Efficiency of Pupillary Stretching in Cataract Surgery

Purpose

To assess the efficiency of pupillary stretching with iris hooks in poorly dilatable pupils during phacoemulsification.

Methods

Forty eyes with maximal preoperative mydriasis less than 4.5 mm (mean 3.9 mm S.D. 1.0) received bimanual pupillary stretching according to the technique of Miller and Keener (1994).

Results

Small pupils were mainly caused by long-term pilocarpine therapy (n=21), posterior synechia (n=11) or diabetic iridopathy (n=7). With multidirectional stretching, the pupil could be enlarged to mean 6.6 mm (S.D. 0.66), lasting throughout phacoemulsification. The effect of stretching was significantly greater in eyes with synechias, but no significant differences in post-operative pupil motility was observed between the three subgroups. Six eyes with pronounced postoperative inflammation responded well to antiinflammatory treatment.

Conclusions

Done with routine surgical instruments, bimanual pupillary stretching seems to be an easy, safe and effective procedure for enlarging small pupils by an average of 2.7 mm during phacoemulsification, especially in eyes with posterior synechias.

An Alternative Proposal for “Mixed Randomization” by Schulz and Grimes

Objective: Randomization is an important part of clinical trials. Using permuted-block randomization for forcing equal group sizes potentially harms the unpredictability of treatment assignments. This can allow bias to creep into a trial. As an alternative, Schulz and Grimes suggest a “Mixed randomization” scheme which introduces more complexity to realize randomization. The objective of our research was to work out a model for randomization which is easier to handle than “Mixed randomization”, with an equal level of performance in unpredictability and balance.

Methods: We analyzed a “Mixed randomization” procedure regarding the degree of unpredictability and balancing power and compared performance using permuted-block randomization with very large block size in a worst case scenario. Our work was done by the application of Blackwell-Hodges model for evaluation of the unpredictability of treatment assignments.

Results: Regarding unpredictability, performance of permuted-block randomization with block size b = 36 was very similar to that of “Mixed randomization”. Regarding balancing power it was more favourable than “Mixed randomization”.

Conclusion: Results of Schulz and Grimes are very important as they emphasized that mildly unequal sample sizes of therapy groups don’t cause problems. But the suggested scheme of “Mixed randomization” to a large extent adds complexity and we do not believe that this proposal is very feasible. Basically, we rather recommend the use of only one restricted randomization procedure in the best way. This can be permuted-block randomization with optimum choice of a large block size.

Comparative Evaluation of Balancing Properties of Stratified Randomization Procedures

Objectives: If in a clinical trial prognostic factors are known in advance to be associated with the outcome of a patient it is often recommended that the randomization for a clinical trial should be stratified on these factors, particularly in a multicenter trial. Unfortunately, stratified or covariate-adaptive randomization does not always promote greater balance between the numbers of treatment assignments to A and B within each stratum and thus overall. Because such designs have numerous parameters that must be specified, simulation is a good tool to investigate the impact of these parameters on balance.

Methods: We investigate and discuss in more detail the difference in balancing performance of three stratified randomization procedures. The permuted-block randomization within strata, the “minimization” method and “self-adjusting” design are assessed overall, within levels of prognostic factors, and within strata.

Results: We show the superior performance of “self-adjusting” design and the extent of balancing losses occurring with permuted-block randomization within levels of factors and with “minimization” within strata. A summary of principal conclusions regarding the balancing properties of stratified randomization procedures is presented and general recommendations are offered.

Conclusions: The relative merits of each procedure should be weighted carefully in relation to the characteristics of the trial. Considering the likelihood of imbalances, the sample size and values of parameters of stratified randomization procedures (number of prognostic factors, number of factor levels, block size) are important when choosing a randomization procedure.

Abstract OT2-02-01: Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The intergroup-sentinel-mamma (INSEMA)-trial

Background:

Currently, axillary surgery for breast cancer is considered as staging procedure that does not seem to influence breast cancer mortality, since the risk of developing metastasis depends mainly on the biological behaviour of the primary. Based on this, the postsurgical therapy should be considered on the basis of biologic tumor characteristics rather than nodal involvement.

Trial design:

The goal of INSEMA is to show that early-stage breast cancer patients with reduced extent of axillary surgery are not inferior regarding invasive disease-free survival (IDFS) outcome. Patients with planned breast-conserving surgery (BCS) will be first randomized (1:4 ratio) to either no axillary surgery or axillary sentinel lymph node biopsy (SLNB). Patients with SLNB and pN+(sn) status will be secondly randomized (1:1 ratio) to either SLNB alone or completion axillary lymph node dissection (ALND) in cases with less than three involved nodes (one or two macrometastases).

Primary objective:

-IDFS after BCS (non-inferiority question)

Inclusion criteria:

-Written informed consent

-Histologically confirmed unilateral primary invasive carcinoma of the breast (core biopsy)

-Age at least 35 years

-Preoperative imaging techniques with estimated tumor size of maximal 5 cm (iT1/iT2 irrespective of hormone sensitivity or HER2 status)

-Clinically and sonographically tumor-free axilla prior to core biopsy

-In cases with cN0 and iN+, a negative core biopsy or fine needle aspiration biopsy of the suspected lymph node is required

-No clinical evidence for distant metastasis (M0)

-Planned breast-conserving surgery (R0 resection) with postoperative external whole-breast irradiation (conventional fractionation or hypofractionation)

Statistics:

Assumptions for first randomization:

-The 5-year IDFS for women with cN0/iN0 axillary lymph nodes and T1/T2 disease is considered to be 88%

-Clinical non-inferiority is defined as the non-SLNB group having a 5-year IDFS of not less than 85% and if the hazard ratio (HR) is less than 1.271 when compared with the SLNB group

The total number of patients in the per-protocol set of the first randomization must be increased from 3,796 to 5,940 (936 events) due to unequal-sample-size design.

