Outcomes of Extracorporeal Membrane Oxygenation (ECMO) for COVID-19 Patients: A Multi-Institutional Analysis

BACKGROUND

In March 2020, COVID-19 was announced as a global pandemic. The first COVID-19 patient was connected to an ECMO device in Israel during that time. Since then, over 200 patients have required ECMO support due to COVID-19 infection. The present study is a multi-institutional analysis of all COVID-19 patients requiring veno-venous (VV) ECMO in Israel. The aim was to characterize and compare the survivors and deceased patients as well as establish risk factors for mortality.

METHODS

This retrospective multi-institutional study was conducted from March 2020 to March 2021 in eleven of twelve ECMO centers operating in Israel. All COVID-19 patients on VV ECMO support were included in the cohort. The patients were analyzed based on their comorbidities, procedural data, adverse event on ECMO, and outcomes. Univariate and multivariate analyses were used to compare the deceased and the surviving patients.

RESULTS

The study included 197 patients, of which 150 (76%) were males, and the mean age was 50.7 ± 12 years. Overall mortality was 106 (54%). Compared with the deceased subjects, survivors were significantly younger (48 ± 11 vs. 53 ± 12 years), suffered less from ischemic heart disease (IHD) (3% vs. 12%), and were ventilated for a significantly shorter period (≤4 days) prior to cannulation (77% vs. 63%). Patients in the deceased group experienced more kidney failure and sepsis. Rates of other complications were comparable between groups.

CONCLUSIONS

Based on this study, we conclude that early cannulation (≤4 days) of younger patients (≤55 years) may improve overall survival and that a history of IHD might indicate a reduced prognosis.

Large multinational evaluation of time to reintervention in patients undergoing bioprosthetic valve implantation during open heart surgery

Introduction

Bioprosthetic valves are increasingly utilized during open heart surgery in favor of mechanical valves. These tissue valves are prone for structural valve degeneration and failure, especially in young patients. Transcatheter aortic valve implantation (TAVI) is an appealing approach in these patients.

Purpose

To describe independent correlates for early need for reintervention.

Method

We used a large multicenter registry of patients (>45 years of age) with failed bioprosthetic surgical valves undergoing TAVI valve-in-valve (VinV) in either aortic or the mitral positions. Early reintervention was (<5 years between open-heart surgery and VinV). Multi-variable properties that were included: patient gender, age at open-heart surgery, valve size, baseline renal failure, position of valve implantation, and bioprosthetic valve label size.

Results

A total of 3,324 patients were included in the study (age at the time of open heart surgery 68.9+7.9 years). Median time to TAVI was 9 years (IQR 6–13 years). A total of 632 (19%) patients experienced early valve degeneration with median time to TAVI of only 3 years [IQR 1–5]. Patients with early degeneration were older than those without early degeneration (mean age at surgery was 72.8±9 years vs. 68.9±8 years; p<0.001). in addition, significant linear relation between older patient age and early valve degeneration (p for trend <0.001). Re-intervention in the mitral position was more common in the group of patients with early degeneration (24.4% vs 18.2% without early degeneration; p<0.001) Patient age and mitral valve position were independently associated with increased rate of early degeneration (OR 1.09 [1.08–1.11], p<0.001; OR 1.62 [1.31–2.01]; p<0.001 respectively).

Conclusions

In this large multicenter analysis of patients undergoing TAVR for failed bioprosthetic valves we identified old patient age and mitral valve (vs. aortic) as independent correlates for early intervention. A discrepancy with known association of young age and rapid bioprosthetic valve degeneration is to be determined.

Funding Acknowledgement

Type of funding sources: None.

The need for cardiac surgery differential tariffs in Israel at the era of aging population and emerging technology: Importance of procedure type and patient complexity as assessed by EuroSCORE

Background

Reimbursement for cardiac surgical procedures in Israel is uniform and does not account for diversity in costs of various procedures or for diversity in patient mix. In an era of new and costly technology coupled with higher risk patients needing more complex surgery, these tariffs may not adequately reflect the true financial burden on the caregivers. In the present study we attempt to determine whether case mix and complexity of procedures significantly affect cost to justify differential tariffs.

