Ludwig Maximilian University Research Articles

Effectiveness and tolerability of radiotherapy for patients with indolent non-Hodgkin\u2019s lymphoma: a monocenter analysis

To analyze the effectiveness and toxicities of radiotherapy in indolent non-Hodgkin’s lymphoma (iNHL) patients treated in our institution. Patients with iNHL treated with radiotherapy between 1999 and 2016 were included. The primary endpoint was progression-free survival (PFS). Secondary endpoints were local control (LC), overall survival (OS) and toxicities. PFS, LC, and OS were analyzed using Kaplan–Meier method. Log-rank test was used to investigate the differences between subgroups. Cox proportional hazard model was used for univariate continuous analysis. Seventy-five patients were identified in our institutional database between 1999 and 2016. Fifty-eight (77.3%) had stage I after Ann-Arbor and 17 patients (22.7%) had stage II. The median follow-up was 87 months (95% CI 72–102 months). Median single dose per fraction was 2.0 Gy (range 1.5–2 Gy) and median total dose was 30.6 Gy (range 16–45 Gy). Radiotherapy was performed in 2D (n = 10; 13.3%), 3D (n = 63; 84.0%) and VMAT (n = 2; 2.7%) techniques, respectively. The median PFS was 14.0 years (95% CI 8.3–19.7 years). The estimated PFS after 5 and 10 years were 73.0% and 65.5% in Kaplan–Meier analysis, respectively. The 5- and 10-year LC were 94.9% and 92.3%, respectively. The 5- and 10-year OS were 88.6% and 73.9%. In univariate analyses of PFS, younger patients (≤ 60 years old) had significantly superior PFS to those older than 60 years old (5-year PFS 81.9% vs. 65.1%, p = 0.021). Dose escalation > 36.0 Gy had no prognostic influence in term of PFS (p = 0.425). Extranodal involvement, stage and histology had no prognostic impact on PFS. Depending on the site of lymphomas, the most common acute side effects were: dermatitis CTCAE° I–II (8.0%), xerostomia CTC° I (8.0%), cataract CTC° I (12.0%) and dry eyes CTC° I–II (14.6%). No adverse event CTC° III was reported. Most acute side effects recovered at 3 to 6 months after radiotherapy except for CTC° I cataract and xerostomia. Local Radiotherapy was highly effective for treatment of early stage iNHL with no serious side effects in our cohort. The most acute CTCAE° I–II side effects recovered 3 to 6 months later. Technique advances seem to have further improved effectiveness and tolerability of radiotherapy.Trial registration: Local ethics committee of Ludwig-Maximilian-University (LMU) Munich approved this retrospective analysis on the May 7th, 2019 (Nr. 19–137).

Pachychoroid disease and its association with retinal vein occlusion: a case\u2013control study

The development of a retinal vein occlusion (RVO) is multifactorial. This study investigates pachychoroid as a risk factor for RVO or as an entity sharing common pathophysiology with RVO. A database screening at the University Eye Hospital, Ludwig-Maximilian University Munich, Germany was performed for patients diagnosed with central or branch RVO (CRVO/BRVO). In every patient a complete ophthalmologic examination was performed, including posterior segment enhanced depth spectral domain optical coherence tomography (EDI-SD-OCT). The SD-OCT scans of respective partner eyes without history of RVO were compared to an age- and refraction-matched, randomly recruited normal control group. In total, 312 eyes of 312 patients were included in this study, with 162 eyes in the RVO and 150 eyes in the control group. A significantly higher subfoveal choroidal thickness (SFCT) was found in the RVO (310.3 ± 72.5 (94 to 583) µm) as compared to the control group (237.0 ± 99.0 (62 to 498); p < 0.00001). Moreover, the RVO group showed a significantly higher prevalence of a symptomatic pachychoroid (22 vs. 9 eyes; odds ratio: 2.46; 95 CI: 1.10 to 5.53; p = 0.029). Since pachychoroid disease represents a bilateral entity, it might be a risk factor for RVO, or share risk factors with RVO.

