[The effects of psychotherapy on Crohn's disease patients--results of a randomized multicenter study]

In a prospective multicenter study of Crohn disease patients, the influence of psychotherapy on the course of the disease and on psychosocial variables (anxiety, depression, life satisfaction and data of the PSKB) was studied. Psychodynamic oriented psychotherapy was provided in addition to a standardized medical treatment and took place during the first year of the two-year observation period. 108 of 488 patients were recruited and randomly assigned to the psychotherapy and the control group. 84 patients completed the somatic and 81 the psychosocial follow up. 23% of the control group and 30% of the psychotherapy group showed episode-free courses, 29% and 17% respectively underwent surgery (worst outcome group). The ranking and comparisons of the disease course showed no significant difference (p = 0.125) between psychotherapy and control group. The psychosocial variables also showed no differences between these groups. Subjectively, the patients report favourable effects to psychotherapy.

[Monitoring clinical studies. Development, measures and consequences]

BACKGROUND

Clinical trials play an important role in developing and establishing new therapeutic and diagnostic procedures. In the planning and execution of these trials procedures and measures which allow for continual observation, description and evaluation of the study progress are to be taken into account. This is due to ethical, scientific and economic considerations. Together these procedures and measures are termed "monitoring". Repeated evaluation of the main study question is one particular monitoring measure. Results from this sequential procedure may lead to an early termination of patient recruitment. In the last 3 decades methods for interim analyses were developed which take into account the increased chance of errors when evaluating repeatedly the same question. By adjustment they guarantee a prespecified level of significance in the end result of the trial. Even though statistical significance may be evident in an interim analysis, this has not always to result in early termination of the trial. The decision to end a trial early must include other considerations than the mere evaluation of the main study question. In particular, consequences of the decision such as credibility and transferability of the trial result to subsequent therapeutic routine application are to be discussed.

[Basic principles of clinical therapeutic studies--what, how and why?]

Treatment evaluation is one of the most important tasks in medical research. Detailed standards have been developed during the last decades. The efficacy/effectiveness of treatments can only be assessed in comparison to control groups. To guarantee the internal validity of these comparisons, the groups have to be comparable at the beginning of the study. This can be achieved by randomized allocation of patients to treatment. Furthermore, as far as possible patient and physician should be blinded to treatment in order to avoid subjective influences on treatment results. Groups should still be comparable when analysing the trial, thus an analysis according to the principle of intention-to-treat ("as randomized") should be performed. These indispensable principles for design, conduct and analysis of clinical trials are widely accepted and contribute to reliable and credible results.

Primary reconstruction of traumatic bony defects using allografts

We retrospectively reviewed 207 patients suffering from traumatic bone defect who had been treated at our institution between 1973 and 1993. Three types of traumatic bone defects were identified: I, minor; II, major cortical; III, major articular. Each type was further subdivided into: A, open injury; B, closed injury. The proposed treatment modality of each type was included within each classification. Types II and III posed the greatest difficulties in management. However, massive bone allografts can be successfully used in these situations, even in the early phases of treatment, but only given specific prerequisites.

[Monitoring of clinical trials. Methodology, interim analyses, and end results]

BACKGROUND

Clinical trials play an important role in developing and establishing new therapeutic and diagnostic procedures. In the planning and execution of these trials procedures and measures which allow for continual observation, description and evaluation of the study progress are to be taken into account. This is due to ethical, scientific and economic considerations. Together these procedures and measures are termed "monitoring". Repeated evaluation of the main study question is one particular monitoring measure. Results from this sequential procedure may lead to an early termination of patient recruitment. In the last 3 decades methods for interim analyses were developed which take into account the increased chance of errors when evaluating repeatedly the same question. By adjustment they guarantee a prespecified level of significance in the end result of the trial. Even though statistical significance may be evident in an interim analysis, this has not always to result in early termination of the trial. The decision to end a trial early must include other considerations than the mere evaluation of the main study question. In particular, consequences of the decision such as credibility and transferability of the trial result to subsequent therapeutic routine application are to be discussed.

A wide and versatile combined surgical approach to the shoulder

Complex injuries and conditions of the shoulder may necessitate wide exposure during the operative procedure. The commonly used approach today is a wide anterior deltopectoral approach with extensive detachment of the deltoid muscle, leading to muscle damage, which may result in difficult postoperative rehabilitation and deteriorated function. We describe a simple combined approach that consists of a deltopectoral approach in conjunction with a subcutaneously performed lateral deltoid split with a single skin incision. We believe this surgical technique provides another useful tool to achieve wide and versatile exposure of the shoulder without jeopardizing the function of either the deltoid muscle or axillary nerve.

