Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial

BACKGROUND

Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants.

METHODS

We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H₂O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control.

DISCUSSION

This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.

Computed tomography of the uterus and ovaries in healthy dogs: a descriptive and comparative study

Canine uterine and ovarian diseases are common in countries where prophylactic ovariohysterectomy is not generally performed and clinical work-up is commonly confined to ultrasonography of the female reproductive tract. Although increasingly used in veterinary practice, there is a lack of computed tomography (CT) data on either the normal or abnormal appearance of these organs. In this prospective, descriptive and comparative study, CT images of the uterus and ovaries of 22 bitches with no clinical signs of reproductive organ disease were examined. CT was compared to ultrasonography and the level of agreement between both was analyzed. The results indicate that it is feasible to evaluate the entire uterus and ovaries using CT. In this study, a range of cervical, uterine horn and ovarian appearances are described and illustrated. Although native CT failed to detect uterine cystic lesions, other CT characteristics were linked to cystic endometrial hyperplasia, warranting ultrasonographic examination. In general, CT can be used to approximate ultrasonographic measurements.

Validation of the German version of the work and social adjustment scale in a sample of depressed patients

BACKGROUND

Depression is one of the key factors contributing to difficulties in one's ability to work, and serves as one of the major reasons why employees apply for psychotherapy and receive insurance subsidization of treatments. Hence, an increasing and growing number of studies rely on workability assessment scales as their primary outcome measure. The Work and Social Assessment Scale (WSAS) has been documented as one of the most psychometrically reliable and valid tools especially developed to assess workability and social functioning in patients with mental health problems. Yet, the application of the WSAS in Germany has been limited due to the paucity of a valid questionnaire in the German language. The objective of the present study was to translate the WSAS, as a brief and easy administrable tool into German and test its psychometric properties in a sample of adults with depression.

METHODS

Two hundred seventy-seven patients (M = 48.3 years, SD = 11.1) with mild to moderately severe depression were recruited. A multistep translation from English into the German language was performed and the factorial validity, criterion validity, convergent validity, discriminant validity, internal consistency, and floor and ceiling effects were examined.

RESULTS

The confirmatory factor analysis results confirmed the one-factor structure of the WSAS. Significant correlations with the WHODAS 2-0 questionnaire, a measure of functionality, demonstrated good convergent validity. Significant correlations with depression and quality of life demonstrated good criterion validity. The WSAS also demonstrated strong internal consistency (α = .89), and the absence of floor and ceiling effects indicated good sensitivity of the instrument.

CONCLUSIONS

The results of the present study demonstrated that the German version of the WSAS has good psychometric properties comparable to other international versions of this scale. The findings recommend a global assessment of psychosocial functioning with the sum score of the WSAS.

TRIAL REGISTRATION

ISRCTN identifier: ISRCTN28972230 . Date of registration June 26th 2018.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

Purpose

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

Patients and Methods

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

Results

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

Conclusion

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

P04.07 Correlation of 18F-fluorethyl-L-tyrosine (18F-FET) uptake in positron emission tomography (PET) and MRI growth rate in low-grade glioma

BACKGROUND

Low-grade gliomas (LGGs, WHO grade II) are a heterogeneous group of tumors of the central nervous system with diverse behavior in histopathology, genetics and growth patterns. Therefore, different therapeutic strategies are discussed ranging from watchful waiting to radical resection and adjuvant radio-/chemotherapy. For a better evaluation of tumor progression or malignant transformation, the O-(2-18F-fluoroethyl)-L-tyrosine (18F-FET) uptake in PET or the tumor growth rate assessed on MRI are used depending on the neurooncological center. Here, we correlated both methods.

MATERIAL AND METHODS

Inclusion criteria for this retrospective study were (1) newly diagnosed and neuropathologically confirmed low-grade glioma; (2) at least two MRIs at initial diagnosis and follow-up for calculation of the tumor growth rate (using IDS7 by Sectra AB, Sweden, 2018); (3) and an additional preoperative 18F-FET PET scan.