Assumptions for second randomization:

-The 5-year IDFS for women with pN+(sn) axillary lymph nodes (1-2 macrometastases) and T1/T2 disease is considered to be 81%

-Clinical non-inferiority is defined as the SLNB alone group having a 5-year IDFS of not less than 76.5% and if the hazard ratio (HR) is less than 1.271 when compared with the completion ALND group

The total number of patients to be included into the per-protocol set for the second randomization will be approximately 1,968. Finally, the calculated total case number for per-protocol analyses is 6,740 (5,940 German and 800 Austrian patients), the expected total number of randomized patients is 7,095.

Time lines:

-First patient in: September 2015

-Last patient in: August 2019

-Final analysis: End of 2024

Funding by Deutsche Krebshilfe (grant no. 110580).

Citation Format: Reimer T, von Minckwitz G, Loibl S, Hildebrandt G, Denkert C, Nekljudova V, Kundt G, Becker D, Gerber B. Comparison of axillary sentinel lymph node biopsy versus no axillary surgery in patients with early-stage invasive breast cancer and breast-conserving surgery: A randomized prospective surgical trial. The intergroup-sentinel-mamma (INSEMA)-trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-02-01.

Influence of local hemostatic and antiplatelet agents on the incidence of bleeding complications in carotid endarterectomies

BACKGROUND

For the reduction of cardio- and cerebrovascular events in carotid endarterectomies continuation of antiplatelet medication is recommended perioperatively. As a result, this patient population is at increased risk for postoperative bleeding complications. Intraoperative application of local hemostatic agents might reduce the incidence of bleeding complications.

MATERIAL AND METHODS

All 565 patients undergoing carotid endarterectomy between January 2005 and January 2011 were analysed retrospectively. Most patients in the earlier cohort years of the study had no perioperative antiplatelet medication. In contrast antiplatelet medication was usually continued perioperatively in the later cohort years. To reduce the risk of perioperative bleeding local hemostatic agents were applied increasingly.

RESULTS

Revision surgery, due to postoperative bleeding or massive hematoma, was necessary in 20 cases (3.5 %). Overall, 383 carotid endarterectomies (67.8 %) were performed with perioperative antiplatelet medication. Local hemostatic agents were applied in 259 cases (45.8 %) intraoperatively. Initially, operations performed in patients taking antiplatelet medication resulted in an increased need for surgical revision. Following an accelerated practice of using local hemostatic agents, the need for revision surgeries fell. Nevertheless, when patients from all years were analysed together there was no significant benefit from the application of local hemostatic agents.

CONCLUSION

Application of local hemostatic agents might have contributed to a reduction of bleeding complications in carotid endarterectomies. However, this could not be shown of statistical significance. Other confounding factors such as different operative techniques or forms of anesthesia might also have influenced this decline.

[Visual analysis for an early detection of diabetic neuropathy]

Diabetic neuropathy is the most common long-term complication of diabetes mellitus. It comes along with significant nerve dysfunction, which is not reversible. Hence, it is essential to detect nerve fibre abnormalities as early as possible. In this paper, we investigate markers describing degradation of corneal nerves. We apply statistical computations and visual analysis to identify those variables of two clinical studies that separate DN patients from a control group. In this way, the diagnosis of DN patients is supported. The visual analysis is based on different representations visualizing both the statistical results and the gathered multi-variate data. The user can interactively manipulate the views, or select data that will be shown by further displays. In this way, the understanding of the data and its classification is supported. Ambiguous categorisations can be identified and grouped into a so-called "fuzzy group". For this group, further investigations are needed to decide about diabetic neuropathy.

[What Makes Happy Doctors? Job Satisfaction of General Practitioners in Mecklenburg-Western Pomerania - a Representative Cross-sectional Study]

AIM

Studies provide evidence for the importance of general practitioners (GPs) job satisfaction for a secure and high quality health care provision. This study focuses on job satisfaction of GPs in Mecklenburg-Western Pomerania (MV), a rural area threatened by a lack of GPs. We investigate how satisfied GPs are with their job and which factors influence their job satisfaction.

METHODS

All 1 133 GPs working in MV in December 2011 were asked to complete a 57-item-questionnaire. The response rate reached 50.1%.

RESULTS

The sample is representative for GPs in MV. Levels of job satisfaction are high and correlate with age and sex: females and GPs below 50 years of age are more satisfied. Factors contributing to high job satisfaction include a good doctor-patient relationship, fair pay, and the variety of reasons for doctor-patient consultations in primary care. Although all GPs were dissatisfied with bureaucracy, this factor has little impact on GPs' overall job satisfaction.

CONCLUSION

In light of the imminent lack of GPs, in future it will be important to improve factors that have been demonstrated to increase job satisfaction.

