Managing vestibular schwannomas with radiosurgery and radiotherapy: AGREE II appraisal of clinical practice guidelines

INTRODUCTION

Vestibular schwannomas (VSs) are rare, benign intracranial tumours that have prompted clinical practice guideline (CPG) creation given their complex management. Our aim was to utilize the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess if such CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality.

METHODS

Relevant CPGs were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. Experienced reviewers then extracted general CPG properties and rated their quality via the AGREE II instrument. Intraclass correlation coefficients (ICCs) were quantified to assess interrater reliability.

RESULTS

Nine CPGs on the management of VSs with radiosurgery and radiotherapy were identified. All CPGs were created in the past six years and developed recommendations based on literature review and expert consensus. One guideline was deemed as high quality with seven others being moderate and one being low in quality. The clarity of the presentation domain had the highest mean scaled domain score of 96.0%. The domains of stakeholder involvement and applicability had the lowest means of 49.2% and 47.2%, respectively. ICCs were either good or excellent across all domains.

CONCLUSION

Current CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality but would greatly benefit from improvements in applicability, stakeholder involvement, editorial independence and rigour of development. We recommend CPG authors reference the European Association of Neuro-Oncology (EANO) guideline as a developmental framework with the Congress of Neurological Surgeons/American Association of Neurological Surgeons (CNS/AANS) CPG being a valid alternative.

Detecting and Locating the Site of Local Relapse Using 18F-PSMA-1007 Imaging After Primary Treatment of 135 Prostate Cancer Patients-Potential Impact on PSMA-Guided Radiation Therapy

PURPOSE

Due to limited imaging options, the visualization of a local relapse of prostate cancer used to pose a considerable challenge. However, since the integration of ¹⁸F-PSMA-1007-PET/CT into the clinic, a relapsed tumor can now easily be detected by hybrid imaging. The present study aimed to evaluate and map the allocate relapse in a large cohort of prostate cancer patients focusing on individual patient management conclusions for radiation therapy.

PROCEDURES

The current study included 135 men with prostate cancer after primary treatment who underwent ¹⁸F-PSMA-1007-PET/CT due to biochemical relapse detecting a local relapse. Imaging data were reassessed and analyzed with regard to relapse locations. For the correlation of tumor foci with clinical data, we used binary logistic regression models as well as the Kruskal-Wallis test and Mann-Whitney test.

RESULTS

In total, 69.6% of all patients (mean age: 65 years) underwent prostatectomy while 30.4% underwent radiation therapy. PET imaging detected most frequently a unifocal relapse (72.6%). There was a statistically significantly higher rate of ipsilateral cases among the relapsed tumors. Comparing both treatment approaches, tumors relapsed most commonly within the posterior region after surgery and transition/peripheral zone after radiation therapy, respectively.

CONCLUSIONS

The present study confirms that ¹⁸F-PSMA-1007-PET/CT is highly suitable for the localization and allocation of a local relapse in patients with prostate cancer. The data enable further optimizing dose prescriptions and target volume delineations of radiation therapy in the future.

POS1173 CLINICAL PRESENTATION AND TREATMENT OF STERNOCOSTOCLAVICULAR HYPEROSTOSIS (SCCH): A SYSTEMATIC REVIEW AND META-ANALYSIS OF SCATTERED EVIDENCE

Background

Sternocostoclavicular hyperostosis (SCCH) is an inflammatory bone disorder within the spectrum of chronic non-bacterial osteomyelitis. SCCH can be a manifestation of SAPHO syndrome, standing acronym for synovitis, acne, pustulosis, hyperostosis and osteitis, but also appears as an isolated clinical entity without joint and skin involvement1,2. Consensus on nomenclature, diagnostic classification, and therapy for SCCH is currently lacking3. Literature is diffuse, and spreads over a wide range of medical disciplines, calling for a first systematic overview.

Objectives

We critically appraised literature with the aim to i) gain overview on the clinical presentation of SCCH and features leading to diagnosis and to ii) evaluate different treatment modalities and treatment response. We focused on the clinical entity of SCCH in adults, either isolated or as a part of SAPHO syndrome.

Methods

We conducted a systematic review and meta-analysis according to the PRISMA guidelines on the clinical presentation and therapeutic modalities applied in adult SCCH patients. Studies covering these respective domains were selected. Risk of bias was assessed using validated tools according to study type. Untransformed numerical data and double-arcsine transformed proportional data were analyzed in a random effects model in R-4.0.5; pooled proportions were reported with 95% confidence intervals (95%CI). Treatment response was categorized as good, partial, or none.

Results

28(i) and 12(ii) studies were included, containing heterogeneous data on 1818 patients. A female predisposition (67%, 95%CI 60-73) and major diagnostic delay (5 years 95%CI 3-7) were noted. Clinical presentation was marked by anterior chest pain (89%, 95%CI 79-96), and swelling (79%, 95%CI 62-91). Pustulosis palmoplantaris was present in 53%, 95%CI37-68, whereas acne (8%, 95%CI4-13) and peripheral arthritis (24%, 95%CI 11-39) were less prevalent. Inflammatory markers were inconsistently elevated and autoantibodies and HLA-B27 prevalence normal. Histopathology was unspecific, and cultures almost exclusively negative. Increased isotope uptake (99%, 95%CI96-100) was the most consistent imaging finding. Amongst manifold treatments (see Figure 1), NSAIDs were mainly partially effective. Pamidronate and biologicals (mainly TNF-α inhibitors) yielded good, though heterogeneous, response in 83%, 95%CI 60-98 and 56%, 95%CI 26-85 respectively.

Figure 1.

Treatment modalities applied in SCCH and their effects on bone pain (data from trials and several cohort studies combined)

Conclusion

Literature on SCCH is extremely heterogeneous. Timely diagnosis proves challenging and mainly follows from the increased isotope uptake on nuclear examination. Biopsies, autoantibodies and HLA-status are non-contributory, and inflammatory biochemical profiles only variably detected. Pamidronate and TNF-α inhibitors emerged as promising therapies, but powered, placebo-controlled research with standardized measures of response is warranted. Inherently, international consensus on SCCH’s diagnostic classification and name appears critical to improve scientific collaboration on this rare disease, and to advance the development of clinical guidelines.

References

[1]Saghafi M, Henderson MJ and Buchanan WW. Sternocostoclavicular hyperostosis. YSARH 1993; 22: 215-223. 10.1016/0049-0172(93)80070-v. DOI: papers3://publication/doi/10.1016/0049-0172(93)80070-v.

