Deep learning-assisted radiomics facilitates multimodal prognostication for personalized treatment strategies in low-grade glioma

Determining the optimal course of treatment for low grade glioma (LGG) patients is challenging and frequently reliant on subjective judgment and limited scientific evidence. Our objective was to develop a comprehensive deep learning assisted radiomics model for assessing not only overall survival in LGG, but also the likelihood of future malignancy and glioma growth velocity. Thus, we retrospectively included 349 LGG patients to develop a prediction model using clinical, anatomical, and preoperative MRI data. Before performing radiomics analysis, a U2-model for glioma segmentation was utilized to prevent bias, yielding a mean whole tumor Dice score of 0.837. Overall survival and time to malignancy were estimated using Cox proportional hazard models. In a postoperative model, we derived a C-index of 0.82 (CI 0.79-0.86) for the training cohort over 10 years and 0.74 (Cl 0.64-0.84) for the test cohort. Preoperative models showed a C-index of 0.77 (Cl 0.73-0.82) for training and 0.67 (Cl 0.57-0.80) test sets. Our findings suggest that we can reliably predict the survival of a heterogeneous population of glioma patients in both preoperative and postoperative scenarios. Further, we demonstrate the utility of radiomics in predicting biological tumor activity, such as the time to malignancy and the LGG growth rate.

Interprofessional Needs Analysis and User-Centred Prototype Evaluation as a Foundation for Building Individualized Digital Education in Dementia Healthcare Supported by Artificial Intelligence: A Study Protocol

Continuous profession-specific training is necessary to provide high-quality care for people with dementia. Research shows the need for more educational programmes that are personalized and responsive to the learning needs and preferences of staff. Digital solutions supported by artificial intelligence (AI) may be a means of making these improvements. There is a lack of formats that support learners in selecting the right content according to their learning needs and preferences. The project "My INdividual Digital EDucation.RUHR" (MINDED.RUHR) addresses this problem and seeks to develop an automatized delivery system for individual learning content using AI. The sub-project presented here aims to achieve the following: (a) explore learning needs and preferences regarding behavioural changes in people with dementia, (b) develop learning nuggets, (c) evaluate the feasibility of the digital learning platform, and (d) identify optimization criteria. Following the first phase of the framework for the design and evaluation of digital health interventions (DEDHI), we use a qualitative approach with focus group interviews for exploration and development, and co-design workshops and expert audits to evaluate the developed learning nuggets. The developed e-learning tool is the first step in supporting the digital training of healthcare professionals in the context of caring for people with dementia, individualized through AI.

[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

Involving patients as research partners exemplified by the development and evaluation of a communication-skills training programme (KOKOS-Rheuma)

Despite widespread recommendations for involving patient research partners (PRPs), there is little information about how patients have been involved in research. Our aim was to describe and assess the contributions of four PRPs in a project on communication-skills training funded by Deutsche Rheuma-Liga Bundesverband e. V. (German League Against Rheumatism [GLR] is a patient organisation for people with rheumatic and musculoskeletal diseases). The PRPs' participation was beneficial with regards to content and organisation. Thanks to their participation, we could enlarge our sample by over a third, and they contributed their own ideas to the training. Four PRPs added their perspective of various regional organisations. Outside this project, they were also very active within GLR and experienced in managing their rheumatic disease. To achieve more representativeness, future studies might also employ strategies to engage individuals with less experience in dealing with their disease, e.g. newly diagnosed patients. While the collaboration between PRPs and researchers proved very successful, more regular discussions about tasks and responsibilities would be worthwhile.

Lehrplanorientierte Inklusion hämophiler Kinder und Jugendlicher im Sportunterricht

Inclusive paedagogic thinking and acting is a modern and increasingly important topic in school sports. It will affect teachers as well as parents and students. The new international guidelines and national curricula enable new ways of inclusion especially for students with chronic illnesses like haemophilia. Special help from the sport teachers is of vital importance.

In our project “fit for life” where we advice children and young adults with haemophilia to find their appropriate sport, we developed a new approach for an optimised inclusion of children with haemophilia into sport lessons. The whole project is running in corporation with the German Sport Teachers Association/ Hessen. We analysed and rated the actual curricula of the different school years and looked at the specific needs, risks and necessary abilities for persons with haemophilia. By this means we gathered about 600 typical movements and/or exercises for school sports and developed individual advice and adapted exercise solutions for sport lessons.

Profile measurements of the electron temperature on the ASDEX Upgrade, COMPASS, and ISTTOK tokamak using Thomson scattering, triple, and ball-pen probes

The ball-pen probe (BPP) technique is used successfully to make profile measurements of the electron temperature on the ASDEX Upgrade (Axially Symmetric Divertor Experiment), COMPASS (COMPact ASSembly), and ISTTOK (Instituto Superior Tecnico TOKamak) tokamak. The electron temperature is provided by a combination of the BPP potential (ΦBPP) and the floating potential (Vfl) of the Langmuir probe (LP), which is compared with the Thomson scattering diagnostic on ASDEX Upgrade and COMPASS. Excellent agreement between the two diagnostics is obtained for circular and diverted plasmas and different heating mechanisms (Ohmic, NBI, ECRH) in deuterium discharges with the same formula Te = (ΦBPP - Vfl)/2.2. The comparative measurements of the electron temperature using BPP/LP and triple probe (TP) techniques on the ISTTOK tokamak show good agreement of averaged values only inside the separatrix. It was also found that the TP provides the electron temperature with significantly higher standard deviation than BPP/LP. However, the resulting values of both techniques are well in the phase with the maximum of cross-correlation function being 0.8.

First results from EBW emission diagnostics on COMPASS

COMPASS tokamak shots at low magnetic field feature overdense plasmas during the extended current flat-top phase. The first harmonic of the electron cyclotron emission is completely cutoff for O and X modes and so the emission caused by electron Bernstein waves (EBWs) propagating obliquely with respect to the magnetic field and undergoing so called EBW-X-O conversion process can be observed. We perform an angular scan of the EBW emission during a set of comparable shots in order to determine the optimum antenna direction. A weak dependence of the radiative temperature on the antenna angles indicates an influence of multiple reflections from the vessel wall. The low temperature at the mode conversion region is responsible for the collisional damping of EBW, which can explain several times lower measured radiative temperature than the electron temperature measured by the Thomson scattering system.