Pneumocystis jirovecii colonisation in HIV-positive and HIV-negative subjects in Cameroon

OBJECTIVE

To determine the prevalence of Pneumocystis pneumonia (PCP), a major opportunistic infection in AIDS patients in Europe and the USA, in Cameroon.

MATERIALS AND METHODS

Induced sputum samples from 237 patients without pulmonary symptoms (126 HIV-positive and 111 HIV-negative outpatients) treated at a regional hospital in Cameroon were examined for the prevalence of Pneumocystis jirovecii by specific nested polymerase chain reaction (nPCR) and staining methods. CD₄ counts and the history of antiretroviral therapy of the subjects were obtained through the ESOPE database system.

RESULTS AND CONCLUSION

Seventy-five of 237 study participants (31.6%) were colonised with Pneumocystis, but none showed active PCP. The Pneumocystis colonisation rate in HIV-positive subjects was more than double that of HIV-negative subjects (42.9% vs. 18.9%, P < 0.001). In the HIV-positive group, the colonisation rate corresponds to the reduction in the CD₄ lymphocyte counts. Subjects with CD₄ counts >500 cells/μl were colonised at a rate of 20.0%, subjects with CD₄ counts between 200 and 500 cells/μl of 42.5%, and subjects with CD₄ counts <200 cells/μl of 57.1%. Colonisation with Pneumocystis in Cameroon seems to be comparable to rates found in Western Europe. Prophylactic and therapeutic measures against Pneumocystis should be taken into account in HIV care in western Africa.

Accompanying DCIS in breast cancer patients with invasive ductal carcinoma is predictive of improved local recurrence-free survival

BACKGROUND

Ductal carcinoma in situ (DCIS) often accompanies invasive ductal carcinoma (IDC). The presence of co-existing DCIS is postulated to present as a less aggressive phenotype than IDC alone.

PATIENTS AND METHODS

Patients diagnosed with hormone receptor-positive breast cancer receiving mastectomy were evaluated. Only patients without adjuvant radio- and chemotherapy were included to decrease treatment bias on local recurrence (LR).

RESULTS

Of 2239 breast cancer patients, 198 fulfilled the inclusion criteria. The overall LR rate was 11.6%. Tumor stage (p = 0.002), nodal status (pN2 vs. pN0, p = 0.023) and pure IDC compared with IDC-DCIS (p = 0.029) were multivariate independent factors for increased LR risk. Patients with IDC-DCIS were significantly younger (p < 0.001), had smaller tumors (p = 0.001), less lymph node involvement (p = 0.012). The LR rate was significantly increased in patients with pure IDC (p = 0.012). The time to distant metastases was decreased in patients with pure IDC compared with that observed in patients with IDC-DCIS (log rank = 0.030).

CONCLUSION

Invasive ductal carcinoma accompanied by DCIS is associated with lower LR. The prognostic value of co-existing DCIS in the adjuvant decision-making process may be considered a new independent prognostic marker. This finding needs further studies to evaluate its usefulness in premenopausal women.

Differentiating between malignant and benign breast masses: factors limiting sonoelastographic strain ratio

PURPOSE

We compared strain ratio vs. qualitative elastography for the further differentiation of focal breast lesions, with special focus on limiting factors.

MATERIALS AND METHODS

215 patients with 224 histologically proven breast masses (116 malignant, 108 benign) were prospectively examined using a high-end ultrasound system (Philips iU22) with serial elastography function. B-mode scans and available mammograms were reviewed according to the BIRADS classification, raw elastogram data was analyzed qualitatively using the Tsukuba score and semiquantitatively by calculating the strain ratio (fat to lesion ratio). For diagnostic performance, Receiver Operating Characteristic (ROC) curve analysis was obtained. A sub-group analysis regarding breast density, lesion size, lesion depth and histological subtypes was performed.

RESULTS

Mean strain ratio values were 3.04 ± 0.9 for malignant and 1.91 ± 0.75 for benign lesions (p < 0,001). The areas under the ROC curve values were 0.832 (95 % CI 0.777; 0.888) for strain ratio, 0.869 (95 % CI 0.822; 0.917) for Tsukuba score, 0.822 (95 % CI 0.768; 0.876) for B-mode ultrasound and 0.853 (95 % CI 0.799; 0.907) for mammography. Sensitivity, specificity, positive predictive value and negative predictive value of the strain ratio were 90.7 %, 58.2 %, 70.3 % and 85.1 %, when a cutoff point of 2.0 was used. Only lesion depth ≤ 4 mm was associated with diagnostic failure in the multivariate analysis of factors influencing accuracy, whereas no significant correlation between breast density and lesion size and the accuracy of the strain ratio could be found.

CONCLUSION

The addition of strain ratio to B-mode ultrasound increases specificity without loss of sensitivity in differentiating between malignant and benign breast tumors. Strain ratio measurements should not be carried out on tumors with a lesion depth ≤ 4 mm.