[2]Carroll MB. Sternocostoclavicular hyperostosis: a review. Therapeutic advances in musculoskeletal disease 2011; 3: 101-110. 10.1177/1759720X11398333. DOI: papers3://publication/doi/10.1177/1759720X11398333

[3] Kalke S, Perera SD, Patel ND, et al. The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey. Rheumatology 2001; 40: 170-177. 10.1093/rheumatology/40.2.170. DOI: papers3://publication/doi/10.1093/rheumatology/40.2.170

Acknowledgements

The authors would like to thank Drs. J.W. Schoones, information specialist at the Walaeus Library, Leiden University Medical Center, for his contribution to the search strategy and selection of studies.

Disclosure of Interests

None declared

Role of Race in Short-Term Outcomes for 1700 Consecutive Patients Undergoing Brain Tumor Resection

BACKGROUND

Access to medical care seems to be impacted by race. However, the effect of race on outcomes, once care has been established, is poorly understood.

PURPOSE

This study seeks to assess the influence of race on patient outcomes in a brain tumor surgery population.

IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY

This study offers insights to if or how quality is impacted based on patient race, after care has been established. Knowledge of disparities may serve as a valuable first step toward risk factor mitigation.

METHODS

Patients differing in race, but matched on other outcomes affecting characteristics, were assessed for differences in outcomes subsequent to brain tumor resection. Coarsened exact matching was used to match 1700 supratentorial brain tumor procedures performed over a 6-year period at a single, multihospital academic medical center. Patient outcomes assessed included unplanned readmission, mortality, emergency department (ED) visits, and unanticipated return to surgery.

RESULTS

There was no significant difference in readmissions, mortality, ED visits, return to surgery after index admission, or return to surgery within 30 days between the two races.

CONCLUSION

This study suggests that race does not independently influence postsurgical outcomes but may instead serve as a proxy for other closely related demographics.

Prediction of Adverse Outcomes Within 90 Days of Surgery in a Heterogeneous Orthopedic Surgery Population

INTRODUCTION

The LACE+ index has been shown to predict readmissions; however, LACE+ has not been validated for extended postoperative outcomes in an orthopedic surgery population. The purpose of this study is to examine whether LACE+ scores predict unplanned readmissions and adverse outcomes following orthopedic surgery. Use of the LACE1 index to proactively identify at-risk patients may enable actions to reduce preventable readmissions.

METHODS

LACE+ scores were retrospectively calculated at the time of discharge for all consecutive orthopedic surgery patients (n = 18,893) at a multicenter health system over 3 years (2016-2018). Coarsened exact matching was used to match patients based on characteristics not assessed in the LACE+ index. Outcome differences between matched patients in different LACE quartiles (i.e. Q4 vs. Q3, Q2, and Q1) were analyzed.

RESULTS

Higher LACE+ scores significantly predicted readmission and emergency department visits within 90 days of discharge and for 30-90 days after discharge for all studied quartiles. Higher LACE+ scores also significantly predicted reoperations, but only between Q4 and Q3 quartiles.

CONCLUSIONS

The results suggest that the LACE+ risk-prediction tool may accurately predict patients with a high likelihood of adverse outcomes after a broad array of orthopedic procedures.

Composite Score for Outcome Prediction in Gynecologic Surgery Patients

BACKGROUND

The LACE+ index is a well-studied metric that compacts patient data in an effort to assess readmission risk.

PURPOSE

Assess the capacity of LACE+ scores for predicting short-term undesirable outcomes in an entire single-center population of patients undergoing gynecologic surgery.

IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY

Proactive identification of high-risk patients, with tools such as the LACE+ index, may serve as the first step toward appropriately engaging resources for reducing readmissions.

METHODS

This study was a retrospective analysis that used coarsened exact matching. All gynecologic surgery cases over 2 years within a single health system (n = 12,225) were included for analysis. Outcomes of interest were unplanned readmission, emergency room (ER) evaluation, and return to surgery. Composite LACE+ scores were separated into quartiles and matched. For outcome comparison, matched patients were assessed by LACE+ quartile, using Q4 as the reference group.

RESULTS

Increasing LACE+ score reflected a higher rate of readmission (p = .003, p = .001) and visits to the ER at 30 postoperative days (p < .001).

CONCLUSION

The data presented here suggest that LACE+ index is a viable metric for patient outcome prediction following gynecologic surgery.

EFFECT OF ELECTR- AND ULTRAPHONOPHORESIS OF THE PHYTOCOMPLEX ON MICROCIRCULATORY AND BIOCHEMICAL PARAMETERS IN PATIENTS WITH KNEE JOINT OSTEOARTHRITIS

The goal was to study the effect of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex on disruptions in the microcirculation system in the affected joint area and on changes in connective tissue metabolism parameters, metabolic processes, and electrolyte metabolism in patients with knee joint osteoarthritis. Seventy-two patients were randomly assigned to five groups. Patients of the first group were prescribed modulated sinusoidal currents electrophoresis of the phytocomplex. The second group was prescribed ultraphonophoresis of the phytocomplex, the third group was prescribed amplipulse therapy (modulated sinusoidal currents), the fourth group was prescribed ultrasound therapy, and the fifth group was prescribed basic drug therapy. Drug therapy of patients of the fifth group was comparable to the drug treatment of patients of the first four groups. The concentration of the phytocomplex in the working composition was 10%. Electrotherapy was carried out in the full-wave modulated sinusoidal currents mode with I and IV types of operation while ultrasound therapy was carried out in continuous mode with an ultrasound intensity of 0.6 W/cm2. To assess the state of microcirculation, the laser Doppler flowmetry method was used. The pronounced anti-dystrophic effect after the use of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex in patients with knee joint osteoarthritis was based on the correction of microcirculatory disruptions: an increase in the capillary blood flow, an increase in the blood perfusion in tissues, and a decrease in congestion effects in the venular microcirculation. The use of modulated sinusoidal currents electrophoresis of the phytocomplex (ultraphonophoresis of the phytocomplex had an even greater effect) improved the connective tissue metabolism and the content of seromucoid, fibrinogen, and mucoproteins. The use of the studied treatment methods improved magnesium and phosphorus parameters of the electrolyte metabolism. Modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex contributed to the elimination of the metabolic imbalance of acid phosphatase. Ultraphonophoresis of the phytocomplex also contributed to balancing of the alanine aminotransferase and alkaline phosphatase content. As a result of the study, the effect of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex on disruptions in the microcirculation system in the affected joint area and on changes in connective tissue metabolism parameters, metabolic processes, and electrolyte metabolism in patients with knee joint osteoarthritis was established. The obtained results provide the basis for further studies to assess the overall effectiveness of the use of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex in patients with knee joint osteoarthritis.

