Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review

OBJECTIVES

We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies.

DESIGN

Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018.

ELIGIBILITY CRITERIA

All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies.

DATA EXTRACTION AND SYNTHESIS

Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently.

RESULTS

The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain.

CONCLUSIONS

There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision.

PROSPERO REGISTRATION NUMBER

CRD42017060825.

Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain

Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.

Assessment of patient-reported outcomes after polytrauma: protocol for a systematic review

INTRODUCTION

Survivors of polytrauma experience long-term and short-term burden that influences their lives. The patients' view of relevant short-term and long-term outcomes should be captured in instruments that measure quality of life and other patient-reported outcomes (PROs) after a polytrauma. The aim of this systematic review is to (1) collect instruments that assess PROs (quality of life, social participation and activities of daily living) during follow-up after polytrauma, (2) describe the instruments' application (eg, duration of period of follow-up) and (3) investigate other relevant PROs that are also assessed in the included studies (pain, depression, anxiety and cognitive function).

METHODS AND ANALYSIS

The systematic review protocol is developed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials and the trials registers ClinicalTrials.gov and WHO International Clinical Trials Registry Platform will be searched. Keywords, for example, 'polytrauma', 'multiple trauma', 'quality of life', 'activities of daily living' or 'pain' will be used. Publications published between January 2005 and the most recent date (currently: August 2016) will be included. In order to present the latest possible results, an update of the search is conducted before publication. The data extraction and a content analysis will be carried out systematically. A critical appraisal will be performed.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as primary data will not be collected. The results will be published in a peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42017060825.

[Upper abdominal pain and febrile episodes in a 44-year-old Filipino woman]

A 44-year-old Filipino woman presented with abdominal pain and fever. Clinical examination and blood tests revealed no pathological results; however, (cross-sectional) imaging showed saccular cystic bile duct dilatation in the right liver with solid intraductal masses. Due to the clinical presentation the patient was admitted for surgical intervention with the diagnosis of Caroli disease. During the surgical procedure histopathology showed an intraductal papillary neoplasm of the bile duct (IPNB). The planned segmentetomy was extended to hemihepatectomy. IPNB is a rare entity of premalignant lesions of the bile duct system first recognized by the World Health Organization in 2010.

[Geriatric trauma centers from the idea to implementation. What has been achieved?]

The geriatric trauma working party, a subgroup of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU), focuses on the challenges of geriatric fractures, which are steadily increasing due to demographic changes. Inherent comorbidities implicate perioperative complications leading to loss of mobility and endangered independence followed by an increased burden on the social services. An interdisciplinary approach is required. The geriatric trauma working party defined criteria for interdisciplinary treatment and comprehensive care as well as early rehabilitation in interdisciplinary geriatric fracture centers. By passing an independent audit process these centers can achieve certification as a geriatric trauma center DGU (AltersTraumaZentrum DGU). Certified centers can participate in a recently established geriatric fracture registry which includes an internationally consented data set. Audit and registry enable centers to acquire an international benchmark, ensure permanent improvement in quality and allow participation in health services research.

Advancing Towards a CDA-Based Trauma Registry Data Submission

This poster presents an assessment to which extent the data submission to one of the largest trauma registries worldwide can be structured compliant to the clincial document architecture (CDA) and semantically annotated. Overall, complete annotation was achieved for 75% of the items, for the remaining ones annotation failed due to missing codes or concepts for individual items or values of value sets.

Ad hoc Participation in Professional Tele-Collaboration Platforms

Tele-collaboration between medical professionals is well established for specialties like radiology, cardiology or pathology. Typically these applications do not allow for ad hoc participation of non-registered users like patients and / or medical professionals. This paper describes an approach for extending these tele-applications to non-registered users and providing ad hoc participation with means for providing and accessing data. A light weight, web-based approach is used to assure acceptance and ease of use while maintaining and complying to the required regulations regarding authentication, authorization and protection of personal data. The approach has been implemented and is in use with a nationwide tele-collaboration network in Germany.