[Curricula oriented inclusion of children and adolescents with haemophilia in school sports--a new approach within the project "fit for life"]

Inclusive paedagogic thinking and acting is a modern and increasingly important topic in school sports. It will affect teachers as well as parents and students. The new international guidelines and national curricula enable new ways of inclusion especially for students with chronic illnesses like haemophilia. Special help from the sport teachers is of vital importance. In our project "fit for life" where we advice children and young adults with haemophilia to find their appropriate sport, we developed a new approach for an optimised inclusion of children with haemophilia into sport lessons. The whole project is running in corporation with the German Sport Teachers Association/Hessen. We analysed and rated the actual curricula of the different school years and looked at the specific needs, risks and necessary abilities for persons with haemophilia. By this means we gathered about 600 typical movements and/or exercises for school sports and developed individual advice and adapted exercise solutions for sport lessons.

[Analysis of muscle function with kinetic superficial EMG in children with haemophilia - recognizing subclinical changes, establishing individual therapy, quality control]

Electromyography (EMG) measures muscle electricity. It depends on muscle contraction and central motor control. Muscles react very sensitive on external signals (e. g. bleeding), The resulting changes can be shown in EMG.

PATIENTS, METHODS

A first study included 51 children and young adults from Costa Rica. They underwent a clinical examination and EMG of the hip, knee and ankle joints. Resting muscle tone, maximal isometric contraction and three typical isotonic movements of the joints were measured. First step of analysis was to characterize typical pathogenic changes in the muscles and to find a corresponding physical therapy to minimize these changes.

RESULTS

It showed that EMG is a good marker for muscle condition. It helps to individualize therapy and improve effectivity of physical and physiotherapeutic treatment of the locomotive system of children and young adults with hemophilia. It can help to recognize early subclinical changes and to control the outcome of therapeutic modalities.

Muskelfunktionsmessung mit kinetischem Oberflächen-EMG bei Kindern mit Hämophilie

Electromyography (EMG) measures muscle electricity. It depends on muscle contraction and central motor control. Muscles react very sensitive on external signals (e. g. bleeding), The resulting changes can be shown in EMG.

Patients, methods A first study included 51 children and young adults from Costa Rica. They underwent a clinical examination and EMG of the hip, knee and ankle joints. Resting muscle tone, maximal isometric contraction and three typical isotonic movements of the joints were measured. First step of analysis was to characterize typical pathogenic changes in the muscles and to find a corresponding physical therapy to minimize these changes.

Results It showed that EMG is a good marker for muscle condition. It helps to individualize therapy and improve effectivity of physical and physiotherapeutic treatment of the locomotive system of children and young adults with hemophilia. It can help to recognize early subclinical changes and to control the outcome of therapeutic modalities.

[How to manage the narrow pupil?]

I describe a new irrigating iris retractor for cataract surgery in small pupils. The retractor, a modified irrigating handpiece has a smooth button-like iris hook in the front. The hook is inserted into the margin of a small pupil and retract the pupil peripherally to allow visualisation of cortical remnant in the equatorial area of the lens capsule. The capsule can then be safely cleaned using the aspirating handpiece in the surgeon's other hand.

Progress of development of Thomson scattering diagnostic system on COMPASS

A new Thomson scattering diagnostic system has been designed and is being built now on the COMPASS tokamak at the Institute of Plasma Physics ASCR in Prague (IPP Prague) in the Czech Republic. This contribution focuses on design, development, and installation of the light collection and detection system. High spatial resolution of 3 mm will be achieved by a combination of design of collection optics and connected polychromators. Imaging characteristics of both core and edge plasma collection objectives are described and fiber backplane design is presented. Several calibration procedures are discussed. The operational deployment of the Thomson scattering diagnostic is planned by the end of 2010.

Cognitive performance in recreational ecstasy polydrug users: a two-year follow-up study

There is important preclinical evidence of long lasting neurotoxic and selective effects of ecstasy MDMA on serotonin systems in non-human primates. In humans long-term recreational use of ecstasy has been mainly associated with learning and memory impairments. The aim of the present study was to investigate the neuropsychological profile associated with ecstasy use within recreational polydrug users, and describe the cognitive changes related to maintained or variable ecstasy use along a two years period. We administered cognitive measures of attention, executive functions, memory and learning to three groups of participants: 37 current polydrug users with regular consumption of ecstasy and cannabis, 23 current cannabis users and 34 non-users free of illicit drugs. Four cognitive assessments were conducted during two years. At baseline, ecstasy polydrug users showed significantly poorer performance than cannabis users and non-drug using controls in a measure of semantic word fluency. When ecstasy users were classified according to lifetime use of ecstasy, the more severe users (more than 100 tablets) showed additional deficits on episodic memory. After two years ecstasy users showed persistent deficits on verbal fluency, working memory and processing speed. These findings should be interpreted with caution, since the possibility of premorbid group differences cannot be entirely excluded. Our findings support that ecstasy use, or ecstasy/cannabis synergic effects, are responsible for the sub-clinical deficits observed in ecstasy polydrug users, and provides additional evidence for long-term cognitive impairment owing to ecstasy consumption in the context of polydrug use.

[Rapid Disability Rating Scale-2 in Alzheimer's disease: NORMACODEM project data]

INTRODUCTION

The study aimed to investigate the Rapid Disability Rating Scale-2 (RDRS-2) in Alzheimer's disease (AD). Test retest reliability, internal consistency, data of discriminant validity of the scale, correlations with other functional and cognitive measures were analyzed.

MATERIAL AND METHODS

451 subjects were assessed: 254 healthy controls, 86 with cognitive impairment but no dementia (CIND) and 111 subjects diagnosed of AD. Total and subscales scores of the RDRS-2 were obtained. The total score is the sum of three subscales: activities of daily living, disability, and special problems. To establish its correlation with other functional scales and cognitive instruments, the following tools were applied: Blessed Dementia Rating Scale (BDRS), Interview for the Deterioration of Daily Living in Dementia (IDDD), Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog) and the Mini-Mental State Examination (MMSE).

STATISTICAL ANALYSIS

lineal multivariate regression analysis. Crossvalidation. ROC curves. Intraclass coefficient. Cronbach's alpha and Pearson's Correlation coefficient.

RESULTS

RDRS-2 scores by group were the following (mean and SD): Controls (18.95; 1.64), CIND (20.61; 2.88), and AD (28.96; 9.07). Results from regression analysis 282 demonstrated absence of influence of sociocultural variables such as age and education in RDRS-2 scores. Correlations with other instruments were as following: BDRS, r=0.820; IDDD, r=0.882; ADAS-Cog, r=0.762, and MMSE, r=0.742. Intraclass coefficient was 0.86 and Cronbach's alpha was 0.91. For the RDRS-2 the best cutoff score was 21 (82.88% sensitivity and 88.8% specificity). Area under the ROC curve was 0.92.