Methods

We included all patients undergoing cardiac surgery at Shaare Zedek Medical Center between the years 1993–2016. Patients were stratified according to (1) type of surgery and (2) clinical profile as reflected by the predicted operative risk according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Approximate cost of each group of patients was estimated by the average number of days in the Intensive Care Unit and days in the postoperative ward multiplied by the respective daily costs as determined by the Ministry of Health. We then added the fixed cost of the components used in the operating room (manpower and disposables). The final estimated cost (the outcome variable) was then evaluated as it relates to type of surgery and clinical profile. ANOVA was used to analyze cost variability between groups, and backward regression analysis to determine the respective effect of the abovementioned variables on cost. Because of non-normal distribution, both costs and lengths of stay were Log-transformed.

Results

Altogether there were 5496 patients: 3863, 836, 685 and 112 in the isolated CABG, CABG + valve, 1 valve and 2 valves replacement groups. By ANOVA, the costs in all EuroSCORE subgroups were significantly different from each other, increasing with increased EuroSCORE subgroup. Cost was also significantly different among procedure groups, increasing from simple CABG to single valve surgery to CABG + valve surgery to 2-valve surgery. In backward stepwise multiple regression analysis, both type of procedure and EuroSCORE group significantly impacted cost. ICU stay and Ward stay were significantly but weakly related while EuroSCORE subgroup was highly predictive of both ICU stay and ward stay.

Conclusions

The cost of performing heart surgery today is directly influenced by both patient profile as well as type of surgery, both of which can be quantified. Modern day technology is costly yet has become mandatory. Thus reimbursement for heart surgery should be based on differential criteria, namely clinical risk profile as well as type of surgery. Our results suggest an urgent need for design and implementation of a differential tariff model in the Israeli reimbursement system. We suggest that a model using a fixed, average price according to the type of procedure costs, in addition to a variable hospitalization cost (ICU + ward) determined by the patient EuroSCORE or EuroSCORE subgroup should enable an equitable reimbursement to hospitals, based on their case mix.

Effects of commercial metronidazole and metronidazole benzoate suspensions on food intake in chinchillas

OBJECTIVES

To evaluate if commercially available metronidazole and metronidazole benzoate suspensions cause a reduction in food intake in healthy chinchillas and if the reduction in food intake is dose-dependent.

MATERIALS AND METHODS

Twelve chinchillas were used in a randomised, controlled, blinded, complete-crossover study. All treatments were administered orally every 12 hours for 3 days. Metronidazole (125 mg/mL) was administered at 20 mg/kg and metronidazole benzoate (25 mg/mL) was administered at 20 and 10 mg/kg. Food intake was recorded daily. The washout period between treatments was at least 14 days.

RESULTS

At 20 mg/kg PO q12h administration of both commercial suspensions resulted in a significant reduction of food intake. The greatest mean reduction in food intake occurred after 2 to 3 days of drug administration (metronidazole: -54 ± 25%; metronidazole benzoate: -44 ± 36%). After administration of metronidazole benzoate at 10 mg/kg PO q12h, the reduction in food intake was significantly less pronounced (-24 ± 36%), suggesting that negative effect of metronidazole on food intake in chinchillas is dose-dependent. Variation in metronidazole-induced food intake reduction differed widely between individual chinchillas.

CLINICAL SIGNIFICANCE

The oral administration of commercial metronidazole and metronidazole benzoate suspensions results in a dose-dependent clinically relevant reduction in food intake in chinchillas. Metronidazole should be used cautiously in this species and food intake should be monitored during treatment. Future studies are needed in order to determine if metronidazole at 10 mg/kg q12h is an effective therapeutic dosage in chinchillas.

Million-year lag times in a post-orogenic sediment conveyor

Understanding how sediment transport and storage will delay, attenuate, and even erase the erosional signal of tectonic and climatic forcings has bearing on our ability to read and interpret the geologic record effectively. Here, we estimate sediment transit times in Australia's largest river system, the Murray-Darling basin, by measuring downstream changes in cosmogenic 26Al/10Be/14C ratios in modern river sediment. Results show that the sediments have experienced multiple episodes of burial and reexposure, with cumulative lag times exceeding 1 Ma in the downstream reaches of the Murray and Darling rivers. Combined with low sediment supply rates and old sediment blanketing the landscape, we posit that sediment recycling in the Murray-Darling is an important and ongoing process that will substantially delay and alter signals of external environmental forcing transmitted from the sediment's hinterland.