[Prevention of bicycle accidents]

For a very precise analysis of all injured bicyclists in Germany it would be important to have definitions for "severely injured", "seriously injured" and "critically injured". By this, e.g., two-thirds of surgically treated bicyclists who are not registered by the police could become available for a general analysis. Elderly bicyclists (> 60 years) are a minority (10 %) but represent a majority (50 %) of all fatalities. They profit most by wearing a helmet and would be less injured by using special bicycle bags, switching on their hearing aids and following all traffic rules. E-bikes are used more and more (145 % more in 2012 vs. 2011) with 600,000 at the end of 2011 and are increasingly involved in accidents but still have a lack of legislation. So even for pedelecs 45 with 500 W and a possible speed of 45 km/h there is still no legislative demand for the use of a protecting helmet. 96 % of all injured cyclists in Germany had more than 0.5 ‰ alcohol in their blood, 86 % more than 1.1 ‰ and 59 % more than 1.7 ‰. Fatalities are seen in 24.2 % of cases without any collision partner. Therefore the ADFC calls for a limit of 1.1 ‰. Some virtual studies conclude that integrated sensors in bicycle helmets which would interact with sensors in cars could prevent collisions or reduce the severity of injury by stopping the cars automatically. Integrated sensors in cars with opening angles of 180° enable about 93 % of all bicyclists to be detected leading to a high rate of injury avoidance and/or mitigation. Hanging lamps reduce with 35 % significantly bicycle accidents for children, traffic education for children and special trainings for elderly bicyclists are also recommended as prevention tools. As long as helmet use for bicyclists in Germany rates only 9 % on average and legislative orders for using a helmet will not be in force in the near future, coming up campaigns seem to be necessary to be promoted by the Deutscher Verkehrssicherheitsrat as, e.g., "Helmets are cool". Also, spots in TV should be broadcasted like "The 7th sense" or "Traffic compass", which were warning car drivers many years ago of moments of danger but now they could be used to warn bicyclists of life-threatening situations in traffic.

Enhancing tele-collaboration Networks by Patient Participation

This paper decribes an approach for extending tele-collaboration to the patient and allowing the patient's participation by accessing and providing data and thereby keeping the responsibilty for maintaining a personal health record with the patient. The approach has been implemented and is in use with the nationwide tele-collaboration network TKmed.

Dynamic contrast-enhanced ultrasound (DCE-US) for the characterization of hepatocellular carcinoma and cholangiocellular carcinoma

PURPOSE

In a prospective study, we compared the different perfusion kinetics of HCC and ICC using dynamic contrast-enhanced ultrasound (DCE-US).

MATERIALS AND METHODS

Patients with proven HCC and ICC were included. Three-minute video clips of CEUS examinations (CPS - low MI mode) after a bolus injection of 1.2 ml SonoVue were recorded and analyzed with quantification software (VueBox). Parameters for the arterial contrast enhancement [rise time (RT), time-to-peak (TTP)] towards portal venous contrast enhancement [mean transit time (local) (mTTl) and fall time (FT)] were quantified. Furthermore, contrast wash-out after peak enhancement (PE) (40 s, 80 s, 100 s and 120 s after PE) was compared between HCC and ICC.

RESULTS

43 patients with proven HCC (n = 23 HCC; cirrhosis n = 16) and ICC (n = 20 ICC; Cirrhosis n = 6) were examined. No statistical difference of the arterial DCEUS parameters was found between HCC and ICC. Contrast enhancement of the portal venous and late phases showed significantly lower values in the ICC group indicating early wash-out of the contrast agent: mTTl (p = 0.0209): HCC 118.4 s (SD± 88.4); ICC 64.8 s (SD± 49.7). FT (p = 0.0433): HCC 42.5 s (SD± 27.7); ICC 27.7 s (SD± 16.2). The percental loss of intensity at a definite time point after PE was significantly higher in ICC than in HCC lesions.

CONCLUSION

DCE-US is able to detect and quantify differences in perfusion kinetics between HCC and ICC. Whereas arterial contrast enhancement patterns may overlap between HCC and ICC, a timed characterization of wash-out kinetics may offer an additional tool to characterize HCC and ICC. The presence of a rapid loss of signal intensity in the early portal venous phase is significantly higher in ICC than in HCC lesions.