Radiograph-based study of gender-specific vertebral area gain in healthy children and adolescents as a function of age, height, and weight

This study reports gender-specific vertebral area gain data from children and adolescents. Vertebral area was measured on lateral and anteroposterior thoracic and lumbar spine radiographs from 100 female and 100 male subjects aged 7-28 yr. T9, T11, T12, L1, and L2 X-ray area calculation was based on calculation of the area of the geometric figure of a trapezoid whose 2 nonparallel sides were equal in length, taking account of the waisted shape of the vertebrae. Both the boys and girls of our study population showed statistically significant dependence (p<0.001) of vertebral area gain on chronologic age, height, and weight right through the end of puberty, and especially so up to age 15 yr. However, height and weight were clearly better predictors of lateral and anteroposterior vertebral area gain than was chronologic age. Once vertebral growth is complete by age 18 yr or so, the lateral vertebral areas of the male subjects-regardless of body weight and height-are, on average, 25% larger, and the anteroposterior areas up to 30% larger than those of their female counterparts. After adjusting for chronologic age, height, and weight however we did not find significant differences, between gender, in vertebral area of male and female subjects, neither among children younger than 11 yr nor adolescents ages of 12-14 yr and young adults older than 18 yr.

Surface and intracardiac ECG for discriminating conduction disorders after CoreValve implantation

Background

Transcatheter aortic valve implantation (TAVI) has been developed to minimize operative morbidity and mortality in high-risk symptomatic patients unfit for open surgery. With the proximity of the aortic valve annulus to the conduction system there is, however, an unknown risk of conduction disturbances necessitating monitoring and often cardiac pacing.

Materials and methods

We enrolled 50 consecutive patients from January 2007 to 2008 in our prospective evaluation of conduction disturbances measured by surface and intracardiac ECG recordings. Baseline parameters, procedural characteristics as well as twelve-lead surface ECG and intracardiac conduction times were revealed pre-interventionally, after TAVI and at 7-day follow-up.

Results

TAVI was performed successfully in all patients. During 7 days of follow-up the rate for first-degree AV block raised from 14% at baseline to 44% at day 7 (p < 0.001), while rates for type II second- and third-degree were 0 versus 8% (p < 0.001) and 0 versus 12% (p < 0.001), respectively. Similarly, the prevalence of new left bundle branch block (LBBB) rose from 2 to 54% (p < 0.001). Intracardiac measurements revealed a prolongation of both AH and HV interval from 123.7 ± 41.6 to 136.6 ± 40.5 ms (p < 0.001) and from 54.8 ± 11.7 to 71.4 ± 20.0 ms (p < 0.001), respectively. Pacemaker implantation at a mean follow-up of 4.8 ± 1.2 days was subsequently performed in 23 patients (46%) due to complete AV block (12%) and type II second-degree AV block (8%) while another 13 patients (26%) received a pacemaker for the combination of new LBBB with marked HV prolongation. The high rate of first-degree AV block was primarily driven by an increase in HV interval.

Conclusion

Cardiac conduction disturbances were common in the early experience with CoreValve implantation necessitating close surveillance for at least 1 week.

Evaluation of imbalance in stratified blocked randomization: some remarks on the range of validity of the model by Hallstrom and Davis

OBJECTIVES

If in a clinical trial prognostic factors are known in advance, it is often recommended that randomization of patients should be stratified. The best-known method is permuted-block randomization within strata. But it suffers from the disadvantage that imbalance still occurs in the trial as a whole if there are a large number of strata, or/and the block sizes are too large for the number of patients. The results of Hallstrom and Davis are appropriate for evaluating the risk of such a troubled situation by using two special cases of their general variance formula. But it is merely generally argued for whichever practical situations these special cases are valid. Consequently, additional investigations are required to reveal the conditions for correct application.

METHODS

We investigated the range of validity of special cases by performing computer simulations, varying a number of trial characteristics, and discuss the application of results for practical situations.

RESULTS

The validity of special cases is not given in each situation. Depending on block size, a binomial distribution model is valid for a permitted average maximum number of patients per stratum between 36% and 57% of considered block sizes, whereas the uniform distribution model works adequately from at least 70%. In an intermediate range of invalidity, implementation of a simulation study is necessary to compute the probability distribution of differences.

CONCLUSIONS

Our results are important if choosing the stratified permuted-block randomization to estimate the risk for an intolerable overall imbalance when planning a trial.

[Knowledge of school pupils about the HIV/AIDS topic at selected schools in Mecklenburg-Western Pomerania]

AIM OF THE STUDY

The increasing numbers of new HIV diagnoses in Germany generate a need to measure the level of knowledge of the young generation about the issue of HIV/AIDS.

METHODOLOGY

A survey was conducted of 769 pupils of different age groups and from different schools in Mecklenburg-Western Pomerania. Data analysis was performed using SPSS; statistically significant differences (p<0.05) were tested between the groups using the chi-square test.

RESULTS

The level of knowledge within the sample differs: more precise knowledge is demonstrated by pupils following an awareness event (60%) and by pupils interested in HIV (69%) than by those who have attended no awareness event (40%) and those who have little interest in the issue (31%). Moreover, it was noted that grammar school pupils generally achieve better results than pupils from comprehensive and intermediate secondary schools. Furthermore, there are significant differences between the genders: girls give correct answers more frequently than boys and more often show an interest in the HIV/AIDS issue. In addition, age-specific differences are also identifiable: from the age of 14, there is a considerable increase in knowledge, which then remains static at the age of 16. AIDS education in biology lessons is common among pupils and 93% are familiar with this. Over 70% of pupils are unfamiliar with local AIDS awareness teams.

