50 years: OR 4.25, 95% CI 3.10-5.83). Both, patients with wild-type/delta variant infection (OR 3.54, 95% CI 3.02-4.15) and patients with omicron variant infection (OR 1.56, 95% CI 1.32-1.84) had a higher risk for in-hospital mortality than patients with influenza infection. After adjusting for age, gender and comorbidities, patients with wild-type/delta variant infection had the highest risk for in-hospital mortality compared to patients with influenza infection. Even for patients with omicron variant infection, the adjusted risk for in-hospital mortality was higher than for patients with influenza infection. The adjusted risk for in-hospital mortality showed a strong age dependency across all virus types and variants. NCT04659187.

Background Machine learning (ML) algorithms have been trained to early predict critical in-hospital events from COVID-19 using patient data at admission, but little is known on how their performance compares with each other and/or with statistical logistic regression (LR). This prospective multicentre cohort study compares the performance of a LR and five ML models on the contribution of influencing predictors and predictor-to-event relationships on prediction model´s performance. Methods We used 25 baseline variables of 490 COVID-19 patients admitted to 8 hospitals in Germany (March–November 2020) to develop and validate (75/25 random-split) 3 linear (L1 and L2 penalty, elastic net [EN]) and 2 non-linear (support vector machine [SVM] with radial kernel, random forest [RF]) ML approaches for predicting critical events defined by intensive care unit transfer, invasive ventilation and/or death (composite end-point: 181 patients). Models were compared for performance (area-under-the-receiver-operating characteristic-curve [AUC], Brier score) and predictor importance (performance-loss metrics, partial-dependence profiles). Results Models performed close with a small benefit for LR (utilizing restricted cubic splines for non-linearity) and RF (AUC means: 0.763–0.731 [RF–L1]); Brier scores: 0.184–0.197 [LR–L1]). Top ranked predictor variables (consistently highest importance: C-reactive protein) were largely identical across models, except creatinine, which exhibited marginal (L1, L2, EN, SVM) or high/non-linear effects (LR, RF) on events. Conclusions Although the LR and ML models analysed showed no strong differences in performance and the most influencing predictors for COVID-19-related event prediction, our results indicate a predictive benefit from taking account for non-linear predictor-to-event relationships and effects. Future efforts should focus on leveraging data-driven ML technologies from static towards dynamic modelling solutions that continuously learn and adapt to changes in data environments during the evolving pandemic. Trial registration number : NCT04659187.

Purpose Treatment of knee dislocation is still controversial. There is no evidence to favour ligament suture or reconstruction. Until now, no meta-analyses have examined suture versus reconstruction of cruciate ligaments in knee dislocations with respect to injury pattern and rupture classification. Methods We searched Medline, the Cochrane Controlled Trial Database, and EMBASE for studies on surgical treatment for ‘knee dislocation’ and ‘multiple ligament injured knee’. A meta-analysis was performed using individual patient data. Results Nine studies including 195 patients (200 knees) with a mean age of 31.4 (±13) years fulfilled the study requirements. Thirteen cases of type II dislocations, 63 cases of type III medial, 84 cases of type III lateral, and 40 cases of type IV dislocations, according to Schenck’s classification, were found. Poor or moderate results were found in 70 % of patients without surgical treatment of ACL or PCL ( n  = 27). Patients ( n  = 40) treated by sutures of the ACL and PCL demonstrated a significantly greater proportion of excellent or good results (40 and 37.5 %, respectively) ( p  < 0.001). Patients who underwent reconstruction of the ACL and PCL ( n  = 75) showed excellent or good results (28 and 45 %, respectively). No significant difference was found when comparing suture versus reconstruction of the ACL and PCL (n.s.). The outcome depends considerably on Schenck’s injury pattern classification. Conclusion Conservative treatment after knee dislocation yields poor clinical results. Suture repair of cruciate ligaments can still serve as an alternative option for multiligament injuries of the knee and achieve good clinical results, which are comparable to those of ligament reconstruction. The data provided by this meta-analysis should be reinforced by a prospective study, in which suture repair and ligament reconstruction are compared. Level of evidence IV.

