Implementing Standardized Patient Education in Radiation Oncology

PURPOSE/OBJECTIVE(S)

Patient education empowers patients, improving their health status during and after cancer treatment (Howell et al., 2017). We hypothesize that standardizing healthcare provider delivery of educational materials (HPE) using an electronic medical record (EMR) will increase delivery to patients (pts).

MATERIALS/METHODS

During the study period (9/2020 - 11/2022) 13,650 pts in a multi-centered single health system (HS) received HPE and were analyzed in a retrospective convenience sample frame. There were 16,769 education touchpoints from Radiation Oncology departments (RO) and 8,269 from Medical Oncology (MO) departments. Provision of HPE was standardized in RO during this era. Relationship of ethnicity, age, and sex/gender to receipt of HPE at single vs multiple time points across the HS was examined using association analysis.

RESULTS

Within the combined sample taken from RO and MO departments in the HS the mean pt age was 64y (7 - >90); 71% of pts identified as white, 95.7% non-Hispanic, and 55% female. Across ethnicity, age, and sex/gender, increased HPE was provided in RO vs MO departments (p < 0.001). Distribution of HPE in RO was equal between male and female pts (73%), while distribution to female pts was higher than male in MO. (60% vs 57%, p < 0.001). Receipt of HPE at more than one time point was increased in RO across cancer types (Table 1). In RO, 73% of patients received education at more than one time point, compared to 58.7% in other departments (p < 0.001). Receipt of HPE at more than one time point was increased in RO for patients identifying as American Indian or Alaska Native (84% vs 0, p = 0.001, n = 28), Asian (73.4% vs 56%, p < 0.001, n = 824), and Black (75% vs 60%, p < 0.001, n = 4005). HPE was received at more than one time point in RO in 75.7% of patients age 7-39, 76.4% 40-64, 71.2% 65-79, and 67.6% in those 80 and above, compared to 62.0%, 63.2%, 56.3%, and 49.2%, respectively in MO departments (p = <0.01).

CONCLUSION

Standardization of HPE within RO increased delivery to patients across gender, race/ethnicity, age, and cancer diagnosis, particularly regarding number of educational touchpoints for patients in underserved populations based on race and age. Our results suggest that widespread standardization of HPE is likely to improve distribution of education to all patient groups and should be systematically supported.

Barriers to and enablers of attendance at diabetic retinopathy screening experienced by immigrants to Canada from multiple cultural and linguistic minority groups

AIM

To identify barriers to/enablers of attendance at eye screening among three groups of immigrantsto Canada from cultural/linguistic minority groups living with diabetes.

METHODS

Using a patient-oriented research approach leveraging Diabetes Action Canada's patient engagement platform, we interviewed a purposeful sample of people with type 2 diabetes who had immigrated to Canada from: Pakistan (interviews in Urdu), China (interviews in Mandarin) and French-speaking African and Caribbean nations (interviews in French). We collected and analysed data based on the Theoretical Domains Framework covering key modifiable factors that may operate as barriers to or enablers of attending eye screening. We used directed content analysis to code barrier/enabler domains. Barriers/enablers were mapped to behaviour change techniques to inform future intervention development.

RESULTS

We interviewed 39 people (13 per group). Many barriers/enablers were consistent across groups, including views about harms caused by screening itself, practical appointment issues including forgetting, screening costs, wait times and making/getting to an appointment, lack of awareness about retinopathy screening, language barriers, and family and clinical support. Group-specific barriers/enablers included a preference to return to one's country of birth for screening, the impact of winter, and preferences for alternative medicine.

CONCLUSION

Our results can inform linguistic and culturally competent interventions to support immigrants living with diabetes in attending eye screening to prevent avoidable blindness.

FRI0365 REAL-WORLD EFFECTIVENESS AND SAFETY OF APREMILAST IN A LARGE COHORT OF GERMAN PATIENTS WITH PSORIATIC ARTHRITIS: 1-YEAR ANALYSIS OF AN ONGOING MULTICENTER, PROSPECTIVE, NON-INTERVENTIONAL STUDY

Background:

Apremilast (APR) has been studied extensively in phase III randomized, controlled trials. However, real-world information is limited on the effectiveness and safety of APR in patients with psoriatic arthritis (PsA).