CONCLUSIONS

There are significant gaps in the level of knowledge about methods of infection, particularly with respect to questions about the no risk areas, which should thus be particularly dealt with in awareness events. As to knowledge transfer, the pupils' interest should be aroused while taking the type of school, gender and age of the pupils into consideration. In the course of the school career, every pupil should take part in at least one awareness event since our survey showed that only 60% attended such an event. Local AIDS awareness teams should be more frequently active in the schools since 73% stated to be unfamiliar with them in our survey.

Different bone sesitivity to malformations induced by procarbazine in fetal rats

The study aimed at to induce cleft-lip-alveolus-palate (CLAP) applying procarbazine in rat fetuses at the 14(th) day of pregnancy, to supply thiocyanate and/or folic acid sufficient for preventive treatment and subsequently to investigate cleft extent in the palatal area as well as bone maturity. In this animal model, female primiparous inbred rats (LEW.1A) were used. The gravid animals were separated into treatment groups: group K (control), group P (procarbazine), group TP (thiocyanate and procarbazine) and group FTP (folic acid, thiocyanate, procarbazine). The results reveal that procarbazine may induce clefts in the palate area. Clefts occurred most frequently in group TP and mainly comprised subtotal clefts of the posterior secondary palate. As for palatal length, group FTP displayed the longest palate which was significantly different only from group K. A different picture was shown for the secondary palate with group TP displaying the shortest values which were significantly different from those in groups K, P, and FTP. Thus, group TP showed the most marked negative changes both for cleft frequency and palatal length as compared to group K and the other groups. The preventive application of either thiocyanate (TP) or thiocaynate and folic acid combined (group FTP) failed to completely prevent cleft formation in the palate area. In conclusion, a preventive effect on palatal clefts and growth inhibition could not be proved for the vitaminoid thiocyanate.

[Bicondylar knee arthroplasty - influence of preoperative functional restriction on early functional postoperative outcome]

AIM

The point of time for total knee arthroplasty has a significant importance due to limited implant survival rate. To what extent the preoperative stage of physical and psychological function limitation, which is increasing with the progression of the osteoarthritis, has an influence on the early functional outcome after total knee arthroplasty should be clarified in a clinical evaluation.

PATIENTS AND METHOD

47 Patients were treated with the same bicondylar knee endoprosthesis system (Type Genia, ESKA Implants, Lübeck). A clinical evaluation was undertaken preoperatively and at 3 and 6 months postoperatively using HSS score, WOMAC index and SF-36 score. In relation to the preoperative HSS score the patients were allocated into three groups depending upon whether their level of function was "good", "average" or "poor". Additionally, all patients were assigned to three body mass index (BMI) groups (< 30, 30 - 35, > 35) which were descriptively analysed.

RESULTS

The preoperative differences in HSS score and SF-36 score in all three groups show a high reduction after 3 and 6 months. Postoperatively there were no significant differences in all three groups at both timepoints. Patients with "poor" preoperative function achieved on average a lower score niveau than patients with preoperative "good" function, but have the benefit of the best function improvement. The early postoperative period (3 months) showed the highest decrease in physical and psychological function derogation. The BMI had no significant influence on the early functional outcome.

CONCLUSION

Therefore, older people should receive early total knee arthroplasty to gain a high postoperative score niveau. In younger patients the indication for implant should be considered essentially because of the limited survival rate. Even in progressive osteoarthritis and extreme functional limitation the bicondylar surface replacement gives the possibility of a good early functional postoperative outcome. Total knee arthroplasty of obese patients is under attention of the perioperative internistic risks, a safe procedure with good functional results and can increase patient's mobility.

[Which factors are predictive for long-term complaints after mild traumatic brain injuries?]

Each year 330 of every 100,000 inhabitants in Germany suffer a mild traumatic brain injury. About 25% suffer persisting post-concussion syndrome (headache, dizziness). Although many studies have been carried out to make a prognosis of the long-term outcome of these patients, there are still no relevant tests for a valuable statement. The aim of our study was to identify parameters to predict post-traumatic complaints. Therefore we conducted a prospective study of 74 patients who were admitted with a mild traumatic brain injury in our hospital from March 2004 till October 2006. We were able to show a significant correlation between complaints and a pathological CT-scan and biochemical markers during the first two weeks. For long-term complaints only the SKT (Syndromkurztest) we used for a neuropsychological assesment was able to show a significant correlation.

A new proposal for setting parameter values in restricted randomization methods

OBJECTIVES

Complete randomization could result in an undesirable imbalance in the number of patients assigned to each treatment, especially in small trials. Therefore, a variety of restricted randomization procedures has been developed. By varying parameters it is possible to appropriately modify the balancing characteristics of these designs. However, there is little information on what are sensible choices for the parameters. Therefore, we suggest a new method for suitable determination of parameter values of restricted randomization rules.

METHODS

For restriction to be effective, it need not yield exact equality. As the reliability of a test is not very sensitive to slight deviations from equal sample sizes we define that a given maximum tolerable imbalance d can be achieved or exceeded with a given probability p(*). By using this condition, parameter values of restricted procedures are determinable.

RESULTS

For permuted-block, biased-coin, urn, and big-stick randomization we investigated the impact of parameters on balancing properties. For different extents of restriction and by using the submitted condition, the values of parameters to be chosen are determined.