Previous studies have indicated that glabellar botulinum toxin (BTX) injections may lead to a sustained alleviation of depression. This may be accomplished by the disruption of a facial feedback loop, which potentially mitigates the experience of negative emotions. Accordingly, glabellar BTX injection can attenuate amygdala activity in response to emotional stimuli. A prototypic condition with an excess of negative emotionality and impulsivity accompanied by elevated amygdala reactivity to emotional stimuli is borderline personality disorder (BPD). In order to improve the understanding of how glabellar BTX may affect the processing of emotional stimuli and impulsivity, we conducted a functional magnetic resonance imaging (fMRI) study. Our hypotheses were (1) glabellar BTX leads to increased activation in prefrontal areas during inhibition performance and (2) BTX decreases amygdala activity during the processing of emotional stimuli in general. Using an emotional go-/no-go paradigm during fMRI, the interference of emotion processing and impulsivity in a sample of n = 45 women with BPD was assessed. Subjects were randomly assigned to BTX treatment or serial acupuncture (ACU) of the head. After 4 weeks, both treatments led to a reduction in the symptoms of BPD. However, BTX treatment was specifically associated with improved inhibition performance and increased activity in the motor cortex. In addition, the processing of negative emotional faces was accompanied by a reduction in right amygdala activity. This study provides the first evidence that glabellar BTX injections may modify central neurobiological and behavioural aspects of BPD. Since the control treatment produced similar clinical effects, these neurobiological findings may be specific to BTX and not a general correlate of symptomatic improvement.

Background Pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB2) in patients with paroxysmal and persistent atrial fibrillation (AF) has demonstrated encouraging acute and mid-term results. Follow-up data on outcome beyond 1-year is lacking. The purpose of this analysis was to investigate the 2-year clinical outcome after CB2-based PVI. Methods Sixty patients (age 62 ± 11 years) with paroxysmal [45/60 (75 %) patients] or short-standing persistent AF [15/60 (25 %) patients] underwent 28-mm CB2-based PVI. Freeze-cycle duration was 240 s. After successful PVI, a bonus freeze-cycle of the same duration was applied. Follow-up was based on outpatient clinic visits at 3, 6, 12, 18, and 24 months including 24 h Holter-ECGs and telephone interviews. Recurrence was defined as any symptomatic and/or documented atrial tachyarrhythmia (ATA) episode >30 s following a 3-month blanking period. Results A total of 231 pulmonary veins (PV) were identified and 230/231 (99.6 %) PVs were successfully isolated. Phrenic nerve palsy occurred in 2/60 (3.3 %) patients. No other periprocedural complications occurred. Follow-up was available for 59/60 (98 %) patients with a mean duration of 838 ± 67 days. A total of 43/59 (73 %) patients remained in stable sinus rhythm. In 10/16 (63 %) patients with ATA recurrence, a repeat procedure was performed using radiofrequency energy. The overall success rate after a maximum of two ablation procedures and a follow-up period of 838 ± 67 days was 88 % (52/59) patients. Conclusions Patients with paroxysmal or short-persistent AF undergoing PVI using the 28-mm CB2 demonstrated a 73 % 2-year single-procedure clinical success rate.