Comparing abundance distributions and range maps in spatial conservation planning for migratory species

Most spatial conservation planning for wide-ranging or migratory species is constrained by poor knowledge of species' spatiotemporal dynamics and is only based on static species' ranges. However, species have substantial variation in abundance across their range and migratory species have important spatiotemporal population dynamics. With growing ecological data and advancing analytics, both of these can be estimated and incorporated into spatial conservation planning. However, there is limited information on the degree to which including this information affects conservation planning. We compared the performance of systematic conservation prioritizations for different scenarios based on varying the input species' distributions by ecological metric (abundance distributions versus range maps) and temporal sampling resolution (weekly, monthly, or quarterly). We used the example of a community of 41 species of migratory shorebirds that breed in North America, and we used eBird data to produce weekly estimates of species' abundances and ranges. Abundance distributions at a monthly or weekly resolution led to prioritizations that most efficiently protected species throughout the full annual cycle. Conversely, spatial prioritizations based on species' ranges required more sites and left most species insufficiently protected for at least part of their annual cycle. Prioritizations with only quarterly species ranges were very inefficient as they needed to target 40% of species' ranges to include 10% of populations. We highlight the high value of abundance information for spatial conservation planning, which leads to more efficient and effective spatial prioritization for conservation. Overall, we provide evidence that spatial conservation planning for wide-ranging migratory species is most robust and efficient when informed by species' abundance information from the full annual cycle.

Delayed aortic dissection and valve thrombosis after transcatheter aortic valve implantation

We report a case of a 78-year-old female who presented with type A aortic dissection 22 months following transcatheter aortic valve implantation (TAVI). In addition, preoperative echocardiogram showed high gradients across the aortic prosthesis which was found to be thrombosed. At surgery, the intimal tear appeared to be non-acute and anatomically related to the rim of the valve cage. The thrombosed valve was not replaced and the patient received anticoagulation therapy following surgery with significant improvement in valve gradients.

Gota úrica visceral em bobo-pequeno (Puffinus puffinus) no sul do Brasil

RESUMO A gota úrica visceral é uma doença que acomete répteis, aves e mamíferos. Caracteriza-se por depósitos de cristais de urato e ácido úrico em diferentes órgãos da região visceral. O objetivo deste trabalho foi relatar um caso de gota úrica visceral em um indivíduo de bobo-pequeno (Puffinus puffinus) encontrado morto no litoral norte de Santa Catarina, sul do Brasil. No período de 20 de agosto de 2015 a 20 de abril de 2016, as praias dos municípios de Araquari, Barra do Sul, São Francisco do Sul e Itapoá foram monitoradas diariamente para o registro e a recuperação de tetrápodes marinhos mortos, incluindo aves marinhas. Foram encontrados e necropsiados 84 indivíduos. Um deles apresentou o pericárdio aderido ao miocárdio e com a coloração esbranquiçada. Os rins, o fígado e os pulmões continham inúmeros pontos esbranquiçados. A ocorrência dessa patologia na espécie foi de 1,19%. Trata-se do primeiro relato de bobo-pequeno com gota úrica visceral encontrado no Brasil.

The use of PIPAC (pressurized intraperitoneal aerosol chemotherapy) in gynecological oncology: a statement by the "Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR)", the Swiss and Austrian AGO, and the North-Eastern German Society of Gynaecologic Oncology