Imagining Rivers: The Aesthetics, History, and Politics of American Waterways. A Conversation Between Lawrence Buell and Christof Mauch

This contribution features a transatlantic conversation between Christof Mauch, environmental historian and Americanist from Ludwig Maximilian University in Munich, and Lawrence Buell, literary scholar and “pioneer” of Ecocriticism from Harvard University. Buell’s The Environmental Imagination: Thoreau, Nature Writing, and the Formation of American Culture (1995) marked the first major attempt to understand the green tradition of environmental writing, nonfiction as well as fiction, beginning in colonial times and continuing into the present day. With Thoreau’s Walden as a touchstone, this seminal book provided an account of the place of nature in the history of Western thought. Other highly acclaimed monographs include Writing for an Endangered World (2001), a book that brought industrialized and exurban landscapes into conversation with one other, and The Future of Environmental Criticism: Environmental Crisis and Literary Imagination (2009), which provides a critical survey of the ecocritical movement since the 1970s, with an eye to the future of the discipline.&#x0D; &#x0D;

Postmortem findings of secondary brodifacoum poisoning in a kestrel (Falco tinnunculus)

AbstractA male common kestrel (Falco tinnunculus) was found dead in a field in April 2019 in the canton of Zurich, Switzerland, and was submitted to the Department for the Protection of Animals and the Environment of the cantonal police Zurich. Because the common kestrel is a protected species, the carcass was forwarded to the Department for Poultry and Rabbit Diseases, University of Zurich, for forensic examination. On necropsy, profuse internal haemorrhage without causal trauma was observed, leading to the suspicion of intoxication with an anticoagulant. Liver tissue samples were sent to the Institute of Pharmacology, Toxicology and Pharmacy of the Ludwig Maximilian University, Munich, Germany, for anticoagulant residue analysis, revealing an amount of 40.3 ng/g brodifacoum, a second‐generation anticoagulant rodenticide. Information from the finding site did not give any evidence of wilful poisoning, thus secondary rodenticide poisoning through intoxicated prey was determined as the cause of death.

Mortality in Cardiogenic Shock Patients Is Predicted by Pao2/Fio2 (Horowitz Index) Measured on ICU After Venoarterial Extracorporeal Membrane Oxygenation Implantation.

Observational, monocentric, retrospective analysis. Cardiac ICU of Ludwig Maximilian University Hospital, Munich, Germany. Two-hundred eleven patients undergoing venoarterial extracorporeal membrane oxygenation treatment for severe cardiogenic shock were included into this analysis. Patients who died within 24 hours after venoarterial extracorporeal membrane oxygenation implantation were excluded. None. To determine lung injury, we investigated the influence of Pao2/Fio2 ratio (Horowitz index). The lowest Horowitz index was measured on ICU 6-12 hours after venoarterial extracorporeal membrane oxygenation implantation. An optimal cutoff value of less than 126 for Horowitz index to predict mortality was identified via receiver operating characteristic analysis (area under the curve, 0.62). Patients with Horowitz index less than 126 had a 30-day mortality rate of 67.5% compared to 37.5% with a Horowitz index greater than or equal to 126 (p < 0.001). Multivariate analysis identified Horowitz index less than 126 as an independent risk factor of ICU mortality (odds ratio, 3.6; 95% CI, 1.8-7.3; p < 0.001). In this hypothesis-generating analysis, a Horowitz index less than 126 is associated with increased mortality in patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation, which may serve as a threshold for further therapeutic interventions.

Spectral domain optical coherence tomography-based retinochoroidal cystine crystal score: a window into infantile nephropathic cystinosis

PrécisCystinosis is a lysosomal storage disease leading to an accumulation of cystine crystals in several organs. We aim to comprehensively describe chorioretinal cystine crystals via spectral domain optical coherence tomography...

Medical students' engagement in the context of the SARS-CoV-2 pandemic: The influence of psychological factors on readiness to volunteer.

Objective: To avert staff shortages during the first wave of the SARS-CoV-2 pandemic in spring 2020, the medical faculties of the Technical University of Munich (TUM) and the Ludwig Maximilian University of Munich (LMU) appealed to their students to volunteer for relief work. In this study, we examine the influence of psychological factors on the students’ decisions to respond to this call or not. Methodology: We report on a cross-sectional study based on an online survey among medical students at the TUM and LMU. The survey consisted of a questionnaire containing items on motivation and other factors related to the decision for or against volunteering. Questions were also asked about anxieties regarding COVID-19 and the occurrence of depressive symptoms, as well as about resilience.Results: Responses from 244 participants were analysed. Students’ decisions to volunteer revealed both altruistic and introjected motivations. For those students who did not volunteer, time overlaps and workload related to other activities played an important role. Between the two groups, no significant difference was detected in terms of their resilience and COVID-19-related anxieties. However, the non-volunteering students reported a significantly higher prevalence of depressive symptoms. Conclusion: Sense of duty and the desire to help were, according to the students, the most important reasons for volunteering. Depressive symptoms and lack of time made volunteering less likely. Resilience and COVID-19-related anxieties do not seem to have had any influence on the decision to volunteer or not.

