Whole-body positional manipulators for ocular imaging of anaesthetised mice and rats: a do-it-yourself guide

Background

In vivo retinal imaging of rodents has gained a growing interest in ophthalmology and neurology. The bedding of the animals with the possibility to perform adjustments in order to obtain an ideal camera-to-eye angle is challenging.

Methods

We provide a guide for a cost-effective, do-it-yourself rodent holder for ocular imaging techniques. The set-up was tested and refined in over 2000 optical coherence tomography measurements of mice and rats.

Results

The recommended material is very affordable, readily available and easily assembled. The holder can be adapted to both mice and rats. A custom-made mouthpiece is provided for the use of inhalant anaesthesia. The holder is highly functional and assures that the rodent’s eye is the centre of rotation for adjustments in both the axial and the transverse planes with a major time benefit over unrestrained positioning of the rodents.

Conclusion

We believe this guide is very useful for eye researchers focusing on in vivo retinal imaging in rodents as it significantly reduces examination times for ocular imaging.

A Mobile App to Stabilize Daily Functional Activity of Breast Cancer Patients in Collaboration With the Physician: A Randomized Controlled Clinical Trial

Background

The well-being of breast cancer patients and reporting of adverse events require close monitoring. Mobile apps allow continuous recording of disease- and medication-related symptoms in patients undergoing chemotherapy.

Objective

The aim of the study was to evaluate the effects of a mobile app on patient-reported daily functional activity in a supervised and unsupervised setting.

Methods

We conducted a randomized controlled study of 139 breast cancer patients undergoing chemotherapy. Patient status was self-measured using Eastern Cooperative Oncology Group scoring and Common Terminology Criteria for Adverse Events. Participants were randomly assigned to a control group, an unsupervised group that used a mobile app to record data, or a supervised group that used the app and reviewed data with a physician. Primary outcome variables were change in daily functional activity and symptoms over three outpatient visits.

Results

Functional activity scores declined in all groups from the first to second visit. However, from the second to third visit, only the supervised group improved, whereas the others continued to decline. Overall, the supervised group showed no significant difference from the first (median 90.85, IQR 30.67) to third visit (median 84.76, IQR 18.29, P=.72). Both app-using groups reported more distinct adverse events in the app than in the questionnaire (supervised: n=1033 vs n=656; unsupervised: n=852 vs n=823), although the unsupervised group reported more symptoms overall (n=4808) in the app than the supervised group (n=4463).

Conclusions

The mobile app was associated with stabilized daily functional activity when used under collaborative review. App-using participants could more frequently report adverse events, and those under supervision made fewer and more precise entries than unsupervised participants. Our findings suggest that patient well-being and awareness of chemotherapy adverse effects can be improved by using a mobile app in collaboration with the treating physician.

ClinicalTrial

ClinicalTrials.gov NCT02004496; https://clinicaltrials.gov/ct2/show/NCT02004496 (Archived by WebCite at http://www.webcitation.org/6k68FZHo2)

Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus

Introduction

We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate.

Step 1 Preoperative Planning

To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes.

Step 2 Patient Positioning

Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier.

Step 3 Approach

The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury.

Step 4 Reduction and Fixation of the Tuberosities the Key to Obtaining Marionette-Like Control

The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like.

Step 5 Fracture Reduction

After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate.

Step 6 Fixation Implant-Specific Considerations

Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities.

Step 7 Tenotomy or Tenodesis of the Long Biceps Tendon

Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval.

Step 8 Wound Closure

Do not close the deltopectoral interval.

Step 9 Rehabilitation

As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol.

Results

In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Clinical intuition ratings are associated with morbidity and hospitalisation

OBJECTIVE

To evaluate how the rating of the severity of sickness - as performed by the physician, nurse and patient - is associated with hospitalisation and acute morbidity.

METHODS

Prospective observational study, performed in the emergency department of a tertiary hospital. Patients, physicians and nurses were interviewed separately after the first contact from 21 October through to 11 November 2013.