Acoustic radiation force impulse (ARFI) and high-frequency ultrasound of the liver surface for the diagnosis of compensated liver cirrhosis

PURPOSE

To evaluate the diagnostic value of acoustic radiation force impulse (ARFI) and high-frequency ultrasound of the liver surface, using histology as a gold standard for the diagnosis of compensated liver cirrhosis.

MATERIALS AND METHODS

73 patients without ascites undergoing liver biopsy were included in the study. The left and right liver lobes were examined with ARFI and high-frequency ultrasound. Liver surface irregularity was quantified using image analysis software to calculate the difference between the real surface and the approximated physiological surface through a 20 mm standardized line.

RESULTS

There is a significant difference between cirrhotic and non-cirrhotic patients for both quantified liver surface (QLS) and ARFI (p < 0.001). The mean values for QLS of the left lobe were 0.71 ± 0.24 mm and 1.17 ± 0.80 mm, of the right lobe 0.56 ± 0.26 mm and 0.87 ± 0.26 mm for non-cirrhotic and cirrhotic patients, respectively. The mean values of ARFI measurements of the left lobe were 2.04 ± 0.76 m/s and 2.85 ± 0.81 m/s, of the right lobe 1.65 ± 0.61 m/s and 3.02 ± 0.77 m/s for non-cirrhotic and cirrhotic patients, respectively. Diagnostic accuracy (AUROC) was 0.78/0.80 for QLS and 0.77/0.91 for ARFI of the left/right lobe, respectively. ARFI of the right lobe is significantly better than ARFI of the left (p = 0.023) or QLS of the left (p = 0.025)/right (p = 0.046) lobe of the liver.

CONCLUSION

Assessment of liver surface irregularity by high-frequency ultrasound (QLS) is a useful diagnostic test for the assessment of compensated liver cirrhosis. ARFI of the right liver lobe is significantly better than high-frequency ultrasound (QLS of the left/right lobe of the liver) and ARFI of the left lobe of the liver.

Outcome analysis of liver stiffness by ARFI (acoustic radiation force impulse) elastometry in patients with chronic viral hepatitis B and C

AIM

To evaluate the association between liver stiffness measured by acoustic radiation force impulse (ARFI) elastometry and the outcome of antiviral treatment in patients with chronic viral hepatitis B and C.

MATERIALS AND METHODS

Thirty-eight patients with chronic viral hepatitis B (n = 16) or hepatitis C (n = 22) underwent liver biopsy and ARFI elastometry of the right hepatic lobe. A follow-up assessment using ARFI was performed a mean of 2.3 years after the baseline evaluation. The patients with favourable outcome were classified in group S and those receiving no treatment, showing no response to treatment, or experiencing a relapse were classified in group N.

RESULTS

The 38 patients had an initial mean ARFI value of 1.56 ± 0.62 m/s as compared with 1.54 ± 0.64 m/s in the follow-up evaluation. Group S showed a significant decline in ARFI values (1.55 ± 0.60 m/s versus 1.34 ± 0.47 m/s; p < 0.05) and included 16 (64%) patients with lower shear wave velocities at follow-up. In group N, liver stiffness values showed a slight but not significant increase (1.57 ± 0.70 m/s versus 1.93 ± 0.77 m/s).

CONCLUSION

Changes in liver stiffness during antiviral therapy can be assessed by ARFI reflecting response or no response. ARFI elastometry is an additional, useful tool for the follow-up assessment of treatment outcome in patients with chronic viral hepatitis B or C infection.

Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?

This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.

Physical exercise through mountain hiking in high-risk suicide patients. A randomized crossover trial

OBJECTIVE

The following crossover pilot study attempts to prove the effects of endurance training through mountain hiking in high-risk suicide patients.