The association of immunosurveillance and distant metastases in colorectal cancer

BackgroundColorectal cancer (CRC) is the third most common malignancy worldwide, but the key driver to distant metastases is still unknown. This study aimed to elucidate the link between immunosurveillance and organotropism of metastases in CRC by evaluating different gene signatures and pathways.Material and methodsCRC patients undergoing surgery at the Department of General, Visceral and Transplantation Surgery at the Ludwig-Maximilian University Hospital Munich (Munich, Germany) were screened and categorized into M0 (no distant metastases), HEP (liver metastases) and PER (peritoneal carcinomatosis) after a 5-year follow-up. Six patients of each group were randomly selected to conduct a NanoString analysis, which includes 770 genes. Subsequently, all genes were further analyzed by gene set enrichment analysis (GSEA) based on seven main cancer-associated databases.ResultsComparing HEP vs. M0, the gene set associated with the Toll-like receptor (TLR) cascade defined by the Reactome database was significantly overrepresented in HEP. HSP90B1, MAPKAPK3, PPP2CB, PPP2R1A were identified as the core enrichment genes. The immunologic signature pathway GSE6875_TCONV_VS_FOXP3_KO_TREG_DN with FOXP3 as downstream target was significantly overexpressed in M0. RB1, TMEM 100, CFP, ZKSCAN5, DDX50 were the core enrichment genes. Comparing PER vs. M0 no significantly differentially expressed gene signatures were identified.ConclusionChronic inflammation might enhance local tumor growth. This is the first study identifying immune related gene sets differentially expressed between patients with either liver or peritoneal metastases. The present findings suggest that the formation of liver metastases might be associated with TLR-associated pathways. In M0, a high expression of FOXP3 + tumor infiltrating lymphocytes (TILs) seemed to prevent at least in part metastases. Thus, these correlative findings lay the cornerstone to further studies elucidating the underlying mechanisms of organotropism of metastases.

Trace Amine-Associated Receptor 1 (TAAR1) Is a Positive Prognosticator for Epithelial Ovarian Cancer.

Trace amine-associated receptor 1 (TAAR1) is a Gαs- protein coupled receptor that plays an important role in the regulation of the immune system and neurotransmission in the CNS. In ovarian cancer cell lines, stimulation of TAAR1 via 3-iodothyronamine (T1AM) reduces cell viability and induces cell death and DNA damage. Aim of this study was to evaluate the prognostic value of TAAR1 on overall survival of ovarian carcinoma patients and the correlation of TAAR1 expression with clinical parameters. Ovarian cancer tissue of n = 156 patients who were diagnosed with epithelial ovarian cancer (serous, n = 110 (high-grade, n = 80; low-grade, n = 24; unknown, n = 6); clear cell, n = 12; endometrioid, n = 21; mucinous, n = 13), and who underwent surgery at the Department of Obstetrics and Gynecology, University Hospital of the Ludwig-Maximilians University Munich, Germany between 1990 and 2002, were analyzed. The tissue was stained immunohistochemically with anti-TAAR1 and evaluated with the semiquantitative immunoreactive score (IRS). TAAR1 expression was correlated with grading, FIGO and TNM-classification, and analyzed via the Spearman’s rank correlation coefficient. Further statistical analysis was obtained using nonparametric Kruskal-Wallis rank-sum test and Mann-Whitney-U-test. This study shows that high TAAR1 expression is a positive prognosticator for overall survival in ovarian cancer patients and is significantly enhanced in low-grade serous carcinomas compared to high-grade serous carcinomas. The influence of TAAR1 as a positive prognosticator on overall survival indicates a potential prognostic relevance of signal transduction of thyroid hormone derivatives in epithelial ovarian cancer. Further studies are required to evaluate TAAR1 and its role in the development of ovarian cancer.