RESULTS

From 2008 to 2018, 34 patients were identified (mean age 39.7 years; 68% diffuse astrocytoma). The mean tumor growth rate on MRI was 0.091 cm3/d. The average mean 18F-FET uptake was 1.42; the average maximum 18F-FET uptake was 2.18. The Pearson correlation coefficient between the tumor growth rate and the mean and maximum 18F-FET uptake was r=0.19, and r=0.10. In the group of diffuse astrocytomas, the mean growth rate in tumors with a mean 18F-FET uptake of >1.5 was significantly higher than the mean growth rate of those with a mean 18F-FET uptake of ≤1.5 (p<0.1).

CONCLUSION

Data suggest that astrocytic LGGs with increased 18F-FET uptake may show a more aggressive behaviour, with a potentially higher risk for an earlier tumor progression or malignant transformation. For further elucidation of a correlation between the tumor growth rate and the 18F-FET uptake, larger prospective studies are needed. In the future, the combination of both methods in the management of low-grade gliomas could help to detect tumor progression as well as tumor malignization more precisely.

P14.29 Prediction of overall survival in patients with malignant glioma using dynamic O-(2-[18F]-fluoroethyl)-L-tyrosine PET

BACKGROUND

Characterization of gliomas according to the revised World Health Organization (WHO) classification of 2016 has gained major importance regarding prognostication. The present study aimed at exploring the prognostic value of dynamic O-(2-[18F]-fluoroethyl)-L-tyrosine (FET) PET in newly diagnosed and molecularly defined astrocytic high-grade glioma (HGG) of the WHO grades III or IV.

MATERIAL AND METHODS

Before initiation of treatment, dynamic FET PET imaging was performed in patients with newly diagnosed glioblastoma (GBM) and anaplastic astrocytoma (AA). Static FET PET parameters such as maximum and mean tumor/brain ratios (TBRmax/mean), as well as the dynamic FET PET parameters time-to-peak (TTP) and slope, were obtained. The predictive ability of FET PET parameters was evaluated with regard to the overall survival (OS). Using ROC analyses, threshold values for FET PET parameters were obtained. Subsequently, univariate Kaplan-Meier and multivariate Cox regression survival analyses were performed to assess their predictive power for OS.

RESULTS

Sixty patients (45 GBM, 15 AA) of two university centers were retrospectively identified. Patients with a methylated MGMT promoter as well as with an IDH mutation had a significantly longer OS (both P<0.001). Furthermore, ROC analysis revealed in IDH-wildtype HGG (n=45) that a TTP>25 minutes (AUC, 0.90; sensitivity, 90%; specificity, 87%; P<0.001) was highly prognostic for a longer OS (29 vs. 12 months; P<0.001). Besides a complete resection and a methylated MGMT promoter, TTP remained significant in the multivariate survival analysis (P=0.002, P=0.016, and P=0.003, respectively), indicating an independent predictor for OS. In contrast, both TBRmax and TBRmean were not prognostic (AUC, 0.37 and 0.32, respectively).

CONCLUSION

Data suggest that within the subgroup of patients with newly diagnosed and untreated IDH-wildtype GBM and AA, dynamic FET PET additionally allows the identification of patients with an improved OS.

P14.18 Prognostic value of serial dynamic O-(2-[18F]-fluoroethyl)-L-tyrosine PET in patients with non-resectable malignant glioma undergoing chemoradiation

BACKGROUND

A complete resection of high-grade gliomas (HGG) is associated with improved survival, which, however, cannot be achieved in a considerable number of patients. We here evaluated the prognostic value of serial O-(2-[18F]-fluoroethyl)-L-tyrosine (FET) PET in patients with newly diagnosed, non-resectable astrocytic HGG undergoing chemoradiation with temozolomide.

MATERIAL AND METHODS

Serial dynamic FET PET scans were performed in 18 newly diagnosed patients with molecularly defined, non-resectable HGG at baseline and after chemoradiation (8±3 weeks). Both static (tumor/brain ratios, FET tumor volumes) and dynamic FET PET parameters (time-to-peak, slope), as well as MRI changes according to RANO criteria at first follow-up after chemoradiation (8±3 weeks), were obtained. The predictive ability of FET PET parameters and RANO criteria was evaluated with regard to the progression-free survival (PFS). Using ROC analyses, threshold values for FET PET parameters were obtained. Subsequently, univariate and multivariate survival analyses were performed to assess their predictive power for PFS.