BACKGROUND

Ovarian, tubal, and peritoneal carcinomas primarily affect the peritoneal cavity, and they are typically diagnosed at an advanced tumor stage (Foley, Rauh-Hain, del Carmen in Oncology (Williston Park) 27:288-294, 2013). In the course of primary surgery, postoperative tumor residuals are, apart from the tumor stage, the strongest independent factors of prognosis (du Bois, Reuss, Pujade-Lauraine, Harter, Ray-Coquard, Pfisterer in Cancer 115:1234-1244, 2009). Due to improved surgical techniques, including the use of multi-visceral procedures, macroscopic tumor clearance can be achieved in oncological centers, in most cases (Harter, Muallem, Buhrmann et al in Gynecol Oncol 121:615-619, 2011). However, to date, it has not been shown that peritoneal carcinomatosis is, per se, an independent factor of prognosis or that it excludes the achievement of tumor clearance. Several studies have shown that a preceding drug therapy in peritoneal carcinomatosis could positively influence the overall prognosis (Trimbos, Trimbos, Vergote et al in J Natl Cancer Inst 95:105-112, 2003). In relapses of ovarian carcinoma, studies have shown that peritoneal carcinomatosis is a negative predictor of complete tumor resection; however, when it is possible to resect the tumor completely, peritoneal carcinomatosis does not play a role in the prognosis (Harter, Hahmann, Lueck et al in Ann Surg Oncol 16:1324-1330, 2009).

RESULTS

PIPAC is a highly experimental method for treating patients with ovarian, tubal, and peritoneal cancer. To date, only three studies have investigated a total of 184 patients with peritoneal carcinomatosis (Grass, Vuagniaux, Teixeira-Farinha, Lehmann, Demartines, Hubner in Br J Surg 104:669-678, 2017). Only some of those studies were phase I/II studies that included PIPAC for patients with different indications and different cancer entities. It is important to keep in mind that the PIPAC approach is associated with relatively high toxicity. To date, no systematic dose-finding studies have been reported. Moreover, no studies have reported improvements in progression-free or overall survival associated with PIPAC therapy.

CONCLUSIONS

Randomized phase III studies are required to evaluate the effect of this therapy compared to other standard treatments (sequential or simultaneous applications with systemic chemotherapy). In cases of ovarian, tubal, and peritoneal cancer, PIPAC should not be performed outside the framework of prospective, controlled studies.

Comparison of quartz vials with polypropylene vials for rapid cryopreservation of human ovarian tissue

Background

Because higher survival of follicles during the freezing/thawing procedure improves the quality of cryopreserved tissue reimplanted after oncological therapies, defining an optimal method for human ovarian tissue cryopreservation remains a major issue in this field. One option to improve the cryopreservation procedure is to use better materials, i.e., vials with better conductivity. The aim of this study was to compare polypropylene (PP) with quartz vials. Between September 2012 and January 2013, eight patients were recruited. The ovarian cortex was cut into 3 slices, assigned randomly to a fresh and a cryopreserved group in PP (method B) or quartz vials (method C). Histological and immunohistochemical (IHC) analysis were used. For IHC three antibodies were analyzed: Ki67 (proliferation index), Bcl2 (anti apoptotic index) and Hsp70 (stress index).

Results

The majority of GCs showed positive staining for Bcl2 in both cryopreservation device, with higher expression in group C than in group B. Oocytes and their nuclei showed intense positive staining for ki67 in both methods B and C, and also a patch positive stromal cells staining for Ki67. Expression of hsp70 was not increased after cryopreservation.

Conclusions

Cryopreservation using quartz vials led to larger numbers of good follicles while maintaining consistent preservation for stromal cells and vessels.

Statement of the AGO Kommission Ovar, AGO Study Group, NOGGO, AGO Austria and AGO Switzerland Regarding the Use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Ovarian Cancer

The AGO Kommission Ovar already published a statement in 2013, warning about the uncritical use of hyperthermic intraperitoneal chemotherapy (HIPEC) outside controlled studies. This statement has now been updated after the most recent literature was reviewed by AGO Kommission Ovar, the AGO Study Group, NOGGO, AGO Austria and AGO Switzerland. The authors conclude that HIPEC remains experimental. Its use is not recommended and should be rejected outside of prospective controlled trials.