CONCLUSIONS

The Spanish adaptation of the RDRS-2 is free of sociocultural influence, and shows very adequate data on internal consistency and stability. Although not specifically designed for its use in AD it correlates highly and significantly with other functional scales as well as with the degree of cognitive impairment in AD.

Serum lipid levels and in-hospital mortality in patients with intracerebral hemorrhage

OBJECTIVE

To test the hypothesis that low serum cholesterol and low serum triglyceride levels at admission are related to an increase of in-hospital mortality in patients with first-ever supratentorial spontaneous intracerebral hemorrhage (ICH).

METHODS

The authors obtained the serum cholesterol and triglyceride levels during the first 48 hours after first-ever ICH in 184 patients. They analyzed the impact of serum cholesterol and triglyceride concentrations on the in-hospital mortality after adjustment for possible confounding variables according to the results of the univariate analysis (age, hemorrhage volume, intraventricular extension, glycemia, serum albumin, and Glasgow Coma Scale score at admission) using the Cox proportional hazards model. They also analyzed the survival curves according to the cholesterol and triglyceride quartiles.

RESULTS

Low serum cholesterol (p = 0.002; hazard ratio [HR] 0.988 [95% CI 0.979 to 0.997] mg/dL) and low serum triglyceride (p = 0.011; HR 0.986 [95% CI 0.976 to 0.997] mg/dL) concentrations were independently associated with increased in-hospital mortality after ICH. Analyzed by quartiles, the HR of in-hospital mortality was 3.136 (95% CI 0.833 to 11.087) for patients in the lowest cholesterol quartile (< 166 mg/dL) and 3.484 (95% CI 1.088 to 11.155) for patients in the lowest triglyceride quartile (< 74 mg/dL).

CONCLUSIONS

Low serum cholesterol and triglyceride levels obtained during the first hours after intracerebral hemorrhage (ICH) are strong independent predictors of in-hospital mortality in patients with spontaneous supratentorial ICH.

[Spanish version of the Memory Impairment Screen (MIS): normative data and discriminant validity]

OBJECTIVE

Present data on discriminative and normative validity for the Memory Impairment Screen (MIS) in a cross-sectional validation study within a dementia-clinic setting using a Spanish adaptation of the MIS. Assess its usefulness as a screening instrument for memory problems related to primary dementing disorders, foremost Alzheimer's Disease (AD).

MATERIAL AND METHODS

403 subjects, including 188 demented subjects according to DSM-IV criteria (119 of which presented AD according to NINCDS-ADRDA criteria) and 215 controls, over 50 years. The MIS, a four word memory test using a specific encoding technique and scoring on a 0-8 range, formed part of the neuropsychological workup, but it was not used for diagnosis. Sensitivity, specificity and predictive values positive (PPV) and negative (NPV) were calculated for the MIS against the gold-standard of clinical diagnosis by two blinded clinicians. ROC curves for the discrimination between demented subjects and controls, and AD subjects and controls were plotted.

RESULTS

Control subjects were significantly younger and better educated than the demented samples (p<0.001). No sex differences could be established. ROC curves demonstrated excellent discriminative validity of the MIS 402 for dementia on a whole (0.944) and even better for AD (0.978). The MIS presents satisfying results regarding sensitivity and specificity as well as PPV for different base rates, but the most effective cut-off score lies at < or = 4 points. For all demented subjects this cut-off represents a sensitivity of 0.74 and specificity of 0.96; for AD results are 0.86 and 0.96. More importantly, PPV values are above 0.65 for assumed base rates of 10% and more. Negative predictive values are almost 1 for all assumed base rates.

CONCLUSION

The Spanish version of the MIS reliably differentiates between normal and demented subjects. Nevertheless one has to consider the setting of the study when interpreting the results. The use of the S-MIS seems to be justified as first level dementia screening tool.

[Diagnostic value and test-retest reliability of the Blessed Dementia Rating Scale for Alzheimer's disease: data from the NORMACODEM project]

INTRODUCTION

This study aims to discover the criterion validity of the Blessed Dementia Rating Scale (BDRS) for the diagnosis of Alzheimer's disease. Different cut-off scores and corresponding diagnostic sensitivities and specificities were established. Test-retest reliability and internal consistency of the BDRS were also analyzed.

METHODS

SAMPLE

451 subjects were studied (254 controls, 86 subjects with mild cognitive impairment and 111 patients with Alzheimer's disease).

INSTRUMENTS

scores from different sections of the Blessed score were obtained. The global score (BBRS-Total) is the result of the sum of the three sections, A (changes in every day activities), B (changes in habits) and C (changes in personality). The sum of parts A and B (BDRS-Mod) were also quantified.

STATISTICS

ROC curves, intraclass correlation coefficient and Cronbach's alpha.

RESULTS

The best cut-off score for the BDRS-Total was 3.5 (sensitivity: 87.39%, and specificity: 90%). For the BDRS-Mod, the best cut-off score was 1.5 (sensitivity: 90%, and specificity: 89%). Area under the ROC curve was 0.964 and 0.963 respectively. Intraclass correlation coefficient was 0.98 and Cronbach's alpha was 0.925.

CONCLUSIONS

The BDRS has good discriminative validity in terms of sensitivity, specificity and predictive value. It also has good test-retest reliability and internal consistency.

Influence of age, sex, and education on the Visual Object and Space Perception Battery (VOSP) in a healthy normal elderly population

The assessment of visual perception and cognition forms an important part of any general cognitive evaluation. We have studied the possible influence of age, sex, and education on a normal elderly Spanish population (90 healthy subjects) in performance in visual perception tasks. To evaluate visual perception and cognition, we have used the subjects performance with The Visual Object and Space Perception Battery (VOSP). The test consists of 8 subtests: 4 measure visual object perception (Incomplete Letters, Silhouettes, Object Decision, and Progressive Silhouettes) while the other 4 measure visual space perception (Dot Counting, Position Discrimination, Number Location, and Cube Analysis). The statistical procedures employed were either simple or multiple linear regression analyses (subtests with normal distribution) and Mann-Whitney tests, followed by ANOVA with Scheffe correction (subtests without normal distribution). Age and sex were found to be significant modifying factors in the Silhouettes, Object Decision, Progressive Silhouettes, Position Discrimination, and Cube Analysis subtests. Educational level was found to be a significant predictor of function for the Silhouettes and Object Decision subtests. The results of the sample were adjusted in line with the differences observed. Our study also offers preliminary normative data for the administration of the VOSP to an elderly Spanish population. The results are discussed and compared with similar studies performed in different cultural backgrounds.