RESULTS

ROC analysis revealed that the mean tumor/brain ratio (AUC, 0.84), FET tumor volume (AUC, 0.89), and slope (AUC, 0.72) at baseline were predictive for a prolonged PFS (9.3 vs. 5.7 months, P=0.05; 10.3 vs. 5.9 months; P=0.03; 13.5 vs. 6.2 months, P=0.02, respectively). Furthermore, FET tumor volume and slope remained significant in the multivariate survival analysis (both P<0.05). In contrast, relative changes of static or dynamic FET PET parameters at follow-up and MRI changes according to RANO criteria were not significant in this albeit small series of patients.

CONCLUSION

Results suggest that before initiation of chemoradiation FET PET parameters at baseline can be used to predict PFS in patients with non-resectable HGG.

Evaluation of the genetic architecture and the potential of genomics-assisted breeding of quality traits in two large panels of durum wheat

New QTL for important quality traits in durum were identified, but for most QTL their effect varies depending on the investigated germplasm. Most of the global durum wheat (Triticum turgidum ssp. durum) production is used for human consumption via pasta and to a lower extent couscous and bulgur. Therefore, durum wheat varieties have to fulfill high demands regarding quality traits. In this study, we evaluated the quality traits protein content, sedimentation volume, falling number, vitreousity and thousand kernel weight in a Central European (CP) and a Southern and Western European panel (SP) with 183 and 159 durum lines, respectively, and investigated their genetic architecture by genome-wide association mapping. Except for protein content, we identified QTL explaining a large proportion of the genotypic variance for different traits. However, most of them were identified only in one panel. Nevertheless, for sedimentation volume a genomic region on chromosome 1B appeared important in both durum panels and a BLAST search against the emmer and bread wheat reference genomes points toward the candidate gene Glu-B3. This was further supported by the protein subunit banding pattern via SDS-PAGE gel electrophoresis. For vitreousity, genomic regions on chromosome 7A explained a larger proportion of the genotypic variance in both panels, whereas one QTL, possibly related to the Pinb-2 locus, also slightly influenced the protein content. Within each panel, high prediction abilities for genomic selection were obtained, which, however, dropped considerably when predicting across both panels. Nevertheless, the across-panel prediction ability was still larger than 0.4 for protein content and sedimentation volume, underlining the potential for genomics-aided durum breeding, if laboratory and logistical facilities are available.

Vacuum phenomenon associated with triple cervical vertebral arch and ligamentum flavum anomaly resulting in severe stenotic myelopathy in a dog

A six-year-old American Staffordshire terrier with proprioceptive deficits of the right thoracic and pelvic limb was referred for further work-up. Cervical computed tomography (CT) and magnetic resonance imaging (MRI) revealed a triple cervical canal stenosis with dorsal spinal cord compression and concomitant compressive myelopathy caused by vertebral arch and ligamentum flavum proliferation and hypertrophy. Vacuum phenomena were noticed within the ligamentum flavum tissue, a previously unreported location for vacuum phenomena, which are primarily reported within degenerative joints and intervertebral discs. Decompressive surgery and rehabilitation resulted in a complete clinical recovery.

Reward and avoidance learning in the context of aversive environments and possible implications for depressive symptoms

BACKGROUND

Aversive stimuli in the environment influence human actions. This includes valence-dependent influences on action selection, e.g., increased avoidance but decreased approach behavior. However, it is yet unclear how aversive stimuli interact with complex learning and decision-making in the reward and avoidance domain. Moreover, the underlying computational mechanisms of these decision-making biases are unknown.

METHODS

To elucidate these mechanisms, 54 healthy young male subjects performed a two-step sequential decision-making task, which allows to computationally model different aspects of learning, e.g., model-free, habitual, and model-based, goal-directed learning. We used a within-subject design, crossing task valence (reward vs. punishment learning) with emotional context (aversive vs. neutral background stimuli). We analyzed choice data, applied a computational model, and performed simulations.

RESULTS

Whereas model-based learning was not affected, aversive stimuli interacted with model-free learning in a way that depended on task valence. Thus, aversive stimuli increased model-free avoidance learning but decreased model-free reward learning. The computational model confirmed this effect: the parameter lambda that indicates the influence of reward prediction errors on decision values was increased in the punishment condition but decreased in the reward condition when aversive stimuli were present. Further, by using the inferred computational parameters to simulate choice data, our effects were captured. Exploratory analyses revealed that the observed biases were associated with subclinical depressive symptoms.