An operative technique for recurrent shoulder dislocations in older patients

Recurrent anterior shoulder dislocation in the elderly is not as exceptional as it was once thought to be. That anterior shoulder dislocation in older patients is caused by a rotator cuff tear through the posterior mechanism is well accepted. However, in the subset of patients who have multiple recurrent or intractable dislocations develop, there may be combined pathologic conditions at work: large or massive rotator cuff tears together with anterior capsulolabral injuries such as a Bankart lesion or fracture of the glenoid rim. These patients have multiple recurrences because of disruption of both the anterior and the posterior stability mechanisms. We suggest a procedure that provides anterior stabilization with the capsular shift technique and that is supplemented by Bankart repair as necessary. The capsule transfer is performed superiorly and posteriorly to close the defect in the cuff. In this way a capsulodesis effect can be achieved that displaces the humeral head downward and produces active centering of the head in the course of abduction. Use of only the anterior capsule for the shift, and not the subscapularis tendon, does not compromise subscapularis function. Between 1990 and 1996, we used this technique to treat 16 patients older than 55 years of age with multiple recurrent anterior shoulder dislocation and massive rotator cuff tear. We report the results for the first 10 patients with a minimum follow-up of 2 years (range 2 to 7 years) and an average follow-up of 52 months. There were 7 excellent results, 2 good results, and 1 fair result according to the Rowe criteria. None of the patients had a recurrence of the dislocation. All the patients regained full or functional range of motion with stable shoulders, and most of them could perform activities of daily living without limitation. The average Constant score was 83%. This procedure appears to be successful in treating older patients with recurrent shoulder dislocation.

Twenty-five years of clinical experience with bone banking in Israel

BACKGROUND

Bone banking and the clinical use of banked tissue are the most common forms of allopreservation and transplantation in modern medicine.

OBJECTIVES

This article reviews 25 years (1973-98) of experience in bone banking in Israel.

METHODS

A nationwide survey on the clinical application of the banked musculoskeletal tissues during 1996 was conducted by means of a written questionnaire sent to all orthopedic departments in Israel.

RESULTS

The response rate to the questionnaire was 84%. A total of 257 cases were allocated bone allografts: the majority comprised 225 spongy bones, 26 were massive bone allografts and 6 were soft tissue allografts.

CONCLUSION

Improvement of quality control and quality assurance of the banked tissues, together with development of skills in the use of osteoinductive and osteoconductive materials, cast the future of musculoskeletal tissue banking.

[Basic principles of clinical trials--what, how, and why?]

Treatment evaluation is one of the most important tasks in medical research. Detailed standards have been developed during the last decades. The efficacy/effectiveness of treatments can only be assessed in comparison to control groups. To guarantee the internal validity of these comparisons, the groups have to be comparable at the beginning of the study. This can be achieved by randomized allocation of patients to treatment. Furthermore, as far as possible patient and physician should be blinded to treatment in order to avoid subjective influences on treatment results. Groups should still be comparable when analysing the trial, thus an analysis according to the principle of intention-to-treat ("as randomized") should be performed. These indispensable principles for design, conduct and analysis of clinical trials are widely accepted and contribute to reliable and credible results.

Effect of psychotherapy on the course of Crohn's disease. Results of the German prospective multicenter psychotherapy treatment study on Crohn's disease. German Study Group on Psychosocial Intervention in Crohn's Disease

BACKGROUND

Our aim was to study the influence of psychotherapy in addition to a standardized corticosteroid treatment on the somatic and psychosocial course of Crohn's disease.

METHODS

In a prospective, randomized multicenter study 108 of 488 patients received either drug treatment or, in the intervention group, additionally psychotherapy in the first half of the 2-year follow-up period.

RESULTS

Eighty-four patients (77.8%) completed the somatic and 81 (75%) the psychosocial follow-up. Twenty-three per cent of the control group and 30% of the psychotherapy group showed episode-free courses; 29% and 17%, respectively, underwent surgery due to failure of drug treatment. The main analysis, which was based on subranking by number, duration, and severity of relapses, failed to show significant differences between the two groups (P = 0.125). The same result was obtained for the psychosocial status after 1 year in the main target criteria depression, anxiety, psychosocio-communicative status, and quality of life.

CONCLUSIONS

The confirmatory analysis did not prove significantly better courses after additional psychotherapy. There was a tendency towards fewer operations.

Results of interleukin-2-based treatment in advanced melanoma: a case record-based analysis of 631 patients

PURPOSE

In patients with stage IV melanoma, durable responses have been reported with treatment regimens that involve high-dose interleukin-2 (IL-2). We analyze long-term results of 631 melanoma patients from 12 institutions who had received IL-2 alone, in combination with interferon alfa 2a or 2b (IFNalpha), or with cytotoxic drugs.

