Bariatric surgery in liver cirrhosis

Introduction

Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.

Material and Methods

Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.

Results

Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation.

Conclusion

BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Effective Ligand Design: Zinc Complexes with Guanidine Hydroquinoline Ligands for Fast Lactide Polymerization and Chemical Recycling

Invited for this month's cover is the group of Sonja Herres-Pawlis at RWTH Aachen University. The image shows how the zinc guanidine complexes help a circular economy of bioplastics by mediating the ring-opening polymerization of lactide and the depolymerization of polylactide (PLA). The Research Article itself is available at 10.1002/cssc.202201075.

Effective Ligand Design: Zinc Complexes with Guanidine Hydroquinoline Ligands for Fast Lactide Polymerization and Chemical Recycling

In this study, the synthesis of two new guanidine hydroquinoline ligands served as basis for six new zinc guanidine complexes. Two of these complexes showed very high activity in the lactide polymerization under industrial conditions. The lactide polymerization was demonstrated in solution and melt conditions observing high activity and molar masses up to 90 000 g mol^-1 . Density functional theory studies elucidated the high activity of the complexes associated with the influence of the ligand backbone and the use of triflate counterions. On the way towards a circular economy, polymerization and depolymerization go hand in hand. So far, guanidine complexes have only shown their good activity in the ring opening polymerization of esters, and guanidine complexes with pure N donors have not been tested in recycling processes. Herein, the excellent ability of zinc guanidine complexes to catalyze both polymerization and depolymerization was demonstrated. The two most promising zinc complexes efficiently mediated the methanolysis of polylactide into methyl lactate under mild reaction conditions.

Spacecraft sample collection and subsurface excavation of asteroid (101955) Bennu

Carbonaceous asteroids, such as (101955) Bennu, preserve material from the early Solar System, including volatile compounds and organic molecules. We report spacecraft imaging and spectral data collected during and after retrieval of a sample from Bennu’s surface. The sampling event mobilized rocks and dust into a debris plume, excavating a 9-m-long elliptical crater. This exposed material that is darker, spectrally redder, and more abundant in fine particulates than the original surface. The bulk density of the displaced subsurface material was 500–700 kg per cubic meter, about half that of the whole asteroid. Particulates that landed on instrument optics spectrally resemble aqueously altered carbonaceous meteorites. The spacecraft stored 250 ± 101 g of material, which will be delivered to Earth in 2023.

Surgeon and surgical conference attendee views on live surgery events

Based on the principles of biomedical ethics, the authors conducted a survey focusing on the ethical aspects of, didactic benefits of and possible alternatives to live surgery events. This work provides an investigation of the ethics of live surgery events in an interdisciplinary and multicentre setting. Critical ethical concerns regarding the justification of such events are highlighted through evaluation of attendees and surgeons.

Ecological momentary intervention to reduce suicide risk among adolescents (EMIRA)

Suicide is among the leading causes of death among adolescents and suicide risk is particularly high after discharge from psychiatric inpatient care. Therefore, interventions to reduce suicidal thoughts and behaviours (STBs) among adolescents discharged from psychiatric inpatient care are integral for successful suicide prevention among this group. However, such interventions are scarce. EMIRA aims to close this important gap in mental health services by developing an ecological momentary intervention (i.e., intervention delivered in real-time and within one's natural setting) consisting of a personalized, automatically triggered crisis support smartphone app to reduce STBs after discharge from psychiatric inpatient care among adolescents aged 14-21 years at risk for suicide. First, we will conduct qualitative interviews with adolescents aged 14-21 years who previously experienced STBs, their parents and health care providers to identify their intervention needs and safety concerns regarding ecological momentary assessment (EMA). Next, we will investigate the short-term variability of STBs and their cognitive and physiological risk factors among adolescents aged 14-21 years using EMA (app-based self-report + wrist worn device). Based on our results and past research we will develop a personalized crisis support smartphone app (mobile safety planning) that is not only self-accessible but starts automatically based on the presence of pre-identified STB risk factors. Finally, we will conduct two consecutive studies to test the feasibility, efficacy and cost-effectiveness of the developed ecological momentary intervention in reducing STBs after discharge from psychiatric inpatient care among adolescents aged 14-21 years at risk for suicide. EMIRA has great potential to close a crucial gap in adolescent mental health services and significantly improve suicide prevention among this group.