CONCLUSION

Our data show that aversive environmental stimuli affect complex learning and decision-making, which depends on task valence. Further, we provide a model of the underlying computations of this affective modulation. Finally, our finding of increased decision-making biases in subjects reporting subclinical depressive symptoms matches recent reports of amplified Pavlovian influences on action selection in depression and suggests a potential vulnerability factor for mood disorders. We discuss our findings in the light of the involvement of the neuromodulators serotonin and dopamine.

Simultaneous improvement of grain yield and protein content in durum wheat by different phenotypic indices and genomic selection

Simultaneous improvement of protein content and grain yield by index selection is possible but its efficiency largely depends on the weighting of the single traits. The genetic architecture of these indices is similar to that of the primary traits. Grain yield and protein content are of major importance in durum wheat breeding, but their negative correlation has hampered their simultaneous improvement. To account for this in wheat breeding, the grain protein deviation (GPD) and the protein yield were proposed as targets for selection. The aim of this work was to investigate the potential of different indices to simultaneously improve grain yield and protein content in durum wheat and to evaluate their genetic architecture towards genomics-assisted breeding. To this end, we investigated two different durum wheat panels comprising 159 and 189 genotypes, which were tested in multiple field locations across Europe and genotyped by a genotyping-by-sequencing approach. The phenotypic analyses revealed significant genetic variances for all traits and heritabilities of the phenotypic indices that were in a similar range as those of grain yield and protein content. The GPD showed a high and positive correlation with protein content, whereas protein yield was highly and positively correlated with grain yield. Thus, selecting for a high GPD would mainly increase the protein content whereas a selection based on protein yield would mainly improve grain yield, but a combination of both indices allows to balance this selection. The genome-wide association mapping revealed a complex genetic architecture for all traits with most QTL having small effects and being detected only in one germplasm set, thus limiting the potential of marker-assisted selection for trait improvement. By contrast, genome-wide prediction appeared promising but its performance strongly depends on the relatedness between training and prediction sets.

Frequency of participation and association with functioning in adolescents born extremely preterm - Findings from a population-based cohort in northern Germany

BACKGROUND

Outcomes after extremely preterm birth (<28 weeks gestation) have been studied intensely, and follow-up into adulthood is well-established. Following the introduction of the International Classification of Functioning, Disability and Health, participation has been recognized to be a relevant outcome in rehabilitation research. During adolescence, participation is crucial to adapting to new social roles. The aim of our study was to investigate participation in the domains Autonomy, Relationships and Community Recreation.

METHODS

Participation was assessed as part of a cross-sectional, population-based study in a German federal state examining all adolescents born between January 1997 and December 1999 at under 27 weeks gestation. Of the surviving 90 adolescents, 72 (80%) were followed-up at age 14 to 17. Frequency of participation was assessed using the short form of the Questionnaire of Young People's Participation and compared to matched peers. Associations with physical, cognitive, and psychological functioning and contextual factors were examined using multivariate regression.

RESULTS

Frequency of participation in Autonomy, Relationships, and Community Recreation in adolescents born extremely preterm was significantly lower than that of matched peers from the general population (p < 0,001). Lower frequency of participation in Autonomy and Relationships was associated with severe physical and cognitive impairment, and psychological problems. Fifty-seven percent of the adjusted variance in Autonomy and 31% of the adjusted variance in Relationships was explained by our regression models.

CONCLUSION

Further research is warranted to investigate additional factors associated with the restricted frequency of participation of adolescents born preterm to design suitable interventions for improving participation.

α,α-Difluoro-β-iminophosphonates, an alternative strategy towards the synthesis of α,α-difluoro-β-aminophosphonate derivatives

Herein, we described the efficient and straightforward synthesis of N-substituted α,α-difluoro-β-aminophosphonates with the use of electrophilic fluorination by Selectfluor®.

