Diagnostic and prognostic markers in gliomas - an update

Gliomas are the most common primary central nervous system tumour seen in adults. There have been many advances over the last two decades as we widen our search for a molecular basis of gliomagenesis. Many biomarkers have been discovered to be important in the management of gliomas, including 1p19q co-deletion, MGMT promoter methylation, BRAF and IDH1 mutations. In this review, we attempt to summarise the available literature on these biomarkers and their use in the diagnosis and management of gliomas. We pay special attention to the recently discovered IDH1 mutation, which is already proving to be a valuable new marker for favourable prognosis and may also indicate a greater response to therapy. 1p19q co-deletions have been shown to delineate a clinically distinct tumour type and are now routinely tested for in certain situations and can help direct treatment. MGMT promoter methylation is one of the most commonly studied biomarkers in gliomas. It has been shown to be a strong positive prognostic marker in gliomas, with positive tumours being more sensitive to chemotherapy. However, a lack of alternatives means that it is not yet a routine mutation tested for clinically. BRAF mutations are new markers found in pilocytic astrocytomas. Although the prognostic value of such mutations is not yet known, they may play a significant role in the diagnosis and treatment of such tumours. IDH1 mutations are 'the new kid on the block' and seem to play a central role in the pathogenesis of gliomas. They represent an independent and favourable prognostic marker and are a new molecular marker for disease diagnosis. Its role in determining response to chemotherapy is still controversial but with further study, IDH1 mutations may prove to be an invaluable marker in the management of gliomas.

IB-MECA, an adenosine A(3) receptor agonist, does not influence survival of lethally γ-irradiated mice

In our previous studies, IB-MECA, an adenosine A(3) receptor agonist, was found to stimulate proliferation of hematopoietic progenitor and precursor cells in mice. This property of IB-MECA was considered to be responsible for its ability to support regeneration of suppressed hematopoiesis after irradiation with sublethal doses of γ-rays when the drug was given in a post-irradiation treatment regimen. This study was aimed at assessing the ability of IB-MECA to influence a 30-day survival of lethally irradiated mice. In a series of experiments, IB-MECA was administered following various lethal radiation doses in various numbers of drug doses and various administration routes. Though in some of these experiments a moderate increase in 30-day survival was observed in IB-MECA-treated mice, the differences in comparison with the controls were not significantly different. It can be inferred from these results and those of previous studies assessing the effects of IB-MECA after sublethal radiation doses that IB-MECA can probably influence only a substantially preserved hematopoiesis like that remaining after sublethal irradiation. Future studies should be aimed at evaluation of the abilities of IB-MECA to influence post-irradiation survival when administered as a part of combined treatment regimens.

[The first clinical use of an Dynamic Registration Tool for Navigation in FESS]

BACKGROUND

The effective register accuracy in an situs issues a challenge to the employment of instrument navigation in the ENT Surgery. The idea of the initially determined process Dynamic Registration Supply (DRS) is to improve the register accuracy by the automatic, and interoperability of the register.

MATERIALS AND METHODS

The aim was to determine clinical use of DRS. Opto-electrical system Navigation Panel Unit, vs. 4.0.0 with the functionality DRS was used. Experiments were carried out on 95 patients who had so called FESS. The data of a control group were available to researchers. The measuring log includes among other things following parameters: retooling time, cutting-suture time, frequency of use of the navigated pointer, frequency of additional registration.

RESULTS

At least once during the procedure DRS has been activated in 85 of 95 interventions (89.5). The time required increased by 15% accumulated 189 s per intervention. The most frequently used additional registration was in the region of sphenoid sinus. The surgeons underlined that out of 95 surveys in 75 cases the DRS rendered the instrument navigation more precise, while 1% of 93 cases considered this function as unwanted.

CONCLUSION

The first clinical study for use of an automatic algorithm for recognition and reduction of faulty registration of a CT, navigation was successful. The findings suggest that by using automatic intraoperative registration DRS consisting inaccuracy can be reduced. In practice this means an efficient quality improvement of the Navigation.

Quality indicators for the development and didactics of ultrasound courses in continuing medical education

PURPOSE

Based on evaluation data from participant feedback, a concept was to be developed for introductory abdominal ultrasound courses lasting several days. This approach was to be developed incrementally with the intent of maximizing the learning effect per time.