Predicting patient outcomes after far lateral lumbar discectomy

INTRODUCTION

The LACE+ (Length of Stay, Acuity of Admission, Charlson Comorbidity Index (CCI) Score, Emergency Department (ED) visits within the previous 6 months) index has never been tested in a purely spine surgery population. This study assesses the ability of LACE + to predict adverse patient outcomes following discectomy for far lateral disc herniation (FLDH).

PATIENTS AND METHODS

Data were obtained for patients (n = 144) who underwent far lateral lumbar discectomy at a single, multi-hospital academic medical center (2013-2020). LACE + scores were calculated for all patients with complete information (n = 100). The influence of confounding variables was assessed and controlled with stepwise regression. Logistic regression was used to test the ability of LACE + to predict risk of unplanned hospital readmission, ED visits, outpatient office visits, and reoperation after surgery.

RESULTS

Mean age of the population was 61.72 ± 11.55 years, 69 (47.9 %) were female, and 126 (87.5 %) were non-Hispanic white. Patients underwent either open (n = 92) or endoscopic (n = 52) surgery. Each point increase in LACE + score significantly predicted, in the 30-day (30D) and 30-90-day (30-90D) post-discharge window, higher risk of readmission (p = 0.005, p = 0.009; respectively) and ED visits (p = 0.045). Increasing LACE + also predicted, in the 30D and 90-day (90D) post-discharge window, risk of reoperation (p = 0.022, p = 0.016; respectively), and repeat neurosurgical intervention (p = 0.026, p = 0.026; respectively). Increasing LACE + score also predicted risk of reoperation (p = 0.011) within 30 days of initial surgery.

CONCLUSIONS

LACE + may be suitable for characterizing risk of adverse perioperative events for patients undergoing far lateral discectomy.

The influence of race on outcomes following pituitary tumor resection

OBJECTIVE

To assess the influence of race on short-term patient outcomes in a pituitary tumor surgery population.

PATIENTS AND METHODS

Coarsened exact matching was used to retrospectively analyze consecutive patients (n = 567) undergoing pituitary tumor resection over a six-year period (June 07, 2013 to April 29, 2019) at a single, multi-hospital academic medical center. Black/African American and white patients were exact matched based on twenty-nine (29) patient, procedure, and hospital characteristics. Matching characteristics included surgical costs, American Society of Anesthesiologists grade, duration of surgery, and Charlson Comorbidity Index, amongst others. Outcomes studied included unplanned 90-day readmission, emergency room (ER) evaluation, and unplanned reoperation.

RESULTS

Ninety-two (n = 92) patients were exact matched and analyzed. There was no significant difference in 90-day readmission (p = 0.267, OR (black/AA vs white) = 0.500, 95% CI = 0.131-1.653) or ER evaluation within 90 days (p = 0.092, OR = 3.000, 95% CI = 0.848-13.737) between the two cohorts. Furthermore, there was no significant difference in the rate of unplanned reoperation throughout the duration of the follow up period between matched black/African American and white patients (p = 0.607, OR = 0.750, 95% CI = 0.243-2.211).

CONCLUSION

This study suggests that the effect of race on post-operative outcomes is largely mitigated when equal access is attained, and when race is effectively isolated from socioeconomic factors and comorbidities in a population undergoing pituitary tumor resection.

Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania

IMPORTANCE

Police in Philadelphia, Pennsylvania, routinely transport patients with penetrating trauma to nearby trauma centers. During the past decade, this practice has gained increased acceptance, but outcomes resulting from police transport of these patients have not been recently evaluated.

OBJECTIVE

To assess mortality among patients with penetrating trauma who are transported to trauma centers by police vs by emergency medical services (EMS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Pennsylvania Trauma Outcomes Study registry and included 3313 adult patients with penetrating trauma from January 1, 2014, to December 31, 2018. Outcomes were compared between patients transported by police (n = 1970) and patients transported by EMS (n = 1343) to adult level I and II trauma centers in Philadelphia.

EXPOSURES

Police vs EMS transport.

MAIN OUTCOMES AND MEASURES

The primary end point was 24-hour mortality. Secondary end points included death at multiple other time points. After whole-cohort regression analysis, coarsened exact matching was used to control for confounding differences between groups. Matching criteria included patient age, injury mechanism and location, Injury Severity Score (ISS), presenting systolic blood pressure, and Glasgow Coma Scale score. Subgroup analysis was performed among patients with low, moderate, or high ISS.

RESULTS

Of the 3313 patients (median age, 29 years [interquartile range, 23-40 years]) in the study, 3013 (90.9%) were men. During the course of the study, the number of police transports increased significantly (from 328 patients in 2014 to 489 patients in 2018; P = .04), while EMS transport remained unchanged (from 246 patients in 2014 to 281 patients in 2018; P = .44). On unadjusted analysis, compared with patients transported by EMS, patients transported by police were younger (median age, 27 years [interquartile range, 22-36 years] vs 32 years [interquartile range, 24-46 years]), more often injured by a firearm (1741 of 1970 [88.4%] vs 681 of 1343 [50.7%]), and had a higher median ISS (14 [interquartile range, 9-26] vs 10 [interquartile range, 5-17]). Patients transported by police had higher mortality at 24 hours than those transported by EMS (560 of 1970 [28.4%] vs 246 of 1343 [18.3%]; odds ratio, 1.86; 95% CI, 1.57-2.21; P < .001) and at all other time points. After coarsened exact matching (870 patients in each transport cohort), there was no difference in mortality at 24 hours (210 [24.1%] vs 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59-1.52; P = .91) or at any other time point. On subgroup analysis, patients with severe injuries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24-0.94; P = .03).

CONCLUSIONS AND RELEVANCE

For patients with penetrating trauma in an urban setting, 24-hour mortality was not different for those transported by police vs EMS to a trauma center. Timely transport to definitive trauma care should be emphasized over medical capability in the prehospital management of patients with penetrating trauma.

Composite score for prediction of 30-day orthopedic surgery outcomes

The LACE+ (Length of stay, Acuity of admission, Charlson Comorbidity Index score, and Emergency department visits in the past 6 months) risk-prediction tool has never been tested in an orthopedic surgery population. LACE+ may help physicians more effectively identify and support high-risk orthopedics patients after hospital discharge. LACE+ scores were retrospectively calculated for all consecutive orthopedic surgery patients (n = 18 893) at a multi-center health system over 3 years (2016-2018). Coarsened exact matching was employed to create "matched" study groups with different LACE+ score quartiles (Q1, Q2, Q3, Q4). Outcomes were compared between quartiles. In all, 1444 patients were matched between Q1 and Q4 (n = 2888); 2079 patients between Q2 and Q4 (n = 4158); 3032 patients between Q3 and Q4 (n = 6064). Higher LACE+ scores significantly predicted 30D readmission risk for Q4 vs Q1 and Q4 vs Q3 (P < .001). Larger LACE+ scores also significantly predicted 30D risk of ED visits for Q4 vs Q1, Q4 vs Q2, and Q4 vs Q3 (P < .001). Increased LACE+ score also significantly predicted 30D risk of reoperation for Q4 vs Q1 (P = .018), Q4 vs Q2 (P < .001), and Q4 vs Q3 (P < .001).