Treatment outcome in 60 children with pathological fractures of the humerus caused by juvenile or aneurysmal bone cysts

The treatment of pathological fractures of the humerus caused by juvenile or aneurysmal bone cysts (JBC/ABC) should be a single approach with a high success rate and low complication rate. This study evaluates how day by day treatment concepts fulfil these aims. Children below 15 years of age with a pathological fracture of the humerus caused by a JBC or ABC between 01.01.2001 and 31.12.2010, were investigated by chart review in four major paediatric trauma centres. Age, gender, fracture localisation, X-ray findings, treatment and outcome - assessed by the Capanna classification (I to IV), were analysed. 60 children [41male, 19 female; mean age: 9 years (4-14 years)] with 43 JBC and 12 ABC were included as well as five cysts, who could not be classified definitively. First treatment was non-operatively in 33 children. Of these 27 cysts did not improve; likewise the supportive installation of cortisone in six patients did not change the outcome. The first treatment consisted of elastic stable intramedullary in 13 children; up to three nail exchanges included. But only six of these reached (nearly) complete resolution (I/II). Overall the combined mechanical and biological treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and in some cases growth factors was performed as the 1st-line treatment in nine patients and further in 2nd or 3rd-line treatments in 13 humeral cysts. More than half of these reached a complete or nearly complete resolution of the cyst (12x I, 5x II, 1x III, 4x IV). Major complications in all operated patients were six nails not removable and two children with upper extremities length differences. Healing rates are low for non-operative treatment, elastic stable intramedullary nailing alone and by using cortisone for cysts resolution in pathological fractures of the humerus. Data support a combined mechanical and biological treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and the use of growth factors.

Shall we really say goodbye to first rank symptoms?

BACKGROUND

First rank symptoms (FRS) of schizophrenia have been used for decades for diagnostic purposes. In the new version of the DSM-5, the American Psychiatric Association (APA) has abolished any further reference to FRS of schizophrenia and treats them like any other "criterion A" symptom (e.g. any kind of hallucination or delusion) with regard to their diagnostic implication. The ICD-10 is currently under revision and may follow suit. In this review, we discuss central points of criticism that are directed against the continuous use of first rank symptoms (FRS) to diagnose schizophrenia.

METHODS

We describe the specific circumstances in which Schneider articulated his approach to schizophrenia diagnosis and discuss the relevance of his approach today. Further, we discuss anthropological and phenomenological aspects of FRS and highlight the importance of self-disorder (as part of FRS) for the diagnosis of schizophrenia. Finally, we will conclude by suggesting that the theory and rationale behind the definition of FRS is still important for psychopathological as well as neurobiological approaches today.

RESULTS

Results of a pivotal meta-analysis and other studies show relatively poor sensitivity, yet relatively high specificity for FRS as diagnostic marker for schizophrenia. Several methodological issues impede a systematic assessment of the usefulness of FRS in the diagnosis of schizophrenia. However, there is good evidence that FRS may still be useful to differentiate schizophrenia from somatic causes of psychotic states. This may be particularly important in countries or situations with little access to other diagnostic tests. FRS may thus still represent a useful aid for clinicians in the diagnostic process.

CONCLUSION

In conclusion, we suggest to continue a tradition of careful clinical observation and fine-grained psychopathological assessment, including a focus on symptoms regarding self-disorders, which reflects a key aspect of psychosis. We suggest that the importance of FRS may indeed be scaled down to a degree that the occurrence of a single FRS alone should not suffice to diagnose schizophrenia, but, on the other hand, absence of FRS should be regarded as a warning sign that the diagnosis of schizophrenia or schizoaffective disorder is not warranted and requires specific care to rule out other causes, particularly neurological and other somatic disorders. With respect to the current stage of the development of ICD-11, we appreciate the fact that self-disorders are explicitly mentioned (and distinguished from delusions) in the list of mandatory symptoms but still feel that delusional perceptions and complex hallucinations as defined by Schneider should be distinguished from delusions or hallucinations of "any kind". Finally, we encourage future research to explore the psychopathological context and the neurobiological correlates of self-disorders as a potential phenotypic trait marker of schizophrenia.

