Is it possible to minimize overdrainage complications with gravitational units in patients with idiopathic normal pressure hydrocephalus? Protocol of the randomized controlled SVASONA Trial (ISRCTN51046698)

Overdrainage is a common complication observed after shunting patients with idiopathic normal-pressure hydrocephalus (iNPH), with an estimated incidence up to 25%. Gravitational units that counterbalance intracranial pressure changes were developed to overcome this problem. We will set out to investigate whether the combination of a programmable valve and a gravitational unit (proGAV, Aesculap/Miethke, Germany) is capable of reducing the incidence of overdrainage and improving patient-centered outcomes compared to a conventional programmable valve (Medos-Codman, Johnson & Johnson, Germany). SVASONA is a pragmatic randomized controlled trial conducted at seven centers in Germany. Patients with a high probability of iNPH (based on clinical signs and symptoms, lumbar infusion and/or tap test, cranial computed tomography [CCT]) and no contraindications for surgical drainage will randomly be assigned to receive (1) a shunt assistant valve (proGAV) or (2) a conventional, programmable shunt valve (programmable Medos-Codman).We will test the primary hypothesis that the experimental device reduces the rate of overdrainage from 25% to 10%. As secondary analyses, we will measure iNPH-specific outcomes (i.e., the Black grading scale and the NPH Recovery Rate), generic quality of life (Short Form 36), and complications and serious adverse events (SAE). One planned interim analysis for safety and efficacy will be performed halfway through the study. To detect the hypothesized difference in the incidence of overdrainage with a type I error of 5% and a type II error of 20%, correcting for multiple testing and an anticipated dropout rate of 10%, 200 patients will be enrolled.The presented trial is currently recruiting patients, with the first results predicted to be available in late 2008.

Factors determining quality of life and level of sporting activity after internal fixation of an isolated acetabular fracture

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities.

We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D).

There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

Topotecan weekly versus routine 5-day schedule in patients with platinum-resistant ovarian cancer (TOWER): A randomized, multicenter trial of the North-Eastern German Society of Gynecological Oncology (NOGGO)

5553

Background: In women with platinum-resistant recurrent ovarian cancer, weekly administration of topotecan (Tw) may be equally effective, but better tolerated than conventional 5-day dosing (Tc). We conducted a randomized multicenter trial to validate this assumption. Methods: The trial was pre-registered at clinicaltrials.gov ( NCT00170677 ). Women with platinum-resistant ovarian and fallopian tube cancers or primary peritoneal carcinoma, and measurable or assessable disease (GCIG criteria) were randomized to receive either Tw (d1,8,15/q28d, 4 mg/m2) or Tc (d1–5/q21d, 1.25 mg/m2). The predefined stopping rule, based on the primary endpoint of best CA-125 or tumor response, was not reached (presented at ASCO 2007, Abstract 5526). This permitted the accrual of 194 patients, 154 of whom could be assessed for CA-125 or tumor response (SD + CR + PR). We also compared progression-free (PFS) and overall survival (OS), as well as toxicity between trial groups. Results: Mean age was 61.8 (SD 9.8) years, and 59 women were on third-line treatment. Patients received a total of 809 cycles of chemotherapy. Demographic baseline characteristics, tumor stages and grades, and previous lines of chemotherapy were well balanced between treatment groups. There were 35 / 75 (47%) and 45 / 79 (57%) responses in the Tw and Tc groups, respectively (risk ratio [RR] 1.22, 95% CI 0.89–1.66). Median PFS and OS did not differ markedly between both regimens (3.2 versus 4.4 months, hazard ratio [HR] 1.30, 95% CI 0.96–1.77 and 9.8 versus 10.0 months, HR 1.08, 95% CI 0.77–1.52). The risk of grade III/IV hematological toxicity was significantly lower in the Tw group (anemia: RR 0.35, p = 0.007, neutropenia: RR 0.38, p = 0.0001, thrombopenia: RR 0.23, p = 0.0004). Conclusions: Weekly administration of topotecan shows no substantial difference in endpoints of effectiveness compared to conventional dosing, but is associated with a significantly lower likelihood of severe hematological toxicity. Weekly topotecan should be considered as a possible treatment alternative in women with platinum-resistant ovarian cancer because of its favourable benefit-risk-profile.