[Correlations between cognition and function in Alzheimer's disease: based on the abbreviated Barcelona Test (a-BT)]

INTRODUCTION

The objective is to establish the existence of possible correlations between cognitive measures using the a-BT, and functional measures in a population of normal to moderately severe demented subjects.

METHODS

A sample of 107 subjects (42 healthy controls, 19 subjects with mild cognitive impairment and 46 patients with probable Alzheimer's disease) were included in the present study. The instruments of the cognitive measure used was the abbreviated Barcelona Test (a-BT), a test of general cognitive function. Apart from that, the following functional scales, evaluating activities of daily living, were used: Rapid Disability Rating Scale-2 (RDRS-2), Blessed Dementia Rating Scale (BDRS), and Interview for Deterioration in Daily living in Dementia (IDDD). The statistical procedures were the correlations between cognitive and functional measures using Pearson's correlation coefficient.

RESULTS

The correlations obtained between the cognitive and all functional measures were all highly significant (p < 0.0001) and consistently high, with correlations ranging between 0.72 and 0.80. Correlations between the a-BT and functional measures of more basic activities of daily living (RDRS-2, BDRS) were lower than those that included instrumental and some advanced activities of daily living (IDDD).

DISCUSSION

The present paper establishes the existence of satisfactory correlations between the functional measures studied and the global scores of the a-BT. These correlations are applicable for groups of subjects with cognitive impairment that does not reach the threshold of a diagnosis of dementia as well as subjects suffering from Alzheimer's disease, at least up to moderately severe cases. The global score of the a-BT allows for some degree of prediction of the functional status of a subject with suspected Alzheimer's disease pathology evaluated.

[Preliminary normative data for the second edition of the Boston Naming Test for young Spanish adults]

INTRODUCTION

The Boston Naming Test (BNT) is one of the most widely used tests in neuropsychological evaluation of language disorders, specifically when testing for anomia. The aim of this study is to establish preliminary normative data for the second edition of the BNT for young spanish adults (age range between 20 and 49 years).

METHODS

A total of 160 subjects (60 % female and 40 % male) were administered the BNT. Mean age was 33.89 years (SD: 9.45) and average number of years of education was 13.98 (SD: 3.97). The version used in the present study is the second edition of the BNT (Kaplan et al., 2001) which includes two new components: multiple choice and error typology.

STATISTICAL ANALYSIS

Descriptive statistics of the test's variables. Lineal regression to establish the possible degree of influence of the variables age and education on test performance.

RESULTS

The sample's mean score was 51.84. Education significantly influences the final score (B: 0.476; p= 0.001). Multiple choice was effective in 89 % of cases.

DISCUSSION

The present results will allow proper clinical interpretation of results in the BNT 2001 version in young Spanish adults.

[Pneumatic retinopexy--method of choice in treatment of retinal detachment]

Authors are presenting their experience with pneumatic retinopexy (PR) in the therapy of primary rhegmatogenous retinal detachment. Technique was for the first time described by Hilton and Grizzard in 1986 as an intravitreal injection of expending gas in combination with transconjunctival cryotherapy or laser photocoagulation of retinal tears. After gas application a patient, particularly his head, must be positioned the way that the rising gas bubble perfectly seals the retinal tear. This also subretinal fluid to be reabsorbed. In the study group of 30 eyes, 11 were pseudophakic and 19 phakic. The reattachment after single PR operation was 77% (23 eyes), in 24% (7 eyes) of cases reoperation was needed. 2 cases required multiple injection of the gas, in 5 cases retinal reattachment after PR was never occurred. The most common causes of failure to reattach the retina were initiation and acceleration of proliferative vitreoretinopathy. In these cases a following operation was needed--most frequently pars plana vitrectomy with tamponading the vitreous cavity by gas or silicone oil. The final reattachment rate was then 94% (28 eyes), one patient refused reoperation, in one case retina remained detached. Pneumatic retinopexy is quite modest and time-saving operative technique which can be used in indicated cases as a one-day surgical procedure, which corresponds with current heading of the eye microsurgery. Although there is always the possibility of failure to reattach the retina using PR as a method of choice. The risk of failure can be significantly lowered by adequate selection of patients.

[Computer-assisted radiologic quantification of hand and foot changes in rheumatoid arthritis]

Driven by the increasing implementation of electronical picture archiving and communications system (PACS) into every days practice a fully operative Java application software was developed to support the efficacy of the scoring process in rheumatoid arthritis. This software, namely the "Rheuma-Coach" offers the possibility to use the Larsen- or the Ratingen-Score. We measured time savings of approximately 20% per case if this computer assistance was used. The lack of a standard for the positioning of limbs was confirmed.

[The hinged knee prosthesis: outdated design or valuable implant for difficult cases?]

There are excellent results after unconstraint or semiconstraint bi- or tricompartimental total knee arthroplasty in case of uncomplicated degenerative joint disease of the knee. In the Swedish knee study, cumulative survival of unconstraint or semiconstraint knee prostheses was about 90 % at 10 years. In studies of single institutions, survival rates of more than 90 % at 15 years are reported. However, there is a need of more constraint designs because of the increasing number of complex total knee arthroplasties with disrupted collateral ligaments, deformities with flexion extension gap imbalance, comminuted distal femur fracture, distal femoral non-union in elderly patients and revision with massive bone loss. Initial hinged total knee designs were associated with a high failure rate. More recent designs have improved the femorotibial articulation and reduced the polyethylene wear. The bone resection necessary in actual hinged designs is similar to the resection in modern condylar prostheses. Due to these improvements, long-term survival of the best hinged designs are similar to the best condylar designs. In our study of a consecutive series of 422 hinged Blauth prostheses, the cumulative survival of the prostheses was 94.4 % at 20 years. Therefore, the hinged knee prosthesis is a valuable implant in case of complex total knee arthroplasty.

Semantic verbal fluency of animals: a normative and predictive study in a Spanish population

Semantic verbal fluency is a very sensible but rather unspecific tool for the detection of neuropsychological deficits. This test is highly influenced by socio-cultural factors. Normative and predictive data for semantic verbal fluency of animals in a Spanish population are presented. The studied sample (n = 445) was stratified according to age and schooling. Statistical analysis reconfirmed a significant negative correlation (- 5.34) for age, and a significant positive correlation (5.34) for years of formal education. A predictive function for the production of names of animals during 1 min was established based on the subject's age and level of education: F(x) = 23.89 + age (- .144) + education (.39). The neuropsychological value and limitations of normative data and the predictive equation are discussed.