[Assessment of REC (Reduction in Earning Capacity) after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 2): The New REC Form Developed by Ottomann and Hartmann in 2010]

The calculation of REC forms the basis of expert opinions for the purposes of making accident insurance assessments after an occupational accident or an accident suffered en route while travelling to or from the workplace. The estimation of REC is based on a procedure quoted in the 1995 "Jahrbuch der Versicherungsmedizin" (Yearbook of Insurance Medicine) using a form developed by Henkel von Donnersmarck and Hoerbrand. The overall estimation of damages resulting from the accident comprises 3 main components, namely the functional impairment, the assessment of local findings and the resulting somatic and vegetative complaints. The criteria for all 3 components are nevertheless imprecise and open to a great deal of interpretation on the part of the evaluator, leading to a highly variable and subjective overall assessment of REC. The new REC form includes a modified factor-based categorisation of the scar quality and the localisation, so that assessment can now be carried out in a differentiated manner. Visible, stigmatising areas such as the neck are provided with their own Q values. The pigmental and textural alterations describing the scar quality are now more precisely defined. Considering the complexity of the somatic and vegetative alterations, more precise (objective) assessments can now be derived. The new REC form increases the validity and transparency of post-thermal trauma REC assessments for the purposes of making statutory accident insurance assessments.

Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice

BACKGROUND

Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN).

METHODS

This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications.

RESULTS

We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (>40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections).

CONCLUSIONS

Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.

[The Assessment of REC after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 1): Low Validity of the REC Form Developed by Donnersmarck and Hörbrand]

The total REC (reduction in earning capacity) after a thermal trauma is usually assessed using an appraisal form for burns victims, initially developed by Hoerbrandt and von Donnersmarck (1995). The criteria for functional impairment, local findings and vegetative-somatic complaints are somewhat imprecise given the broad scope of interpretation which the evaluator can employ in making an appraisal. This means that the overall appraisal of REC is subjective on the part of the evaluator. In addition, one can only calculate an overall REC of at most 40% from local findings and vegetative-somatic symptoms, even in patients with extensive large area burns. Considering these points we investigated the dependency of the results on the evaluator as well as the limited validity of the appraisal form originally developed by Hörbrand and Donnersmark.

The dipeptidylpeptidase-IV inhibitors sitagliptin, vildagliptin and saxagliptin do not impair innate and adaptive immune responses

Inhibitors of dipeptidylpeptidase IV (DPP-IV) represent a novel class of frequently used anti-diabetic drugs. In addition to its function in metabolic regulation, DPP-IV also plays a role in the immune system. Whether the DPP-IV inhibitors sitagliptin, vildagliptin or saxagliptin impair immune responses is, however, currently unknown. Here, we investigated the effect of these agents on both innate and adaptive immunity. We found that the DPP-IV inhibitors did not affect the innate immune response induced by Toll-like receptor (TLR) ligands, as cytokine secretion and induction of co-stimulatory molecules by human blood mononuclear cells was not impaired. Furthermore, proliferation of T cells and suppressive function of regulatory T cells was preserved. Mice treated with vildagliptin showed normal cytokine production, immune cell activation and lymphocyte trafficking upon TLR activation. Thus, crucial immunological parameters remain unaffected upon treatment with DPP-IV inhibitors, a fact that is reassuring with respect to safety of these drugs.

Gastrointestinaler stromaler Tumor im Zäkum bei einem Pony mit Kolik

Eine 25-jährige Ponystute wurde mit vorberichtlich hochgradiger akuter Koliksymptomatik in der Klinik vorgestellt. Laut Anamnese bestanden bereits seit einer Woche Inappetenz, Apathie und Fieber ungeklärter Genese. Die klinische Untersuchung sowie die Sondierung mit der Nasenschlundsonde ergab die Befunde einer sekundären Magenüberladung. Bei der rektalen Exploration wurden eine mittelgradige Zäkumtympanie, mit straff gespannter, schmerzhafter medialer Tänie, sowie flüssigkeitsgefüllte und dilatierte Dünndarmschlingen befundet. Zudem war ventral im kaudalen Abdomen eine derbe, verschiebliche, nicht schmerzhafte Struktur mit ca. 10 cm Durchmesser zu fühlen. Sonographisch konnte von der rechten Flanke aus eine hyperechogene Masse im Bereich des Blinddarms dargestellt werden. Das Bauchhöhlenpunktat stellte sich als Exsudat dar und zeigte zytologisch die Merkmale einer akuten bis subakuten Peritonitis. Bei der Blutuntersuchung fielen eine deutlich erhöhte Plasma-Laktatkonzentration und eine geringgradige Neutrophilie und Lymphopenie bei einer Gesamtleukozytenzahl von 6 G/l auf. Da der Besitzer einer diagnostisch-therapeutischen Laparotomie nicht zustimmte und sich die Schmerzsymptomatik trotz Medikation verschlechterte, wurde das Pony euthanasiert. Bei der pathologisch-anatomischen Untersuchung ergab sich als Hauptbefund eine umfangreiche Verklebung der Zäkumspitze mit der linken und rechten Kolonlage sowie dem Ileum und eine intramurale Umfangsvermehrung in der Zäkumspitze. Diese von Schleimhaut überzogene Umfangsvermehrung war von derber Konsistenz und im Anschitt grau-weiß bis beige, multilobuliert mit zahlreichen Nekroseherden und akuten Einblutungen. Durch histopathologische und immunhistologische Untersuchung ließ sich die Umfangsvermehrung als „gastrointestinaler stromaler Tumor (GIST)“, eine beim Pferd seltene Neoplasie, klassifizieren.