Editorial: New conversations in development studies

Editorial: New conversations in development studies

Lung ultrasound predicts clinical course but not outcome in COVID-19 ICU patients: a retrospective single-center analysis

BackgroundPoint-of-care lung ultrasound (LU) is an established tool in the first assessment of patients with coronavirus disease (COVID-19). Purpose of this study was to evaluate the value of lung ultrasound in COVID-19 intensive care unit (ICU) patients in predicting clinical course and outcome.MethodsWe analyzed lung ultrasound score (LUS) of all COVID-19 patients admitted from March 2020 to December 2020 to the Internal Intensive Care Unit, Ludwig-Maximilians-University (LMU) of Munich. LU was performed according to a standardized protocol at ICU admission and in case of clinical deterioration with the need for intubation. A normal lung scores 0 points, the worst LUS has 24 points. Patients were stratified in a low (0–12 points) and a high (13–24 points) lung ultrasound score group.ResultsThe study included 42 patients, 69% of them male. The most common comorbidities were hypertension (81%) and obesity (57%). The values of pH (7.42 ± 0.09 vs 7.35 ± 0.1; p = 0.047) and paO2 (107 [80–130] vs 80 [66–93] mmHg; p = 0.034) were significantly reduced in patients of the high LUS group. Furthermore, the duration of ventilation (12.5 [8.3–25] vs 36.5 [9.8–70] days; p = 0.029) was significantly prolonged in this group. Patchy subpleural thickening (n = 38; 90.5%) and subpleural consolidations (n = 23; 54.8%) were present in most patients. Pleural effusion was rare (n = 4; 9.5%). The median total LUS was 11.9 ± 3.9 points. In case of clinical deterioration with the need for intubation, LUS worsened significantly compared to baseline LU. Twelve patients died during the ICU stay (29%). There was no difference in survival in both LUS groups (75% vs 66.7%, p = 0.559).ConclusionsLU can be a useful monitoring tool to predict clinical course but not outcome of COVID-19 ICU patients and can early recognize possible deteriorations.

Silent Spread of SARS-CoV-2 in Ethiopia: Longitudinal Cohort Study Among Frontline Healthcare Workers and Community

Background: Over a year since the first reported case, COVID-19 burden in Ethiopia remains unknown due to limited surveillance. We aimed to investigate seroepidemiology of SARS-CoV-2 among frontline healthcare workers (HCW) and communities in Ethiopia.Methods: We conducted a population-based, prospective, longitudinal cohort study involving HCW, urban residents, and rural communities in Jimma and Addis Ababa. Serology was performed with Elecsys® Anti-SARS-CoV-2 anti-nucleocapsid assay (Roche Diagnostics, Switzerland) in three consecutive rounds with a mean interval of six weeks between tests to obtain seroprevalence and incidence estimates within the cohorts.Findings: SARS-CoV-2 seroprevalence among HCW increased dramatically during the study period: in Addis Ababa from 10·9% (95% Credible Interval: 8·3%; 13·8%) in August 2020 to 53·7% (44·8; 62·5) in February 2021, incidence rate 2,223 (1,785; 2,696) per 100,000 person-weeks; in Jimma from 30·8% (26·9; 34·8) in November 2020 to 56·1% (51·1; 61·1) in February 2021, incidence rate 3,810 (3,149; 4,540) per 100,000 person-weeks. Among urban communities, an almost 40% increase in seroprevalence was observed in early 2021, with incidence rates of 1,622 (1,004; 2,429) in Jimma and 4,646 (2,797; 7,255) per 100,000 person-weeks in Addis Ababa. Seroprevalence in rural communities increased from 18·0% (13·5, 23·2) in November 2020 to 31·0% (22·3, 40·3) in March 2021.Interpretation: SARS-CoV-2 spread in Ethiopia has been highly dynamic among HCW and urban communities. It can be speculated that the greatest wave of SARS-CoV-2 infections is currently evolving in rural Ethiopia and thus requires focused attention in respect to healthcare burden and disease prevention.Funding Information: Bavarian State Ministry of Sciences, Research and the Arts (Bayerisches Staatsministerium, F.4-V0122.4/3/20), Germany Ministry of Education and Research (MoKoCo19; 01KI20271), EU Horizon2020 program (ORCHESTRA; 101016167), Deutsche Forschungsgemeinschaft (SEPAN; HA 7376/3-1), Volkswagenstiftung (E2; 99450).Declaration of Interests: The authors declare no competing interests.Ethics Approval Statement: This research was approved by the institutional review boards of (i) the Jimma University Institute of Health, (ii) St. Paul’s Hospital Millennium Medical College, and (iii) Ludwig Maximilian University of Munich. Additional approvals were obtained from Addis Ababa and Oromia Regional Health Bureaus. Written informed consent was obtained from all participants.