No significant financial relationships to disclose.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

[Outcomes research: definitions, methods and challenges in trauma and orthopaedic surgery]

BACKGROUND

Besides basic, illness- and patient-oriented research, outcomes research is regarded as the fourth pillar of modern health care systems. Outcomes research investigates both the desirable and adverse effects of medical and surgical interventions under day-to-day conditions.

METHOD

Because of rigorous entry criteria and selection of eligible subjects, the efficacy of a certain treatment derived from clinical experiments (i.e. classic randomized trials) may not necessarily be transferred to common patient populations or clinical settings. Apart from efficacy, a valuable (thus reimbursable) diagnostic or therapeutic procedure must prove its effectiveness in clinical practice as well. Demanding study designs are necessary to model effectiveness and to separate the observed intervention-related effects from bias and confounding.

RESULTS

Registries and pragmatic randomized trials may represent the most appropriate modalities to establish outcomes research in trauma and orthopaedic surgery. Good examples for interventions still needing proof of effectiveness are kyphoplasty and vertebroplasty, navigated surgery, damage control, interlocking implants and bone growth factors. Revealing over- and undersupply, generating negative lists (i.e. interventions of questionable or almost nil effectiveness) and integrating patients as co-therapists requires networking between hospitals and private practitioners.

CONCLUSION

Also, since outcomes research is a societal need, its development and funding must be ensured by all providers and payers of health care services.

Topotecan weekly versus routine 5-day schedule in patients with platinum-resistant ovarian cancer (TOWER): A randomized, two-stage phase-II study of the North-Eastern German Society of Gynaecological Oncology (NOGGO)

5526

Background: Optimizing the therapeutic index (that is, maintaining drug effectiveness while reducing toxicity) is a major goal in chemotherapy for platinum-resistant ovarian cancer. Early phase-I/II studies suggest that weekly topotecan (T) might be effective and apparently better tolerated than the established 5-day regimen. As yet, no randomized comparison of both regimes was attempted. To prove the hypothesis of an improved therapeutic index with weekly T, we conducted a randomized, multicenter, two-stage phase-II trial, and herein present the data of the planned interim analysis. Methods: Pts with platinresistent ovarian and fallopian tube cancers or primary peritoneal carcinoma, measurable or assessable disease (GCIG-CA-125 response criteria), were eligible. Pts were randomized to receive either weekly T (d1,8,15/q28d, 4 mg/m2) or T from d1–5/q21d at a dose of 1.25 mg/m2. According to Gehan’s two-stage-design, both arms were handled as independent studies. Overall response rate (CR + PR) was defined as primary study endpoint, secondary endpoints of the interim analysis were toxicity and safety. Results: 28 pts in the weekly and 21 pts in the conventional group, enrolled at 38 centers form the basis of this report. 230 cycles of chemotherapy were evaluated for toxicity analyses. Median age was 61 years (range, 36 - 82 years). Demographic baseline characteristics, including tumor stage and grade were well balanced between treatment arms. There were 2/28 and 5/21 responses in weekly and the conventional arm, respectively (Risk Ratio [RR] 0.30, 95% confidence interval [CI] 0.06 - 1.40, p=0.122). The risk of early treatment termination due to tumor progression (RR 1.39, 95%CI 0.75 - 2.56), haematological (RR 0.20, 95% CI 0.01 - 3.97) or non- hematological toxicities (RR 1.96, 95% CI 0.18 - 20.83) did not differ significantly between groups. The only three events of neutropenic fever occurred in the conventional arm (RR 1.70, 95% CI 0.99 - 1.16). Conclusions: Weekly T is well tolerated and potentially active. The second stage of this study will require additional 46 patients each arm. Complete enrolment is expected to be accomplished in May 2007.

No significant financial relationships to disclose.

Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability

PURPOSE

To analyse the functional and radiological outcomes of the Bristow-Latarjet procedure in patients with recurrent anterior glenohumeral instability.

METHODS

Records of 29 patients were reviewed retrospectively. Date of first dislocation, injury mechanism, and number of recurring dislocations before and after surgery were recorded. The overall function and stability of the shoulder was evaluated.

RESULTS

24 (83%) of the glenohumeral instabilities were caused by trauma. The mean number of recurring dislocations was 8 (95% confidence interval [CI], 0-18); one patient had had 40 recurrences. No dislocation ensued postoperatively. The overall functional outcome was good, with a mean Rowe score of 90 points (95% CI, 78-100). Scores of 17 (59%) of the patients were excellent, 7 (24%) were good, 3 (10%) were fair, and 2 (7%) were poor.

