Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

PATHOLOGIC FINDINGS IN GENDER-AFFIRMING MASTECTOMY: A SYSTEMATIC REVIEW

Following increased cultural awareness, expanded access to care, and decreased stigmatization, the number of transgender individuals seeking gender affirmation surgery such as gender-affirmation mastectomy (GAM) continues to rise. While post-mastectomy breast tissue is often sent for pathologic evaluation, few studies address the utility and standardization of this practice. This literature review evaluates the pathology findings in GAM specimens reported in the medical literature. A systematic review following PRISMA guidelines was performed to evaluate all medical publications related to pathology reports following GAM. The overall type and incidence of benign and malignant breast lesions were analyzed to elucidate which patient characteristics significantly affect the pathology findings. Overall, eight of 488 identified studies met inclusion criteria (1278 patients). The incidence of pre-malignant lesions was 2.42%, including flat epithelial atypia (0.08%), atypical hyperplasia (0.23%), atypical ductal hyperplasia (1.33%), atypical lobular hyperplasia (0.39%), and lobular carcinoma in situ (0.39%).Patient age, hormonal therapy, and family / patient history of breast cancer were inconsistently reported among included studies. Lack of standardized pathologic classification did not permit further statistical analysis. Although patients who undergo GAM are unlikely to have premalignant or malignant findings on breast pathology examination, pathologic evaluation of breast tissue remains common practice. Additional studies, which include a standardized method of pathologic evaluation, are necessary before practice guidelines can be recommended.

Use of PET-CT in diagnostic workup of periprosthetic infection of hip and knee joints: significance in detecting additional infectious focus

Introduction

The diagnosis and management of periprosthetic knee and hip infections as well as the identification and management of possible additional infectious foci is of great importance for successful therapy. This study analyses the importance of ¹⁸F deoxyglucose PET-CT (PET-CT) in the identification of additional infectious focus and subsequent impact on management of periprosthetic infection (PPI).

Material and methods

A retrospective analysis of the clinical data and findings in the period from January 2008 to December 2018 was carried out. One hundred and four patients with in-hospital treatment due to PPI of a hip or knee joint were identified and included in this study. All patients underwent a standardized clinical examination and further surgical and antibiotic therapy. The reevaluation of performed PET-CTs was specifically carried out with regard to the local PPI or detection of secondary foci.

Results

PET-CT successfully verified the PPI in 84.2% of the patients. A total of 78 possible additional foci were detected in PET-CT in 56 (53.8%) of the examined patients. Predilection sites for possible secondary foci were joints (42.3%), pulmonary (15.4%), ear-nose-throat (15.4%), spine (11.5%), and the musculocutaneous tissues (11.5%). Fifty-four positive PET-CT findings were confirmed clinically with need of additional adequate treatment.

Conclusion

PET-CT is a valuable diagnostic tool to confirm periprosthetic joint infection. At the same time, the whole-body PET/CT may detect additional foci of infection with impact on subsequent treatment strategy. PET was of special value in detecting infections at distant locations far from the primary infected joint in significant number. These distant infection locations can be potential cause of a re-infection. This clearly reflects the need of their diagnosis.

BCG scarring and improved child survival: a combined analysis of studies of BCG scarring

Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) is recommended at birth in TB-endemic areas. Currently, BCG vaccination programmes use "BCG vaccination coverage by 12 months of age" as the performance indicator. Previous studies suggest that BCG-vaccinated children, who develop a scar, have better overall survival compared with BCG-vaccinated children, who do not develop a scar. We summarized the available studies of BCG scarring and child survival. A structured literature search for studies with original data and analysis of BCG scarring and mortality were performed. Combined analyses on the effect of BCG scarring on overall mortality. We identified six studies covering seven cohorts, all from Guinea-Bissau, West Africa, with evaluation of BCG scarring amongst BCG-vaccinated children and follow-up for mortality. Determinants of BCG scarring were BCG strain, intradermal injection route, size of injection wheal, and co-administered vaccines and micronutrients. In a combined analysis, having a BCG scar vs. no BCG scar was associated with a mortality rate ratio (MRR) of 0.61 (95% CI: 0.51-0.74). The proportion with a BCG scar varied from 52 to 93%; the estimated effect of a BCG scar was not associated with the scar prevalence. The effect was strongest in the first (MRR = 0.48 (0.37-0.62)) and second (MRR = 0.63 (0.44-0.92)) year of life, and in children BCG-vaccinated in the neonatal period (MRR = 0.45 (0.36-0.55)). The effect was not explained by protection against TB. Confounding and genetic factors are unlikely to explain the strong association between BCG scarring and subsequent survival. Including "BCG scar prevalence" as a BCG vaccination programme performance indicator should be considered. The effect of revaccinating scar-negative children should be studied.

Tailored intervention with peer-to-peer as a tool to promote childhood vaccination in migrants

Background

A tailored intervention about childhood vaccination in Stockholm, Sweden, has focused on different activities with the aim to improve vaccination confidence and in particular Measles, Mumps and Rubella (MMR) vaccination coverage. The intervention included provided peer education focusing on vaccination information, the vaccine-preventable diseases, child development and communication skills in Somali and Swedish language and for the peers to further inform other parents in their communities.

Aim

This study aims to explore peers’ experiences of the interventions and their role to promote vaccination confidence.

Methods

This study follows a qualitative methodology with in-depth interviews and the data collection is ongoing. The study participants consist of seven peers who participated in the program. The interviews aimed to explore how the peers used the training in real life. All interviews conducted were tape-recorded and transcribed verbatim in order to facilitate deep content analysis. The analysis followed a content analysis, by first coding the data and then developing categories and emerging themes.

Results

Preliminary findings show that peers expressed the importance of having a training that equipped them with knowledge and confidence to discuss fact-based information with hesitant parents. The peers shared that after the training they had several opportunities to talk about childhood vaccinations in particular MMR vaccination with other parents. Some peers took an active role in reaching other parents by utilising the film and the cards to facilitate their dialogue. Other also acknowledged that when they could not answer a specific question, they encouraged the parents to address the query with the child health clinic nurses.

Conclusions

The use of a peer-to-peer concept to increase vaccination confidence provides additional forums for parents to dialogue about their concerns and receive correct vaccination information.

Key messages

Tailored interventions in close collaboration with communities are crucial for sustainable improvements of vaccination acceptance and coverage. The peer-to-peer concept provides a new arena to reach vaccination hesitant parents and can complement the communication on vaccination from health care provides.

[Bone marrow edema-differential diagnosis of the femoral head necrosis]

In patients with hip pain, clinical examination is of only restricted value in the differential diagnosis. Besides a patient's age, their medical history is often helpful in finding the correct diagnosis. Additionally, imaging can give valuable hints for excluding or validating a differential diagnosis. Nowadays, magnetic resonance imaging (MRI) is often used as a primary imaging modality in Germany. These MRIs show a bone marrow edema (BME) in many different pathologies. BME occurs in transitory bone marrow edema and outside of the atraumatic femoral head necrosis, concomitant with coxarthrosis, arthritis, herniation pit, and osteoid osteoma, amongst other conditions. This article describes several frequent differential diagnoses and gives hints on how to find the correct diagnosis.

[Challenges of primary hip arthroplasty with high hip dislocation]

BACKGROUND

Endoprosthetic care of high hip dislocation is a surgical challenge. The hip anatomy is greatly altered in these patients, including a rather flat and small acetabulum with impaired bone quality and a relevant chance of a bony defect of the acetabular roof. Additionally, the front coverage and in some cases even the dorsal coverage of the hip are missing. The proximal femur is characterized with an increased antetorsion, a coxa valga position and an enlarged greater trochanter. The medullary cavity is narrowed, the offset is reduced, and the absolut leg length can be enlarged. Further anatomic variations can have been caused by previous surgeries.