Predictive index for 90-day postoperative outcomes following gynecologic surgery

OBJECTIVES

Assessment of the potential of LACE+ index scores in patients undergoing gynecologic surgery to predict short-term undesirable outcomes.

STUDY DESIGN

Retrospective study over a 2-year time period (2016-2018).

METHODS

Coarsened exact matching was used to assess the predictive capacity of the LACE+ index among all gynecologic surgery cases over a 2-year period (2016-2018) at 1 health system (N = 12,225). Study subjects were matched on characteristics not assessed by LACE+, including race and duration of surgery. For comparison of outcomes, LACE+ score was divided into quartiles and otherwise matched populations were compared in reference to LACE+ quartile (Q): Q4 vs Q1, Q4 vs Q2, Q4 vs Q3.

RESULTS

A total of 1715 patients were matched for Q1 to Q4, 1951 patients were matched for Q2 to Q4, and 1822 patients were matched for Q3 to Q4. Escalating LACE+ score significantly predicted increased readmission, reoperation, and emergency department (ED) visits from 30 to 90 postoperative days as well as readmission, reoperation, and ED visits from 0 to 90 postoperative days.

CONCLUSIONS

The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a gynecologic surgery population.

The LACE+ Index as a Predictor of 90-Day Supratentorial Tumor Surgery Outcomes

BACKGROUND

The LACE+ (Length of stay, Acuity of admission, Charlson Comorbidity Index [CCI] score, and Emergency department [ED] visits in the past 6 mo) index risk-prediction tool has never been successfully tested in a neurosurgery population.

OBJECTIVE

To assess the ability of LACE+ to predict adverse outcomes after supratentorial brain tumor surgery.

METHODS

LACE+ scores were retrospectively calculated for all patients (n = 624) who underwent surgery for supratentorial tumors at the University of Pennsylvania Health System (2017-2019). Confounding variables were controlled with coarsened exact matching. The frequency of unplanned hospital readmission, ED visits, and death was compared for patients with different LACE+ score quartiles (Q1, Q2, Q3, and Q4).

RESULTS

A total of 134 patients were matched between Q1 and Q4; 152 patients were matched between Q2 and Q4; and 192 patients were matched between Q3 and Q4. Patients with higher LACE+ scores were significantly more likely to be readmitted within 90 d (90D) of discharge for Q1 vs Q4 (21.88% vs 46.88%, P = .005) and Q2 vs Q4 (27.03% vs 55.41%, P = .001). Patients with larger LACE+ scores also had significantly increased risk of 90D ED visits for Q1 vs Q4 (13.33% vs 30.00%, P = .027) and Q2 vs Q4 (22.54% vs 39.44%, P = .039). LACE+ score also correlated with death within 90D of surgery for Q2 vs Q4 (2.63% vs 15.79%, P = .003) and with death at any point after surgery/during follow-up for Q1 vs Q4 (7.46% vs 28.36%, P = .002), Q2 vs Q4 (15.79% vs 31.58%, P = .011), and Q3 vs Q4 (18.75% vs 31.25%, P = .047).

CONCLUSION

LACE+ may be suitable for characterizing risk of certain perioperative events in a patient population undergoing supratentorial brain tumor resection.

LACE+ index as a predictor of 90-day plastic surgery outcomes

OBJECTIVES

This study used coarsened exact matching to assess the ability of the LACE+ index to predict adverse outcomes after plastic surgery.

STUDY DESIGN

Two-year retrospective study (2016-2018).

METHODS

LACE+ scores were retrospectively calculated for all patients undergoing plastic surgery at a multicenter health system (N = 5744). Coarsened exact matching was performed to sort patient data before analysis. Outcomes including unplanned hospital readmission, emergency department visits, and reoperation were compared for patients in different LACE+ score quartiles (Q1, Q2, Q3, Q4).

RESULTS

A total of 2970 patient procedures were matched during coarsened exact matching. Increased LACE+ score significantly predicted readmission within 90 days of discharge for Q4 versus Q1 (6.28% vs 1.91%; P = .003), Q4 versus Q2 (12.30% vs 5.56%; P <.001), and Q4 versus Q3 (13.84% vs 7.33%; P <.001). Increased LACE+ score also significantly predicted emergency department visits within 90 days for Q4 versus Q1 (9.29% vs 3.01%; P <.001), Q4 versus Q2 (11.31% vs 3.57%; P <.001), and Q4 versus Q3 (13.70% vs 8.48%; P = .003). Higher LACE+ score also significantly predicted secondary reoperation within 90 days for Q4 versus Q1 (3.83% vs 1.37%; P = .035), Q4 versus Q2 (5.95% vs 3.37%; P = .042), and Q4 versus Q3 (7.50% vs 3.26%; P <.001).

CONCLUSIONS

The results of this study demonstrate that the LACE+ index may be suitable as a prediction model for patient outcomes in a plastic surgery population.

The Risk Assessment and Prediction Tool (RAPT) for Discharge Planning in a Posterior Lumbar Fusion Population

BACKGROUND

As the use of bundled care payment models has become widespread in neurosurgery, there is a distinct need for improved preoperative predictive tools to identify patients who will not benefit from prolonged hospitalization, thus facilitating earlier discharge to rehabilitation or nursing facilities.

OBJECTIVE

To validate the use of Risk Assessment and Prediction Tool (RAPT) in patients undergoing posterior lumbar fusion for predicting discharge disposition.

METHODS

Patients undergoing elective posterior lumbar fusion from June 2016 to February 2017 were prospectively enrolled. RAPT scores and discharge outcomes were recorded for patients aged 50 yr or more (n = 432). Logistic regression analysis was used to assess the ability of RAPT score to predict discharge disposition. Multivariate regression was performed in a backwards stepwise logistic fashion to create a binomial model.

RESULTS

Escalating RAPT score predicts disposition to home (P &lt; .0001). Every unit increase in RAPT score increases the chance of home disposition by 55.8% and 38.6% than rehab and skilled nursing facility, respectively. Further, RAPT score was significant in predicting length of stay (P = .0239), total surgical cost (P = .0007), and 30-d readmission (P &lt; .0001). Amongst RAPT score subcomponents, walk, gait, and postoperative care availability were all predictive of disposition location (P &lt; .0001) for both models. In a generalized multiple logistic regression model, the 3 top predictive factors for disposition were the RAPT score, length of stay, and age (P &lt; .0001, P &lt; .0001 and P = .0001, respectively).