Determination of discharge parameters via OES at the Linac4 H⁻ ion source

Optical emission spectroscopy (OES) measurements of the atomic Balmer series and the molecular Fulcher transition have been carried out at the Linac4 ion source in order to determine plasma parameters. As the spectroscopic system was only relatively calibrated, the data evaluation only yielded rough estimates of the plasma parameters (T(e) ≈ 1.2 eV, n(e) ≈ 1 × 10(19) m(-3), and n(H/)n(H2) ≈ 0.5 at standard operational parameters). The analysis of the Fulcher transition revealed a non-thermal "hockey-stick" rotational population of the hydrogen molecules. At varying RF power, the measurements at the on-axis line of sight (LOS) showed a peak in the rotational temperatures between 25 and 40 kW of RF power, whereas a steady decrease with power was observed at a tilted LOS, indicating the presence of strong plasma parameter gradients.

Isotopically exchangeable Al in coastal lowland acid sulfate soils

Periodic discharges of high concentrations of aluminium (Al) causing fish kills and other adverse effects occur worldwide in waterways affected by coastal lowland acid sulfate soils (CLASS). The exchangeability - a metal's ability to readily transfer between the soil solid- and solution-phases - of Al in these soils is therefore of particular importance as it has implications for metal transport, plant availability and toxicity to living organisms. In the present study, the concentrations of isotopically exchangeable Al (E values) were measured in 27 CLASS and compared with common salt extractions (i.e. KCl and CuCl2) used to estimate exchangeable soil pools of Al. E values of Al were high in the soils, ranging from 357 to 3040 mg·kg(-1). Exchangeable concentrations estimated using 1 M KCl were consistently lower than measured E values, although a reasonable correlation was obtained between the two values (E=1.68×AlKCl, r(2)=0.66, n=25). The addition of a 0.2 M CuCl2 extraction step improved the 1:1 agreement between extractable and isotopically exchangeable Al concentrations, but lead to significant mobilisation of non-isotopically exchangeable Al in surficial 'organic-rich' CLASS having E values<1000 mg·kg(-1). It was concluded that currently used (i.e. 1 M KCl) methodology severely underestimates exchangeable Al and total actual acidity values in CLASS and should be corrected by a factor similar to the one determined here.

Assessment and refinement of intra-bone marrow transplantation in mice

Intra-bone marrow transplantation (IBMT) may improve the seeding efficiency of transplanted hematopoietic stem cells compared to the routinely used intravenous injection. Current IBMT protocols are optimized for ease of use and to improve experimental results. However, there have been no investigations to assess the impact of IBMT on animal welfare. Here, we report the results of pain assessment after IBMT and the effects of refinements to the current standard procedure. IBMT was performed in either the tibia or the femur of a recipient mouse under general anesthesia. Impact was determined using clinical scoring of different parameters (lameness, grip capacity, body weight loss, footprint analysis), behavioural tests (burrowing, open-field), monitoring of stress hormones and post-mortem histology. The results revealed that IBMT definitely induces severe post-operative distress. Although IBMT in the tibia is technically easier, the degree of impairment and the distress observed were consistently higher than for transplantation in the femur. A refinement for IBMT in the tibia was achieved by using 30- instead of 26-gauge needles and by sparing the patellar tendon. Consequently, for IBMT, we recommend either using the femur, or if the tibia is required due to its better feasibility, using our refined protocol. Furthermore, IBMT should definitely be limited to one leg per animal.

Frequency and risk factors of lower limb lymphedema following lymphadenectomy in patients with gynecological malignancies

OBJECTIVE

Lower limb lymphedema (LLL) is a major cause of morbidity in patients with gynecological malignancies after surgical treatment involving lymph node (LN) dissection. The aim of this study was to estimate the prevalence of LLL in such patients and detect risk factors for its occurrence.

MATERIALS AND METHODS

A retrospective analysis of all patients undergoing lymphadenectomy in newly-diagnosed gynecological malignancies at the University Hospital of Zurich between 2000 and 2007 was performed. Data from 313 patients were collected. Twenty patients with pre-existing edema or missing information were excluded before analysis. Time-to-LLL was estimated using the Kaplan-Meier estimate and potential risk factors were evaluated by a Cox regression model.