AIM OF THE TREATMENT

The goal of the endoprosthetic care is the re-creation of a hip with an anatomic center of rotation, an anatomic offset and equal leg length.

TREATMENT

This can be achieved by a medial shift of the acetabular cup. An acetabular osteotomy including central cancellous bone graft or a bony graft to reinforce the acetabular roof might be necessary. In cases in which an anatomic acetabular cup placement is not possible, a more cranial placement can be done. Further strategies that are essential in several cases are shortening or re-orientation osteotomies of the femur, reaming of the medullary cavity and correct implant selection. Additionally, thorough soft tissue management is of main importance. Generally, the surgery should be well prepared preoperatively.

Low-grade infections as a possible cause of arthrofibrosis after total knee arthroplasty

Purpose

Arthrofibrosis after total knee arthroplasty represents a considerable burden for the patient and a therapeutic challenge for the practitioner. One possible cause discussed in the literature is a low-grade infection. This hypothesis should be examined within the scope of this retrospective study.

Patients and methods

Nineteen patients with clinical symptoms of arthrofibrosis after primary total knee arthroplasty were examined between January, 1999 and January, 2012. Incorrect positioning was radiologically ruled out. All patients were examined clinically (score of Freeman as well as Blauth and Jäger), radiologically (component and leg alignment, patella height according to Insall and Salvati), microbiologically (culture-based procedures), molecular biologically (PCR) and histologically in the course of an open revision of the prosthesis.

Results

According to the score of Freeman et al. (1977), a highly significant improvement in pain (p = 0.007) and in the overall score (p = 0.003) was shown. The knee joint mobility did not change significantly (p = 0.795). PCR was negative in 17 patients. One patient showed a PCR-positive result of the synovial membrane for Corynebacterium spp., while Staphylococcus warneri was detected in the culture. Another patient had a positive result of synovia PCR for Enterococcus cecorum as well as Corynebacterium spp. However, this culture was sterile. In 16 patient samples, no bacterial growth was detectable. Two samples were not evaluable. The main histopathological findings were synovialitis and fibrosis.

Conclusion

The hypothesis of low-grade-infection-induced arthrofibrosis after total knee arthroplasty could not be confirmed in this study. However, based on this small study population the conclusion needs to be confirmed by new and larger studies, ideally prospectively designed including a control group.

Metabolite profiles evaluated, according to sex, do not predict resting energy expenditure and lean body mass in healthy non-obese subjects

PURPOSE

Differences in resting energy expenditure (REE) between men and women mainly result from sex-related differences in lean body mass (LBM). So far, a little is known about whether REE and LBM are reflected by a distinct human metabolite profile. Therefore, we aimed to identify plasma and urine metabolite patterns that are associated with REE and LBM of healthy subjects.

METHODS

We investigated 301 healthy male and female subjects (18-80 years) under standardized conditions in the cross-sectional KarMeN (Karlsruhe Metabolomics and Nutrition) study. REE was determined by indirect calorimetry and LBM by dual X-ray absorptiometry. Fasting blood and 24 h urine samples were analyzed by targeted and non-targeted metabolomics methods using GC × GC-MS, GC-MS, LC-MS, and NMR. Data were evaluated by predictive modeling of combined data using different machine learning algorithms, namely SVM, glmnet, and PLS.

RESULTS

When evaluating data of men and women combined, we were able to predict REE and LBM with high accuracy (> 90%). This, however, was a clear effect of sex, which is supported by the high degree of overlap in identified important metabolites for LBM, REE, and sex, respectively. The applied machine learning algorithms did not reveal a metabolite pattern predictive of REE or LBM, when analyzing data for men and women, separately.

CONCLUSIONS

We could not identify a sex independent predictive metabolite pattern for REE or LBM. REE and LBM have no impact on plasma and urine metabolite profiles in the KarMeN Study participants. Studies applying metabolomics in healthy humans need to consider sex specific data evaluation.