[Implementation of the principle of supported employment in Germany : Position paper of a task force of the DGPPN]

The effects of mental diseases on the employment and working situation can be substantial. They are one of the main reasons for inability to work and reduced earning capacity. Against this background the question arises about suitable occupational reintegration measures for people with severe mental illnesses. In recent years, the principle of supported employment has been internationally shown to be increasingly more successful. In this context mentally ill people are primarily placed at a position of the first employment market and supported on-site by a job coach. This concept is inclusive, individual and evidence based. Despite proven effectiveness, it has so far been insufficiently implemented in German-speaking regions. In the future it will be a matter of considering the individual needs for assistance of mentally ill people more intensively than previously and to respond with functional and in a best-case scenario, multiprofessional and flexible offers.

An enhanced prognostic score for overall survival of patients with cancer derived from a large real-world cohort

BACKGROUND

By understanding prognostic biomarkers, we gain insights into disease biology and may improve design, conduct, and data analysis of clinical trials and real-world data. In this context, we used the Flatiron Health Electronic Health Record-derived deidentified database that provides treatment outcome and biomarker data from >280 oncology centers in the USA, organized into 17 cohorts defined by cancer type.

PATIENTS AND METHODS

In 122 694 patients, we analyzed demographic, clinical, routine hematology, and blood chemistry parameters within a Cox proportional hazard framework to derive a multivariable prognostic risk model for overall survival (OS), the 'Real wOrld PROgnostic score (ROPRO)'. We validated ROPRO in two independent phase I and III clinical studies.

RESULTS

A total of 27 variables contributed independently and homogeneously across cancer indications to OS. In the largest cohort (advanced non-small-cell lung cancer), for example, patients with elevated ROPRO scores (upper 10%) had a 7.91-fold (95% confidence interval 7.45-8.39) increased death hazard compared with patients with low scores (lower 10%). Median survival was 23.9 months (23.3-24.5) in the lowest ROPRO quartile Q1, 14.8 months (14.4-15.2) in Q2, 9.4 months (9.1-9.7) in Q3, and 4.7 months (4.6-4.8) in Q4. The ROPRO model performance indicators [C-index = 0.747 (standard error 0.001), 3-month area under the curve (AUC) = 0.822 (0.819-0.825)] strongly outperformed those of the Royal Marsden Hospital Score [C-index = 0.54 (standard error 0.0005), 3-month AUC = 0.579 (0.577-0.581)]. We confirmed the high prognostic relevance of ROPRO in clinical Phase 1 and III trials.

CONCLUSIONS

The ROPRO provides improved prognostic power for OS. In oncology clinical development, it has great potential for applications in patient stratification, patient enrichment strategies, data interpretation, and early decision-making in clinical studies.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination

BACKGROUND

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

METHODS

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

RESULTS

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

CONCLUSIONS

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Prefrontal cognitive deficits in patients with schizophrenia treated with atypical or conventional antipsychotics

Forty-three patients with schizophrenia were investigated with a short neurocognitive screening battery focussing on working memory and executive functions. As compared to healthy controls, patients showed impairments in the modified card sorting test, in verbal fluency and all span tasks with exception of digit span forward. Patients who were treated with atypicals showed better performance in the digit ordering test (manipulation task) when compared to a group of patients who received conventional antipsychotics; this difference was not due to disease severity, age or education. Manipulation tasks might be useful for neurocognitive follow-up and intervention studies.

EPA guidance on the quality of mental health services

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

Lazy Sundays: role of day of the week and reactivity on objectively measured physical activity in older people

Background

The aim of this study was to assess the effect of day of the week and wearing a device (reactivity) on objectively measured physical activity (PA) in older people.

Methods

Walking duration as a measure for PA was recorded from 1333 German community-dwelling older people (≥65 years, 43.8% women) over 5 days using accelerometers (activPAL). Least-square means of PA with 95%-confidence intervals (95%-CI) from multi-level analysis were calculated for each day of the week and each measurement day (days after sensor attachment).