[A gastrointestinal stromal tumour of the caecum in a pony with colic]

A 25-year-old pony mare was presented to the clinic with preliminarily reported severe acute colic. The pony during the previous week had shown inappetence, apathy and fever of unknown origin. Clinical examination and placement of a gastric tube were indicative of a secondary gastric dilation. Rectal exploration found moderate caecal meteorism with a tensed and painful medial taenia as well as a dilated and fluid-filled small intestine. In addition, a solid, mobile, non-painful structure of approximately 10 cm diameter was palpated ventrally. A hyperechogenic mass close to the caecum was detected using ultrasonography of the abdomen in the right flank. The peritoneal fluid was an exudate with cytological signs of an acute to subacute peritonitis. Blood analysis showed markedly increased plasma lactate concentration and a marginal neutrophilia and lymphopenia, with a total leukocyte count of 6 G/l. Because the owners refused consent for a laparotomy and the pony showed increased signs of severe pain despite conservative medical treatment, it was euthanized. The main findings on necropsy were extensive adherence of the caecal apex to the right and left colon and the ileum as well as a neoplasia in the lumen of the caecal apex. The mass, which was covered with a mucous membrane, had a tough consistency. The cut surface was grey-white to beige-coloured and multilobular with numerous necrotic and acute haemorrhagic areas. According to histopathological and immunohistochemical findings, the mass was characterized as a gastrointestinal stromal tumour (GIST), a rare neoplasia in horses.

[Suicide Rates and Suicide Prevention in Women of Turkish Origin in Berlin]

Suicidality in female Turkish immigrants is higher as compared to that of native-born women of the same age. The analysis of the national mortality registry in Germany reported a 2-fold suicide risk in the target group compared to German women of the same age. A population-based multi-modal intervention project was conducted. Suicidal crisis were analysed in focus groups and guided the development of the intervention module. The intervention consisted of a public awareness campaign, a telephone hotline, and the training of key persons. All parts of the intervention were subsequently evaluated. Suicide attempts of the target group that were presented at all emergency units in Berlin were registered. In a population-based interview survey the aim was to elicit central sociodemographic and psychosocial variables that may influence distress and help-seeking behaviour in women of Turkish origin.

Longitudinal analysis of quality of life, clinical, radiographic, echocardiographic, and laboratory variables in dogs with myxomatous mitral valve disease receiving pimobendan or benazepril: the QUEST study

BACKGROUND

Myxomatous mitral valve disease (MMVD) is an important cause of morbidity and mortality in dogs.

OBJECTIVES

To compare, throughout the period of follow-up of dogs that had not yet reached the primary endpoint, the longitudinal effects of pimobendan versus benazepril hydrochloride treatment on quality-of-life (QoL) variables, concomitant congestive heart failure (CHF) treatment, and other outcome variables in dogs suffering from CHF secondary to MMVD.

ANIMALS

A total of 260 dogs in CHF because of MMVD.

METHODS

A prospective single-blinded study with dogs randomized to receive pimobendan (0.4-0.6 mg/kg/day) or benazepril hydrochloride (0.25-1.0 mg/kg/day). Differences in outcome variables and time to intensification of CHF treatment were compared.