CONCLUSION

The Bristow-Latarjet procedure is a good surgical treatment for recurrent anterior-inferior instability of the glenohumeral joint.

Randomized clinical trial comparing bipolar coagulating and standard great saphenous stripping for symptomatic varicose veins

Background

Typical side-effects of saphenous stripping for symptomatic varicose veins include painful thigh haematomas, which a new bipolar coagulating electric vein stripper (EVS) may reduce.

Methods

In a randomized, single-blind trial at three vascular centres, 99 patients were assigned to EVS and 101 to conventional stripping. The primary outcome was postoperative pain at rest and following physical exercise (climbing stairs). Haematomas were quantified by ultrasonography. Further endpoints were duration of postoperative compression, sick leave and quality of life (measured by the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ) and Short Form 36 (SF-36®)).

Results

Mean resting visual analogue scale for pain 24 h after surgery was 1·6 in the EVS group and 3·3 in the conventional stripping group (mean difference 1·7, 95 per cent confidence interval (c.i.) 1·4 to 1·9, P &lt; 0·001). Mean ratings following exercise were 3·3 and 5·5 (mean difference 2·3, 95 per cent c.i. 2·0 to 2·6, P &lt; 0·001) respectively. No patient in the EVS group had a measurable thigh haematoma, compared with 74 patients after conventional stripping (P &lt; 0·001). The EVS significantly decreased the length of compression therapy and sick leave, and produced superior CIVIQ and SF-36 ratings.

Conclusion

The EVS was safe and effective in avoiding painful haematomas following varicose vein surgery.

[Surgical management of abdominal injury]

PURPOSE

Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.

METHODS

Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.

RESULTS

Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.

DISCUSSION

Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

[The clinical use of the ISO-C(3D) imaging system in calcaneus fracture surgery]

We compared in a prospective study including 82 patients treated with ORIF of an intraarticular calcaneus fracture the quality of fluoroscopy, intraoperatively Iso-C(3D) and postoperative CT-scans. Therefore the posterior facet of the calcaneus (PFOC) was divided into three sectors. Joint steps and fracture gaps were detected by two independent investigators and statistically analysed. Another focus was to evaluate if the findings due to intraoperatively Iso-C(3D) assessment performed by the surgeon were correct and subsequently influenced the surgical procedure. There were no statistically differences between the Iso-C(3D)- and CT findings concerning joint steps or fracture gaps in PFOC sectors I-III. With fluoroscopy an assessment of the PFOC sectors I and II was not possible. In six cases (7.3%), intraoperative reduction was redone after performing an Iso-C(3D) scan. In ten cases, 12 malpositioned screws were replaced (12.2%/14.6%). These results suggest that intraoperative 3D Iso-C(3D) imaging provides a high diagnostic reliability. By careful assessment of the images the surgeons receive information which could lead to a change of the operative strategy.

A randomized multicenter phase III trial of topotecan monotherapy versus topotecan + etoposide versus topotecan + gemcitabine for second-line treatment of recurrent ovarian cancer