CONCLUSIONS

Up to now choice of parameter values has often occurred at random. Now it is possible to determine values of parameters by specifying the tolerable degree of imbalance and the risk to be worse. As a consequence restriction will, as much as possible, not be imposed and not imposed more than necessary in order to preserve the intrinsic quality of randomization.

Pharmacokinetic profiling of cyclosporine microemulsion during the first 3 weeks after simultaneous pancreas-kidney transplantation

The optimal effect of therapy with cyclosporine (CsA) seeks to minimize undesirable side effects while maximizing immunosuppression. This balance, depends on CsA exposure, which may be characterized by the area under the concentration-time-curve (AUC). Therefore, we tested the pharmacokinetic profile of microemulsion CsA as a superior approach to guide clinical immunosuppression after de novo simultaneous pancreas-kidney transplantations. We examined 10 consecutive pancreas-kidney recipients with type 1 diabetes and end-stage renal disease. All patients were treated with a regimen consisting of CsA, mycophenolate mofetil (MMF), and prednisone. Full (9-point) pharmacokinetic studies (C0, C1, C2, C3, C4, C6, C8, C10, C12) were performed on week 1 and during week 3 to examine CsA pharmacokinetic profiles. Mean AUC0-12 of 4431 +/- 2400 microg x h/L at week 1 remained stable at week 3 (5119 +/- 1190 microg x h/L). The C6 sampling time displayed the best correlation with AUC0-12 (r2 = 0.881), followed by C3 (r2 = 0.758). Our preliminary data after simultaneous pancreas-kidney transplantation support the hypothesis that C3 or C6 sampling is a more accurate predictor of the AUC0-12 than C0. The combination of two samplings, namely C3 + C6 (r2 = 0.938) or C2 + C6 (r2 = 0.955) proved excellent prediction of exposure after simultaneous pancreas-kidney transplantation.

Cytomegalovirus and Proliferative Signals in the Vascular Wall of CABG Patients

OBJECTIVE

To further elucidate the mechanism by which cytomegalovirus (CMV) may promote atherosclerosis, we studied the expression pattern of cellular inflammatory and proliferative signals in the aortic wall of CMV(+) and CMV(-) patients undergoing coronary artery bypass grafting (CABG).

METHODS

Aortic biopsies and blood samples of 68 CABG patients were investigated for CMV-DNA by PCR and IN SITU hybridisation. Expression of pp65 antigen, adhesion molecules (ICAM-1, VCAM-1, E-selectin), growth factors (PDGF-AA, TGF-beta), and the cellular proliferation factor Ki-67 was studied by immunohistochemistry. Logistic regression was used to test the correlation between the presence of CMV, vascular inflammation, and traditional noninflammatory risk factors for atherosclerosis.

RESULTS

CMV-DNA was detected in the aortic tissue of 52 (76%) patients, and was localised predominantly in vascular smooth muscle cells. In CMV(+) patients, the expression of adhesion molecules and growth factors in the aortic endothelium was increased compared with CMV(-) patients. A positive correlation of elevated CRP, the induction of adhesion molecules and growth factors and CMV(+) was found. Female gender, smoking, and hyperlipidaemia were identified as risk factors for CMV(+).

CONCLUSIONS

CMV-DNA in smooth muscle cells induces local growth factor expression as well as endothelial activation, both of which can promote the progression of atherosclerosis. Since traditional atherogenic risk factors increase the likelihood of aortic CMV manifestation, we suggest that CMV plays a crucial role in mediating the progression of atherosclerosis.

Urologische Komplikationen nach Nierentransplantation

Between August 1981 and May 2005, 1065 consecutive kidney transplants were performed at our center; 393 patients (36.9%) developed urological complications in the first 60 postoperative days. Urinary tract infections occurred in 28.5% of all patients. The major urological problems seen were urinary leakage and ureteral obstruction in 6.2% and 1.4% of the patients. Two grafts were lost due to severe urinary leakage. No patient death occurred due to urological complications. The incidence of urological complications is mainly influenced by the surgical procedure of organ retrieval and ureteroneocystostomy. With double-J stenting of the extravesical ureteroneocystostomy, we observed a significantly lower rate of urinary leakage but a higher rate of urinary tract infections in our series. Early diagnosis and treatment of urological complications may prevent further morbidity of our transplant patients.

An alternative proposal for "Mixed randomization" by Schulz and Grimes

OBJECTIVE

Randomization is an important part of clinical trials. Using permuted-block randomization for forcing equal group sizes potentially harms the unpredictability of treatment assignments. This can allow bias to creep into a trial. As an alternative, Schulz and Grimes suggest a "Mixed randomization" scheme which introduces more complexity to realize randomization. The objective of our research was to work out a model for randomization which is easier to handle than "Mixed randomization", with an equal level of performance in unpredictability and balance.

METHODS

We analyzed a "Mixed randomization" procedure regarding the degree of unpredictability and balancing power and compared performance using permuted-block randomization with very large block size in a worst case scenario. Our work was done by the application of Blackwell-Hodges model for evaluation of the unpredictability of treatment assignments.

RESULTS

Regarding unpredictability, performance of permuted-block randomization with block size b = 36 was very similar to that of "Mixed randomization". Regarding balancing power it was more favourable than "Mixed randomization".