Cyclophosphamide, Adriamycin and Platinum (CAP) Combination Chemotherapy, A New Effective Approach in the Treatment of Disseminated Breast Cancer. Preliminary Report

The prospective controlled Phase III clinical trial tested the therapeutic value of the cis-platinum-adriamycin-cyclophosphamide combination (CAP), compared with the combination including cyclophosphamide, methotrexate, 5-fluorouracil, vincristine and prednisolone (CMFVP), in untreated metastatic breast cancer. One hundred and twenty-three patients (> 2 cycles) were evaluated: 61 on the CAP, and 62 on the CMFVP schedule. An objective response (CR+PR) to CAP combination chemotherapy was achieved in 72% of patients (43/61), with a high rate (36%) of complete remissions. In terms of metastatic site, the response rate appeared to be particularly high in soft tissue and visceral organ (lung, liver) metastases. In the CMFVP group, an objective response was noted in 26 of 62 patients (42%), with 16% complete remissions. The difference in overall therapeutic response - and in the complete remission rate as well - was statistically significant to the advantage of the CAP regimen (P < 0.01). The duration of remissions was 6-28 + months (mean = 14) for the CAP, and 4-15+ months (mean = 9) for the CMFVP schedule. Toxic side effects were more pronounced in the CAP group, particularly myelosuppression, with anemia prevailing. Side effects to CMFVP treatment were moderate. In 39 CMFVP previously treated cases, CAP was administered as second-line treatment, and an objective response was observed in 51% of cases (20/39). Results of this controlled trial showed the advantage of the CAP combination chemotherapy in the treatment of metastatic breast cancer.

High Doses of 5-Fluorouracil and Epirubicin with or without Cisplatin in Advanced Gastric Cancer: A Randomized Study

Background

A prospective randomized clinical study was performed in patients with locally advanced or metastatic gastric cancer. The purpose of the study was to determine the activity of high doses of 5-fluorouracil and epirubicin (FE) vs the same combination + cisplatin (FEP), and particularly the value of cisplatin in the combination.

Patients and Methods

A total of 122 patients was included in the study; 110 of them were assessable. In the FE arm, the treatment involved 1000 mg/m2 in a 6-hr infusion of 5-fluorouracil on days 1, 2, 3, 4 and 5 and 120 mg/m2 of epirubicin iv on day 1. In the FEP arm, the same combination of cytostatics + cisplatin (30 mg/m2) was administered on days 2 and 4. The cycles were repeated after 4 weeks. Altogether, 468 cycles of chemotherapy were given (FE, 240; FEP, 228).

Results

In the FE arm, 56 patients were assessable, with 2 complete and 14 partial remissions (28.6%); in the FEP arm, 4 complete and 19 partial remissions (42.6%) were observed in 54 assessable patients. Median survival in the FE group was 7.1 months and in the FEP group 9.6 months. The survival difference was statistically significant (Cox's test, P<0.05). The most frequent side effects included grade 2 and 3 alopecia (FE, 93%; FEP, 94%) and grade 2 and 3 vomiting (FE, 20%; FEP, 35%). Grade 3 and 4 leukopenia was observed in 9% of patients in the FE group and in 13% of patients in the FEP group, with 6 cases of febrile neutropenia (FE, 4%; FEP, 7%). Stenocardia was registered in 1 patient in the FE group and in 2 patients in the FEP group. No treatment-related death was registered.

Conclusions

The addition of cisplatin to high doses of 5-fluorouracil and epirubicin resulted in a statistically significant better survival of treated patients.