5030

Background: Topotecan combined with etoposide (GINECO 1998) and gemcitabine (NOGGO 2001) proved effective for second-line treatment of recurrent ovarian cancer. It is, however, unclear whether combined treatment improves survival and tumor control compared to topotecan alone. Methods: Women with recurrent ovarian cancer after primary surgery and platinum therapy were enrolled in an open-label randomized phase-III trial at 93 German institutions. Stratifying for treatment-free intervals (TFI) of less or more than 12 months, subjects were centrally allocated to topotecan 1.25 mg/m2/d (TM), topotecan 1.0 mg/m2/d plus oral etoposide 50 mg/d (TE) on day 6–12, or topotecan 0.5 mg/m2/d plus gemcitabine (TG) 800 mg/m2/d1 and 600 mg/m2/d8 every three weeks. Local institutional review boards approved this study, and all patients provided written informed consent. With 145 subjects each arm, this study yielded 90% power to detect a Hazard Ratio (HR) of 0.60 in overall survival (OS) at a two-sided alpha of 0.01. We employed Cox regression for primary endpoint analysis, and addressed progression-free survival (PFS) and toxicity descriptively. Results: Between September 1999 and November 2004, 3036 courses were administered to 505 patients (mean age 60.4 [SD 11.3] years), 208 of whom had a TFI <12 months. Women assigned to TM, TE, and TG received a median of 6.7 (range, 0–10), 6.2 (0–9), and 5.4 (1–42) cycles. Median OS after TM, TE, and TG was 17.8, 17.8, and 15.3 months. Setting TM as the reference, HRs for OS with TE and TG were 1.13 (95% confidence interval [CI] 0.87–1.47) and 1.07 (95% CI 0.80–1.43, p = 0.590). HRs for PFS with TE and TG versus TM were calculated at 0.84 (95% CI 0.66–1.07) each. Subgroup analysis suggested enhanced PFS among subjects with TFI ≥12 months who received TE (HR 0.62, 95% CI 0.42–0.91) or TG (HR 0.68, 95% CI 0.46–1.01) rather than TM. TE produced higher CTC grade 3/4 hematotoxicity than TM or TG, with cumulative incidences of 24.4% (95% CI 20.2–29.0%), 16.0% (95% CI 11.9–20.9%), and 14.7% (10.6–19.5%). Conclusions: This large RCT does not provide evidence that combined treatment performs generally better than topotecan monotherapy in recurrent ovarian cancer.

No significant financial relationships to disclose.

Biweekly pegylated liposomal doxorubicin in patients with relapsed ovarian cancer: results of a multicenter phase-II trial

BACKGROUND

The obvious benefit of pegylated liposomal doxorubicin (PLD) for tumour control in recurrent ovarian cancer is frequently offset by severe palmar-plantar erythrodysesthesia (PPE). There is evidence that dose reduction from 50 to 40 mg/m(2) reduces the incidence of PPE without compromising cytotoxic activity. We set out to investigate whether biweekly application further improves the therapeutic index of PLD.

PATIENTS AND METHODS

Patients with recurrent ovarian cancer after surgery and adjuvant chemotherapy with platinum and taxane compounds were eligible to participate in this multi-institutional phase II study. PLD was administered at a dose of 20 mg/m(2) every two weeks. Eligible patients had ECOG performance status of < or =2, and sufficient organ function. We employed an optimized two-stage design to test the hypothesis that biweekly application of PLD reduces the frequency of grade III and IV PPE from 25% to 10%. Response and survival were addressed descriptively.

RESULTS

Between October 2001 and February 2004, 64 patients with median age of 59 (range 38-81) years were recruited onto this trial. We evaluated 553 (median 7, range 1-25) courses of PLD treatment. Most patients were in their third or fourth line of chemotherapy. PPE was noted in 30 patients (47.6%), but only three participants progressed to grade 3 severity (4.7%, 95% confidence interval 1.0-13.1%). Partial response, stable disease, and tumour progression were observed in 5, 13, and 24 patients, respectively. Median overall and progression-free survival were 18.2 (range, 1.4-34.0) and 4.3 (range 0.5-22.3) months.

CONCLUSIONS

Biweekly PLD may reduce the incidence of PPE while retaining efficacy in relapsed ovarian cancer. Our data support the need for a randomized trial to strengthen these assumptions.

Second-line treatment of limb-threatening diabetic foot infections with intravenous fosfomycin

Diabetic foot infections (DFI) expanding to bones and joints are associated with a poor prognosis of limb salvage. The bactericidal epoxide fosfomycin accumulates in inflamed soft and bone tissue, and may represent a potential treatment option for targeting severe DFI. Fifty-two patients (35 men, 17 women, mean age 62.9 +/- SD 9.2 years) with limb-threatening DFI (that is, Wagner grade 3 and higher) were enrolled in a multi-center compassionate use program of fosfomycin. Twenty-two patients (42.4%) had unsuccessfully been pretreated with other antimicrobials. Besides standard treatment (topical wound care and surgical debridement), eligible subjects received a combination of 8 to 24 g fosfomycin daily, and a conventional antibiotic agent, usually a beta-lactam compound. Treatment duration averaged 14.4 +/- 8.3 days. Limb-sparing surgery was possible in 48 patients (92.3%, 95% confidence interval 81.5-97.9%). Only four participants faced mild drug-related side effects (nausea, rash). Logistic regression analysis showed a trend towards better results with prolonged treatment, whereas a dose increase above 12 g daily did not affect outcomes. In DFI being resistant to conventional antibiotic agents, intravenous fosfomycin offers an effective treatment choice that may increase the likelihood of limb preservation. The present data warrant a larger comparative trial to stabilize effect estimates.