[Multimodal interdisciplinary therapy to improve function and long-term survival in patients with high-grade osteosarcoma of the extremities]

INTRODUCTION

The probability for survival of patients with highly malignant osteosarcoma of the extremities was essentially improved by (neo-)adjuvant chemotherapy. The goal was to further improve survival rates by introducing operative treatment of metastases. In the last 20 years, the percentage of limb-preserving operations has increased.

PATIENTS AND METHODS

A consecutive series of 23 patients with localized highly malignant osteosarcoma of the extremities received (neo-) adjuvant chemotherapy according to the Cooperative Osteosarcoma Study (COSS) protocol. Local treatment was performed by wide (22 patients) or radical (1 patient) resection (17 limb salvage procedures, 5 amputations, and 1 rotationplasty). In four of seven patients who developed pulmonary metastases, the metastases (up to four) were resected. The patients did not receive salvage chemotherapy.

RESULTS

The cumulative survival was 87% at 174 months. The four patients who underwent metastasectomy survived between 42 and 116 months without evidence of disease. One local recurrence developed outside the operative field and could be resected without influencing the functional or oncological outcome. After limb salvage procedures, the mean score according to the Musculoskeletal Tumor Society (MSTS) was 83%, and after rotationplasty 67%.

CONCLUSIONS

In patients with osteosarcoma of the extremities, limb salvage is possible in a high percentage of cases with a low risk of local recurrence by an effective interdisciplinary cooperation between diagnostic radiologists, oncologists, and orthopedic surgeons. The midterm survival could be improved by the multimodal therapy from about 20% up to about 80%. Metastasectomy gives patients with a limited number of pulmonary metastases a realistic chance to survive.

The surgical treatment of bony metastases of the spine and limbs

The skeleton is the most common site to be affected by metastatic cancer. The place of surgical treatment and of different techniques of reconstruction has not been clearly defined. We have studied the rate of survival of 94 patients and the results of the surgical treatment of 91 metastases of the limbs and pelvis, and 18 of the spine. Variables included the different primary tumours, the metastatic load at the time of operation, the surgical margin, and the different techniques of reconstruction. The survival rate was 0.54 at one year and 0.27 at three years. Absence of visceral metastases and of a pathological fracture, a time interval of more than three years between the diagnosis of cancer and that of the first skeletal metastasis, thyroid carcinoma, prostate carcinoma, renal-cell carcinoma, breast cancer, and plasmacytoma were positive variables with regard to survival. The metastatic load of the skeleton and the surgical margin were not of significant influence. In tumours of the limbs and pelvis, the local failure rate was 0% after biological reconstruction (10), 3.6% after cemented or uncemented osteosynthesis (28) and 1.8% after prosthetic replacement (53). The local failure rate after stabilisation of the spine (18) was 16.6%. There was local recurrence in seven patients (6.4%), and in four of these the primary tumour was a renal-cell carcinoma. The local recurrence rate was 0% after extralesional (24) and 8.2% after intralesional resection (85). Improvements in the oncological management of patients with primary and metastatic disease have resulted in an increased survival rate. In order to avoid additional surgery, it is essential to consider the expected time of survival of the reconstruction and, in bony metastases with a potentially poor response to radiotherapy, the surgical margin.

The surgical treatment of bony metastases of the spine and limbs

The skeleton is the most common site to be affected by metastatic cancer. The place of surgical treatment and of different techniques of reconstruction has not been clearly defined.

We have studied the rate of survival of 94 patients and the results of the surgical treatment of 91 metastases of the limbs and pelvis, and 18 of the spine. Variables included the different primary tumours, the metastatic load at the time of operation, the surgical margin, and the different techniques of reconstruction.

The survival rate was 0.54 at one year and 0.27 at three years. Absence of visceral metastases and of a pathological fracture, a time interval of more than three years between the diagnosis of cancer and that of the first skeletal metastasis, thyroid carcinoma, prostate carcinoma, renal-cell carcinoma, breast cancer, and plasmacytoma were positive variables with regard to survival. The metastatic load of the skeleton and the surgical margin were not of significant influence. In tumours of the limbs and pelvis, the local failure rate was 0% after biological reconstruction (10), 3.6% after cemented or uncemented osteosynthesis (28) and 1.8% after prosthetic replacement (53). The local failure rate after stabilisation of the spine (18) was 16.6%. There was local recurrence in seven patients (6.4%), and in four of these the primary tumour was a renal-cell carcinoma. The local recurrence rate was 0% after extralesional (24) and 8.2% after intralesional resection (85).

Improvements in the oncological management of patients with primary and metastatic disease have resulted in an increased survival rate. In order to avoid additional surgery, it is essential to consider the expected time of survival of the reconstruction and, in bony metastases with a potentially poor response to radiotherapy, the surgical margin.

[Catalan version of Barcelona Test's verbal subtests]

Test Barcelona. Bilingüismo catalán-castellano. Adaptación lingüística de instrumentos neuropsicológicos.

BACKGROUND AND OBJECTIVES

The present paper develops the Catalan version of the language subtests of the Barcelona Test (Peña-Casanova,1986) the original version of which was published in Spanish.

METHODS

To reach the Catalan version of the test it has been necessary to analyse the psycholinguistic variables of every item to then establish linguistically equivalent correlations.

RESULTS

There are some subtests for which no modifications have been needed. Nevertheless, and because of some psycholinguistic features of Catalan (Catalan's spelling is not completely free of ambiguity) some subtests have suffered substantial modifications. The following paper presents the justification of every modification based on the features of the Catalan language and also based on the original goals of the test. An appendix contains the final version of the Catalan adaptation for the language subtests of the Barcelona Test.

CONCLUSION

The present paper represents an advance in the assessment of neurological patients with language disfunctions. It will permit an appropiate assessment for the Spanish-Catalan bilingual patients.

[Technique and results of CT-guided percutaneous bone biopsy]

PURPOSE

The aim of the study was to evaluate the feasibility and results of CT-guided percutaneous bone biopsy (PBB) of unknown bone lesions in a representative number of patients.

METHODS

In 92 patients (100 biopsies) with different bone lesions CT-guided PBB was performed.

RESULTS

The rate of technical success, defined as a successful retrieval of a sufficient tissue sample which then was sent for histological evaluation, was 89% (89/100 biopsies). The diagnostic accuracy was defined as a clinically useful histological result and was obtained in 80% (80/100 biopsies). Minor complications (minimal bleedings) occurred in 3% of all biopsies, no special therapy was necessary. Osteolytic lesions (92%) were classified more accurately by PBB than osteoplastic (80%) or mixed lesions (67%). Considering the anticipated dignity of the lesions prior to PBB, the suspected malignant bone lesions had a better diagnostic accuracy of 82% than the suspected benign bone lesions with an accuracy of 50%.