Results

Walking duration on Sundays was significantly lower compared to working days (Sunday vs. Monday-Friday: − 12.8 min (95%-CI: − 14.7; − 10.9)). No statistically significant difference compared to working days was present for Saturdays. The linear slope for measurement day and walking duration was marginal and not statistically significant.

Conclusions

Studies using PA sensors in older people should assess Sundays and working days to adequately determine the activity level of the participants.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery

AIM

Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers.

METHOD

This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement.

RESULTS

Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring.

CONCLUSION

A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

[Scientific development of critical care : Position paper]

Demographic changes in Germany means that nursing and medical care is becoming increasingly complex. This is especially true for intensive care. Despite the closure of hospitals in Germany, the number of beds in intensive care units rose between 2002 from 23,113 to 26,162 in 2010. At the same time the number of patients treated in intensive care units increased by 148,989 to 2,049,888. The increasing complexity requires specific education for nurses in intensive care based on a model of advanced nursing practice (ANP). Nursing experts who fulfill an advanced practise nursing are competent to make decisions autonomously and accountably within complex care situations. This includes decisions such as artificial ventilation, weaning, nutrition management and the management of delirium, wounds and pain. Nursing experts are responsible for specific clearly defined areas of care and initiate nurse-led services and practice. Scientific and research based evidence are transferred directly into health care practice and can be implemented directly. The DGF demands a scientific and with it academic development of critical care as advanced nursing practice based on a master level qualification. This also includes the request for expansion of competencies and roles and the assignment of decision making authority within complex health care situations and an orientation on the Competencies for European Critical Care Nurses of the European Federation of Critical Care Nursing Associations (EfCCNa).

Cohort-level disease prediction by extrapolation of individual-level predictions in transition dairy cattle

Dairy cattle experience metabolic stress during the transition from late gestation to early lactation resulting in higher risk for several economically important diseases (e.g. mastitis, metritis, and ketosis). Metabolic stress is described as a physiological state composed of 3 processes: nutrient metabolism, oxidative stress, and inflammation. Current strategies for monitoring transition cow nutrient metabolism include assessment of plasma non-esterified fatty acids and beta-hydroxybutyrate concentrations around the time of calving. Although this method is effective at identifying cows with higher disease risk, there is often not enough time to implement intervention strategies to prevent health disorders from occurring around the time of calving. Previously, we published predictive models for early lactation diseases at the individual cow level at dry-off. However, it is unknown if predictive probabilities from individual-level models can be aggregated to the cohort level to predict cohort-level incidence. Therefore, our objective was to test different data aggregation methods using previously published models that represented the 3 components of metabolic stress (nutrient metabolism, oxidative stress, and inflammation). We included 277 cows from five Michigan dairy herds for this prospective cohort study. On each farm, two to four calving cohorts were formed, totaling 18 cohorts. We measured biomarker data at dry-off and followed the cows until 30 days post-parturition for cohort disease incidence, which was defined as the number of cows: 1) having one or more clinical transition disease outcome, and/or 2) having an adverse health event (abortion or death of calf or cow) within each cohort. We tested three different aggregation methods that we refer to as the p-central, p-dispersion, and p-count methods. For the p-central method, we calculated the averaged predicted probability within each cohort. For the p-dispersion method, we calculated the standard deviation of the predicted probabilities within a cohort. For the p-count method, we counted the number of cows above a specified threshold of predicted probability within each cohort. We built four sets of models: one for each aggregation method and one that included all three aggregation methods (p-combined method). We found that the p-dispersion method was the only method that produced viable predictive models. However, these models tended to overestimate incidence in cohorts with low observed counts and underestimate risk in cohorts with high observed counts.