Objectives:

To assess the effectiveness and safety of APR in a large cohort of patients with active PsA from routine clinical practice settings in Germany.

Methods:

In this multicenter, prospective, non-interventional study, the primary endpoint was the proportion of patients reaching ≥1 point (≥20%) improvement from baseline (BL) in the Physician’s Global Assessment of Disease Activity (PhGA) score. Other endpoints included effects on swollen and tender joint counts (SJC/TJC), psoriasis-involved body surface area (BSA), enthesitis, dactylitis, Patient’s Global Assessment of Disease Activity score (PtGA), Psoriatic Arthritis Impact of Disease (PsAID) tool, pain, and pruritus. The current analysis is based on observed data through 1 year of study duration.

Results:

A total of 545 German patients were enrolled and followed up to 12 months of APR treatment; 488 patients were included in the safety analysis and 418 in the full analysis set. The mean age was 55 years, mean body mass index was 29.5 kg/m2, and 60% were female. The mean duration of psoriasis and PsA was 26 years and 18 years, respectively. At BL, 46.7% of patients had enthesitis based on the Leeds Enthesitis Index (LEI; mean [SD]: 2.9 [1.72]) and 23% had dactylitis (mean [SD]: 2.2±2.03); 74% of patients were biologic-naive. Effectiveness is shown after ~1 month (Visit 1 [V1]) and ~4 months (Visit 2 [V2]) and for up to 225 patients after 12 months (Visit 5 [V5]) of treatment (Table).

Improvements were also seen in PtGA, overall pain, and pruritus. A subanalysis suggests APR was associated with greater benefits in biologic-naive patients compared with patients who previously received biologic therapy. Observed safety and tolerability through V5 were consistent with the known overall safety profile of APR. Common adverse events in clinical trials were similar, with a lower incidence of diarrhea (11.1%), nausea (7.0%), headache (3.9%), and respiratory tract infection (0.8%).

Conclusion:

Data from this large, real-world cohort of patients with PsA show the effectiveness of APR. In patients with up to 12 months of follow-up, APR was associated with rapid and maintained improvements in physician-assessed and patient-reported outcomes. Safety and tolerability were consistent with the known profile of APR.

Table.

Disclosure of Interests:

Jürgen Wollenhaupt Grant/research support from: Abbott, BMS, MSD, Pfizer, UCB – grant/research support, Consultant of: Abbott, BMS, MSD, Pfizer, UCB – consultant, Harald Strothmeyer: None declared, Michael Fiene: None declared, Stephan Morys Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct, Christian Bach Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct, Josefine Roemmler-Zehrer Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct

Positioning human body models for crashworthiness using model order reduction

A new technique to accelerate the positioning of human body models (HBMs) by means of a dimensionality reduction of a database of precomputed simulations is presented. First, a set of important subspace deformation modes which are used to approximate the model's movements observed in the training simulations are computed. In the second step, a convex optimization problem is solved in order to obtain an optimal position of the human body model as described by the user. We apply the proposed method to a new reclined seating position of the Total Human Model for Safety (THUMS, v5).

Identifying Barriers and Enablers to Attending Diabetic Retinopathy Screening in Immigrants to Canada From Ethnocultural Minority Groups: Protocol for a Qualitative Descriptive Study

Background

Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness.

Objective

This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance.

Methods

The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains.

Results

This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020.

Conclusions

Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15109

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group

OBJECTIVE

Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction.

MATERIAL AND METHOD

A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases.

RESULTS

Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04).

CONCLUSION

Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Anti-HLA alloantibodies of the IgA isotype in re-transplant candidates part II: Correlation with graft survival

We reported previously on the widespread occurrence of anti-HLA alloantibodies of the IgA isotype (anti-HLA IgA) in the sera of solid-organ re-transplantation (re-tx) candidates (Arnold et al., ). Specifically focussing on kidney re-tx patients, we now extended our earlier findings by examining the impact of the presence and donor specificity of anti-HLA IgA on graft survival. We observed frequent concurrence of anti-HLA IgA and anti-HLA IgG in 27% of our multicenter collective of 694 kidney re-tx patients. This subgroup displayed significantly reduced graft survival as evidenced by the median time to first dialysis after transplantation (TTD 77 months) compared to patients carrying either anti-HLA IgG or IgA (TTD 102 and 94 months, respectively). In addition, donor specificity of anti-HLA IgA had a significant negative impact on graft survival (TTD 74 months) in our study. Taken together, our data strongly indicate that presence of anti-HLA IgA, in particular in conjunction with anti-HLA-IgG, in sera of kidney re-tx patients is associated with negative transplantation outcome.