Open Phase II with 5-Fluorouracil, 4-Epi-Doxorubicin and Mitomycin C (Fem) in Advanced Gastric Cancer

Forty-four patients with advanced gastric cancer were treated with a combination including 5-fluorouracil, 4-epi-doxorubicin and mitomycin C. 4-Epi-doxorubicin was substituted for adriamycin in MacDonald's original schedule. The combined treatment involved 600 mg/m2 i.v. of 5-fluorouracil on days 1, 8, 29 and 36; 80 mg/m2 i.v. of 4-epi-doxorubicin on days 1 and 29; and 10 g/m2 i.v. of mitomycin C on day 1. The cycle was repeated on day 57 after the start of treatment. Out of 44 patients, 39 were evaluable. Thirteen partial remissions (33 %) were achieved. The average duration of remission was 7 months (range, 3–12 months). The average survival of the responders was 9 months, and that of nonresponders 3.5 months. Toxicity was moderate, well-tolerated and, as compared with the FAM schedule, less pronounced, particularly as regards myelotoxicity. Thus, the substitution of 4-epi-doxorubicin for adriamycin in the original schedule of MacDonald et al. (1980) did not improve treatment results, but the observed toxicity was less pronounced.

Methylprednisolone as an Antiemetic in Patients on Cis-Platinum Chemotherapy. Results of a Controlled Randomized Study

In cytostatic drug treatment, nausea and vomiting are very frequent, unpleasent and undesirable side effects that cause considerable discomfort to the patient. However, many established antiemetics (Torecan, haloperidol, Valium, Largactil etc.) have not shown significant antiemetic activity in the patients to whom cytostatics were applied. In our controlled randomized clinical trial, the antiemetic activity of methylprednisolone was investigated and compared with placebo (10 ml saline) and Torecan. All the compounds were injected before cis-platinum administration, knowing that this agent induces vomiting in almost 100% of patients. Ninety patients entered the study and have been evaluated. The results of the trial have shown that methylprednisolone in the single dose of 250 mg applied i.v. 2 h before injection of a cytostatic agent experienced pronounced antiemetic activity in 48% of the patients (15/31), as compared to Torecan 21% (6/29) and placebo 13% (4/30). This difference was statistically significant (P < 0.01). No side effects were recorded after methylprednisolone application. The results of the study showed that methylprednisolone possesses a pronounced antiemetic activity in almost half of the patients treated with cis-platinum.

Adriamycin Alone and in Combination with Radiotherapy in the Treatment of Inoperable Esophageal Cancer

Thirty-three patients with inoperable esophageal cancer were treated in a randomized study. There were 24 squamous cell, 2 anaplastic, 4 unclassified, and 3 adenocarcinomas. Eighteen patients were treated with 6 cycles of adriamycin with a 3 week rest period between cycles. Adriamycin was administered in doses of 40 mg/m2 body surface daily for 2 days during each cycle. The other group of 15 patients were treated with both adriamycin and radiation. The tumor was irradiated with speed electrons (4500–5200 rads total dose), and during irradiation, 3 cycles of adriamycin were given. All patients previously had had no treatment. In the group of patients treated with adriamycin, the response rate (> 50 % tumor regression) was 33 % (6/18) with 1 complete and 5 partial remissions. In the combined treatment group, there were 4 complete and 5 partial remissions (9/15) with a response rate of 60 %. In both groups of patients, remissions were obtained in the squamous cell carcinomas, except 1 patient with anaplastic carcinoma in the adriamycin-treated group, and 1 adenocarcinoma in the combined treated group. Remissions lasted 2–12 months (M = 3.2 months) in the adriamycin-treated group and 3–15 months (M = 8.6 months) in the combined treatment group. There were no significant differences in the toxic side effects, except a slightly increased myelodepression in the combined treatment modality. One patient of the combined treatment group showed a potentiation of radiation dermititis. The results obtained show that adriamycin does have an antitumor effect on esophageal (squamous cell) carcinoma, which so far has not been proven. Significantly better results with longer remission duration can be obtained when both adriamycin and radiation are combined.