AimsThis study aimed to evaluate feasibility and safety as well as 1-year clinical outcome of pulmonary vein isolation (PVI) using a unique radiofrequency ablation catheter (“Thermocool SmartTouch SurroundFlow”; STSF) incorporating both, contact force (CF) sensing technology and enhanced tip irrigation with 56 holes, in one device.MethodsA total of 110 patients suffering from drug-refractory atrial fibrillation underwent wide area circumferential PVI using either the STSF ablation catheter (75 consecutive patients, study group) or a CF catheter with conventional tip irrigation (“Thermocool SmartTouch”, 35 consecutive patients, control group). For each ablation lesion, a target CF of ≥ 10–39 g and a force time integral (FTI) of > 400 g s was targeted.ResultsAcute PVI was achieved in all patients with target CF obtained in > 85% of ablation points when using either device. Mean procedure time (131.3 ± 33.7 min in the study group vs. 133.0 ± 42.0 min in the control group; p = 0.99), mean fluoroscopy time (14.0 ± 6 vs. 13.5 ± 6.6 min; p = 0.56) and total ablation time were not significantly different (1751.0 ± 394.0 vs. 1604.6 ± 287.8 s; p = 0.2). However, there was a marked reduction in total irrigation fluid delivery by 51.7% (265.52 ± 64.4 vs. 539.6 ± 118.2 ml; p < 0.01). The Kaplan–Meier estimate 12-month arrhythmia–free survival after the index procedure following a 3-month blanking period was 79.9% (95% CI 70.4%, 90.4%) for the study group and 66.7% for the control group (95% CI 50.2%, 88.5%). This finding did not reach statistical significance (p = 0.18). Major complications occurred in 2/75 patients (2.7%; one pericardial tamponade and one transient ischemic attack) in the study group and no patient in the control group (p = 18).ConclusionPVI using the STSF catheter is safe and effective and results in beneficial 1-year clinical outcome. The improved tip irrigation leads to a significant reduction in procedural fluid burden.

The current study sought to assess the impact of the intraprocedural heart rhythm (sinus rhythm [SR] vs. atrial fibrillation [AF]) on acute procedural characteristics, durability of pulmonary vein isolation (PVI) and long-term clinical outcomes of cryoballoon (CB) ablation. A total of 195 patients with symptomatic paroxysmal (n = 136) or persistent AF (n = 59) underwent CB-based PVI. Ablation procedures were either performed in SR (SR group; n = 147) or during AF (AF group; n = 48). Persistent AF was more frequent in the AF group than in the SR group (62% vs. 20%). All other patient baseline characteristics did not differ between the two groups. The nadir temperature during the CB applications was significantly lower in the AF group than in patients in the SR group (-49 [interquartile range, -44; -54]°C vs. -47 [-42; -52]°C, p = 0.002). Median procedure and fluoroscopy times as well as the rate of real-time recordings were not different between the two groups. Repeat ablation for the treatment of atrial arrhythmia recurrence was performed in 60 patients (SR: 44 [30%] patients; AF: 16 [33%] patients), with a trend towards a lower rate of pulmonary vein reconnections in the AF group (p = 0.07). There was no difference in 3-year arrhythmia-free survival (p = 0.8). Cryoballoon-based PVI during AF results in lower nadir balloon temperatures and a trend towards a higher durability of PVI as compared to procedures performed in SR. The rate of real-time PVI recordings was not affected by the intraprocedural heart rhythm.

Background Portal venous embolization (PVE) is a minimal invasive preoperative strategy that aims to increase future liver remnant (FLR) in order to facilitate extended hemihepatectomy. We analyzed our data retrospectively regarding complications and degree of hypertrophy (DH). Methods: 88 patients received PVE either by particles / coils ( n  = 77) or by glue / oil ( n  = 11), supported by 7 right hepatic vein embolizations (HVE) by coils or occluders. All complications were categorized by the Clavien- Dindo (CD) and the CIRSE classification. Results In 88 patients (median age 68 years) there was one intervention with a biliary leak and subsequent drainage (complication grade 3 CD, CIRSE 3), two with prolonged hospital stay (grade 2 CD, grade 3 CIRSE) and 13 complications grade 1 CD, but no complications of grade 4 or higher neither in Clavien- Dindo nor in CIRSE classification. The median relative increase in FLR was 47% (SD 35%). The mean pre-intervention standardized FLR rose from 23% (SD 10%) to a post-intervention standardized FLR of 32% (SD 12%). The degree of hypertrophy (DH) was 9,3% (SD 5,2%) and the kinetic growth rate (KGR) per week was 2,06 (SD 1,84). Conclusion PVE and, if necessary, additional sequential HVE were safe procedures with a low rate of complications and facilitated sufficient preoperative hypertrophy of the future liver remnant.