Monitoring of Palliative Care Symptoms and Concerns in Specialized Palliative Home Care Using an Electronic Version of the Integrated Palliative care Outcome Scale (Palli-MONITOR): protocol for a mixed-methods study

IntroductionOver the last decades, patient-reported outcome (PRO) measures have been developed to better understand the patient’s perspective and enable patient-centred care. In palliative care, the Integrated Palliative care Outcome Scale...

Changes in the facial soft tissue profile after maxillary orthognathic surgery.

ObjectivesTo compare the changes of the soft tissue profile in relation to the displacement of the underlying hard structures in maxillary orthognathic surgery and to contribute to the esthetic prediction of the facial profile after surgical procedures.Materials and methodsWe analyzed the sagittal changes in the facial soft tissue profile related to surgical changes in skeletal structures after maxillary osteotomy in a retrospective study. The study sample comprised 115 adult patients between the ages of 18–50 years who had undergone maxillary orthognathic surgery and interdisciplinary orthodontic treatment at the Department of Orthodontics, Ludwig-Maximilians University of Munich, Germany. LeFort I osteotomy cases in both maxillary monognathic and bignathic osteotomy procedures were included. All subjects had received rigid fixation. A cephalometric analysis of presurgical and postsurgical cephalograms was performed and the correlations between hard tissue and soft tissue change ratios were evaluated using a bivariate linear regression analysis. A vertical line through the landmark sella (S) perpendicular to the nasion-sella line (NSL) served as the reference plane.ResultsThe subnasale (Sn) followed the A point (A) by 57%, the soft tissue A point (A′) followed the A point (A) by 73% and the upper lip, represented by the landmark labrale superius (Ls) followed the upper incisor (Is) by 73%; all three in a linear correlation with a mean prediction error of nearly 2 mm.ConclusionThe scatterplots show a linear correlation with a wide spread for all three pairs of reference points. The wide spread and the high prediction error of almost 2 mm indicate low predictability of the expected lip position and Sn.

In celebration of the 70thbirthday of Peter Klüfers

In celebration of the 70^thbirthday of Peter Klüfers

Safety and Efficacy of Current Sclera Fixation Methods for Intraocular Lenses and Literature Overview.

Evaluation of the three currently most common techniques for intraocular lens (IOL) sclera fixation: (1) Prolene suture with Hoffman sclera pocket (2) four-point GoreTex suture technique (3) sutureless flanged intrascleral IOL fixation with double-needle ("Yamane") technique. Retrospective, clinical case series (chart review) at the Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany. Enrolled in the study were 51 patients with 55 eyes. Best-corrected visual acuity (BCVA); manifest refraction (OR); corneal tomography (central corneal thickness, CCT); biometry; central macular thickness (CMT) by optical coherence tomography (OCT); intraocular pressure (IOP); and IOL type and IOL power were recorded and compared prior to and 3 - 12 months post IOL sclera fixation surgery. Pre- and postsurgery difference analysis was performed by Wilcoxon rank sum testing (z). Intrascleral fixation by GoreTex suture was performed in 14 (25.5%) eyes, by Prolene suture in 19 (34.5%,) and by Yamane technique in 22 (40.0%) eyes. Within the 3 - 12 months follow-up post scleral fixation, a total of 2 (14.3%) eyes from the GoreTex, 3 (15.8%) from the Prolene and 1(4.5%) eye from the Yamane group required refixation. Pre- and post-surgery analysis revealed a statistically significant difference in the total patient population BCVA (exact Wilcoxon test: z = - 3.202; p = 0.001; n = 55) and the Yamane subgroup (exact Wilcoxon test: z = - 2.068; p = 0.001; n = 22). The GoreTex (n = 14) and Prolene (n = 19) subgroups revealed no statistically significant differences versus preoperative baseline. Across groups, there was no statistically significant difference in IOP, CMT, and CCT. No retinal complications were observed, neither intraoperatively nor during follow-up. The volume of IOL revision surgery is increasing. Often, the only option left for visual rehabilitation is scleral IOL fixation. All three scleral fixation techniques studied demonstrated a good safety profile with no statistically significant impact on IOP, CMT, CCT, but with a notable revision rate. Visual rehabilitation to preoperative baseline levels (GoreTex [n = 14] and Prolene [n = 19]) and a statistically significant increase in visual acuity (total cohort [n = 55] and Yamane [n = 22]) seems possible. Unlike iris fixation, scleral fixation is surgically more complex and the surgeon must master a steeper learning curve.