CONCLUSION

Preoperative RAPT score is a highly predictive tool in lumbar fusion patients for discharge disposition.

Loi de santé 2015 : une nécessaire résistance ?

La loi de santé 2015 introduit le principe du tiers payant généralisé (TPG), qui a déjà généralisé l’opposition de la quasi-totalité des médecins libéraux. Au-delà des aspects symboliques du circuit de l’argent, objets de réflexions psychanalytiques plus ou moins légitimes, il s’agit aussi d’un processus macroéconomique qui permet aux assureurs privés d’avoir leur mot à dire sur ce qui est remboursé ou pas. Or les intérêts de la Sécurité sociale sont-ils tout à fait les mêmes que ceux des assureurs privés ? Les déclarations des dirigeants des groupes mutualistes sont tout à fait éclairantes sur le sujet… notamment leur regret de ne pas constituer eux-mêmes la plateforme de paiement qui reste aux mains de la Sécurité sociale. Tous les outils se mettent néanmoins progressivement en place pour passer du « remboursement selon les besoins, basé sur une cotisation selon les moyens », au principe assurantiel du « remboursement selon le niveau de cotisation et de risque ». Où est donc l’amélioration de l’accès, et pour quels soins ? Dans le même temps, les « mutuelles » deviennent obligatoires pour tous les salariés, ce qui accroît considérablement le nombre de cotisants, et « responsables » ce qui limite les remboursements notamment des dépassements d’honoraires. S’il s’agissait initialement de répondre au problème hautement médiatisé du renoncement aux soins, la loi de santé bénéficiera-t-elle bien aux patients ? Pendant ce temps, rien n’est fait sur les questions de démographie médicale, et de répartition géographique des praticiens libéraux, soumis aussi aux technocratiques nouvelles normes d’accessibilité aux personnes handicapées. L’unité créée chez les médecins libéraux contre cette loi permettra-t-elle de trouver des issues honorables ? Le pire pourrait être que les médecins libéraux se retrouvent mieux rémunérés grâce aux mutuelles, sur le modèle des rémunérations sur objectifs de santé publique (ROSP)…

Micro-CT analyses of historical bone samples presenting with osteomyelitis

OBJECTIVE

Osteomyelitis is an inflammation of the bone marrow mainly caused by bacteria such as Staphylococcus aureus. It typically affects long bones, e.g. femora, tibiae and humeri. Recently micro-computed tomography (μCT) techniques offer the opportunity to investigate bone micro-architecture in great detail. Since there is no information on long bone microstructure in osteomyelitis, we studied historic bone samples with osteomyelitis by μCT.

MATERIALS AND METHODS

We investigated 23 femora of 22 individuals suffering from osteomyelitis provided by the Collection of Anatomical Pathology, Museum of Natural History, Vienna (average age 44 ±19 years); 9 femora from body donors made available by the Department of Applied Anatomy, Medical University of Vienna (age range, 56-102 years) were studied as controls. Bone microstructure was assessed by μCT VISCOM X 8060 II with a minimal resolution of 18 μm.

RESULTS

In the osteomyelitic femora, most prominent alterations were seen in the cortical compartment. In 71.4% of the individuals with osteomyelitis, cortical porosity occurred. 57.1% of the individuals showed cortical thinning. In 42.9% trabecularisation of cortical bone was observed.

CONCLUSION

Osteomyelitis is associated with severe alterations of cortical bone structure otherwise typically observed at old age such as cortical porosity and cortical thinning.

Abstract CT338: Combination of a PI3K- and a PARP-inhibitor to treat high-grade serous ovarian or triple-negative breast cancer

Clinical trials have shown promising responses of BRCA-linked breast and ovarian cancers to PARP inhibitor therapy, but remissions are often short-lived and incomplete. The PI3K pathway is frequently activated in these malignancies. Recently, we reported in vivo synergy of a PI3K- and a PARP-inhibitor in a mouse model of BRCA1-related breast cancer. While the PARP-inhibitor olaparib alone attenuated tumor growth modestly, a dramatic reduction in tumor growth was observed when olaparib was combined with the PI3K-inhibitor BKM120. In BRCA1-mutant HCC1937 BC cells, PI3K- (but not akt-) inhibition increased indicators of DNA damage, such as poly-ADP-ribosylation and γH2AX, suggesting a critical role of PI3K activity for the maintenance of genomic stability. Here, we report on the molecular mechanism underlying this synergy, on treatment outcomes in an improved mouse model system and the development of an early-phase clinical study. Pre-clinical modeling was done in BRCA1-mutant HCC1937 cells and in a mouse model based on the syngenic transplantation of tumors derived on the K14-Cre BRCA1f/fp53f/f background. Metabolic profiling in vitro and in vivo showed that PI3K-inhibition decreased flux through glycolysis and specifically through the non-oxidative pentose-phosphate pathway, the main source of ribose-5-phosphate required for the de novo synthesis of nucleotides in HCC1937 cells. Within 3 hours and preceding cell cycle changes, BKM120 caused a decrease in nucleotide pools that was further exacerbated by the addition of olaparib. Nucleotide shortage led to to replication stress with the appearance of γH2AX and increased poly-ADP-ribosylation. Tumors with complete loss of BRCA1 and p53 proved particularly vulnerable to this treatment strategy. We were able to induce complete and durable remissions of murine tumors arising on the K14-Cre BRCA1f/fp53f/f background with a 28-day course of BKM120 and Olaparib. These preclinical data have served as the rationale for a phase I, multi-center study (NCT01623349) combining the oral PARP inhibitor olaparib with the oral PI3-kinase inhibitor BKM120 in patients with recurrent HGSC or recurrent TNBC. The study is being conducted through the Stand Up to Cancer (SU2C)'s Targeting PI3-kinase in Women's Cancers Dream Team. It has a 3 + 3 design, escalating if 0/3 or 1/6 participants have a DLT during the first cycle of therapy. The study objectives are to determine the recommended phase II dose (RP2D) of daily continuous oral olaparib (using the tablet formulation) and BKM120, assess toxicities, safety, and preliminary activity of this combination, and determine pharmacokinetic profiles of both agents as well as translational endpoints. The study serves as an example for the development of a clinical trials concept for TNBC and HGSC based on a close collaboration of basic and clinical scientists through the SU2C mechanism.