[Age and survival likelihood of polytrauma patients. "Local tailoring" of the DGU prognosis model]

INTRODUCTION

Age is one of five prognostic parameters identified based on data of the trauma registry of the German Association for Trauma Surgery (DGU). We asked ourselves if the suggested prognostic model provides the same predictive power of data from an independent hospital. Furthermore, we investigated whether age itself or age-associated comorbidity causes an unfavorable prognostic effect.

METHODS

The investigation was based on data of 103 multiply injured patients (67 male, 36 female, mean age 35,4+/-SD 19,0 years, ISS 36,8+/-10,9). Data were collected prospectively following the guidelines of the trauma registry of the German Association for Trauma Surgery. Based on documented comorbidities, a risk calculation was performed using the ASA classification. Correlation between age and ASA was analyzed using Spearman's method. The prognostic value of the original model in our patient pool with or without ASA classification, possible interactions, and the discriminatory power of the model were estimated using logistic regression.

RESULTS

Attributable mortality was 31,7% (95% CI 22,7-41,7%). Age, ISS, GCS and ASA were included into the final logistic model. Odds ratios of the origin model were reproducible nearly identical in our patinet pool (OR: age 1,048; ISS 1,066; GCS 0,822). In spite of the fact that we have found a strong correlation between age and ASA-Classification (rho=0,60, p<0,0001) there was no prognostic value of comorbidity.

CONCLUSION

The suggested prognostic model based on multicenter data evaluation can be applied to a single center with only minimal loss of discriminatory power. In this context, age seems to have a prognostic value independent of comorbidity.

Osteomyelitis der Mittelhand- und Handwurzelregion

AIM

Because of the low prevalence, there is poor evidence on the effective management of bone and joint infections of the carpus and metacarpus. We therefore studied the outcomes of patients undergoing surgical treatment at our department.

METHOD

We conducted a retrospective study on all patients operated on because of osteomyelitis of the carpus and metacarpus between January 1998 and June 2004. Main study endpoint were the infection control rate at end of treatment and at time of follow-up.

RESULTS

Of eleven subjects (nine men, two women) with a median age of 43 years (range, 19 to 79 years) serial débridement with temporary wound closure and surgical fixation proved successful in ten cases. We identified causative pathogens in ten cases (S. aureus: n = 3, P. aeruginosa: n = 3, mixed: n = 4) by intraoperative biopsy. Eight subjects received local or free tissue flaps. A 73 year old man died in hospital. Follow-up information was available for eight patients after a median of 19.5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection.

CONCLUSION

Adhering to accepted standards of treating osteomyelitis, satisfactory control rates in carpal and metacarpal infection can be achieved while salvaging the hand.

[Modelling critical information measurement traumatic surgery decisions. "Sequential Information Appraisal Module (SIAM)"]

We studied the quality and quantity of information leading to the emergency physician's decision to intubate severely injured patients on scene. Our aim was to assess intuitive aspects of clinical decision making. The experiment involved three different phases, with a fourth phase examining retest reliability. We used trauma register data from 98 patients. Based on various parameters (physiological data, injury assessment on scene, definite injury pattern), three emergency surgeons were requested to decide on the need for endotracheal intubation.We applied multivariate logistic regression to estimate the likelihood of intubation given certain clinical characteristics or combinations of characteristics. We compared the participants' decisions to those made by "true" emergency physicians on scene. Kappa statistics marked inter-observer agreement beyond chance. The Glasgow Coma Scale (GCS) was the only single predictor of intubation in the ideal test setting (area under the receiver operating characteristics curve [AUC] >98%) as well as on scene (AUC 0.85, 95% confidence interval 0.78-0.92). There was no difference between the discriminatory features of the single item GCS and complex multivariate models that included anatomically defined injury scales (best model in phase 2: AUC 0.96, best model in phase 3: AUC 0.98). Overall inter-observer agreement was substantial in phase 1 (kappa=0.74), fair to moderate in phase 2 (kappa=0.49) and slight to fair in phase 3 (kappa=0.23). Retest reliability ranged from 51% to 91%. Doctors give priority to only a small part of the information available in deciding for or against a particular intervention.