The Value of Two Combined Chemoradiotherapy Approaches in the Treatment of Inoperable Esophageal Cancer

The antitumor activity of 5-fluorouracil (5-FU), combined either with bleomycin or adriamycin plus radiation, was studied in a controlled randomized clinical trial. Sixty-one previously untreated inoperable esophageal cancer patients entered the study and 56 have been evaluated: 58 male and 3 female patints with a mean age of 57 years (range 37–74). Concerning localization of the tumors in the esophagus, 2 were in the upper third, 36 in the middle third and 18 in the lower third. The length of the filling defects in the esophagogram (X-ray) was in 9 patients < 5 cm, in 31 5–8 cm, and in 16 patients > 8 cm. Squamous cell carcinoma was found in 51 patients, adenocarcinoma in 3, and anaplastic (squamous cell) carcinoma in 2 patients. Modality A consisted of a combination of 5-FU (10 mg/kg i.v. 2 × weekly, 4 weeks) and bleomycin (10 mg/m2 i.v., 2 × 4 weeks) which was given concurrently with radiation (3600–4000 rad - 1000 rad weekly). In modality B the combination of 5-FU (same dose) and adriamycin (30 mg/m2 i.v. day 1, 2, 23 and 24) was applied with the same schedule and dosage of radiation. Seventy-five percent of the patients (21/28) have responded to treatment (CR + PR) in modality A, with 11 complete and 10 partial responses. In arm B, response was recorded in 64 % of patients (18/28), with 2 complete and 16 partial responses. The difference in complete responses (39 % vs 8 %) was statistically significant (P < 0.05). The median remission duration in complete responders was 12 months in modality A (range 6–18 months), and 6.8 months in modality B (range 3–10 months). All the responses occurred in patients with squamous cell carcinoma, except one partial response in a case of adenocarcinoma. As far as the age is concerned (< 55 vs > 55 years), no significant difference in response rate was found (67 % vs 71 %). More favorable results were observed in the group of patients with < 10 % weight loss (79 % vs 63 %). Toxicity was moderate (myelosuppression, cardiotoxicity), but one treatment-related death (pulmonary fibrosis, cardiac failure) was recorded in arm A, as well as one death (rupture of aorta) in group B. Approximately 60 % of patients in both modalities suffered from severe mucositis and retrosternal pain. The results of the study showed that the combination of 5-FU with adriamycin and particularly with bleomycin, given concurrently with lower radiation dosage, is an effective palliative treatment for inoperable esophageal cancer.

Histologic and Cytologic Liver Changes in 120 Patients with Malignant Lymphomas

The purpose of this study was to determine the frequency of liver involvement in malignant lymphomas. Non-specific liver changes were also registered. Percutaneous liver biopsy was performed on 120 patients with untreated malignant lymphomas. There were 38 patients with Hodgkin's disease, 42 with histiocytic and 40 with lymphocytic lymphomas. AH the biopsy specimens were histologically and cytologically analyzed. Positive liver findings (lymphomatous infiltration) were observed in 27.5% of patients with lymphocytic, 23.8% with histiocytic lymphomas, and 7.8% with Hodgkin's disease. Liver involvement in non-Hodgkin's lymphomas was significantly higher (P < 0.025) than in Hodgkin's disease. In the whole group of patients, there were non-specific liver changes: 23 chronic persistent hepatitis, 5 aggressive hepatitis, 9 liver steatosis and 4 liver hemosiderosis. Based on these results, it can be concluded that liver involvement with lymphomatous tissue is more common in non-Hodgkin's lymphomas. Knowledge of this is relevant for clinical staging and the treatment program. These findings also confirm that percutaneous liver biopsy is a valuable diagnostic procedure in the staging of malignant lymphomas.