Citation Format: Gerburg M. Wulf, Ashish Juvekar, Costas A. Lyssiotis, Hai Hu, Sina Yadegarynia, Hui Liu, Baek Kim, Eric Winter, Ralph Scully, John Asara, Lewis C. Cantley, Ursula Matulonis. Combination of a PI3K- and a PARP-inhibitor to treat high-grade serous ovarian or triple-negative breast cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr CT338. doi:10.1158/1538-7445.AM2014-CT338

Medical preparedness, incidents, and group dynamics during the analog MARS2013 mission

Participants on spaceflights and international scientific analog Mars missions can encounter medical incidents (accidents, illnesses) and psychological issues (e.g., stress, group interaction, sleep disturbance, emotions). The aim of this study was to examine these parameters in a field crew living in a desert environment similar to Mars (Group 1) and in Mission Support Center (MSC) personnel on "Earth" (Group 2) during a 4-week mission. Of the 107 medical interventions in the field, 73 mainly minor incidents together with four near accidents and 29 medical checkup interventions were recorded. Of the 32 medical interventions, medical treatments for 23 incidents of minor severity were necessary in Group 2. Injuries (Group 1: 1.4/100 h, Group 2: 0.1/100 h) were significantly increased in the field, and illnesses (Group 1: 0.3/100 h, Group 2: 3.0/100 h) in the MSC personnel. Causes of accidents and illnesses are described. Psychological results show that emotions and stress remained stable in both groups. Sympathy, social competence, teamwork, and leadership showed high scores. These scores were lower on "Earth" but significantly increased in the last weeks. The Sahara's nighttime coldness was reflected in an increased wake-up frequency, and a longer sleeping time peaked in the third week, probably as a result of overfatigue. MARS2013 was a successful mission with highly motivated participants and minor medical incidents. For future analog missions and possibly long-distance open-space missions, some recommendations in terms of medical and psychological preparedness are made to reduce risks for field crew members and MSC personnel.

EXPLOITING CHEMICAL ECOLOGY FOR LIVELIHOOD IMPROVEMENT OF SMALL HOLDER FARMERS IN KENYA

"Push-Pull" is an inexpensive and eminently practical strategy designed for developing countries in order to exploit sound principles of chemical ecology for agricultural pest management. This strategy is specifically suitable for small holder farmers. Their experience can easily be integrated into existing farming practices in their immediate environment. "Push-pull" within one and a half decades became widely established and meanwhile is greatly beneficial to practitioners in East Africa, mainly Kenya. The classical push-pull approach used for applied plant-insect management was pioneered by Khan and Pickett (2000) and subsequent papers of Pickett (2003) and Khan et al. (2006, 2008). Relevant plant species explored so far were maize or sorghum intercropped with other East African plants (Desmodium spp. resp. Melinis minutiflora) possessing natural chemicals repellent resp. attractive for stem borer moths Chilo partellus (Lepidoptera), whereby Desmodium spp. was grown inside the maize rows while M. minutiflora surrounded it. Both simultaneous actions combined resulted in a significant decrease of stem borers in the area to be protected. A benefit to cost ratio of 2.5 was realized. Within a period of 15 years the number of subscribing farmers substantially increased from a few dozen to more than 80,000 in 2014. Two experiments along the paths of chemical ecology were undertaken between Sept 2012 and Feb 2013: One was designed to investigate if the legume D. intortum known to produce repellent volatiles against stem borer moths induces defence in Zea mays varieties. We looked at two open-pollinated farmers' varieties and two commercial hybrid varieties suspecting the farmers' varieties to be responsive rather than the hybrids. However, no defence induction was detected in this study so far. This could be explained by an insufficient production of defence inducing volatiles in leaves of D. intortum whereas flowers might produce a sufficient response. More detailed study is needed. A second approach made use of species-specific insect monitoring traps baited with highly specific female sex pheromones for attracting and monitoring destructive insect pests. The female sex pheromone (8-methyl-decane-2-ol propanoate) of Diabrotica virgifera virgifera (Coleoptera: Chrysomelidae) (Western Corn Rootworm) is readily available as bait in the "Metcalf sticky cup trap" for trapping males, an extraordinarily sensitive technique for monitoring the presence or absence of male beetles in a given area. Li et al. (2006) had argued for the likelihood of easy immigration of this cosmopolitan maize pest into East Africa. Our results, however, so far indicate the absence of a local population in the area of Mbita, while not excluding its presence at Nairobi or Mombasa. Both investigations contribute to different aspects of Kenyan economic development and may be seen as two independent but complementary contributions towards livelihood improvement of small holder farmers in Kenya.

[Drug therapy of fibromyalgia syndrome. Systematic review, meta-analysis and guideline]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

Amitriptyline and-in case of comorbid depressive disorder or generalized anxiety disorder-duloxetine are recommended. Off-label use of duloxetine and pregabalin can be considered in case of no comorbid mental disorder. Strong opioids are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Down-regulation of KRAS-interacting miRNA-143 predicts poor prognosis but not response to EGFR-targeted agents in colorectal cancer

BACKGROUND

MicroRNA-143 (miRNA-143) is frequently down-regulated in colorectal cancer (CRC) and may influence CRC cell proliferation, apoptosis and sensitivity to 5-fluorouracil. mRNA encoded by the KRAS oncogene has been identified as a target of miRNA-143. However, the prognostic significance of miRNA-143 expression and the ability to predict patient response to epidermal growth factor receptor (EGFR)-targeted agents have not yet been explored.

METHODS

We examined 77 CRC patients who were identified by pyrosequencing to have wild-type KRAS and were subsequently treated with EGFR-targeted therapy with the monoclonal antibodies cetuximab or panitumumab. MicroRNA-143 expression was measured in CRC tissue and corresponding non-neoplastic colon tissue by RT-PCR and its expression level was correlated with clinico-pathological characteristics. Univariate and multivariate analyses were used to calculate cancer-specific survival (CSS). The progression-free survival (PFS) and objective response rates on EGFR-targeted therapy were also evaluated.

RESULTS

Down-regulation of miRNA-143 was observed in 47 out of 77 (61%) tumours. Multivariate Cox regression analysis identified low levels of miRNA-143 expression as an independent prognostic factor with respect to CSS (hazard ratio=1.92, confidence interval=1.1-3.4, P=0.024). A significant difference was also observed with regard to PFS on EGFR-targeted therapy (P=0.031), but there were no significant differences with regard to the objective response rates.

CONCLUSION

Our data indicate that miRNA-143 expression levels serve as an independent prognostic biomarker for CRC in KRAS wild-type patients. No role for miRNA-143 expression as a predictive biomarker for EGFR-targeted agents could be identified. Given its negative impact on CSS and PFS, miRNA-143 represents a novel prognosticator and a promising drug target for patients with CRC.

[Pharmacological treatment of fibromyalgia syndrome]

BACKGROUND

An interdisciplinary guideline for the treatment of fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) was developed in cooperation with ten German medical and psychological associations and two patients' self-help organizations.

METHODS

Using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/ 2006) a systematic literature search was performed, which included all randomised controlled trials (RCT) evaluating multicomponent therapy in FMS and CWP. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of recommendation was graded according to the German program for disease management guidelines. Consensus was achieved using a multi-step nominal group procedure.