RESULTS

A total of 124 dogs were randomized to pimobendan and 128 to benazepril. No difference was found between groups in QoL variables during the trial. Time from inclusion to 1st intensification of CHF treatment was longer in the pimobendan group (pimobendan 98 days, IQR 30-276 days versus benazepril 59 days, IQR 11-121 days; P = .0005). Postinclusion, dogs in the pimobendan group had smaller heart size based on VHS score (P = .013) and left ventricular diastolic (P = .035) and systolic (P = .0044) dimensions, higher body temperature (P = .030), serum sodium (P = .0027), and total protein (P = .0003) concentrations, and packed cell volume (P = .030). Incidence of arrhythmias was similar in treatment groups.

CONCLUSIONS AND CLINICAL IMPORTANCE

Pimobendan versus benazepril resulted in similar QoL during the study, but conferred increased time before intensification of CHF treatment. Pimobendan treatment resulted in smaller heart size, higher body temperature, and less retention of free water.

The impact of sequential vs. combined radiochemotherapy with temozolomide, resection and MGMT promoter hypermethylation on survival of patients with primary glioblastoma--a single centre retrospective study

BACKGROUND

The benefit of the introduction of alkylating chemotherapy in the treatment of glioblastoma multiforme (GBM) patients has been demonstrated by comparing radiotherapy with concomitant plus intermittent temozolomide (iTMZ) to radiation therapy. The isolated impact of the concomitant part of this protocol on survival was not investigated. We were therefore interested in the impact of the effect of the concomitant therapy part on survival. Hence, we compared patients treated with open surgery followed by radiotherapy and iTMZ with patients treated with concomitant plus iTMZ chemotherapy regarding overall (OS) and progression-free survival (PFS).

METHODS

We performed a retrospective database search for the period between 2002 and 2007 and aimed at the identification of patients with primary GBM treated by open resection, radiotherapy (only radiotherapy = Group A and plus concomitant TMZ = Group B) and at least two cycles of TMZ. Patients were stratified for established prognostic markers like extent of resection, MGMT promoter methylation, Karnofsky Performance Scale (KPS), and age.

RESULTS

Eighty-five patients were analysed, among which 42 patients (49%) were affiliated with Cohort A and 43 patients (51%) with Cohort B. Between both cohorts there was no significant difference regarding MGMT methylation status (p = 0.929), extend of resection (p = 0.102), KPS (p = 0.197) and age (p = 0.327). For the entire patient population, median OS was 18.6 months and PFS was 5.6 months. The extent of resection was significantly correlated with survival (OS: 21.5 vs. 16.1 months (p = 0.001) and PFS: 11.0 vs. 3.9 months (p = 0.044)). MGMT methylation status revealed a significant impact on OS (p = 0.008). Affiliation to Cohort A or B was neither correlated with PFS (p = 0.168) nor with OS (p = 0.343).

CONCLUSION

Our study demonstrates that PFS and OS are strongly determined by the MGMT status and the extent of resection. Interestingly, concomitant radiochemotherapy was not superior to radiotherapy followed by iTMZ chemotherapy regarding OS and PFS.

Increasing stability by pre-bending the nails in elastic stable intramedullary nailing: a biomechanical analysis of a synthetic femoral spiral fracture model

Elastic stable intramedullary nailing (ESIN) is generally acknowledged to be the treatment of choice for displaced diaphyseal femoral fractures in children over the age of three years, although complication rates of up to 50% are described. Pre-bending the nails is recommended, but there are no published data to support this. Using synthetic bones and a standardised simulated fracture, we performed biomechanical testing to determine the influence on the stability of the fracture of pre-bending the nails before implantation. Standard ESIN was performed on 24 synthetic femoral models with a spiral fracture. In eight cases the nails were inserted without any pre-bending, in a further eight cases they were pre-bent to 30° and in the last group of eight cases they were pre-bent to 60°. Mechanical testing revealed that pre-bending to 60° produced a significant increase in the stiffness or stability of the fracture. Pre-bending to 60° showed a significant positive influence on the stiffness compared with unbent nails. Pre-bending to 30° improved stiffness only slightly. These findings validate the recommendations for pre-bending, but the degree of pre-bend should exceed 30°. Adopting higher degrees of pre-bending should improve stability in spiral fractures and reduce the complications of varus deformity and shortening.