Encouraging treatment algorithm for computer-assisted navigated total knee arthroplasty (TKA): A retrospective cohort analysis

OBJECTIVE

Navigated computer-assisted total knee arthroplasty (TKA) shows inconclusive mid- to long-term outcome results and is limited by increased costs, surgery-time and an additional learning curve. We introduced a treatment algorithm preserving computer-assisted TKA for patients with adipositas-per-magna, posttraumatic leg-deformities, osteosynthetic material in-situ or reduced preoperative X-ray quality.

METHODS

237 primary unilateral TKA were allocated based on the treatment concept described above. A retrospective pre- and postoperative radiological analysis was performed.

RESULTS

222 TKA (93.7%) were within 3° varus/valgus of mechanical-lower-limb axis (mean absolute deviation: 1.8° ± 1.3°).

CONCLUSION

This algorithm showed an excellent postoperative implantation-accuracy based on an accurate preoperative surgery-planning.

Radical prostatectomy for locally advanced and metastatic prostate cancer

The management of advanced prostate cancer remains challenging. Traditionally, radical prostatectomy was discouraged in patients with locally advanced or node positive disease owing to the increased complication rate and treatment related morbidity. However, technical advances and refinements in surgical techniques have enabled the outcomes for patients with high risk prostate cancer to be improved. More recently, the concept of cytoreductive prostatectomy has been described where surgery (often Combined with an extended lymph node dissection) is performed in the setting of metastatic disease. Indirect evidence suggests an advantage using the cytoreductive approach. Hypothetical explanations for this observed benefit include decreased tumour burden, immune modulation, improved response to secondary treatment and avoidance of secondary complications attributable to local tumour growth. Nevertheless, prospective trials are required to investigate this further.

[Predictive factors and prognostic consequences of perioperative complications of radical cystectomies for urothelial carcinoma in patients of 80 years or more]

OBJECTIVE

To define the predictive factors and the prognostic consequences of perioperative complications occurrence while radical cystectomies for urothelial carcinoma treatment in patients older than 80 years.

MATERIAL AND METHOD

Retrospective analysis of clinical and biological preoperative data and outcome of eighty patients of 80 years or more, treated with radical cystectomy between 1990 and 2010 in one centre. Perioperative complications were graded according to the classification from Clavien-Dindo.

RESULTS

Twenty-eight patients (35%) had a single perioperative complication and nineteen (24%) had multiple (≥2) perioperative complications. Overall survival of patients with multiple perioperative complications was significantly lower than that of patients who had no complications (Log-rank P=0.0004). The occurrence of multiple perioperative complications was associated with Charlson and ASA scores, with pelvic irradiation and induction chemotherapy histories. However, in multivariate analysis, only the existence of respiratory comorbidity was an independent risk factor for the occurrence of multiple perioperative complications.

CONCLUSIONS

The occurrence of multiple perioperative complications was associated with reduced overall survival in elderly patients after radical cystectomy. The existence of respiratory comorbidity was the only independent risk factor for the occurrence of multiple perioperative complications.

LEVEL OF EVIDENCE

5.

Soil Parameters Drive the Structure, Diversity and Metabolic Potentials of the Bacterial Communities Across Temperate Beech Forest Soil Sequences