Therapy of Advanced Esophageal Cancer with Bleomycin, Irradiation and Combination of Bleomycin with Irradiation

Results from treating 51 patients with advanced esophageal cancer are presented. Fifteen patients were treated with Bleomycin, 12 with radiotherapy, and 24 with a combination of Bleomycin and radiotherapy. The best results were achieved in the group of patients treated with combined therapy showing 62% objective remissions (15/24) which was statistically significant (P < 0.001) in comparison to the other groups. In the Bleomycin therapy group, there were 26% objective remissions (4/15), and in the group treated only with radiotherapy 33% (4/12). The median duration of remission was 9 months in the combined therapy group, 6.3 months in the group treated with radiotherapy, and 2.6 months in the Bleomycin treated group. The authors concluded that the combination of Bleomycin and radiotherapy seems to be a further step in palliative treatment of advanced esophageal cancer.

Bleomycin Infusions Combined with Radiotherapy in the Treatment of Inoperable Esophageal Cancer

A combination of bleomycin, in a 12 h infusion, and radiotherapy was applied in 25 patients with untreated inoperable esophageal cancer. Bleomycin was administered 15 mg/m2 twice weekly, concurrently with irradiation (total dose 3600–4000 rad). Such combined treatment produced 3 complete remissions of the esophageal tumor, 10 partial remissions (response rate 52 % - 13/25), 3 stable disease cases, while in 9 cases the disease progressed in spite of therapy. The median duration of remissions was 8.7 months in complete responders, 6.0 months in partial responders, and 3.0 months in stable disease cases. Similarly, median survival was the longest in complete remission cases (10.3 months). Patients who did not respond to therapy had a median survival of only 2.8 months. Adverse treatment reactions were of a milder character, except retrosternal pain and burning caused by irradiation mucositis, which occurred in 80 % of patients. The trial showed that the combination of bleomycin applied in the form of 12 h infusion and irradiation can produce remissions in 50 % of inoperable esophageal cancer cases, i.e., a rate of remission which is similar to that achieved by irradiation and bleomycin applied in the form of rapid (push) i.v. injections.

Combination Chemotherapy with 1-Methyl-1-Nitrosourea and Cyclophosphamide in Metastatic Melanoma

Twenty one patients with advanced metastatic melanoma were treated with a combination of 1-methyl-1-nitrosourea (MNU) and cyclophosphamide. AH the patients had not previously been treated with cytostatics. MNU in the dose of 4 mg/kg and cyclophosphamide in the dose of 8 mg/kg body weight was administered daily. The drugs were given in 6 day cycles. Objective response (> 50% tumor regression) was obtained in 8 (38%) of the 21 treated patients, with 2 complete and 6 partial remissions. The duration of remission was 2–12 months (M = 6.2 months). Injections of MNU caused nausea and vomiting in approximately all the treated patients. Combination of these drugs, however, produced myelodepression in 33% of treated patients. This combination of drugs showed antitumor activity in metastatic malignant melanoma, particularly in melanoma metastasis of the lung, brain and lymph nodes and needs further investigation.

Preliminary Report on Antitumorigenic Activity of CIS-Dichlorodiamine Platinum in Metastatic Brain Tumors

In spite of pharmacokinetic studies, which have shown that only cis-DDP traces are found in brain tissue, cytotoxic activity of this drug in primary brain tumors has recently been reported. The purpose of our study was to examine whether cis-DDP also has antitumor properties in metastatic brain tumors. Twelve consecutive untreated patients with brain metastases recorded by CAT scans or radionuclide scans plus neurologic examinations underwent the treatment. Histology of primaries revealed 4 bronchial, 3 breast, 1 gastric, 1 colorectal carcinoma, 2 melanomas, and 1 soft tissue sarcoma. Cis-DDP was administered at the doses of 30 mg/m2 body surface daily for 4 days. All the patients were evaluated. Objective response (3 complete and 2 partial remissions) was observed in 5 of 12 patients (response rate 42%). Three stable disease cases were also noted; however, in the remaining 4 patients the disease in the brain progressed. Complete response (5 months) was observed in a breast cancer patient, in a melanoma (4+ months), and in a microcellular bronchial cancer (2+ months). Two partial responses (lung, breast) lasted 2+ and 2+ months. Toxicity was moderate but tolerable for the patients. The preliminary results of this study show that cis-DDP posesses antitumorigenic properties also in patients with metastatic brain tumors, which has not been proved till now.