METHOD

Participants (n = 20) having attempted suicide at least once and clinically diagnosed with hopelessness were randomly distributed among two groups. Group 1 (n = 10) began with a 9-week hiking phase followed by a 9-week control phase. Group 2 (n = 10) worked vice versa. Assessments included the Beck Hopelessness Scale (BHS), Beck Depression Inventory (BDI), Beck Scale of Suicide Ideation (BSI), and maximum physical endurance.

RESULTS

Ten participants of Group 1 and seven participants of Group 2 completed the study. A comparison between conditions showed that, in the hiking phase, there was a significant decrease in hopelessness (P < 0.0001, d = -1.4) and depression (P < 0.0001, d = -1.38), and a significant increase in physical endurance (P < 0.0001, d = 1.0), but no significant effect for suicide ideation (P = 0.25, d = -0.29). However, within the hiking phase, there was a significant decrease in suicide ideation (P = 0.005, d = -0.79).

CONCLUSION

The results suggest that a group experience of regular monitored mountain hiking, organized as an add-on therapy to usual care, is associated with an improvement of hopelessness, depression, and suicide ideation in patients suffering from high-level suicide risk.

Establishing end-to-end security in a nationwide network for telecooperation

Telecooperation is used to support care for trauma patients by facilitating a mutual exchange of treatment and image data in use-cases such as emergency consultation, second-opinion, transfer, rehabilitation and out-patient aftertreatment. To comply with data protection legislation a two-factor authentication using ownership and knowledge has been implemented to assure personalized access rights. End-to-end security is achieved by symmetric encryption in combination with external trusted services which provide the symmetric key solely at runtime. Telecooperation partners may be chosen at departmental level but only individuals of that department, as a result of checking the organizational assignments maintained by LDAP services, are granted access. Data protection officers of a federal state have accepted the data protection means. The telecooperation platform is in routine operation and designed to serve for up to 800 trauma centers in Germany, organized in more than 50 trauma networks.

FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke

Despite benefit in acute ischaemic stroke, less than 3% of patients receive tissue plasminogen activator (tPA) in Australia. The FASTER (Face, Arm, Speech, Time, Emergency Response) protocol was constructed to reduce pre-hospital and Emergency Department (ED) delays and improve access to thrombolysis. This study aimed to determine if introduction of the FASTER protocol increases use of tPA using a prospective pre- and post-intervention cohort design in a metropolitan hospital. A pre-hospital assessment tool was used by ambulance services to screen potential tPA candidates. The acute stroke team was contacted, hospital bypass allowed, triage and CT radiology alerted, and the patient rapidly assessed on arrival to ED. Data were collected prospectively during the first 6 months of the new pathway and compared to a 6-month period 12 months prior to protocol initiation. In the 6 months following protocol introduction, 115 patients presented within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, significantly greater than five (7%) of 67 patients over the control period, p=0.03. Overall, 42 patients were referred via the FASTER pathway, with 21 of these receiving tPA (50%). One inpatient stroke was also treated. Only two referrals (<5%) were stroke mimics. Introduction of the FASTER pathway also significantly reduced time to thrombolysis and time to admission to the stroke unit. Therefore, fast-track referral of potential tPA patients involving the ambulance services and streamlined hospital assessment is effective and efficient in improving patient access to thrombolysis.

A Probabilistic Framework for Learning Kinematic Models of Articulated Objects

Robots operating in domestic environments generally need to interact with articulated objects, such as doors, cabinets, dishwashers or fridges. In this work, we present a novel, probabilistic framework for modeling articulated objects as kinematic graphs. Vertices in this graph correspond to object parts, while edges between them model their kinematic relationship. In particular, we present a set of parametric and non-parametric edge models and how they can robustly be estimated from noisy pose observations. We furthermore describe how to estimate the kinematic structure and how to use the learned kinematic models for pose prediction and for robotic manipulation tasks. We finally present how the learned models can be generalized to new and previously unseen objects. In various experiments using real robots with different camera systems as well as in simulation, we show that our approach is valid, accurate and efficient. Further, we demonstrate that our approach has a broad set of applications, in particular for the emerging fields of mobile manipulation and service robotics.