RESULTS

The short-term use of amitriptyline is strongly recommended (grade A) and the short-term use of fluoxetine und duloxetine is recommended (grade B).

CONCLUSIONS

The recommendations regarding pharmacological treatment of FMS are limited by the short duration of the RCT, the lack of follow-ups and absence of cost-effectiveness studies.

Biosynthesis, axonal transport and turnover of neuronal substance P

In dorsal root ganglia substance P is synthesized ribosomally, probably via a precursor. A second peptide, apparently a modified form of substance P (8-11), is cosynthesized with substance P and transported with it down both dorsal roots and peripheral branches. Four times as much substance P-like immunoreactivity is transported peripherally as centrally. Only 30% of axonal substance P-like immunoreactivity is available for rapid axonal transport and this is transported at a rate of 4.9 mm h-1. Axonal transport is not necessary for substance P synthesis. Doses of anisomycin which inhibit CNS protein synthesis by more than 95% do not cause any fall in substance P levels over an eight-hour period in ganglia, spinal cord or brain, suggesting that turnover is slower than that of conventional transmitters. However, stimulation of the hindlimbs of these animals reduces substance P levels in the dorsal horn. The turnover rate of spinal cord substance P, estimated either by relating the amount transported down dorsal roots to that in terminals or by measuring the decline of substance P levels after intrathecal colchicine, is four to five days. The functional organization of the substance P neuron is discussed with particular reference to the maintenance of peptide levels in terminals.

Optimized synthesis of AMPA receptor antagonist ZK 187638 and neurobehavioral activity in a mouse model of neuronal ceroid lipofuscinosis

Previous structure-activity relationship studies in the search for a potent, noncompetitive alpha-amino-3-(3-hydroxy-5-methyl-4-isoxazolyl)propionic acid (AMPA) receptor antagonist led to 2,3-dimethyl-6-phenyl-12H-[1,3]dioxolo[4,5-h]imidazo[1,2-c][2,3]benzodiazepine (ZK 187638). However, the first synthesis had some drawbacks regarding reagents, processes, and overall yield, which furthermore decreased when the synthesis was scaled up. Therefore, we now report a new synthetic route for this compound which requires fewer steps and is suited for large-scale production. This compound significantly relieved the symptoms of neuromuscular deficit in mnd mice, a model of neuronal ceroid lipofuscinosis with motor neuron dysfunction. After oral administration, the concentrations of the compound in the brain and spinal cord were about threefold higher than those in the plasma. In summary, this novel AMPA antagonist is accessible through an optimized synthetic route, has good neurobehavioral activity, oral bioavailability, and favorable brain penetration. This opens new possibilities for the treatment of devastating neurological diseases that are mediated by the AMPA receptor.

Efficient Large-Scale Synthesis of BILN 2061, a Potent HCV Protease Inhibitor, by a Convergent Approach Based on Ring-Closing Metathesis

A multistep scalable synthesis of the clinically important hepatitis C virus (HCV) protease inhibitor BILN 2061 (1) is described. The synthesis is highly convergent and consists of two amide bond formations, one etherification, and one ring-closing metathesis (RCM) step, using readily available building blocks 2-5. The optimization of each step is described at length. The main focus of the paper is the study of the RCM step and the description of the main problems faced when scaling up to pilot scale this highly powerful but very challenging synthetic operation. Eventually, the RCM reaction was smoothly scaled up to produce >400 kg of cyclized product.

Regulation of insulin-like growth factor binding protein-5, four and a half lim-2, and a disintegrin and metalloprotease-9 expression in osteoblasts

The roles of insulin-like growth factors (IGFs) in regulating growth and their modulation by six IGF binding proteins (IGFBP) are well established. IGFBP-5, the most abundant IGFBP stored in bone, is an important regulator of bone formation via IGF-dependent and -independent mechanisms. Two new proteins, four and a half lim (FHL)-2, a transcription modulator that interacts with IGFBP-5, and a disintegrin and metalloprotease (ADAM)-9, an IGFBP-5 protease, have been identified as potential regulators of IGFBP-5 action in bone. We tested the hypothesis that agents which modulate bone formation by regulating IGFBP-5 expression would also regulate FHL-2 and ADAM-9 expression in a coordinated manner. We evaluated the expression of IGFBP-5, FHL-2, and ADAM-9 by real-time reverse transcriptase (RT)-PCR during differentiation of mouse bone marrow stromal cells into osteoblasts and in response to treatment with bone formation modulators in the LSaOS human osteosarcoma cell line. IGFBP-5 and FHL-2 increased 4.3- and 3.0-fold (P < or = 0.01), respectively, during osteoblast differentiation. Dexamethasone (Dex), an inhibitor of bone formation, decreased IGFBP-5 and FHL-2 and increased ADAM-9 in LSaOS cells (P < or = 0.05). Bone morphogenic protein (BMP)-7, a stimulator of bone formation, increased IGFBP-5 and decreased ADAM-9 (P<0.01). To determine if BMP-7 would eliminate Dex inhibition of IGFBP-5, cells were treated with Dex+BMP-7. The BMP-7-induced increase in IGFBP-5 was reduced, but not eliminated, in the presence of Dex (P < or = 0.01), indicating that BMP-7 and Dex may regulate IGFBP-5 via different mechanisms. Transforming growth factor (TGF)-beta, a stimulator of bone formation, increased IGFBP-5 and FHL-2 expression (P < or = 0.01). IGF-I and TNF-alpha decreased expression of ADAM-9 (P<0.05). In conclusion, our findings are consistent with the hypothesis that FHL-2 and ADAM-9 are important modulators of IGFBP-5 actions and are, in part, regulated in a coordinated manner in bone.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Personality pathology and outcome in recurrently depressed women over 2 years of maintenance interpersonal psychotherapy

BACKGROUND

Empirical data on the impact of personality pathology on acute treatment outcome for depression are mixed, in part because of challenges posed by assessing trait-like personality patterns while patients are in an active mood episode. To our knowledge, no previous study has examined the effect of personality pathology on maintenance treatment outcome. By maintenance treatment we refer to long-term treatment provided to prevent depression recurrence among remitted patients.

METHOD

Structured Clinical Interviews for the DSM-III-R Personality Disorders (SCID-II) were obtained on a sample of 125 recurrently depressed women following sustained remission of the acute mood episode and prior to entering maintenance treatment. SCID-II interviews were then repeated following 1 and 2 years of maintenance interpersonal psychotherapy.