Soil and climatic conditions as well as land cover and land management have been shown to strongly impact the structure and diversity of the soil bacterial communities. Here, we addressed under a same land cover the potential effect of the edaphic parameters on the soil bacterial communities, excluding potential confounding factors as climate. To do this, we characterized two natural soil sequences occurring in the Montiers experimental site. Spatially distant soil samples were collected below Fagus sylvatica tree stands to assess the effect of soil sequences on the edaphic parameters, as well as the structure and diversity of the bacterial communities. Soil analyses revealed that the two soil sequences were characterized by higher pH and calcium and magnesium contents in the lower plots. Metabolic assays based on Biolog Ecoplates highlighted higher intensity and richness in usable carbon substrates in the lower plots than in the middle and upper plots, although no significant differences occurred in the abundance of bacterial and fungal communities along the soil sequences as assessed using quantitative PCR. Pyrosequencing analysis of 16S ribosomal RNA (rRNA) gene amplicons revealed that Proteobacteria, Acidobacteria and Bacteroidetes were the most abundantly represented phyla. Acidobacteria, Proteobacteria and Chlamydiae were significantly enriched in the most acidic and nutrient-poor soils compared to the Bacteroidetes, which were significantly enriched in the soils presenting the higher pH and nutrient contents. Interestingly, aluminium, nitrogen, calcium, nutrient availability and pH appeared to be the best predictors of the bacterial community structures along the soil sequences.

Processing of membranes for oxygenation using the Bellhouse-effect

State-of-the-art lung support systems are limited to short time application because of a lack of long term hemocompatibility and protein absorption on the membrane surfaces. In a highly interdisciplinary project at RWTH Aachen University a biohybrid lung assist system with endothelialised gas exchange flat membranes is developed to improve long term compatibility of oxygenators. To increase the gas exchange performance of flat membranes hollows are imprinted in the membrane surfaces. This approach is based on the research of B. J. Bell-house et al. [1], who discovered this effect, now known as Bellhouse-effect, around 1960. In this paper a processes to manufacture membrane assemblies for oxygenation with imprinted hollows on the flat membrane surfaces is reviewed.

BDNF Val66Met and reward-related brain function in adolescents: role for early alcohol consumption

Changes in reward processing have been identified as one important pathogenetic mechanism in alcohol addiction. The nonsynonymous single nucleotide polymorphism in the brain-derived neurotrophic factor (BDNF) gene (rs6265/Val66Met) modulates the central nervous system activity of neurotransmitters involved in reward processing such as serotonin, dopamine, and glutamate. It was identified as crucial for alcohol consumption in healthy adults and, in rats, specifically related to the function in the striatum, a region that is commonly involved in reward processing. However, studies in humans on the association of BDNF Val66Met and reward-related brain functions and its role for alcohol consumption, a significant predictor of later alcohol addiction, are missing. Based on an intermediate phenotype approach, we assessed the early orientation toward alcohol and alcohol consumption in 530 healthy adolescents that underwent a monetary incentive delay task during functional magnetic resonance imaging. We found a significantly lower response in the putamen to reward anticipation in adolescent Met carriers with high versus low levels of alcohol consumption. During reward feedback, Met carriers with low putamen reactivity were significantly more likely to orient toward alcohol and to drink alcohol 2 years later. This study indicates a possible effect of BDNF Val66Met on alcohol addiction-related phenotypes in adolescence.

[Freiburg index of patient satisfaction: interdisciplinary validation of a new psychometric questionnaire to describe treatment-related patient satisfaction]

BACKGROUND

The recently introduced Freiburg index of patient satisfaction (FIPS) is a new questionnaire to assess treatment-related patient satisfaction after surgery and interventional procedures. The questionnaire had first been tested psychometrically in a mixed population of urology patients. The current study describes the results of an interdisciplinary validation. In addition, an English version is presented.

METHODS

The questionnaire was used in two cohorts of cardiology (n = 120) and surgical (n = 127) patients. The evaluation included a comprehensive methodological and statistical evaluation including validation in comparison to the ZUF-8 questionnaire.

RESULTS

The psychometric evaluation showed good results. The analyzed samples showed no missing values or ceiling effects. Furthermore, a high reliability (Cronbach's alpha 0.82), unidimensionality, sufficient distribution of values and validity (high correlation to the ZUF-8, r = 0.65, p < 0.001) of the questionnaire could be confirmed.

CONCLUSIONS

The FIPS constitutes an interdisciplinary validated questionnaire to evaluate treatment-related patient satisfaction which can be used to objectify and compare results from clinical studies and quality in patient care. Colleagues of English-speaking countries are invited to participate in the validation of the hereby presented English version.

Body mass index is related to autonomic nervous system activity as measured by heart rate variability--a replication using short term measurements

OBJECTIVES

The present analysis is a replication of previous findings presenting first evidence of an association between body mass index (BMI) and autonomic nervous system (ANS) activity as measured by heart rate variability (HRV), in healthy non-obese adults.