RESULTS

Of 2426 presenting patients, 1861 were screened, and 1196 were included. A total of 299 (25%) were hospitalised, 504 (42%) suffered acute morbidity. In the univariate analysis, the physician's, nurse's and patient's rating of severity of sickness, expressed on a scale from 0 to 10, was significantly associated with hospitalisation (physicians: OR 1.61, 95% CI 1.50-1.73; nurses: OR 1.52, 1.41-1.64; patients: OR 1.16, 1.10-1.22), and with acute morbidity (OR 1.49, 1.40-1.59; OR 1.39, 1.30-1.48 and OR 1.05, 1.003-1.09 respectively). The area under the curve of the receiver operating characteristic curves was 0.77, 0.72 and 0.61 for hospitalisation, and 0.72, 0.68 and 0.54 for acute morbidity. The interrater reliability was estimated by the intraclass correlation, which was 0.49 for physician/nurse, 0.17 for nurse/patient and 0.07 for physician/patient. In a multivariable analysis model consisting of age, male sex, ethnic origin, ratings of severity of sickness, symptoms, ability to go home and hospitalisation during the preceding 12 months, only age, and the physician's and nurses' rating of severity of sickness remained significantly associated with both outcomes.

CONCLUSION

The first impression of severity of sickness was associated with hospitalisation and morbidity.

Return-to-Work Following Open Reduction and Internal Fixation of Proximal Humerus Fractures

Objectives :

Shoulder disorders have an important impact on a patient’s capacity to work. We investigated whether there is a relationship between subjective or objective outcome measures and the ability and time for returning to work (RTW) after a proximal humerus fracture (PHF).

Design :

Retrospective single-centre study from March 2003 to June 2008.

Setting :

City hospital, trauma level one centre.

Intervention :

All PHF stabilized with a PHILOS^®.

Main Outcome Measurements :

Routine follow-up examinations (X-ray, Constant-Murley Score (CMS), Short-Form 36 (SF-36)) were performed prospectively after 1.5, 3, 6 and 12 months or until RTW. Primary interest was the comparison of the outcome scores with the time needed for RTW.

Results :

72 patients (52 years (22-64), 37 (51%) women) fulfilled the inclusion criteria. We distinguished “office-workers” (OW) (n = 49, 68%) from patients who worked at a physically demanding job (PW) (n = 23, 32%). Although time for RTW was fundamentally different (42 (OW) vs 118 days (PW), p<0.001), CMS (64.7 vs 64.1) and SF-36 (66.8 vs 69.9) at time of RTW were almost identical. At follow-up, CMS and SF-36 were always lower in the PW group.

Conclusion :

Jobs which require higher physical demands were likely to influence and to delay RTW. This study identifies cut off values for CMS and SF-36 at which a patient feels capable or willing to RTW after PHF. These values show the importance and impact of a patient’s occupation or demands on RTW. We were able to show, that besides age, sex and fracture, the type of occupation might alter the scores in postoperative outcomes.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

The Nuclear Quadrupole Interaction of 204mPb in Cadmium Monitored by γ–γ –Perturbed Angular Correlations

For the first time the nuclear probe 204mPb was produced at the on-line isotope separator ISOLDE at CERN and used for time differential perturbed angular correlation experiments. The electric field gradient of 204mPb at room temperature in Cd metal was determined to be = 19(1) 1021 V/m2. Ab initio-calculations of the electric field gradient for the impurities Pt to Bi in cadmium were performed with the full-potential linearized augmented plane waves code WIEN97 to interpret this result. For Au, Hg and Pb, where experimental results are now available, these agree with the calculations within 10 %.

Strategic management and the economics of the firm

Purpose

The purpose of this paper is to argue for the need to reconcile managerial and economic approaches of the firm. Strategic management seems to be the perfect playground for this.

Design/methodology/approach

The paper shows many divergences between the economic and managerial approach of the firm but also highlights many topics where both approaches come in handy.

Findings

The authors underline the topics and theories in strategic management with the greatest benefits of mixing economics and management can be expected and they echo the papers in this special issue.