CONCLUSION

Results of Schulz and Grimes are very important as they emphasized that mildly unequal sample sizes of therapy groups don't cause problems. But the suggested scheme of "Mixed randomization" to a large extent adds complexity and we do not believe that this proposal is very feasible. Basically, we rather recommend the use of only one restricted randomization procedure in the best way. This can be permuted-block randomization with optimum choice of a large block size.

Multivariate analyses of prognostic factors in acute myeloid leukemia: relevance of cytogenetic abnormalities and CD34 expression

Identification of additional prognostic factors besides karyotype is important for the improvement of the risk adapted treatment strategies in acute myeloid leukemia (AML). The aim of this study was to investigate whether other factors besides karyotype could be used as a prognostic tool in newly diagnosed AML. Biological and disease related established and potential prognostic factors were retrospectively analysed in 124 consecutive AML patients treated between 1993 and 2002 at the University hospital Rostock (Germany). One hundred patients received a potential curative intensive chemotherapy (81%), of whom 28 received an allogeneic HSCT at some point of their treatment course, 17 patients (14%) received palliative therapies and 7 patients (5%) received supportive care only. In patients that received potential curative therapies LDH >or=2000 U/l, WBC >50 GPT/l, CD34 surface expression on the AML blasts, secondary AML, unfavorable karyotype and no allogeneic HSCT at some point of treatment course were associated with unfavorable prognosis. However, in the multivariate risk factor analyses only unfavorable karyotype (p=0.012), CD34 positivity of AML blasts (p=0.046), no allogeneic HSCT (p=0.008) and first diagnosis after 1997 (p=0.025) were independent unfavourable prognostic factors. In conclusion, karyotype and CD34 expression are independent prognostic markers in newly diagnosed AML. Furthermore, receiving an allogeneic HSCT at some point of the treatment course seems to be of benefit for AML patients.

Predicting the risk of early atherosclerotic disease development in children after repair of aortic coarctation

AIMS

Increased cardiovascular morbidity is manifested a long time after the repair of aortic coarctation (CoA). By way of impaired flow-mediated vasodilation (FMD) and increased intima media thickness (IMT), surrogate parameters of atherosclerosis, cardiovascular risk factors (RFs) can be correlated with early vascular wall changes in children. This study investigated whether changes in arterial wall function and morphology are detectable in children after coarctation repair.

METHODS AND RESULTS

We examined 28 children after successful repair of CoA vs. 30 control subjects. All children underwent identical screening, with a broad RF profile and FMD/IMT measurements. CoA-children presented significantly (P < 0.001) impaired FMD (4.87 +/- 2.6 vs. 10.2 +/- 3.1%) and higher IMT values (P < 0.001) than the controls (0.48 +/- 0.08 vs. 0.38 +/- 0.05 mm). The blood pressure during rest and exercise and the left ventricular mass were significantly elevated, but no additional RF could be identified in CoA-children. Only a remaining pressure gradient related significantly to FMD.

CONCLUSION

This study documents early vascular wall changes in children after successful coarctation repair. Arterial hypertension and a resting pressure gradient are the major contributing factors to early atherosclerotic development and should be primary targets for therapy. Vascular status should be monitored regularly by FMD and IMT.

Do folic acid and thiocyanate have a preventive effect on exogenously induced disturbances of embryonic cranial development?

The preventive influence of folic acid and thiocyanate on procarbazine-induced disturbances of embryonic cranial development was investigated on experimental animals. Low dosages of folic acid or thiocyanate demonstrated no prophylactic effect. When thiocyanate was administered alone, an increased cleft rate was unexpectedly found for the secondary palate. The combined application of folic acid and thiocyanate showed a cleft-prophylactic effect in the secondary palate in addition to growth protection in the primary palate. It can be assumed that thiocyanate has a positive effect on chondral and osseous growth of the palate during the post-sensitive phase of embryogenesis, while in the sensitive phase, it can function as a carrier for teratogenous and toxic substances.

Ein perioperatives Screening auf Metastasen ist bei Patientinnen mit einem primär operablem Mammakarzinom und fehlender klinischer Symptomatik einer Metastasierung nicht indiziert

OBJECTIVE

Is a perioperative metastatic screening programme indicated in patients presenting with primary operable breast cancer and no signs of distant metastases?

PATIENTS AND METHODS

The impact of staging results (chest X-ray, bone scanning, liver ultrasound) for prognosis, treatment, quality of life and costs was retrospectively analysed in 1 076 patients with an operable breast cancer and no clinical signs of metastases.

RESULTS

Staging examinations revealed 30 (2.8 %) distant metastases, 130 (12.1 %) suspect findings and excluded metastases in 916 (85.1 %) patients. Further diagnostic procedures confirmed distant metastases in 7 (5.4 %) and excluded them in 123 (94.6 %) out of 130 patients with suspect findings. Distant metastases were detected more frequently with increasing tumor size (pT < or = 2.0 cm: 1.6 %, pT 2.1-5.0 cm: 3.0 %, respectively pT > 5.0 cm: 15.1 %; p < 0.001) and increasing number of involved axillary lymph nodes (pN0: 1.4 %, pN1-3 +: 1.8 %, pN4-9 +: 4.0 %, pN > 10 +: 12.5 %; p < 0.001). Due to false positive findings 123 (11.4 %) patients had to live for a significant period of time with the psychological distress of suspected metastatic disease. The abandonment of a perioperative screening in 1 076 patients saves costs of at least euro 259,366.68.