The folic acid endophenotype and depression in an elderly population

OBJECTIVES

Folate status and/or genes have been linked to depression in a number of studies. This may be via a direct action (or actions) on neuronal membranes or indirect effects through the metabolism of methyl groups involved in neurotransmitter synthesis. This study examines folate and related thiol metabolism that might underpin either phenomenon.

DESIGN

Cohort study describing the relationship between several genetic and nutritional aspects of folic acid homeostasis and depression assessed by the HADS psychometric index in an elderly cohort.

SETTING

New South Wales (Australia) retirement village.

PARTICIPANTS

118 elderly participants (age 65-90 years).

RESULTS

Stepwise multiple regression was used to determine the best statistical model to predict depression; C677T-MTHFR (p=0.0103) was found to be positively associated with depression, while the thiol dipeptide Cys-Gly was negatively associated (p=0.0403). The statistical models used accounted for the major folate related indices (genetic and biochemical) that are most often evaluated in the context of health and disease. When only genetic data were examined for interactions, C677T-MTHFR was found to be negatively associated with the HADS Depression Index Score (p=0.0191).

CONCLUSION

The potential influence of Cys-Gly on this phenotype is novel, and of considerable interest given that it has been linked to altered spontaneous activity and sedation in an animal model. Cys-Gly is a recognised ligand at the N-methyl-D-aspartatic acid (NMDA) subclass of glutamate receptor, a system associated with depression. In addition, the C677T-MTHFR association adds further support to existing findings underscoring the potential role of folate in depression.

[The Trauma Network of the German Society for Trauma 2009]

In 2009, 3 years after the foundation of the Trauma Network of the German Society for Trauma (TraumaNetzwerkD DGU), the majority of German hospitals participating in the treatment of seriously injured patients is registered in regional trauma networks (TNW). Currently there are 41 trauma networks with more than 660 hospitals in existence, 18 more are registered but are still in the planning phase. Each Federal State has an average of 39 trauma centres of different levels taking part in the treatment of seriously injured patients and every trauma network has an average catchment area of 8708 km(2). The most favourable geographical infrastructure conditions exist in Nordrhein-Westfalen, the least favourable in Sachsen-Anhalt and Mecklenburg-Vorpommern. A total of 95 hospitals have already fulfilled the first audit of the structural, personnel and qualitative requirements by the certification bodies. Examination of the check lists of 26 hospitals showed shortcomings in the clinical structure so that these hospitals must be rechecked after correction of the shortcomings. A total of 59 hospitals throughout Germany were successfully audited and only one failed to fulfil the requirements. Because of the varying sizes of the trauma networks there are differences in the areas covered by each trauma network and trauma centre. Concerning the process of certification and auditing (together with the company DIOcert) it could be seen that by careful examination of the check lists of each hospital unforeseen problems during the audit could be avoided. The following article will present the current state of development of the Trauma Network of the German Society for Trauma and describe the certification and auditing process.

[Trauma centers in Germany. Status report]

BACKGROUND

In Germany, a total of more than 30,000 polytraumatized patients are treated in level I-IV trauma centers. The exact number of hospitals fulfilling the requirements for the treatment of severely injured patients is unknown. We analyzed the number of hospitals in Germany capable of managing polytraumatized patients. We further analyzed the influence of various geographic and infrastructure conditions on the management of severely injured patients in the various Federal States in Germany.

METHODS

First we conducted a nationwide research of all hospitals specialized in trauma management. Points of interest were structural and personnel requirements. These data were compared to the data obtained by the Federal Statistical Office. With a special software program we were able to conduct for the first time a geographic visualization of all trauma hospitals.

RESULTS

There are 108 level I trauma centers, 209 level II trauma centers, and 431 level III and IV trauma centers in Germany. The geographic concentration of hospitals fulfilling the requirements for the treatment of severely injured patients differs regionally. There is an obvious correlation between trauma deaths and a low hospital concentration and less developed infrastructure.

CONCLUSION

Objectively, the number of trauma centers for the treatment of severely injured patients seems to be adequate in Germany. Nevertheless, there are substantial differences between various Federal States in Germany concerning the distribution of hospitals as well as the geographic and infrastructure conditions. To optimize trauma management in Germany we think that the formation of regional trauma networks is mandatory.