RESULTS

Estimated prevalence of LLL one year after surgery was 32%, increasing to 58% eight years after surgery. Median time to diagnosis of LLL was 5.2 years. The number of removed lymph nodes was significantly associated with time-to-LLL. Diagnosis of postoperative lymphocysts and local infections were accompanied by a significantly elevated risk for the development of LLL. Furthermore, time-to-LLL decreased with a higher body mass index (BMI) of the patient. In contrast, chemo- and radiotherapy, age, positive LNs, site of lymphadenectomy, and type of cancer were not observed to be associated with the occurrence of LLL.

CONCLUSIONS

LLL is a frequent postoperative complication in patients undergoing lymphadenectomy for gynecological malignancies. It is thus imperative to sufficiently educate patients about the risk and symptoms of LLL prior to surgery. The data clearly show an association between time-to-LLL and number of dissected LNs, stressing the need to prospectively analyze the prevalence of LLL and carefully plan LN sampling as increasing knowledge is gained regarding the therapeutic benefit of sentinel and systemic lymphadenectomy in patients with different stages of gynecological malignancies.

Loss of DNA mismatch repair due to knockout of MSH2 or PMS2 results in resistance to cisplatin and carboplatin

Loss of DNA mismatch repair is a common finding in hereditary nonpolyposis colon cancer as well as in many types of sporadic human tumors. The effect of loss of DNA mismatch repair activity on sensitivity to cisplatin and carboplatin was tested using MSH2 and PMS2 knockout cell lines. The knockout dMsh2 embryonic stem cell line was 2.1-fold more resistant to cisplatin and 1.7-fold more resistant to carboplatin when compared to the isogenic wild-type wt-2 cell line. Likewise, the PMS2(-/-) mouse fibroblasts were 1.9-fold more resistant to cisplatin and 1.5-fold more resistant to carboplatin when compared to the isogenic PMS2(+/+) fibroblasts. These findings demonstrate that loss of mismatch repair due to knockout of either MSH2 or PMS2 results in low-level resistance to cisplatin and carboplatin, drugs that form the same types of adducts in DNA. These data validate results previously obtained using non-isogenic mismatch repair-proficient and -deficient cell lines, and indicate that simple recognition of the cisplatin adduct by the MSH2/MSH6 heterodimer is not sufficient for full detector function, but that PMS2 is also required for the pro-apoptotic signal to be generated from this detector.

[Gynecology: urinary incontinence - mini-review and case reports]

Although urinary incontinence affects one in three women, it is still a taboo topic. Today, effective conservative and surgical treatment options are available. When conservative therapies fail, minimally invasive surgical methods can be offered. The tension-free vaginal tape TVT is gold standard in the treatment of female stress urinary incontinence. In case of immobile urethra or in multi-morbid patients, the minimally invasive technique of periurethral injection of bulking agents may be useful. In patients with refractory overactive bladder, the intravesical injection of botulinum neurotoxin is available.

Q value and half-lives for the double-β-decay nuclide 110Pd

The 110Pd double-β decay Q value was measured with the Penning-trap mass spectrometer ISOLTRAP to be Q=2017.85(64) keV. This value shifted by 14 keV compared with the literature value and is 17 times more precise, resulting in new phase-space factors for the two-neutrino and neutrinoless decay modes. In addition a new set of the relevant matrix elements has been calculated. The expected half-life of the two-neutrino mode was reevaluated as 1.5(6)×10(20) yr. With its high natural abundance, the new results reveal 110Pd to be an excellent candidate for double-β decay studies.

Upgrade of the resonance ionization laser ion source at ISOLDE on-line isotope separation facility: new lasers and new ion beams

The resonance ionization laser ion source (RILIS) produces beams for the majority of experiments at the ISOLDE on-line isotope separator. A substantial improvement in RILIS performance has been achieved through a series of upgrade steps: replacement of the copper vapor lasers by a Nd:YAG laser; replacement of the old homemade dye lasers by new commercial dye lasers; installation of a complementary Ti:Sapphire laser system. The combined dye and Ti:Sapphire laser system with harmonics is capable of generating beams at any wavelength in the range of 210-950 nm. In total, isotopes of 31 different elements have been selectively laser-ionized and separated at ISOLDE, including recently developed beams of samarium, praseodymium, polonium, and astatine.