Predictive models for early lactation diseases in transition dairy cattle at dry-off

During the transition period, dairy cattle undergo tremendous metabolic and physiological changes to prepare for milk synthesis and secretion. Failure to sufficiently regulate these changes may lead to metabolic stress, which increases risk of transition diseases. Metabolic stress is defined as a physiological state consisting of 3 components: aberrant nutrient metabolism, oxidative stress, and inflammation. Current monitoring methods to detect cows experiencing metabolic stress involve measuring biomarkers for nutrient metabolism. However, these biomarkers, including non-esterified fatty acids, beta-hydroxybutyrate, and calcium are typically measured a few weeks before to a few days after calving. This is a retroactive approach, because there is little time to integrate interventions that remediate metabolic stress in the current cohort. Our objective was to determine if biomarkers of metabolic stress measured at dry-off are predictive of transition disease risk. We designed a prospective cohort study carried out on 5 Michigan dairy farms (N = 277 cows). We followed cows from dry-off to 30 days post-calving. Diseases and adverse outcomes were grouped in an aggregate outcome that included mastitis, metritis, retained placenta, ketosis, lameness, pneumonia, milk fever, displaced abomasum, abortion, and death of the calf or the cow. We used best subsets selection to select candidate models for four different sets of models: one set for each component of metabolic stress (nutrient metabolism, oxidative stress, and inflammation), and a combined model that included all 3 components. We used model averaging to obtain averaged predicted probabilities across each model set. We hypothesized that the averaged predictions from the combined model set with all 3 components of metabolic stress would be more effective at predicting disease than each individual component model set. The area under the curve estimated using receiver operator characteristic curves for the combined model set (0.93; 95% confidence interval [CI] = 0.90-0.96) was significantly higher compared with averaged predictions from the inflammation (0.87; 95% CI = 0.83-0.91), oxidative stress (0.78; 95% CI = 0.72-0.84), and nutrient metabolism (0.73; 95% CI = 0.67-0.79) model sets (p < 0.05). Our results indicate that it may be possible to detect cattle at risk for some transition diseases as early as dry-off. This has important implications for disease prevention, as earlier identification of cows at risk of health disorders will allow for earlier implementation of intervention strategies. A limitation of the current study is that we did not perform external validation. Future validation studies are needed to confirm our findings.

[The German Association for Psychiatry, Psychotherapy and Psychosomatics participation compass II : Implementation of social participation for people with mental illnesses]

For most people living with mental illnesses, participating in society is of existential importance; however, psychosocial care often fails to recognize its significance and therefore rarely includes the patient's interaction with society in the course of treatment. The reasons for this are both substantial and organizational in nature. The endless opportunities for participating in society, current areas as well as ways of taking part in social life even beyond the terms of the social legislative definition are, in addition to institutional variety and regional differences, all too often barriers to providing the very urgently needed support. Further aspects are insufficient knowledge of therapists about established options of rehabilitative treatment and about responsibilities related to participation in specialized training and further education for professional caregivers. The presented compass of participation for social integration of persons with mental illnesses starts at this point: it provides guidelines for psychiatric and psychotherapeutic practitioners, general practitioners as well as for physicians working in residential or day care institutions with a psychiatric and psychotherapeutic background. Both this article and planned online versions should help professionals to timely and successfully assist people, particularly those with severe mental illnesses, to navigate the broad spectrum of services for social and vocational integration in Germany.

Development and multicentre validation of a prognostic model to predict resectability of pancreatic head malignancy

Background

At the time of planned pancreatoduodenectomy patients frequently undergo exploratory laparotomy without resection, leading to delayed systemic therapy. This study aimed to develop and validate a prognostic model for the preoperative prediction of resectability of pancreatic head tumours.

Methods

This was a retrospective study of patients undergoing attempted resection for confirmed malignant tumours of the pancreatic head in a university hospital in Hannover, Germany. The prognostic value of patient and tumour characteristics was investigated in a multivariable logistic regression model. External validation was performed using data from two other centres.

Results

Some 109 patients were included in the development cohort, with 51 and 175 patients in the two validation cohorts. Eighty patients (73·4 per cent) in the development cohort underwent resection, and 37 (73 per cent) and 141 (80·6 per cent) in the validation cohorts. The main reasons for performing no resection in the development cohort were: local invasion of vasculature or arterial abutment (15 patients, 52 per cent), and liver (12, 41 per cent), peritoneal (8, 28 per cent) and aortocaval lymph node (6, 21 per cent) metastases. The final model contained the following variables: time to surgery (odds ratio (OR) 0·99, 95 per cent c.i. 0·98 to 0·99), carbohydrate antigen 19-9 concentration (OR 0·99, 0·99 to 0·99), jaundice (OR 4·45, 1·21 to 16·36) and back pain (OR 0·02, 0·00 to 0·22), with an area under the receiver operating characteristic (ROC) curve (AUROC) of 0·918 in the development cohort. AUROC values were 0·813 and 0·761 in the validation cohorts. The positive predictive value of the final model for prediction of resectability was 98·0 per cent in the development cohort, and 91·7 and 94·7 per cent in the two external validation cohorts. [Corrections added on 18 July 2018, after first online publication: The figures for OR of the variables time to surgery and CA19-9 in the abstract and in Table 3 and Table 4 were amended from 1·00 to 0·99].