DESIGN

A total of fifty-nine apparently healthy male (M) and female (F) individuals (M/F = 15/44) were included in the trial. HRV data for analysis was derived from 5 minutes of baseline recordings, while the subject was sitting on a comfortable chair. Subjects' body measures (weight and height) were taken and BMI was obtained according to common calculation (kg/m²).

RESULTS

BMI was inversely related to pNN50 and RMSSD components of HRV. Statistically significant differences between stratified groups (BMI<20, BMI 20-25, BMI >25) only occurred for analysis of pNN50 components. The pNN50 components and RMSSD are strongly associated with cardiac vagal influence, and thus represents parasympathetic activity.

CONCLUSIONS

The present data supports previous findings, that sympatho-vagal balance is related to BMI in non-obese, healthy individuals, providing evidence for a prominent role of the vagus nerve in the modulation of the energy expenditure of the human organism. Furthermore, this relation can be observed in short term recordings of HRV of 5 minutes in length.

The Barts 'flank-free' modified supine position for percutaneous nephrolithotomy

BACKGROUND

The last decade has seen the emergence of a variety of supine positions for carrying out percutaneous nephrolithotomy (PCNL). These positions all differ with regard to ease of puncture under image guidance, operative field availability, ability to make and dilate multiple tracts and ease of combining retrograde intrarenal surgery (RIRS). As all of these positions have their limitations regarding the important parameters mentioned above, there is a need for a supine position which addresses some of the difficulties.

METHODS

We describe and illustrate our flank-free modified supine position, which we believe addresses a number of the issues.

RESULTS

Our position allows easy percutaneous access under fluoroscopy (torso only tilted to around 15°), space for placing (flank free of support) and dilating multiple tracts (kidney lies in a fairly neutral position and hence less mobile), a fairly horizontal tract allowing low intrarenal pressures and easy washout of fragments as well as allowing RIRS in a position of relative familiarity. The lesser torso rotation compared with the Valdivia, Galdakao modified and the Barts modified Valdivia positions also means it is more comfortable for patients.

CONCLUSIONS

Our results are encouraging and easily comparable with published series on prone position, Valdivia, complete supine and the Barts modified Valdivia positions. We would like to highlight the Barts 'flank-free' modified supine position as one of the standard positions for carrying out supine PCNL.

The new digital flexible ureteroscopes: 'size does matter'--increased ureteric access sheath use!

OBJECTIVES

To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy.

METHODS

140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind.

RESULTS

157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group.

CONCLUSIONS

A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

Use of a virtual reality simulator to improve percutaneous renal access skills: a prospective study in urology trainees

OBJECTIVES

This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees.

METHODS

A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees' performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training.

RESULTS

Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training.

CONCLUSIONS

We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Use of a segmental thermoexpandable metal alloy stent in the management of malignant ureteric obstruction: a single centre experience in the UK

INTRODUCTION

The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases.

METHODS

All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively.

RESULTS

42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5-60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases.

CONCLUSION

Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures.

Alterations of the CxxC domain preclude oncogenic activation of mixed-lineage leukemia 2

The mixed-lineage leukemia (MLL) family of histone methyltransferases has become notorious for the participation of the founding member, MLL, in fusion proteins that cause acute leukemia. Despite structural conservation, no other MLL homolog has so far been found in a similar arrangement. Here, we show that fusion proteins based on Mll2, the closest relative of MLL, are incapable of transforming hematopoietic cells. Elaborate swap experiments identified the small CxxC zinc-binding region of Mll2 and an adjacent 'post-CxxC' stretch of basic amino acids as the essential determinants for the observed difference. Gel shift experiments indicated that the combined CxxC and post-CxxC domains of MLL and Mll2 possess almost indistinguishable DNA-binding properties in vitro. Within the cellular environment, however, these motifs guided MLL and Mll2 to a largely nonoverlapping target gene repertoire, as evidenced by nuclear localization, reporter assays, and measurements of homeobox gene levels in primary cells expressing MLL and Mll2 fusion proteins. Therefore, the CxxC domain appears to be a promising target for therapies aimed at MLL fusion proteins without affecting the general function of other MLL family members.