[Analysis of muscle function with kinetic superficial EMG in children with haemophilia - recognizing subclinical changes, establishing individual therapy, quality control]

Electromyography (EMG) measures muscle electricity. It depends on muscle contraction and central motor control. Muscles react very sensitive on external signals (e. g. bleeding), The resulting changes can be shown in EMG.

PATIENTS, METHODS

A first study included 51 children and young adults from Costa Rica. They underwent a clinical examination and EMG of the hip, knee and ankle joints. Resting muscle tone, maximal isometric contraction and three typical isotonic movements of the joints were measured. First step of analysis was to characterize typical pathogenic changes in the muscles and to find a corresponding physical therapy to minimize these changes.

RESULTS

It showed that EMG is a good marker for muscle condition. It helps to individualize therapy and improve effectivity of physical and physiotherapeutic treatment of the locomotive system of children and young adults with hemophilia. It can help to recognize early subclinical changes and to control the outcome of therapeutic modalities.

[Erythropoietinin oncologic therapy -- what so we know about the risks?]

Erythropoietin is a glycoprotein predominantly produced in the kidney. It is an essential regulator of erythropoiesis in the bone marrow. Although cancer-associated anemia is caused by multiple factors, recombinant erythropoietin (rhuEpo) was widely used to treat and prevent this condition. Several clinical studies showed that the use of rhuEpo results in an efficient reduction of red blood cell transfusions in cancer-associated anemia. However, over the past twenty years, Epo and its receptor EpoR were found to be expressed also outside the hematopoietic system and in malignant tumors. This led to a discussion concerning potential risks associated with the application of erythropoiesis-stimulating agents in oncology.

Hospital mortality under surgical care

INTRODUCTION

The 'hospital standardised mortality ratio' (HSMR) has been used in England since 1999 to measure NHS hospital performance. Large variations in reported HSMR between English hospitals have recently led to heavy criticism of their use as a surrogate measure of hospital performance. This paper aims to review the mortality data for a consultant general surgeon contributed by his NHS trust over a 3-year period as part of the trust's HSMR calculation and evaluate the accuracy of coding the diagnoses and covariates for case mix adjustment.

SUBJECTS AND METHODS

The Dr Foster Intelligence database was interrogated to extract the NHS trust's HSMR benchmark data on inpatient mortality for the surgeon from 1 April 2006 to 31 March 2009 and compared to the hospital notes.

RESULTS

30 patients were identified of whom 12 had no evidence of being managed by the surgeon. This represents a potential 40% inaccuracy rate in designating consultant responsibility. The remaining 18 patients could be separated into 'operative' (11 patients) and 'non-operative' (7 patients) groups. Only 27% in the operative group and 43% of the non-operative mortality group respectively had a Charlson co-morbidity index recorded despite 94% of the cases having significant co-morbidities

CONCLUSIONS

Highlighting crude and inaccurate clinician-specific mortality data when only 1-5% of deaths under surgical care may be associated with avoidable adverse events seems potentially irresponsible.

Development of glioblastoma cell lines expressing red fluorescence for non-invasive live imaging of intracranial tumors

Glioblastoma (GBM) cell lines expressing red fluorescent proteins were evaluated as a tool for non-invasive imaging of orthotopic tumors.

MATERIALS AND METHODS

mKate2- and mCherry-transduced U251MG GBM lines were sorted by flow cytometry. The growth rates and drug sensitivity of the resulting cell lines were compared to those of the parental line. Following orthotopic implantation, mKate2-expressing cells were detected using multispectral imaging.

RESULTS

Flow cytometry-sorted fluorescent populations exhibiting growth curves that were comparable to those of the parental line were selected. mKate2-expressing cells were inoculated orthotopically and formed tumors which were visualized non-invasively, allowing monitoring of tumor growth over time and the assessment of tumor response to temozolomide drug treatment.

CONCLUSION

The strategy reported here led to the successful development of GBM models expressing mKate2 or mCherry. The fluorescence signal intensity measured in the brain of live animals correlates with tumor size, thus providing a method to assess tumor progression and response to treatment.