Conclusion

For preoperative prediction of the likelihood of resectability of pancreatic head tumours, this validated model is a valuable addition to CT findings.

Modelle für eine zukunftsfähige psychiatrische Versorgung

Die Psychiatrische Versorgungslandschaft steht vor großen Herausforderungen: einerseits steigt die Inanspruchnahme psychiatrisch-psychotherapeutischer Leistungen, andererseits wird auf diesem Hintergrund eine teilweise schon reale und zum Teil noch erwartete Ressour-cenverknappung deutlich. Seit Jahren gibt es Bestrebungen, die Ausgabensteigerung zu begrenzen. Ebenfalls seit Jahren zeigt sich ein Mangel an qualifizierten Mitarbeitern, der in der Berufsgruppe der Ärzte vielfach schon spürbar ist, in der Pflege für die nahe Zukunft prognostiziert wird. Hinzu kommt der vielbeschriebene demografische Wandel, der neben einer Zunahme von älteren Nutzern auch mit einer Zunahme an alternden Helfern einhergehen wird. Aufbauend auf diesen Herausforderungen beschreibt der Beitrag die Aspekte, die für ein zukunftsfähiges psychiatrisches Versorgungssystem aus Sicht der Autoren zu bedenken sind und wendet sich dann bestehenden Versorgungsmodellen zu, die als Antwortversuche auf diese Fragestellungen verstanden werden können. Zum Abschluss werden die sich daraus entwickelnden Zukunftsperspektiven umrissen und ein Ausblick auf eine gesundheitsfördernde psychiatrische Versorgungslandschaft gegeben.

[Robotic pylorus-preserving pancreaticoduodenectomy : Video article]

Pylorus-preserving pancreaticoduodenectomy is one of the most complex procedures in general surgery. Laparoscopic pancreaticoduodenectomy was initially described in 1994; however, its worldwide distribution is so far limited to only a few specialist centers. Robotic surgery using the DaVinci® system can overcome many limitations of laparoscopic surgery. The system is a promising tool for a more widespread introduction of minimally invasive surgery for pancreatic diseases. Mortality rates of 0-5% and pancreatic fistula rates of 0-35% are described in the literature; therefore, thorough complication management is crucial in the postoperative course. The video presents a robotic pylorus-preserving pancreaticoduodenectomy for periampullary carcinoma in a female patient.

Duodenal intussusception of the remnant stomach after biliopancreatic diversion: a case report

Background

We present a rare case of an antegrade intussusception of the remnant stomach four years after a biliopancreatic diversion.

Case presentation

A 55-year-old female patient presented with epigastric pain in our emergency room. Laboratory parameters showed an anemia as well as elevated transaminases and hyperbilirubinemia. The CT scan showed an intussusception of the remnant stomach into the duodenum followed by cholestasis. At laparotomy the remnant stomach was resected.

Conclusion

Bowel obstruction and intussusception after bariatric surgery are a rare but often unrecognized complication. Sonography as well as a CT scan should be performed. The exploratory laparoscopy however is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations.

Eight-plate epiphysiodesis

Aims

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates.

Patients and Methods

A retrospective study was performed including 42 children at a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion in the proximal tibia for correction of coronal plane deformities or LLD between 2007 and 2015. A total of 64 plates were inserted; 48 plates (34 patients) were inserted to correct angular deformities and 16 plates (8 patients) for LLD. Medical records, Picture Archive and Communication System images, and conventional radiographs were reviewed. Measurements included interscrew angle, lateral and medial plateau slope angles measured between the plateau surface and the line between the ends of the physis, and tibial plateau roof angle defined as 180° minus the sum of both plateau angles. Measurements were compared between radiographs performed adjacent to surgery and those at latest follow-up, and between operated and non-operated plateaus. Statistical analysis was performed using BMDP Statistical Software.