CONCLUSION

Due to its universal availability combined with a low risk and a high diagnostic value the PBB of unknown bone lesions can be regarded as a valuable diagnostic tool. However, leave-me-alone lesions should be excluded.

Femoral revision with the Wagner SL revision stem : evaluation of one hundred and twenty-nine revisions followed for a mean of 4.8 years

BACKGROUND

It is difficult to achieve a successful revision total hip replacement when a patient has severe proximal femoral bone loss. The Wagner SL revision stem has some theoretical advantages, but the durability of this prosthesis is not known.

METHODS

We reviewed the results of 129 revisions of the femoral component with a Wagner SL revision stem in 123 patients. The indication for revision was aseptic loosening in ninety-seven hips, periprosthetic fracture in thirteen (one of which also had an infection), and septic loosening in sixteen. In the three remaining hips, a Wagner revision stem was inserted during a second-stage reimplantation after the performance of a Girdlestone resection arthroplasty to treat chronic deep infection. The prerevision defects were classified with the system described by Pak et al. as well as with our system. A functional evaluation of the patients and a survival analysis of the revision stems were performed.

RESULTS

The mean duration of follow-up was 4.8 years (range, two months to 11.1 years). Six revision stems required repeat revision. With removal of the stem for any cause or the worst case (removal of the stem for any cause and/or lost to follow-up) as the end point, cumulative survival at 11.1 years was 93.9% and 92.8%, respectively. The mean Merle d'Aubigné score improved from 7.7 points preoperatively to 14.8 points at the latest follow-up examination. The most recent radiographs showed good or excellent restoration of the proximal part of the femur in 113 hips (88%).

CONCLUSIONS

Because of the encouraging results of implantation of this femoral component with distal fixation, we will continue to use it in the majority of femoral revisions. However, the need for regular follow-up remains, since the rate of complications such as osteolysis of the femur, aseptic loosening, periprosthetic fracture, and late infection may increase in the future.

[Cement-free diaphyseal fixation principle for hip shaft exchange in large bone defects--analysis of 12 years experience with the Wagner revision shaft]

PURPOSE

Considering the increasing incidence of revision for failed total hip arthroplasty, we evaluated if the principle of uncemented diaphyseal fixation which is realised with the Wagner SL revision stem, can solve the technical problems of significant bone loss of the proximal femur and can offer good preconditions for bony restoration in the medium term.

METHODS

A consecutive series of 129 femoral revisions with the Wagner SL revisions stem was evaluated. In 87 cases, the acetabular component was revised simultaneously. The revision was indicated in 97 cases of aseptic loosening, in 13 periprosthetic fractures (12 aseptic and 1 septic hip), in 16 cases of septic loosening and in 3 Girdlestone-hips after chronic deep infection. At the time of revision, the mean age of the patients was 64.9 (36.7-86.3) years. For classification of the preoperative defects, both the classification system proposed by Pak et al. and our own classification system were used.

RESULTS

The mean period of time between operation and latest follow-up examination, rerevision, or death of the patient was 5.4 years (0.13-11.7 years). Six revision stems required rerevision because of malpositioning (1), significant subsidence (1), periprosthetic fracture (1), and deep infection (3). The mean Merle d'Aubigné score improved from preoperatively 7.7 points to 14.8 at follow-up. Cumulative survival (end point removal of the stem for any cause) was 94.4 percent at 11.7 years. A clear, good, or excellent bony restoration of the proximal femur was seen in 87.6 percent of the cases. The cumulative survival of the revised acetabular components was 97.7 percent at 11.7 years and for the non-revised cups it was 86.9 percent at 10.9 years.

CONCLUSION

Due to the encouraging results with the Wagner revision stem, the principle of uncemented diaphyseal fixation seems to us to be able to solve most of the technical problems in cases of significant bone loss and obviously offers good preconditions for bony restoration. Our own classification system was effective and useful for preoperative planning.

Adult Gaucher disease in association with primary malignant bone tumors

BACKGROUND

Malignant neoplastic disorders are more common in patients with Gaucher disease (GD) than in the general population. Very few cases of primary malignant bone tumors in association with GD have been reported to date. Thus, the recommendations for an adequate therapy are often based on limited professional experience. To their knowledge, the authors report the first case of a leiomyosarcoma of the bone in a patient with GD and report another patient with GD and an anaplastic large cell non-Hodgkin lymphoma with localized osseous manifestation. A review of the literature is included.

METHODS

The clinical, radiologic, and histologic data of the authors' two patients who had GD and primary malignant bone tumor are presented. Epidemiologic data, clinical data, and treatment results from published reports of 18 patients who had GD and various malignancies and the authors' 2 patients were compared and evaluated.

RESULTS

Radiographic examination showed a destructive osteolytic lesion in a case of a leiomyosarcoma of the bone and in a case of anaplastic, large-cell, non-Hodgkin lymphoma. In both cases, the bone marrow architecture was partially effaced by sheets of large histiocytic cells with striated or fibrillary cytoplasm. In both patients, chemotherapy was performed. Whereas the patient who had the leiomyosarcoma showed poor recovery of the bone marrow that necessitated withdrawal of aggressive chemotherapy, the patient who had non-Hodgkin lymphoma and enzyme therapy tolerated the chemotherapy well. In spite of local control after preoperative radiotherapy and hemipelvectomy, the first patient developed lung metastases and finally died. The second patient was continuously free of disease at a follow-up examination 32 months after chemotherapy and radiotherapy. In a total of 20 patients who had malignant disorders and GD, the numbers of males and females were equivalent, and the mean age was 55 years. Approximately 33% presented with a cancer originating in the bone. In 16 patients, follow-up data were available. Of these, after a mean follow-up of 36 months (range, few days-108 mos), only 2 patients were continuously free of disease, and one patient was alive with disease. The other patients had died of disease or hemorrhagic complications of GD.

CONCLUSIONS

Because there is a relatively high incidence of malignant disorders of the bone, the study suggested that malignant disorders have to be included in the differential diagnosis of painful lytic lesions in patients who have GD. Evaluation of the expense and value of enzyme therapy to patients who have GD should be undertaken with regard to the incidence of malignant disorders and patient survival.