CONCLUSIONS

In breast cancer patients without clinical signs of tumor spread perioperative screening for metastases is not warranted because of low frequency of metastases, false positive findings, missing therapeutic consequences and high costs.

Comparison of cyclosporine absorption profiles over a 12-month period in stable pediatric renal transplant recipients

Evidence suggests that the pharmacokinetic (PK) profile of microemulsion- cyclosporine A (m-CsA) during the 4-hour absorption phase represents an accurate tool to estimate drug exposure. In addition, several reports suggest a close correlation between selected single CsA concentrations at 1, 2, or 3 hours post-dose (C(1), C(2), and C(3)) and the abbreviated area under the curve (AUC)(0-4) among pediatric renal transplant patients. However, it is still unclear whether these PK correlations remain stable and reliable over 12 months posttransplant. In this study, we obtained 4-hour pharmacokinetic profiles (AUC(0-4)) from stable pediatric renal transplant recipients (phase 1) with repeat measurements 12 months later (phase 2). In addition, we evaluated the optimal single sampling point that correlated with the AUC(0-4) during both phases of the study. Over 1 year there was no significant change in the AUC(0-4) of m-CsA in pediatric renal transplant recipients. The mean dose-normalized AUC(0-4) values changed by less than 2.5%, namely, 557 versus 545 ng x h/mL per unit dose, respectively. The C(1) value was the sampling point that showed the best correlation with AUC(0-4); C(0) displayed the weakest correlation. No changes in cyclosporine dosing or glomerular filtration rate estimates were observed throughout the study period. This study demonstrates the stability of drug measurements during m-CsA therapy.

Treatment of gingivitis with hyaluronan

OBJECTIVES

Hyaluronic acid (hyaluronan) is a glycosaminoglycan with anti-inflammatory and antiedematous properties. It was evaluated in a gel formulation for its effect in the treatment of plaque-induced gingivitis.

METHOD

In a randomised double-blind study, 50 male subjects with plaque-induced gingivitis were divided into two groups and used a verum or placebo gel twice daily additionally to oral hygiene for a 3-week treatment period. Clinical indices (API, Turesky index, PBI) and crevicular fluid variables (peroxidase, lysozyme) were determined at baseline and after 4, 7, 14 and 21 days, respectively.

RESULTS

Significant improvements could be found for all clinical variables in both groups. The verum group showed significant improvement in the study area for the plaque indices beginning with day 4 (P = 0.011) and the PBI beginning with day 7 (P = 0.001) in comparison with the placebo group. The crevicular fluid variables were significantly improved in the centre of the studied inflammation area in the verum group. Here all studied sites had significant decreases in peroxidase (176.72-128.75 and 188.74-128.75 U/L) and lysozyme (1.27-0.27 and 1.30-0.33 mg/L) activities after 7, 14 and 21 days (P between 0.034 and < 0.001), whereas in the placebo group only one site showed a significant decrease for lysozyme (1.74-0.75 mg/L) after 7 and 21 days (P = 0.048 and 0.025).

CONCLUSIONS

These data suggest that a hyaluronan containing gel has a beneficial effect in the treatment of plaque-induced gingivitis.

Cartographic mapping of health data

Health is a primary, individual interest of the population. The observation of health standard and health risks requires the consideration of geographical information. The cartographic visualization of health data is used to show spatial relations and correlations. A presupposition is that health data has local references. There are various local references: the local reference by domicile is most important in investigating the spatio-temporal occurrence, the geographically spread, the intensity and temporal periodicity of diseases. Cartographic visualization allows a quick and intuitive recognition of the situation in a geographical region.

[Skin sparing mastectomy with autologous immediate reconstruction: oncological risks and aesthetic results]

OBJECTIVE

Is the oncological safety of skin sparing mastectomy (SSM) with immediate autologous reconstruction and improved aesthetic results comparable to postoperative findings in patients treated with modified radical mastectomy (MRM)?

MATERIAL AND METHODS

Sixty patients with T1-2 breast carcinomas and contraindications for breast conserving therapy were treated by SSM and compared to 81 patients of the same age groups and MRM with regard to oncological and aesthetic data. In 33 (55%) patients the nipple areola complex (NAC) could be spared. For autologous tissue TRAM- and Latissimus dorsi-flaps were used. The mean follow-up was 40 (range 20-71) months.

RESULTS

The observed local recurrence rates were not significantly different (p = 0.443) after SSM (n = 3; 5.0%) or MRM (n = 5; 6.2%). Distant metastases and death were seen in 26.7% and 15.0% (SSM), respectively, and in 25.9% and 13.5% (MRM), respectively. Body mass index, operation time and postoperative haemoglobin concentration differed between both groups significantly (p < 0.001) but not the rate of complications (p = 0.232). Aesthetic results of SSM were judged as excellent or good in 90.0% of patients and in 83.4% of surgeons. Nine patients (11.1%) underwent a secondary breast reconstruction after MRM. Furthermore, 12 (14.8%) patients with MRM would prefer a SSM with immediate reconstruction in a similar situation.

CONCLUSION

Skin-sparing mastectomy improves aesthetic results to a high degree without increasing of local or distant recurrence rates. Skin-sparing mastectomy should be offered to selected patients with breast cancer as an alternative to modified radical mastectomy.