Practical implications

The paper comes as a warning for those using only managerial perspective without listening to the caveats and ideas put forward by the economic approach of the firm.

Originality/value

The paper offers an agenda of how economics and management could be reunited, and shows the relevance of doing so to both theory and practice.

Validation of a transparent decision model to rate drug interactions

Background

Multiple databases provide ratings of drug-drug interactions. The ratings are often based on different criteria and lack background information on the decision making process. User acceptance of rating systems could be improved by providing a transparent decision path for each category.

Methods

We rated 200 randomly selected potential drug-drug interactions by a transparent decision model developed by our team. The cases were generated from ward round observations and physicians’ queries from an outpatient setting. We compared our ratings to those assigned by a senior clinical pharmacologist and by a standard interaction database, and thus validated the model.

Results

The decision model rated consistently with the standard database and the pharmacologist in 94 and 156 cases, respectively. In two cases the model decision required correction. Following removal of systematic model construction differences, the DM was fully consistent with other rating systems.

Conclusion

The decision model reproducibly rates interactions and elucidates systematic differences. We propose to supply validated decision paths alongside the interaction rating to improve comprehensibility and to enable physicians to interpret the ratings in a clinical context.

Surgical treatment of Neer Group VI proximal humeral fractures: retrospective comparison of PHILOS® and hemiarthroplasty

BACKGROUND

Neer Group VI proximal humeral fractures often are related to persistent disability despite surgical treatment. We retrospectively compared the outcome after open reduction and internal fixation with the PHILOS(®) plate or primary hemiarthroplasty in patients with Neer Group VI fractures focusing on complications, shoulder function, health-related quality of life (SF-36), and potential risk factors for complications.

QUESTIONS/PURPOSES

The aim of this study was to compare the PHILOS(®) plate with primary hemiarthroplasty for treatment of specific Neer Group VI fractures. We asked whether (1) both procedures have comparable clinical and radiologic complication rates; (2) one procedure is superior in terms of revision rate; (3) objective and subjective shoulder function (Constant-Murley score) and health-related quality of life (SF-36) were comparable in both groups at final followup; and (4) there are clinical or radiologic predictors for complications in any group?

METHODS

Between 2002 and 2007, 44 consecutive patients (mean, 75.2 years) with a Neer Group VI proximal humeral fracture were included. Twenty-two patients treated with a PHILOS(®) plate were compared with 22 patients treated by primary hemiarthroplasty. Both groups were similar in all criteria. At minimum followup of 12 months (mean, 30 months; range, 12-83 months), radiographic control, Constant-Murley score, and SF-36 were performed.

RESULTS

Fourteen patients with complications (63.6%) were counted in the PHILOS(®) plate group, of which 10 (45.4%) needed revision surgery, mostly as a result of avascular necrosis and screw cut-outs. In the primary hemiarthroplasty group, only one patient needed revision surgery (4.5%). Smoking and steroid therapy were substantially associated with complications in the PHILOS(®) plate group. There were no differences between the two groups regarding Constant-Murley or SF-36 scores.

CONCLUSIONS

Angular stable open reduction and internal fixation was associated with high complication and revision rates, especially in patients who smoked and those receiving steroid therapy. Primary hemiarthroplasty provides limited function, which had little influence on the quality of life in this elderly collective. There are predictive factors for complications after the treatment of Neer Group VI proximal humeral fractures with the PHILOS(®) plate. Primary hemiarthroplasty remains a good option, especially when treating elderly patients.