[Acquired dyslexias and dysgraphias under the prism of cognitive neuropsychology: a model for the Spanish language]

The present paper discusses the different clinical manifestations of acquired disorders of reading and writing from a neurocognitive viewpoint. Based on a specific functional architecture of reading and writing--a cognitive model; presented as well--the different syndromes of acquired dyslexias and dysgraphias, that have been described in the specialized literature during the last 25 years, will be reviewed. The different pathologies are distributed along three different functional axes: a plurimodal component, including the semantic system, for the description of peripheric disorders of reading and writing; a lexical block which is justified by the findings in patients with surface dyslexia/dysgraphia; and a third, sublexical component, in order to illustrate the different functional impairments in phonological dyslexia/dysgraphia. Following the description of syndromes due to selective "functional lesions", we discuss deep dyslexia/dysgraphia, a syndrome due to multiple functional lesions. All of the syndromes will be justified and discussed with respect to the different components of the functional architecture presented and are based on cases of the literature and personal observations. Concluding remarks will evaluate the new insights gained by the presented functional arquitecture in relation to other cognitive models for the analysis of reading aloud and writing to dictation of single words.

Mortality after total knee arthroplasty in patients with osteoarthrosis and rheumatoid arthritis

Total knee arthroplasty (TKA) is a widely used procedure in the treatment of severe destruction of the knee joint because of osteoarthrosis (OA) or rheumatoid arthritis (RA). The aim of this study was to explore whether there is an increased mortality in patients after TKA with the underlying diagnosis OA or RA compared with the general population. We studied a consecutive series of 422 primary TKAs with a hinged Blauth prosthesis in 330 patients (OA: 208 patients, 175 women, 33 men; RA: 122 patients, 109 women, 13 men) with a mean follow-up of 6 years (range 0-20 years). The mean age of the patients at the time of surgery was 70 years (range 29-87 years), being 72 years (range 46-87 years) for OA, and 66 years (range 29-84 years) for RA. Age standardized mortality ratios (SMRs) were calculated for OA and RA. In patients with OA, the SMR was 1.03 (95% CI 0.76-1.37) for women and 1.14 (95% CI 0.68-1.80) for men. SMRs of patients suffering from RA showed a clear shortening of the life span (women: 2.92, 95% CI 2.17-3.85; men: 3.09, 95% CI 1.0-7.19). In spite of the risk of intra- and perioperative complications and further operative procedures necessary because of late complications, the implantation of a knee prosthesis per se does not necessarily significantly reduce the life expectancy in patients with OA. Patients with RA who require the implantation of a total knee prosthesis obviously represent a high-risk group with a high mortality rate.

[Neuropsychological exploration in frontotemporal degeneration]

The present paper discusses the neuropsychological assessment in fronto-temporal lobe degeneration. Having established the neuroanatomical and functional basis for the discussion the major syndromes included in the concept of frontotemporal degeneration are reviewed from a neuropsychological standpoint. With reference to fronto-temporal dementia the different frontal or executive function tests and their limitations are discussed. With reference to progressive aphasia and semantic dementia we differentiate the distinct language profiles as observed in aphasia batteries and general neuropsychological tests. Reference is made to especially useful tests for the differentiation of the two syndromes from each other, as well as from other primary progressive disorders. Concluding remarks postulate a series of axis of cognitive function in fronto-temporal lobe degenerations, which exist at the functional as well as the anatomical level and along which the different syndromes evolve.

The Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in young adults

The results were evaluated for 29 adult patients (33 hips) who had undergone a Salter innominate osteotomy because of painful developmental dysplasia of the hip (DDH). The mean age at the time of the index operation was 24.8 years (range 19-35 years), and the mean duration of follow-up was 3.5 years (range 2-8 years). Complications included one non-union and one dislocation of the osteotomy after a fall; both patients had to undergo re-operation. The mean Harris hip score improved from 65 points preoperatively to 82 points at the latest follow-up examination. In hips with no coxarthrosis (n = 11), the mean Harris hip score improved from 78 points to 89 points; in hips with coxarthrosis grade 1 (n = 15), it improved from 59 points to 85 points, while in hips with coxarthrosis grade 2 (n = 7), it improved only from 57 to 68 points. There was a diminution of coxarthrosis in 11 hips, no change in 17, and worsening in 5 hips. The mean center-edge angle of Wiberg was 11.2 deg (range 0-19 deg) preoperatively compared with 27.4 deg (range 21-37.5 deg) postoperatively and 27.6 deg at the latest follow-up examination. Our findings demonstrate that the Salter innominate osteotomy provides clinical improvement as well as radiographic improvement in adult patients with DDH, and this procedure is, compared with more complex pelvic osteotomies, a relatively simple and safe procedure with a low risk of complications.

Phase II study of oral trofosfamide as palliative therapy in pretreated patients with metastatic soft-tissue sarcoma

This phase II study investigated the activity of continuously administered oral trofosfamide in chemotherapy-pretreated patients with metastatic soft-tissue sarcoma (STS). Trosfosfamide is an oxazaphosphorine with ifosfamide as the predominant metabolite. Eighteen patients with a median age of 60 years were treated with trofosfamide given as continuous oral treatment. Starting dose was 300 mg/day for 7 days and subsequently 150 mg/day. All patients had previously received at least one chemotherapy regimen including doxorubicin and ifosfamide. Three patients achieved partial responses (18%) and nine a disease stabilization (53%) for an overall response rate of 18% (95% CI: 0.5-35%). Median progression-free interval was 4 months (0-17 months) and median overall survival was 10 months (4-39+) months. Toxicity was generally mild. Only one WHO grade III nausea, but no other non-hematologic WHO grade III/IV toxicity occurred. Leukopenia WHO grade III/IV was observed in four patients (22%). No thrombocytopenia <50,000/microl and no neutropenic infection was seen. Continuously administered oral trofosfamide is a well-tolerated palliative treatment in anthracycline/oxazaphosphorin-pretreated patients with advanced STS achieving responses and/or disease stabilization in up to 70% of patients.

Acetabular revision with allograft bone. 103 revisions with 3 reconstruction alternatives, followed for 0.3-13 years

We reviewed 103 consecutive acetabular revisions in 92 patients, for whom allograft bone and 1 of 3 alternative acetabular components had been used: Harris-Galante cup (HGC, 38 hips), Müller acetabular roof reinforcement ring (ARR, 39 hips), or Burch-Schneider antiprotrusio reinforcement cage (APC, 26 hips). The mean follow-up was 4.5 (0.3-13) years. 7 HGCs, 1 ARR, and 1 APC required revision because of aseptic loosening. Using the endpoint revision because of such loosening, the HGC gave 73% survival after 8 years, the ARR 89% after 13 years, and the APC 94% after 11 years. Using a worst-case criterion, survival was 69% for the HGC after 8 years, 84% for the ARR after 13 years, and 83% for the APC after 11 years. Radiographic incorporation of the allograft, no resorption of the allograft, use of a bulk allograft, male gender, and implantation of a reinforcement device were associated with a lower mechanical failure rate. Good durability of allograft bone in reconstructions of bone deficiencies in acetabular revision surgery can be expected when the implant can bridge the temporary period of mechanical weakness of the allograft. Therefore, in severe acetabular deficiencies, reinforcement devices with sufficiently stable fixation in the host bone should be preferred.