Benefits of active motion for joint position sense

Anterior cruciate ligament (ACL) ruptures lead to a proprioceptive deficit and therefore joint position sense. This study examined whether active motion is better suited than passive motion to address this deficit. Sixty patients with ACL rupture were prospectively randomised into two groups [continuous active motion (CAM)/continuous passive motion (CPM)]. All patients had an ACL reconstruction. An angle reproduction test was used to assess the proprioceptive deficit. The relevant examinations were performed before surgery (pre-op evaluation) and after the seventh postoperative day. No preoperative difference was found between the two groups. After postoperative treatment, the deficit was reduced in both groups. Significantly better results were, however, obtained in the CAM group (CPM, 4.2+/-1.6 degrees; CAM, 1.9+/-1.2 degrees; P<0.001). During the first postoperative week, a CAM device produced a significantly greater reduction in the proprioceptive deficit and should be the first choice in immediately postoperative rehabilitation after ACL replacement.

The effect of fixation and location on the stability of the markers in navigated total hip arthroplasty

In navigated total hip arthroplasty, the pelvis and the femur are tracked by means of rigid bodies fixed directly to the bones. Exact tracking throughout the procedure requires that the connection between the marker and bone remains stable in terms of translation and rotation. We carried out a cadaver study to compare the intra-operative stability of markers consisting of an anchoring screw with a rotational stabiliser and of pairs of pins and wires of different diameters connected with clamps. These devices were tested at different locations in the femur. Three human cadavers were placed supine on an operating table, with a reference marker positioned in the area of the greater trochanter. K-wires (3.2 mm), Steinman pins (3 and 4 mm), Apex pins (3 and 4 mm), and a standard screw were used as fixation devices. They were positioned medially in the proximal third of the femur, ventrally in the middle third and laterally in the distal portion. In six different positions of the leg, the spatial positions were recorded with a navigation system.

Compared with the standard single screw, with the exception of the 3 mm Apex pins, the two-pin systems were associated with less movement of the marker and could be inserted less invasively. With the knee flexed to 90° and the dislocated hip rotated externally until the lower leg was parallel to the table (figure-four position), all the anchoring devices showed substantial deflection of 1.5° to 2.5°. The most secure area for anchoring markers was the lateral aspect of the femur.

Dynamic 13C NMR studies of ligand exchange in linear (d10) silver(I) and gold(I) and square-planar (d8) rhodium(I) homoleptic metal carbonyl cations in superacidic media

The dynamic CO exchange of the monovalent metal carbonyl cations [Ag(13CO)]+, [Au(13CO)2]+-Au(13CO) SO3F and [Rh(12CO)4-x(13CO)x]+ (x < or = 1) in superacidic solutions was studied by variable-temperature 13C NMR methods. The exchange rates are strongly dependent on the acidity of the solvent, the concentration of metal carbonyl cations and temperature. Whereas a suitable exchange rate of the Ag(I) system is only accessible in magic acid (HSO3F-SbF5), the more stable Au(I) and Rh(I) systems were studied in the less acidic fluorosulfuric acid. Selected solutions of Ag(I), Rh(I) and Au(I) yielded activation barriers deltaG* of 42.7, 43.5, and 56.2 kJ mol(-1) respectively.

Maternal soluble tumour necrosis factor receptor type 2 (sTNFR2) and adiponectin are both related to blood pressure during gestation and infant's birthweight

OBJECTIVE

Tumour necrosis factor alpha (TNF-alpha) and adiponectin are strongly related to insulin sensitivity; insulin resistance of pregnancy is a major determinant of infant's birthweight. We aimed to study the contributions of maternal serum concentrations of soluble TNF-alpha receptors (sTNFR1 and sTNFR2) and adiponectin to infant's birthweight.

DESIGN

Cross-sectional, hospital-based study of insulin sensitivity during gestation.

PATIENTS

Fifty-one healthy women with uncomplicated pregnancy and delivery (except for elective Caesarian section) and their healthy newborn infants. measurements Maternal blood levels of glucose, insulin, glycosylated haemaglobin (HbA1c), sTNFR1, sTNFR2 and adiponectin at delivery; cord-blood levels of sTNFR1, sTNFR2 and adiponectin.