METHODS

Case records that contained pretreatment parameters, response data, and updated survival information were collected. After univariate analysis, the multivariate evaluation of the impact of pretreatment parameters on response and survival was performed by logistic regression and Cox's regression, respectively.

RESULTS

Patients were divided into four groups according to treatment: IL-2 alone (n=117), IL-2 and chemotherapy (n=49), IL-2 and IFNalpha (n=153), and IL-2, chemotherapy, and IFNalpha (n=312). The median survival of all patients was 10.5 months and the 2- and 5-year survival rates were 19.9% and 10.4%, respectively. Independent prognostic factors for response and survival were entirely different, treatment group being the only significant factor for response, and serum lactate dehydrogenase (LDH), metastatic site, and performance predicting survival. The addition of IFNalpha to IL-2 was associated with prolonged survival, but the effect of additional chemotherapy was less obvious.

CONCLUSION

Serum LDH, metastatic site, and performance status are useful stratification factors for randomized trials in metastatic melanoma. The improved long-term survival rates observed in melanoma patients treated with IL-2/IFNalpha-containing regimens are notable in contrast to the reported 5-year survival rates of 2% to 6% achieved with chemotherapy, but because selection bias cannot be ruled out, the impact of IL-2, as well as all other components of the treatment regimens, on survival needs to be confirmed in prospective randomized trials.

Monteggia and equivalent lesions. A study of 41 cases

Forty-one patients who suffered from a Monteggia fracture and were treated between 1984 and 1993 were reviewed retrospectively using a new motion score of the elbow joint. There were 14 children and 27 adults of whom 34 were available for review. The results in children were significantly better than those of the adults. Among the adults, the final results of the patients who had a Bado Type 1 equivalent injury were significantly worse than those of the other groups, especially when associated with a fracture of the radial head. The type of fracture, open or closed, the presence of a fracture of the olecranon, and the energy level of the trauma did not have any significant prognostic value. Good correlation was shown between the new motion score and the Figgie elbow score. The Bado Type 1 equivalent injuries should be considered as a special subgroup of the Monteggia lesion, necessitating extra attention in treatment and rehabilitation, and a close followup of the patient.

Prognostic factors for response and survival in patients with metastatic melanoma receiving immunotherapy

Sixty-five patients with advanced melanoma treated in phase II trials with interferon-alpha and high dose interleukin-2 were analysed for pretreatment prognostic parameters. Three levels of response were used: objective remission [three complete response (CR)/14 partial response (PR)], stable disease and progression. Elevated lactate dehydrogenase (LDH), impaired performance status and high tumor load were associated with poor response. Multivariate analysis considering two levels of response [CR/PR vs stable disease (SD)/progressive disease (PD)] did not reveal any model with more than one significant factor. Considering survival, LDH was also a strong factor. Additional prognostic factors here were performance status, metastatic sites, alkaline phosphatase and tumor load. A Cox regression analysis revealed LDH, performance status and metastatic sites as independent factors. The prognostic values of these parameters will have to be confirmed in a larger patient cohort. Using the landmark method, it was estimated whether the response obtained after two cycles of treatment predicted survival. Patients with PD at this time had a median further survival of 6 months, SD of 27 months, and PR/CR of more than 31 months. This observation may help making decisions at this time.

Pharmacokinetics and pharmacodynamics of lisinopril in advanced renal failure. Consequence of dose adjustment

To prevent drug accumulation and adverse effects the dose of hydrophilic angiotensin-converting enzyme (ACE) inhibitors, e.g. lisinopril, must be reduced in patients with renal failure. To obtain a rational basis for dose recommendations, we undertook a prospective clinical trial. After 15 days of lisinopril treatment pharmacokinetic and pharmacodynamic parameters were determined in patients with advanced renal failure (n = 8; endogenous creatinine clearance [CLCR]: 18 ml.min-1.1.73 m-2) and in healthy subjects with normal renal function (n = 16; CLCR: 107 ml.min-1.1.73 m-2). The volunteers received 10 mg lisinopril once daily, the daily dose in patients (1.1-2.2 mg) was adjusted to the individual CLCR according to the method of Dettli [13]. After 15 days of lisinopril treatment the mean maximal serum concentration (Cmax) in patients was lower than in volunteers (30.7 vs 40.7 ng.ml-1, while the mean area under the concentration-time curve (AUC0-24 h) was higher (525 vs 473 ng.h-1.ml-1). ACE activity on day 15 was almost completely inhibited in both groups. Plasma renin activity, angiotensin I and angiotensin II levels documented marked inhibition of converting enzyme in volunteers and patients. Furthermore, average mean arterial blood pressure in patients decreased by 5 mmHg and proteinuria from 3.9-2.7 g per 24 h after 15 days of treatment with the reduced dose of lisinopril. Adjustment of the dose of lisinopril prevents significant accumulation of the drug in patients with advanced renal failure during chronic therapy. Mean serum levels did not exceed this in subjects with normal renal function receiving a standard dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of serum neural cell adhesion molecule as a new tumor marker in small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is distinguished from other histologic types of lung cancer by possessing a variety of neuroendocrine properties. Neuron-specific enolase (NSE) is the most frequently elevated tumor marker for patients with SCLC at diagnosis. To assess the value of neural cell adhesion molecules (NCAM), another possible tumor marker for small cell lung cancer, NCAM was evaluated in the sera of patients with histologically confirmed SCLC in two prospective multicenter trials.