A Bibliometric Analysis and Visualisation of Research Trends in Allergy of Cobalt Implants

The metal hypersensitivity of implants is a vital factor affecting the safety of implants. The bibliometric analysis had been conducted to understand the active authors, organizations, journals, and countries involved in the research domain of “allergy of Cobalt implants”. All published articles related to “allergy of Cobalt implants” from “Scopus”, were analyzed using the VOS viewer to develop analysis tables and visualization maps. This article had set the objective to consolidate the scientific literature regarding “allergy of Cobalt implants” and also to find out the trends related to the same. The most active journal in this research domain was Contact Dermatitis. The most active countries were the United States of America and Germany. The leading organization of this research domain was Ludwig Maximilian University of Munich, Germany. The most active author who had made valuable contributions related to the allergy of Cobalt implants was Thomas P.

A Bibliometric Analysis and Visualisation of Research Trends in Allergy of Chromium Implants

The metal hypersensitivity of implants is a vital factor affecting the safety of implants. The bibliometric analysis had been conducted to understand the active authors, organizations, journals, and countries involved in the research domain of “allergy of Chromium implants”. All published articles related to “allergy of Chromium implants” from “Scopus”, were analyzed using the VOS viewer to develop analysis tables and visualization maps. This article had set the objective to consolidate the scientific literature regarding “allergy of Chromium implants” and also to find out the trends related to the same. The most active journal related to this research domain was Contact Dermatitis. The most active countries were the United States of America and Germany. The leading organization was Ludwig Maximilian University of Munich, Germany. The most active authors who had made valuable contributions related to the allergy of implants was Thomas P.

A Bibliometric Analysis and Visualisation of Research Trends in Allergy of knee Implants

Several metals are used for Knee implants. The allergy of metals used for knee implants is an important issue to be addressed. The bibliometric analysis had been conducted to understand the active authors, organizations, journals, and countries involved in the research domain of “Allergy of knee implants”. All published articles related to “Allergy of knee implants” from “Scopus”, were analyzed using the VOS viewer to develop analysis tables and visualization maps. This article had set the objective to consolidate the scientific literature regarding “Allergy of knee implants” and also to find out the trends related to the same. The most active journals in this research domain were the Contact Dermatitis. The most active countries were Germany and Italy. The leading organization engaged in research regarding knee implants was the Ludwig Maximilian University of Germany. The most active authors were Thomas P.; Arkansan J.N, and Drancourt M.

The frequency of performing vascular anastomoses determines the learning curve in a retrospective analysis of 212 participants of the Munich course of microsurgery

Microsurgical courses are a widely accepted and common method of acquiring microsurgical skills outside of the operation theatre. In-vivo models are often used to prepare surgeons for vascular microsurgery in patients. Although microsurgical courses are commonly offered and attended, the learning curve acquired in such courses remains elusive. The patency of end-to-end anastomoses performed by a total of 212 participants with different education levels and from different specialist fields were assessed in models of living rats. Participants attended the annually held microsurgical course at the Department for Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich, between 2013 and 2018. A highly significant correlation (rp = 0,658; p < 0,001) between number of trials and patent anastomoses was observed. There was no significant correlation between years of surgical experience and age and total number of patent anastomoses achieved during the course. No statistically significant difference of total number of patent anastomoses between residents and board-certified surgeons was detected. Looking at the steep learning curves of our participants and the high rate of patent anastomoses, we recommend the setting of microsurgical courses using in-vivo models to overcome potential failures in the beginning of vascular microsurgery careers.