RESULTS

At delivery, maternal sTNFR2 correlated with systolic blood pressure (SBP; r = 0.38, P = 0.005). In multiple regression analyses, SBP and HbA1c were independent predictors of sTNFR2, explaining 18 and 7% of its variance, respectively; insulin resistance index (HOMA-IR), body mass index at delivery and SBP were independent predictors of adiponectin, explaining 15, 8 and 7% of its variance, respectively. Both maternal sTNFR2 and SBP were negatively correlated with infant's birthweight (r = -0.28, P = 0.04 and r = -0.36, P = 0.01 respectively, adjusted for sex and gestational age). In multivariate regression analyses, infant's sex and either maternal sTNFR2 or adiponectin were independent predictors of infant's birthweight, each explaining between 6 and 9% of birthweight variance. Further addition of maternal SBP to these models revealed that this variable was the main predictor of infant's birthweight, explaining 13% of its variance.

CONCLUSIONS

Maternal sTNFR2 and adiponectin are independently related to both maternal blood pressure and infant's birthweight in uncomplicated pregnancy. The contributions of the TNF-alpha system and adiponectin to hypertensive disorders of pregnancy and fetal growth merit further studies.

Contamination during removal of cement in revision hip arthroplasty. A cadaver study using ultrasound and high-speed cutters

Instruments used in surgery which rotate or vibrate at a high frequency can produce potentially contaminated aerosols. Such tools are in use in cemented hip revision arthroplasties. We aimed to measure the extent of the environmental and body contamination caused by an ultrasound device and a high-speed cutter. On a human cadaver we carried out a complete surgical procedure including draping and simulated blood flow contaminated with Staphylococcus aureus (ATCC 12600). After cemented total hip arthroplasty, we undertook repeated extractions of cement using either an ultrasound device or a high-speed cutter. Surveillance cultures detected any environmental and body contamination of the surgical team. Environmental contamination was present in an area of 6 x 8 m for both devices. The concentration of contamination was lower for the ultrasound device. Both the ultrasound and the high-speed cutter contaminated all members of the surgical team. The devices tested produced aerosols which covered the whole operating theatre and all personnel present during the procedure. In contaminated and infected patients, infectious agents may be present in these aerosols. We therefore recommend the introduction of effective measures to control infection and thorough disinfection of the operating theatre after such procedures.

Retrograde injection of a nutrient vein with cement in cemented total hip arthroplasty

An 80-year-old woman received a cemented total hip arthroplasty. The surgery was performed without intraoperative complications. Postoperative radiographs and a computed tomography scan revealed a nutrient vein perforating the femur, which was retrogradely filled with cement. An abdominal and thoracic computed tomography scan showed no further dissemination of cement.

Excessive heat generation during cutting of cement in the Robodoc hip-revision procedure

The ROBODOC system is a promising new method for removing cement with high-speed milling. Heat is generated during the milling process. This study was designed to measure temperatures in the cutting area, and to assess the risk of heat injury and the effectiveness of irrigation. We measured temperatures at the bone-cement cutting area in three experimental settings, two involving the proximal area comprising a cement mantle, and one the distal cement plug beneath the prosthesis. Without cooling facilities, a mean temperature of 94 degrees C was measured in proximal areas. However, this could effectively be reduced below 70 degrees C with irrigation. In the area of the distal cement plug, we measured a mean temperature of 172 degrees C without irrigation. In this area, the integrated irrigation system with an additional high-flow irrigation system could not guarantee cooling to an acceptable temperature of below 70 degrees C since the irrigation stream was impeded by the cutter in the narrow cavity. We need an integrated irrigation device that guarantees continuous cooling at the cutting interface in front of the cutter.

Multiple previous surgeries, infection, and preoperative radiation: a cause for arterial rupture in closed reduction?

We report a patient who underwent revision hip arthroplasty with preoperative radiation after a septic loosening of the primary hip prosthesis. Subsequently the patient presented with a dislocation of the hip. During the closed reduction with general anesthesia, a rupture of the arteria profunda femoris occurred. The patient was treated by angiographic obliteration of the arteria profunda femoris followed by an open reduction and augmentation of the acetabular component.