[Giant cell tumor of bone. Morphological, immunohistochemical, morphometric and DNA flow cytometric findings]

Giant cell tumour (GCT) of bone is a locally aggressive tumour with a high rate of recurrence if not completely excised. The present study was undertaken to clarify whether flow cytometric, immunohistochemical and morphometric studies can be a useful tool to assess the prognosis of patients with GCT. DNA flow cytometry, cell cycle studies and immunohistochemical investigations with antibodies against CD 68, CD 34, p53 and Ki67 were performed on paraffin embedded tissue of 10 cases of GCT. As a further possible prognostic parameter angiogenesis within the tumour was investigated using an automatic image analysis system. Histologically 4 cases were grade 1 tumours and 6 cases grade 2. Among the Grade 1 cases, all were diploid. Of the Grade 2 cases, 4 were diploid and 2 were aneuploid. Both of the patients with an aneuploid tumour developed a loval recurrence. All GCT revealed large numbers of CD 68 positive giant cells, but mononuclear tumour cells exhibiting CD 68 immunoreactivity were also present. Corresponding to the immunohistochemical findings with MIB-1 the flow cytometric DNA histogram revealed high proliferation rates (mean value 14.9%). None of the tumours exhibited p53 immunoreactive cells. All cases showed high content of vessels with on the average relative vessel area of 7.7%. No correlation between clinical outcome and vascular parameters (number of vessels, vessel area, perimeter) was found. Our findings suggest that DNA flow cytometry is useful in predicting tumour behaviour in some cases. GCT exhibits extensive angiogenesis, but none of the vascular parameters investigated was found to be of prognostic value.

Differentiation of benign and malignant tumors of the parotid gland: value of pulsed Doppler and color Doppler sonography

To establish criteria for the differentiation of benign and malignant tumors of the parotid gland using color Doppler sonography (CDS) and pulsed Doppler sonography (PDS) we examined 37 patients with parotid tumors by gray-scale ultrasound, CDS, and PDS. Tumor vascularization displayed by CDS was graded subjectively on a 4-point scale (0 = no vascularization, 3 = high vascularization). From the Doppler spectrum, the highest systolic peak flow velocity, the resistive index (RI), and the pulsatility index (PI) were calculated. There were 11 malignant and 26 benign tumors. Tumor vascularization by CDS was grade 0 or 1 in 88.5% of benign lesions, whereas it was grade 2 or 3 in 82% of malignant lesions (P < 0.0001). The highest systolic peak flow velocity was statistically significantly higher in malignant lesions than in benign lesions. Using a threshold systolic peak flow velocity of 25 cm/s, sensitivity was 72% and specificity was 88% for the detection of a malignant tumor. Evaluation of tumor vascularization by CDS and PDS cannot differentiate between benign and malignant parotid tumors with certainty. However, high vascularization and high systolic peak flow velocity in tumor vessels should raise the suspicion of malignancy, even if tumor morphology on gray-scale sonography indicates a benign lesion.

Re-implantation of autoclaved bone segments in musculoskeletal tumor surgery. Clinical experience in 9 patients followed for 1.1-8.4 years and review of the literature

Nine patients who had malignant bone tumors of the lower extremity were managed with wide en bloc resection and re-implantation of the extracorporeally autoclaved specimens. The segments were fixed by plate osteosynthesis, knee arthrodesis rod, or intramedullary nails. In one patient the complete femur was re-implanted. After a mean follow-up of 66 months (range 13-101 months), 8 out of 9 patients were still free of disease. One patient with Ewing's sarcoma and re-implantation of the complete femur died of systemic recurrence. No local recurrence was seen. One patient with Ewing's sarcoma of the tibia who had undergone postoperative irradiation developed a local infection 18 months postoperatively which finally had to be treated by knee disarticulation. After an average duration of 13 months, all graft-host junctions had healed. The functional result of the patient with the knee disarticulation was poor. In all other patients, the functional outcome was good or excellent. The evaluation of 115 patients (106 from the literature, 9 from our study) with a mean follow-up of 63 months showed 8 local recurrences. There were 4 secondary infections and only 1 primary infection. In tumors of the extremities and the pelvis, the functional outcome was excellent or good in about 80%. Limb salvage using re-implantation of autoclaved tumor-bearing bone segments for reconstruction has a low complication rate and good functional results in appropriately selected patients compared with other options of management.

Clinical validity and utility of the interview for deterioration of daily living in dementia for Spanish-speaking communities NORMACODEM Group

The assessment of activities of daily living is a central procedure in the diagnosis of dementia. Few instruments in the field allow for early detection of functional decline because the items they use refer mainly to basic activities of daily living (BADL), which do not become compromised until later in the disease process. The Interview for Deterioration of Daily Living in Dementia (IDDD) may be a valuable tool for early detection of functional decline because it includes, apart from a BADL subscale, another subscale containing a variety of instrumental activities of daily living (LADL), which are the first to be affected in dementing processes. We present an adaptation and validation of the IDDD for Spanish-speaking communities (S-IDDD). A total of 254 control subjects (CONT), 86 patients with mild memory/cognitive impairment with no dementia (CIND), and 111 patients diagnosed with probable dementia of the Alzheimer type (DAT) participated in this project. IDDD total scores (mean and SD) were as follow: CONT: 33.1 (0.4); CIND: 35.2 (3.4); DAT: 54.3 (18.6). The present validation showed no sociodemographic effects on the IDDD total scores. The IDDD demonstrated great internal consistency (alpha = .985) and reproducibility (intraclass correlation coefficient = .94). Correlations were high (r = .81; p < .1) when they took into account the whole sample, but decreased significantly when the groups were separated by pathologic condition. The scale showed significant differences between DAT versus CIND and CONT. The IADL subscale differentiated all three groups, which makes it extremely valuable for early detection of functional decline. The present study shows that the S-IDDD is a reliable adaptation of the original IDDD scale and may be used successfully in Spanish populations for staging and follow-up of subjects with dementia.