RESULTS

At the pre-maintenance assessment, 21.6% of the sample met SCID-II personality disorder criteria. Co-morbid personality pathology was related to an earlier age of onset, more previous depressive episodes, and a greater need for adjunctive pharmacotherapy to achieve remission of the acute mood episode. Co-morbid personality pathology predicted both higher rates of depression recurrence and a shorter time to recurrence over the 2-year course of maintenance treatment. Notably, among those patients who remained depression-free, continuous levels of personality pathology steadily declined over the 2-year course of maintenance therapy.

CONCLUSIONS

Results highlight the need for early and effective intervention of both episodic mood disorder and inter-episode interpersonal dysfunction inherent to the personality disorders. Future maintenance treatment trials are needed to clarify the relationship between episodic mood disorder and personality function over time.

[Treatment of pain in cancer patients]

Patients experiencing constant pain continue to receive less than optimal treatment. In the case of cancer pain in particular, adequate therapy is a must. On the basis of the WHO analgesic ladder, nonopioids and opioids of varying potency must be applied as required, together with antiemetics, laxatives, gastric-protective preparations and bisphosphonates to ameliorate side effects. A particular problem in the treatment of cancer pain is the suddenly occurring stress and perforation pain. This can be reduced with fast-acting opioids such as the fentanyl stick. If the patient does not respond adequately to any of the noninvasive methods, local anesthetics and opiates applied via an i.v. pump system that permits bolus application and spinal and epidural methods have proven useful.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[Distinctive features of the os naviculare pseudarthrosis vs the os naviculare accessorius]

We report on two cases in which the differential diagnosis between an os tibiale externum (os naviculare accessorius) and a post-traumatic pseudarthrosis of the os naviculare was subject to discussion.Both patients had suffered an acute trauma in the region of the middle foot and showed identical clinical symptoms. Conventional X-ray did not allow a definite classification of the diagnosis either.However, this was possible in both cases by virtue of typical signs evidenced by computed tomography and magnetic resonance imaging.

[Cemented versus uncemented hip replacement--rational decision making using the BiCONTACT total hip system]

The BiCONTACT femoral stem has been developed as a modular system which is suitable for both cemented and uncemented implantation. A highly standardized procedure using an identical set of instruments for both modes of fixation ensures bone preservation. Primary stability is achieved by special design parameters. The cementless implants are coated proximally, thus facilitating osteointegration and proximal load transfer. Cemented stems provide an identical design but a smooth surface and are anchored by a homogenous cement mantle. The BiCONTACT stem is in use in the BG Trauma Center Tuebingen since 14 years and a consecutive series of 250 cases (series A) with uncemented implantation and of 250 cases (series B) with cemented implantation has been analyzed in two different prospective follow-up studies. Long-term survival after 11 years was 97.1 % (95 % confidence limits: 93.8 %-98.7 %) for series A, the follow-up rate was 99.2 %. For series B, the follow up-rate was also 99.2 %, survival estimate after 11 years was 97.5 % (95 % CI: 94.2 %-99.0 %).

Long-term results with the BiCONTACT system--aspects to investigate and to learn from

The BiCONTACT femoral stem for cementless fixation is being used without any technical modification after 15 years. The long-term results should be evaluated in this study. A consecutive series was continuously monitored in a prospective follow-up study. A survival analysis was performed, clinical results were rated according to the Harris score. There were 236 patients with 250 total hip replacements (THR); mean age at time of implantation was 58.2 years. Indications for THR included osteoarthritis (62.4%), dysplasia (16.8%), trauma (8.4%) and femoral-head necrosis (16.8%). Average time of follow-up evaluation was 8.9 years (range 7.4-10.7 years). At follow-up, 27 patients had died and two could not be located. Seven patients were revised--two for infection, one for recurrent dislocation, two for component undersizing with rapid subsidence, and one for aseptic loosening of a varus-malaligned stem; one radiologically well-fixed stem had been revised during acetabular revision. Survival estimate showed an overall survival rate of 97.1% after 11 years (confidence limits: 98.7% upper and 93.6% lower). Radiologically, tiny reactive lines (< 2 mm) were present in the distal zones of the femoral shaft, but no radiolucencies could be found in the proximal anchoring zone. Migration analysis with Ein-Bild-Röntgen-analyse/femoral component analysis (EBRA/FCA) demonstrated a very small amount of migration: in 31.0%, the overall migration was between 0.5 and 1 mm after 120 months; 8.5% had an absolute amount of subsidence exceeding 2 mm after 120 months (one case more than 3 mm). Mean subsidence was 0.2 mm after 3 months and 6 months, 0.3 mm after 12 months, and reached 0.5 mm after 10 years. An initial small amount of subsidence could be detected in 45.1%, and 15.5% had a late onset of subsidence. Continuous sinking could be found in 12.7%, while 26.8% had irregular patterns of migration. Clinical results were somewhat compromised by a higher-than-average rate of cup loosening (uncoated threaded cup). The average Harris hip score at follow-up was 84.3 points. Interestingly, no femoral osteolysis could be detected, even in cases with severe acetabular osteolyses, indicating sealing of the stem interface by tight osseointegration of the proximally-coated stem.

The risks of reuse: legal implications for hospitals of reusing single-use medical devices

There is no doubt that the practice of reuse in hospitals is a reaction to the budgetary constraints under which hospitals are operating. However, the costs of appropriately monitoring and sterilizing reused equipment as well as the significant risk of patient harm and potential liability raise the unavoidable question of whether this practice is an advisable one. These costs and risk should be carefully examined before a decision about whether to reuse single-use devices is made.

Testicular germ cell cancer despite previous local radiotherapy to the testis

BACKGROUND

Testicular intraepithelial neoplasia (TIN, also carcinoma in situ of the testis) is the uniform precursor of testicular germ cell cancer. Local radiotherapy to the testis with dosages of 18-20 Gy has been found to safely eradicate TIN and germ cells, too. Thus, the general assumption is that the development of invasive germ cell tumours can be prevented by this radiotherapy.

PATIENTS AND METHODS

Herein, we report two patients with one-sided testicular tumour and biopsy-proven contralateral TIN. Both of them developed germ cell neoplasms in the remaining testis although local radiotherapy with 20 Gy had been applied to the testis.

RESULTS

One patient developed pure seminoma 7 years after completion of radiotherapy, the other developed a combined tumour consisting of embryonal carcinoma and seminoma after 5 years. Treatment consisted of orchiectomy in each of the cases. Histologically, both had TIN in the testicular tissue surrounding the new growths.

CONCLUSIONS

Pathogenetically, a small fraction of radioresistent TIN cells overcoming irradiation and progressing to full-blown germ cell cancer in the later course may be the histogenetic clue to explain these unexpected events. Other explanations, though less probable, could be technical radiotherapeutic failure due to targeting problems and a pre-existing radioresistent germ cell tumour in the irradiated testicle.