Environmental and body contamination through aerosols produced by high-speed cutters in lumbar spine surgery

STUDY DESIGN

A cadaver study to evaluate contamination in the operating room through the use of a high-speed bone cutter.

OBJECTIVES

To determine the grade of contamination of animate and inanimate objects through an aerosol intraoperatively, produced by a high-speed cutter during lumbar laminectomy.

SUMMARY OF BACKGROUND

In spinal surgery, high-speed cutters are used that produce an aerosol consisting of a mixture of irrigation solution, blood, and tissue debris. Such aerosols can be contaminated with potential pathogens. The surgical personnel and the environment are therefore exposed to a contamination risk.

METHODS

Laminectomies at three points (L2-L4) were performed on a human cadaver using a high-speed cutting device. The aerosol produced by the irrigation solution was contaminated with Staphylococcus aureus ATCC 12600. To detect the contamination of the environment and of the surgical team, surveillance cultures were used.

RESULTS

By air sampling, staphylococci were detected in the operating room at an extension of 5 by 7 m. The surgical team showed extensive face and body contamination with S. aureus. Despite protection by a barrier drape, similar contamination was observed on both the cadaver's head and the anesthesiologist.

CONCLUSIONS

The use of high-speed cutters in spinal surgery produces an aerosol that can be contaminated with blood-borne pathogens from infected patients. This aerosol is spread over the whole surgical room and contaminates the room and all personnel present. It is therefore critical to ensure that effective infection control measures are performed, not only by the surgeons but by everyone present in the operating room. The room itself must be sufficiently disinfected after such procedures.

Knee pain caused by a fiducial marker in the medial femoral condyle: a clinical and anatomic study of 20 cases

After 2-pin-based ROBODOC hip arthroplasty procedures, 10 of 18 patients reported persistent severe pain at the site of pin implantation in the medial femoral condyle. In a cadaver study, we found that the infrapatellar branch of the saphenous nerve, the saphenous nerve and the anterior cutaneous branches of the femoral nerve had been injured by the pins. At least one of these nerves was injured in 11 of the 20 specimens examined. Our findings indicate that the knee-pain may be partly caused by injuries to these nerves.

Aerosols produced by high-speed cutters in cervical spine surgery: extent of environmental contamination

High-speed cutters are used in the surgery of the cervical spine. Such high-speed devices can produce an aerosol cloud. As a patient can be a reservoir for pathogens, with aerosol-borne paths of transmission, such an aerosol has to be seen as a potential risk of infection for health care professionals present during the surgery and for patients if micro-organisms are transferred through the medical personnel. The study was performed in order to measure the extension of environmental and body contamination through contaminated aerosols produced by a high-speed cutter. Three laminectomies (C4-C6) were performed on an intact human cadaver with a high-speed 0.6-mm ball cutter. A complete surgical setup was arranged, including surgical draping and a barrier drape to the anesthesiologist's workplace. Body and environmental contamination was detected by the use of surveillance cultures. The irrigation solution was artificially contaminated with Staphylococcus aureus ATCC 12600. Following the surgery, staphylococci were detected in the operating room at an extension of 5x7 m. Everybody showed extensive face and body contamination with Staphylococcus aureus. The study showed that the use of high-speed cutters in surgery of the cervical spine produces an aerosol cloud that is spread over the whole surgical room and contaminates the theater and all personnel present. Such aerosols can be contaminated with pathogens if the patient was infected or colonized. Therefore, sufficient protective measures have to be recommended for everyone present in the operating room during such surgeries. In addition, efficient disinfection of the room and all mobile equipment is necessary after each surgery involving high-speed cutting devices.

Semiclassical treatment of reactions at surfaces with electronic transitions

The semiclassical treatment of reactions at surfaces with electronic transitions based on the fewest-switches algorithm is compared with full quantum mechanical results. As a model system the ionization probability in I2 scattering from a diamond surface is chosen. In the calculations we treat the molecular distance from the surface and one surface oscillator coordinate explicitly. Furthermore, we also consider molecular rotation in the semiclassical calculations. The semiclassical results agree with the quantum results although some discrepancies remain, as far as the phase coherence is concerned. We identify energy transfer to molecular and surface degrees of freedom as a possible mechanism that could explain the experimental dependence of the ionization probability on the incident kinetic energy of the molecule.