MATERIALS AND METHODS

This concept has been modified annually over several years based on the findings of educational research and the scores on final examinations in OSCE format. It has been modified with the aid of detailed questionnaires completed by approximately 2000 participating physicians and has thus undergone incremental optimization.

RESULTS

Analysis of the most recent 1005 questionnaires has shown that participants recommend a modular course design with only brief lectures on theory (average optimal duration of 20 min., SD 9.6 min.). These should alternate with longer practical "hands-on" ultrasound exercises (60 - 90 min., accounting for at least 50 - 60 % of the course time), consolidating drawing exercises, and breaks. 51 % of the physicians specified 5 participants as the ideal group size for practical exercises, while 43 % specified only 4. The discussion presents 10 specific quality indicators for efficient ultrasound courses. It elucidates the feasibility and logistical prerequisites of this model, and compares it with other basic course concepts. Furthermore, this article presents a model for an evaluation covering the course concept and tutors as well as discussing a training program for tutors including a cost analysis.

CONCLUSION

In summary, the participants estimate the course design to represent a mature concept that has demonstrated its feasibility and broad acceptance among physicians in CME.

Imaging of the sinuses for functional sinus surgery using navigational guidance

Advances in the understanding of mucociliary activity and pathophysiology of the nasal cavity and paranasal sinuses have revolutionized the surgical management of chronic and recurrent sinusitis. The development of functional endoscopic sinus surgery (FESS) can also be seen as the pioneer task in endoscopic surgery. Today, in more than 50% of all sinus surgeries FESS is being used. Inflammatory causes are the most common indication for surgery, which can be evaluated best preoperatively using (multi-detector) computed tomography. Even today there are further relevant developments of FESS that result in alleviation of the surgeon due to different degrees of automation. Using a preoperatively acquired navigational dataset helps choosing the optimal surgical strategy. Intraoperatively the navigational dataset is at present mainly used for localization of surgical tools. These newer operation methods demand for high-quality radiological imaging and evaluation, consisting of delineation of the local (inflammatory) process, detection of disease related complications and description of anatomical variations that may be important to the surgeon. Since patients with chronic recurrent sinusitis are relatively young on average and recurrent disease or further CT examinations are not uncommon, there should always be a focus on reduction of radiation exposure as much as possible. Technical advances like cone-beam tomography seem promising to further improve dose reduction as well as spatial resolution.

[Clinical experiences with an automatic collision warning system: instrument navigation in endoscopic transnasal surgery]

PROBLEM

The goal of this work is the extension of instrument navigation with a collision warning function. With the help of an additional distance display and warning system the performance of surgical navigation systems should be improved.

MATERIAL AND METHODS

The collision warning system (DCS) is an extension of an optoelectric navigation system (NPU, Karl Storz GmbH&Co.KG, Tuttlingen, Germany). The measurement of situation awareness was performed on phantom models of functional endoscopic surgery of the paranasal sinuses (FESS; Phacon, Leipzig). Altogether 450 measurement pairs for the analysis of surgical accuracy to the risk structure (frontal skull base, lamina papyracea, internal carotid artery) were available. To examine the influence on the clinical process, a prospective analysis of intraoperative complications was carried out. Of the 104 FESS patients, two groups, one of 56 patients with only navigation (NAV) and one of 48 patients (NAV+DCS), were examined. Efficiency was evaluated on the basis of times for system preparation and intraoperative application.

RESULTS

A significant increase in the assumed and actual distance values between instrument tip and risk structure using the collision warning system was seen at 76%. The complication rate was more favorable for the NAV+DCS group. The time needed for preparation of the navigation system with the application of the collision warning system increased on average by 48%, or 1.2 min. However, the relation between preparation time and utilization time was approximately the same at 53.5% in the NAV group and 57.4% in the NAV+DCS group.

CONCLUSIONS

This work supports the clinical use and efficiency of a collision warning system as an addition to well-known instrument navigation in endo- and transnasal surgery. The segmenting algorithm is suitable for clinical requirements.

Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture

Fractures of the distal radius in postmenopausal women may cause prolonged pain and disability, but little is known about their natural course beyond the first year. In this study, women of 50-75 years of age, initially treated with cast or external fixation, were examined 1 year after distal radial fracture and then re-evaluated after a mean of 3 (range, 2-4) years. The evaluation included pain, disability (DASH) scores, grip strength and range of motion. In the 49 participating women pain scores, grip strength and range of motion improved significantly, although the mean improvement was moderate or small. In a subgroup of 13 patients with moderate or severe malunion, the 1 year DASH score was significantly worse than in the remaining patients but improved significantly together with grip strength and range of motion. After fractures of the distal radius, pain, grip strength and range of motion continued to improve beyond 1 year, up to 2-4 years. Patients with malunion had more disability at 1 year but showed significant improvement at 2-4 years.

A single dose of an inhibitor of cyclooxygenase 2, meloxicam, administered shortly after irradiation increases survival of lethally irradiated mice

This study extends earlier findings of the authors demonstrating that meloxicam, a selective inhibitor of cyclooxygenase 2, supports hematopoietic recovery in sublethally irradiated mice and is radioprotective when given before irradiation. We report here that when meloxicam was administered in a single dose 1 h after a lethal 9-Gy whole-body dose, an increased 30-day survival was achieved. Additional studies showed that administration of meloxicam 24 h after lethal irradiation is ineffective and its repeated administration deleterious. Possible mechanisms of the therapeutic effects of meloxicam administered early after irradiation are discussed.

[Influence of an auto-motorised optical navigation camera to the surgical workflow in ENT surgery]

BACKGROUND

With the application of optical navigation systems an interruption of the line of sight (LOS) between navigation camera and the patient/instrument can occur. The goal of this work is the clinical evaluation of a newly developed system for automatic adjusting of an optical navigation camera (Navigation Camera Assistant, NCA). NCA is a miniature robot, which is able to position the navigation camera autonomously in 2 levels.

MATERIAL AND METHODS

The influence of the NCA was examined on 128 patients: 55 procedures at the paranasal sinuses and 9 procedures at the temporal bone with the NCA were evaluated and compared with available workflow data of adequate surgeries without NCA. An optical navigation system of the 3 (rd) generation was used. The following parameters were recorded: Preparation time of the system, time of using the system, LOS-interruptions.

RESULTS

The LOS-interruption decreased in the group of FESS with application of the NCA by 92%, in the group tympanic cavity by 85%. The number of corrective motions of the navigation camera was increased with application of the NCA in the group FESS by 73%, in the group tympanic cavity by 89%. The usage time of navigation increased with the application of the NCA in the group of FESS by 36%, in the group tympanic cavity by 16%.

CONCLUSIONS

With a motorized navigation camera can be the interruption rate of LOS significantly improved at frontal and lateral skull base. The technical expenditure for installation of the NCA robot is little even during, for this reason there is the potential that this module can be established for the clinical practice.

[Food allergy in children: anything new in its management?]

The prevalence of food allergy in children is increasing, in particular in its most severe presentation, i.e. anaphylaxis. Food allergy has an important impact on children's and their parent's quality of life, because of the fear of accidental ingestion and limitations of social activities. Quality of life questionnaires adapted to food allergy are now available, as well as new diagnostic procedures using recombinant technology. Their interpretation and their clinical correlation remain difficult, especially in children, in the absence of references values. Various oral and subcutaneous immunotherapy strategies are currently under evaluation, using modified or native allergens.

[Surgical manipulators in ear surgery: a future vision?]

INTRODUCTION

Middle ear surgery bears a high risk for injury of difficult to differentiate risk structures. Thus, a precise preparation in this area must be the surgical task.

LIMITATIONS

However, there are human (tremor) and systematic limitations (OR setup, narrow access). Assistance systems in terms of manipulators are so far not part of the clinical routine. Although, they could compensate for the above mentioned limitations. MANIPULATORS: This work reviews existing surgical manipulator systems. The expected value is an elevated patient safety through improving surgical accuracy and the reduction of ergonomic deficits. CLINICAL APPLICATION AND DEVELOPMENT: In clinical application there are simply modified industrial robots, highly complex master slave systems and small miniature master slave systems which are directly located at the patient.

CONCLUSION

A disadvantage of most systems is the limited number of applicable instruments. Often, only especially designed instruments can be used. The goal in development should be to create a compact, short distance operated master slave system. The usability of standard (already available) instruments with an easy integration into the surgical and sterilisation procedure would lower the threshold for acceptance of such systems.The surgeon will remain the key player. He can only work efficiently in an ergonomic environment and will always have the responsibility for the intervention. From the authors perspective, highly automated systems should not be the research goal.