Muskelfunktionsmessung mit kinetischem Oberflächen-EMG bei Kindern mit Hämophilie

Electromyography (EMG) measures muscle electricity. It depends on muscle contraction and central motor control. Muscles react very sensitive on external signals (e. g. bleeding), The resulting changes can be shown in EMG.

Patients, methods A first study included 51 children and young adults from Costa Rica. They underwent a clinical examination and EMG of the hip, knee and ankle joints. Resting muscle tone, maximal isometric contraction and three typical isotonic movements of the joints were measured. First step of analysis was to characterize typical pathogenic changes in the muscles and to find a corresponding physical therapy to minimize these changes.

Results It showed that EMG is a good marker for muscle condition. It helps to individualize therapy and improve effectivity of physical and physiotherapeutic treatment of the locomotive system of children and young adults with hemophilia. It can help to recognize early subclinical changes and to control the outcome of therapeutic modalities.

Deconvolution of charged particle spectra from neutron depth profiling using Simplex method

Neutron depth profiling (NDP), based on neutron induced nuclear reactions, is a well known, nondestructive technique for the determination of the concentration depth profiles of some isotopes in the surface layers of solids. The profile determination consists of deconvolution of a relevant part of the energy spectra of the charged reaction products. Several solutions have been suggested for this problem. In this work, an alternative computer code (LIBOR), which makes use of the Simplex minimization technique for the deconvolution of the NDP spectra, is described and its performance is documented on several examples.

Evaluation of Swiss guidelines for the indication for hysterectomy in relation to patient outcome

BACKGROUND

The application of national guidelines which specify the appropriateness for hysterectomy is believed to lead to improved patient outcomes. However, there was no evidence to support this assumption by outcome data.

GOALS

To evaluate adherence to guidelines and the validity of the 1997 Swiss guidelines for the appropriateness of hysterectomy based on changes in patients' functional and psychosocial status.

METHOD

Multicentre study of 370 consecutive cases from 18 public hospitals assessing data on appropriateness and changes in patient status following hysterectomy. Data on appropriateness were obtained before the procedure (n = 286). Changes in patient status following hysterectomy were assessed using an adapted and weighted score. Baseline data were collected up to 8 weeks prior to hysterectomy. Outcome data were obtained 16-32 weeks after surgery (n = 237). Patients for whom appropriateness data were available (n = 286) were categorized into three groups: (1) 214 patients (74.82%) with an indication for hysterectomy, (2) 36 patients (12.58%) classified as having an indication with regard to their preference, and (3) 36 patients (12.58%) classified as not being appropriate for surgery according to national guidelines.

RESULTS

In 87% the indication for hysterectomy was judged as appropriate according to the guidelines. The status of all three groups of patients after hysterectomy was found to be significantly improved compared to baseline levels. Patients with an appropriate indication tended to profit more from hysterectomy.

CONCLUSION

The appropriateness rating found may be interpreted as an example of justified use of medical procedural intervention. There was a positive correlation between appropriateness and outcome. The 1997 guidelines still seem to be valid.

Q fever endocarditis; not always expected

Q fever endocarditis is a chronic disease with protean manifestations. The clinical and serological manifestations of nine patients diagnosed as having Q fever endocarditis during a 19-year period are reviewed. Four patients (44%) required valve replacement due to congestive heart failure. Three of these four patients were diagnosed as having Q fever endocarditis only after elective valve surgery, by histopathological examination of the valve and subsequent serological tests. Prior to surgery they were afebrile and had no other symptom or sign indicative of endocarditis. The antibiotic treatment and the decreasing titres of Q fever antibodies of all nine patients during several years of follow-up are summarized. Careful assessment of heart valves for histopathological evidence of inflammation is suggested, even after elective replacement. If found, clinical and laboratory evaluation should include determination of anti-Coxiella burnetti antibodies.

[New developments in reproductive medicine]

Several developments in the field of reproductive medicine intend to improve the efficiency of the treatment and to reduce the number of unwanted side effects. These advancements are among others the production of long-acting FSH, polar body biopsy and the identification of factors, which can optimize the implantation potential of the endometrium. Cryopreservation of ovarian tissue enables the maintenance of fertility in tumor patients.