Influence of grape treatment on the wine yeast populations isolated from spontaneous fermentations

AIM

To study the influence of different methods of grape treatment in wineries on the diversity of the yeast species in spontaneous fermentations.

METHODS AND RESULTS

Grapes were crushed and pressed in three different ways followed by spontaneous fermentation. The same grape material picked and crushed aseptically directly in the vineyard served as control. Yeasts isolated at different stages of the fermentation were characterized by 5.8S-ITS-RFLP. Yeasts of the Saccharomyces sensu stricto complex were additionally analysed by microsatellite polymerase chain reaction fingerprinting. The diversity of yeast species isolated from winery fermentations was much greater than from the vineyard fermentation in respect to yeasts of the genus Saccharomyces as well as non-Saccharomyces.

CONCLUSIONS

Oenonogical methods alter significantly the yeast diversity in spontaneous fermentations of grape juice.

SIGNIFICANCE AND IMPACT OF THE STUDY

Managing spontaneous fermentations successfully depends not only on choosing the suitable grapes but also on the crushing and pressing techniques leading to different yeast populations.

Ileus secondary to wireless capsule enteroscopy

Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio-CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.

Peritoneal cancer treatment with CYP2B1 transfected, microencapsulated cells and ifosfamide

The prognosis of peritoneal spread from gastrointestinal cancer and subsequent malignant ascites is poor, and current medical treatments available are mostly ineffective. Targeted chemotherapy with intraperitoneal prodrug activation may be a beneficial new approach. L293 cells were genetically modified to express the cytochrome P450 enzyme 2B1 under the control of a cytomegalovirus immediate early promoter. This CYP2B1 enzyme converts ifosfamide to its active cytotoxic compounds. The cells are encapsulated in a cellulose sulfate formulation (Capcell). Adult Balb/c mice were inoculated intraperitoneally with 1 x 10(6) colon 26 cancer cells, previously transfected with GFP to emit a stable green fluorescence, by injection into the left lower abdominal quadrant. Two or five day's later animals were randomly subjected to either i.p. treatment with ifosfamide alone or ifosfamide combined with microencapsulated CYP2B1-expressing cells. Peritoneal tumor volume and tumor viability were assessed 10 days after tumor inoculation by means of fluorescence microscopy, spectroscopy and histology. Early i.p. treatment with ifosfamide and CYP2B1 cells resulted in a complete response. Treatment starting on day 5 and single-drug treatment with ifosfamide resulted in a partial response. These results suggest that targeted i.p. chemotherapy using a combination of a prodrug and its converting enzyme may be a successful treatment strategy for peritoneal spread from colorectal cancer.

Adjuvant therapy with edrecolomab versus observation in stage II colon cancer: a multicenter randomized phase III study

BACKGROUND

In a phase III study recruiting patients with stage II colon cancer the effect of adjuvant therapy with edrecolomab, a murine monoclonal antibody to the cell-surface glycoprotein 17-1A, was compared to observation alone.

PATIENTS AND METHODS

From January 1997 until July 2000 a total of 377 patients were postoperatively stratified according to tumor stage (T3 vs. T4) and center, and randomly allocated to either treatment with edrecolomab (cohort A, n = 183) or observation (cohort B, n = 194). Patients in cohort A received a total of 900 mg edrecolomab. The study was terminated prematurely because of discontinuation of drug supply in Germany.

RESULTS

305 patients were eligible for the primary endpoint of overall survival and 282 patients for disease-free survival. After a median follow-up of 42 months overall survival and disease-free survival were not significantly different. Toxicity was mild.

CONCLUSIONS

In the present study, postoperative adjuvant treatment with edrecolomab in patients with resected stage II colon cancer did not improve overall or disease-free survival.

Einfluss von Rettungsmittel und Zielklinik auf die Letalität nach Polytrauma

BACKGROUND

The aim of this study was to document the present knowledge from the medical literature on (1) efficacy of aeromedical evacuation (helicopter emergency medical service, HEMS) and (2) influence of the level of the first receiving hospital on mortality of patients.