Minimal invasive long PHILOS®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus

Minimal invasive plate osteosynthesis (MIPO) not only meets the criteria of a "biological" osteosynthesis by minimising invasivity as well as iatrogenic soft tissue damage, but can also provide adequate stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the anterolateral deltopectoral approach for proximal plate insertion. Objective of the present study was to assess the feasibility and clinical outcome of MIPO for metadiaphyseal fractures of the proximal humerus through a lateral approach using angular stable long PHILOS(®)-plates. We retrospectively evaluated 29 patients (mean age 77 years, range 48-95 years) with displaced metadiaphyseal fractures of the proximal humerus treated with MIPO technique. For the first time, an angular stable long PHILOS(®)-plate through a lateral deltoid-split approach proximally and a brachialis/brachioradialis intermuscular approach with exposure of the radial nerve distally, were used. There were no infections and no iatrogenic injuries to the axillary and radial nerve. One patient showed subacromial impingement and one patient had to be reoperated for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Besides one patient who refused further follow-up, 28 patients could be followed up to a mean of 8 months (range 3-12 months) each with an entirely healed fracture. Furthermore, patient's quality of life was documented using the SF-36 questionnaire. Comparison with published United States normative data showed no significant deficits in the physical as well as in the mental domains 8 months after MIPO. Minimal invasive long PHILOS(®)-plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe procedure for the treatment of metadiaphyseal fractures of the proximal humerus with low morbidity and full restoration of quality of life in these elderly patients.

Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis

PURPOSE

Hartman's procedure (HP) or primary anastomosis (PA) are the two surgical techniques used in patients undergoing emergency colectomy for perforated diverticulitis. There are no objective criteria to guide the surgeon's choice of procedure. This study assesses whether classification and scoring systems can be used in the decision-making process.

METHODS

One hundred eleven patients undergoing emergency laparotomy for perforated diverticulitis were analyzed. Logistic regression and interaction models were used to determine the predictive value in the two settings.

RESULTS

Sixty five patients underwent HP and 46 patients underwent PA. Patients with HP had significantly higher scores, median age, and were more often on immunosuppressive medication. Mortality and surgical morbidity did not differ between the groups. The clinical anastomotic leak rate was 28.3% in the PA group. In the univariate logistic regression for in-hospital death, all scores showed a significant influence. The multivariate logistic regression analysis showed that only Charlson comorbidity index (CCI) and American Society of Anesthesiologists score had a significant influence on mortality. Each score was analyzed for its predictive value regarding mortality and morbidity with respect to type of operative procedure. Only CCI revealed a trend towards statistical significance. The risk of death increases with increasing CCI when PA is performed compared to HP.

CONCLUSION

None of the tested scores can be used to help the surgeon decide whether a PA or HP is appropriate in a specific patient. Comorbidity, represented as CCI in this study, might be more important than the locoregional situation.

Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis

OBJECTIVE

Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model.

METHOD

Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score.

RESULTS

Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients.

CONCLUSION

The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of CTEP-sponsored studies

CRA6509

Background: Post-activation barriers to oncology clinical trial accruals are well documented; however, potential barriers prior to trial opening are not. We investigate one such barrier: trial development time. Methods: National Cancer Institute Cancer Therapy Evaluation Program (NCI-CTEP) sponsored trials for all therapeutic, non-pediatric phase I,I/II, II, and III studies activated in an eight year period (2000–2007) were investigated (n=553). Successful trials were those achieving 100% of minimum accrual goal. Time to open a study was the calendar time from initial CTEP submission to trialactivation. Multivariable logistic regression analysis was used tocalculate unadjusted and adjusted odds ratios, controlling for study phase and size of expected accruals. Results: 40.0 percent (n=221) of CTEP-approved oncology trials failed to achieve minimum accrual goals, with 49.2 percent (n=30) of phase III trials failing to achieve at least 25 percent of accrual goals. A total of 8,723 patients (17.0% of accruals) accrued to those studies that were unable to achieve the projected minimum accrual goal. Trials requiring 9–12 months development were significantly more likely to achieve accrual goals (odds ratio, 1.94; 95% CI, 1.06 to 3.52, P=0.031) than trials requiring the median time (15–18 months); trials that exceeded 27 months of development time were significantly less likely of achieving accrual goals (odds ratio, 0.14; 95% CI, 0.04 to 0.54, P=0.004). Conclusions: A large percentage of oncology clinical trials do not achieve minimum projected accruals. Trial development time appears to be one important predictor of the likelihood of successfully achieving the minimum accrual goals.

[Table: see text]

No significant financial relationships to disclose.