METHODS

The study includes 221 patients with SCLC, normal human blood donors (n = 34), patients with benign lung disease (n = 53), and patients with non-small cell lung cancer (n = 28). NCAM was determined by means of an enzyme immunoassay, NSE by a radioimmunoassay.

RESULTS

The data show the following: (1) 51% (113 of 221) of all patients with SCLC had NCAM levels higher than 20 U/ml, 34% (75 of 221) had NSE levels higher than 25 ng/ml; (2) levels of both markers significantly differ between limited and extensive disease patients; (3) patients with pathologic NCAM and NSE levels have significantly shorter survival times; (4) a positive correlation between pretreatment NSE and NCAM levels was found (n = 221, r = 0.60); and (5) a correlation between serum marker levels and clinical status was found in follow-up studies of 19 patients.

CONCLUSIONS

From these data, it is concluded that NCAM is, along with NSE, a potential tumor marker for SCLC.

Adhesions of distal tibiofibular syndesmosis. A cause of chronic ankle pain after fracture

Ankle pain after uncomplicated ankle fractures poses a diagnostic and therapeutic challenge, especially in joints that exhibit insignificant radiographic changes. Ankle joint arthroscopy has become an important diagnostic and therapeutic tool for such cases. Adhesion of the distal tibiofibular syndesmosis, as yet an undescribed entity, was found to be the cause of chronic ankle pain in 11 of 19 patients suffering from chronic ankle pain after an uncomplicated fracture of the ankle. Symptoms resolved after arthroscopic resection of the adhesions in all 11 patients. Arthroscopy has an important role in diagnosis and management of unexplained ankle pain after a seemingly uncomplicated fracture.

The snapping biceps femoris syndrome

Snapping of tendons is a well-described entity in the literature, occurring mostly in athletes around the hip, ankle, shoulder, and elbow, but rarely the knee. A case of snapping of the biceps femoris tendon (BFT) in a patient with a painful knee and no history of trauma is described. An abnormal anterior insertion of the BFT was found to be the cause of the pain and snapping. Surgical treatment, reinsertion of the tendon in its anatomic position, completely corrected the abnormality, whereas conservative treatment failed.

Cyclic-alternating versus response-oriented chemotherapy in small-cell lung cancer: a German multicenter randomized trial of 321 patients

To test whether alternating chemotherapy is a favorable treatment modality in small-cell lung cancer (SCLC), 334 patients were randomized to receive either fixed cyclic-alternating treatment with ifosfamide/etoposide (IE), cyclophosphamide, doxorubicin, and vincristine (CAV), or response-oriented treatment with IE therapy up to maximal response and subsequently an immediate switch to CAV. In both arms, six cycles were given in 3-week intervals. After chemotherapy, patients with limited-stage disease received chest irradiation with 45 Gy. Prophylactic cranial irradiation with 30 Gy was applied to all complete responders. No maintenance therapy was given to patients with complete response. Minimum follow-up was 2 years. Of 321 assessable patients, the overall response rate was 70% for cyclic alternating and 77% for response-oriented treatment. Complete remission (CR) rates were 26% versus 26%. The median survival times were 9.7 months for cyclic-alternating versus 10.7 months for response-oriented treatment; the 2-year survival rates were 11% versus 9%. In limited-stage disease (LD) patients, there was a median survival of 12.5 months versus 12.3 months and a 2-year survival rate of 21% versus 18%. In extensive-stage disease (ED) patients, median survival was 8.5 versus 9.1 months, and the 2-year survival rate 3% versus 4%. From these results, we conclude that the cyclic-alternating treatment according to the hypothesis of Goldie et al has no advantage in comparison to a sequential treatment strategy with an immediate switch to a second-line protocol at the time no further response to first-line therapy is seen. Our major aim in the treatment of SCLC is to administer an active regimen at any time during the course of treatment regardless of whether sequential or alternating therapy is used.