METHODS

Systematic review of the literature between 1970 and 2003; identification of studies with an evidence level of at least III and included control group; own results.

RESULTS

(1) 17 studies concerning the efficacy of HEMS were included into the review. No single study yielded shorter rescue times with the use of HEMS. 11 of 17 studies showed a significantly higher survival rate (8.2 to 52%) with the employment of HEMS especially with mid-degree polytrauma. (2) All 6 relevant studies dealing with hospital level found a considerable lower mortality rate (19 to 42%) for patients treated primarily at a level 1 trauma center or comparable institution.

CONCLUSIONS

The analyzed studies showed a trend toward decreased mortality rates with the employment of HEMS. Considering the comparable hospital level and even longer rescue times with HEMS, these differences can be explained with higher quality of initial diagnosis and treatment of the HEMS rescue team. Furthermore, mortality rates can be lowered significantly through primary treatment at a level 1 trauma center. Thus, the more flexible choice of the first receiving hospital represents a specific, clinically relevant advantage of HEMS in emergency medicine.

Die Bedeutung des Advanced Trauma Life Support� (ATLS�) im Schockraum

INTRODUCTION

There is clinical evidence, that a standardized management of trauma patients in the emergency room improves outcome.

METHODS

The ATLS training course teaches a systematic approach to the trauma patient in the emergency room. The aim is a rapid and accurate assessment of the patient's physiologic status, the treatment according to priorities and the decision making if transfer to a trauma center is necessary. The German Trauma Society has taken over the course concept from the American College of Surgeons (ACS) and is authorized to organize ATLS courses in Germany.

RESULTS

A standardized management in the emergency room helps to prevent secondary injury, to realize timing as a relevant factor in the initial treatment and to assure a high standard of care. The ATLS course provides the participant with knowledge, skills and attitudes and is open to doctors of all specialties involved in the initial management of severely injured patients.

CONCLUSION

ATLS teaches a standardized and established approach to the trauma patient in the emergency room. It has been transferred to 46 countries and the content is reviewed regularly to consider new scientific evidence. Germany has the chance to participate in this international standard of care and to introduce own experiences into the review process.

[Primary diagnostics of acute diverticulitis of the sigmoid]

AIM

The initial diagnostics of acute diverticulitis of the sigmoid should render the correct diagnosis as well as assisting in the decision on the options of conservative or surgical treatment by ruling out or demonstrating complications. At present, sonography or computed tomography (CT) are the two competing diagnostic options. This study was designed to demonstrate that sonography could be used as the method of choice.

METHOD

63 patients with clinical suspicion of acute diverticulitis of the sigmoid were examined initially by sonography or CT in a prospective study.

RESULTS

Sonography and CT showed a 97 % sensitivity and specificity for reaching the accurate and clinically plausible diagnosis. As to the demonstration of complications of the disease, sensitivity and specificity were comparably high for both diagnostic methods.

CONCLUSIONS

Sonography can compete with the more complex CT examination and therefore represents the recommended primary diagnostic procedure.

Impact of donor dopamine on immediate graft function after kidney transplantation

Optimizing medical donor management may have a considerable impact on transplantation outcome. This study investigated the effect of donor dopamine on initial graft function in renal allograft recipients, involving 254 consecutive recipients of a cadaver kidney, aged 18-74 years, transplanted between 1990 and 2003. Immunosuppression was based on cyclosporine. Patients were grouped according to donor use of dopamine during intensive care. Delayed graft function (DGF), and serial creatinine concentrations were compared between the groups. Dopamine-treated and -untreated donors were very similar regarding hemodynamics and renal function. Delayed graft function occurred in 47/158 treated and 48/96 untreated kidneys (p = 0.001). Donor dopamine was associated with a more rapid decrease of s-creatinine, which became obvious on the first postoperative day. Of patients in the treated and untreated group, respectively, 81.9% and 65.8% reached a s-creatinine level less than 2 mg/dL during the first month (p = 0.005). Donor dopamine remained predictive of a normalized s-creatinine level [HR 1.71; 95% CI 1.22-2.41] after controlling for confounding factors by multivariate Cox regression. Donor dopamine is associated with improvements of initial graft function after kidney transplantation. The beneficial effect of dopamine is achievable without side-effects for the recipients, and correlates with superior long-term graft survival.