Results

Slope angle increased in 31 (49.2%) of operated epiphyses by a mean of 5° (1° to 23°) compared with 29 (31.9%) in non-operated epiphyses (p = 0.043). Roof angle decreased in 29 (46.0%) of operated tibias and in 25 (27.5%) of non-operated ones by a mean of 5° (1° to 18°) (p = 0.028). Slope angle change frequency was similar in patients with LLD, varus and valgus correction (p = 0.37) but roof angle changes were slightly more frequent in LLD (p = 0.059) and correlated with the change in inter screw angles (r = 0.74, p = 0.001).

Conclusion

The use of eight-plates in the proximal tibia for deformity correction and limb-length equalization causes a change in the bony morphology of the tibial plateau in a significant number of patients and the effect is more pronounced in the correction of LLD. Cite this article: Bone Joint J 2018;100-B:1112–16.

[Performance of prehospital emergency anesthesia and airway management : An online survey]

BACKGROUND

The goal of rapid sequence induction (RSI) in cases of emergency situations is to secure the airway as quickly as possible to prevent pulmonary aspiration of gastric contents; however, the technique itself is not standardized. For example, the choice of drugs, application of cricoid pressure and the patient position remain controversial. A survey of emergency medical services (EMS) physicians throughout Germany was carried out to assess the different RSI techniques used and with respect to complying with the national guidelines for emergency airway management anesthesia and local standard operating procedures (SOP).

MATERIAL AND METHODS

Between 1 April 2017 and 31 May 2017, EMS medical directors in Germany were contacted and asked to distribute a 28-question online questionnaire to local EMS physicians. Of the questions 26 were multiple choice and 2 with plain text. After 6 weeks an e‑mail reminder was sent. In addition, the survey was distributed via social media to EMS physicians.

RESULTS

In total the survey was opened 2314 times and 1074 completed responses were received (completion rate 46%). Most of the participants were male (78%) and anesthesiologists (70%) and only one quarter had a local SOP for RSI. The most frequently used muscle relaxant was succinylcholine (62%) and over half of the participants reported using cricoid pressure (57%). There was a distinction between the specialist disciplines in the selection of drugs. Propofol was used most by anesthesiologists, while the others still used etomidate on a larger scale. Nearly 100% could fall back on supraglottic devices (one third laryngeal mask, two thirds laryngeal tube) but only 32.8% with the recommended esophageal drainage. A video laryngoscope was available to 51% of all EMS physicians surveyed.

CONCLUSION

The results of the survey demonstrate heterogeneity in RSI techniques used by EMS physicians in Germany. Medical equipment and safe care practices, such as labeling of syringes varied considerably between different service areas. The recommendations of the S1 national guidelines on emergency airway management and anesthesia should be adhered to together with the implementation of local SOPs.

Differences in the placebo response in duloxetine and venlafaxine trials

OBJECTIVE

Our analysis aimed at comparing the placebo effect sizes from randomized controlled trials (RCTs) of two widely prescribed antidepressants, namely duloxetine and venlafaxine, and at analysing a potential influence of the investigated drugs on the placebo response.

METHOD

We conducted a comprehensive systematic review and meta-analysis of placebo-controlled, double-blind RCTs, which examined the efficacy of duloxetine and venlafaxine in the acute treatment of major depressive disorder.

RESULTS

We included 71 studies (29 duloxetine trials and 43 venlafaxine trials; one study provided data for the duloxetine and the venlafaxine data set). The placebo effect sizes, defined as pre-postscore change divided by baseline standard deviation, differed significantly between venlafaxine and duloxetine studies (-2.51 vs. -2.09; test for subgroup differences P = 0.028; high heterogeneity). The analysis of effect modifiers and the metaregression analyses confirmed the drug, next to baseline depression severity and publication status, as the most influential independent predictor.

CONCLUSION

Our analyses show a significant difference in the placebo response between venlafaxine and duloxetine trials and suggest that the investigated drug has an influence on the placebo response that is not related to baseline severity, changes over the years or other variables we included.