Adjuvant chemotherapy in stage III colon cancer with 5-fluorouracil and levamisole versus 5-fluorouracil and leucovorin

BACKGROUND

Adjuvant chemotherapy for colon cancer has been established during the past decade. From 1990 until recently treatment with 5- fluorouracil (5-FU) and levamisole (LEV) lasting 12 months was recommended as standard treatment. At the initiation of this study in 1993 improvement of adjuvant therapy was expected by the modulation of 5-FU with folinic acid (FA). Therefore, we decided to perform a prospective randomized multicenter trial to compare standard 5-FU/LEV to 5-FU/FA for either 6 or 12 months.

PATIENTS AND METHODS

Patients with stage III colon cancer after curative en bloc resection were randomized in 3 treatment groups: arm A (5-FU/LEV, weekly, 12 months), arm B (5-FU/FA, days 1-5, every 4 weeks, 12 months) and arm C (like B, 6 months).

RESULTS

Between March 1993 and November 1997, 180 patients were randomized into the study, 155 were eligible for further evaluation. The interim analysis in November 2000 showed no significant difference for recurrence and disease-free survival in arm B and C, therefore the data from both 5-FU/FA treatment arms (B+C) were combined for comparison with 5-FU/LEV-treatment (A). Most pronounced toxicity in all treatment arms was mild nausea, loss of appetite and leukopenia. A tendency for more diarrhea and stomatitis was observed in arm B+C. After a median follow-up of 36.2 months no significant difference was seen for disease free survival (p = 0.9) and overall survival (p = 1.0). 3-year recurrence rates were 39.6% in arm A and 39.1% in arm B+C, 3-year survival rates amounted to 74.1% in arm A and 74.9% in arm B+C.

CONCLUSION

Only a limited number of patients could be recruited in this study. The observed data support the results of other studies, which concluded that 6 months (or 12 months) treatment with 5-FU/FA is equivalent to 12 months treatment with 5-FU/LEV. Therefore the 6 months treatment with 5-FU/FA can be supported as standard for adjuvant therapy of stage III colon cancer.

Hydrolytic degradation of nitrendipine and nisoldipine

The development of a new HPLC-UV diode array procedure applied to follow the hydrolytic degradation of two well-known 4-nitrophenyl-1,4-dihydropyridine derivatives, nitrendipine and nisoldipine is reported. Hydrolysis of each drug were carried out in ethanol/Britton-Robinson buffer at different pHs, stored into amber vials at controlled temperatures of 40, 60 and 80 degrees C and periodically sampled and assayed by HPLC. Nitrendipine degradation in different parenteral solutions was also evaluated. The HPLC procedure exhibited an adequate selectivity, repeatability (<1%) and reproducibility (<2%). The recoveries were higher than 98% with CV of 1.13 and 1.54% for nitrendipine and nisoldipine, respectively. A significant degradation was observed at alkaline pH (>pH 8) with a first order kinetic for both drugs. At pH 12, 80 degrees C, k values of 3.56x10(-2) x h(-1) and 2.22x10(-2) for nitrendipine and nisoldipine, respectively were obtained. Also, activation energies of 16.8 and 14.7 kcal x mol(-1) for nitrendipine and nisoldipine, respectively, were calculated. Furthermore, from the results obtained from hydrolytic degradation in different solutions for parenteral use, we can affirm that solutions significantly increased the degradation of nitrendipine. In conclusion, the HPLC proposed procedure exhibited adequate analytical requirements to be applied to the hydrolytic degradation studies of nitrendipine and nisoldipine. Furthermore, all tested parenteral solutions significantly increased the hydrolytic degradation of nitrendipine, the composition of solution being a relevant factor.