A water-soluble, bay-functionalized perylenediimide derivative - correlating aggregation and excited state dynamics

The aggregation and the photophysics of a water soluble perylenediimide (PDI) derivative that features two bromine substituents in the bay positions has been probed. Non-fluorescent aggregates were found to be present at concentrations of 1.0 × 10^-5 M. In situ small-angle X-ray scattering (SAXS) measurements and complementary molecular modeling showed the presence of PDI aggregates. In their singlet excited states, the PDI aggregates are characterized by distinct transient fingerprints and rapid deactivation, as revealed by pump-probe experiments on the femto-, pico-, nano-, and microsecond timescales. The product of this deactivation is a PDI triplet excited state. The efficiency of the triplet formation depends on the concentration, and hence on the degree of aggregation. Notably, for PDI concentrations in the range of the critical micelle concentration, the efficiency of intersystem crossing is close to zero. In short, we have demonstrated, for the first time, aggregation-induced formation of triplet excited states for PDI derivatives.

Atypische Femurfraktur bei liegender Hüfttotalendoprothese unter langjähriger Bisphophonat-Therapie

Der vorliegende Fall beschreibt das Auftreten von Oberschenkelschmerzen bei einer 71-jährigen Patientin zehn Jahre nach zurückliegender Hüft-TEP-Implantation der linken Seite mit einer anschließenden periprothetischen Femurfraktur nach Niedrigener gietrauma unter langjähriger-Bisphosphonat Therapie. Für die Oberschenkelschmerzen wurden primär differenzialdiagnostisch aus-geprägte degenerative Veränderungen der Lendenwirbelsäule und ein radiologisch festgestellter Inlayverschleiß der Hüft-TEP als Ur sache diskutiert. Erst in der Gesamtschau al ler Befunde zeigte sich eine subprothetische diaphysäre Fissur, welche bereits einige Tage vor dem Trauma radiologisch nachweisbar war und die spätere Frakturlinie darstellte. Als Ursache wird die Behandlung der Osteo-porose durch die Einnahme von Bisphosphonaten über einen Zeitraum von mehr als fünf Jahren vermutet.

Fullerenes – how 25 years of charge transfer chemistry have shaped our understanding of (interfacial) interactions

Over 25 years research in charge transfer chemistry are highlighted in terms of interfacial interactions between fullerenes and porphyrins in electron donor–acceptor systems.

[Patella fractures in knee arthroplasty]

Periprosthetic patella fractures occur both with and without retropatellar joint replacement. A non-operative treatment yields satisfactory results with low morbidity. It can be applied in minimally displaced fractures that have an intact retropatellar component and an intact extensor mechanism, combined with an initial immobilization. The surgical treatment is associated with relatively poor results and with high complication rates. There was only minor improvement of functional results, no matter which surgical technique was used. Surgical intervention is still required in fractures with a loosening of the patellar component, considerable dislocations of fragments, and damage to or rupture of the extensor mechanism. In particular, type II fractures require repair of the extensor mechanism and the fracture or patellectomy. Type III fractures require a revision or resection of the patella, a patelloplasty or total patellectomy. In addition, early or late reconstruction using allograft to restore the extensor mechanism can be taken in consideration.

ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common malignancies in Western countries. Over the last 20 years, and the last decade in particular, the clinical outcome for patients with metastatic CRC (mCRC) has improved greatly due not only to an increase in the number of patients being referred for and undergoing surgical resection of their localised metastatic disease but also to a more strategic approach to the delivery of systemic therapy and an expansion in the use of ablative techniques. This reflects the increase in the number of patients that are being managed within a multidisciplinary team environment and specialist cancer centres, and the emergence over the same time period not only of improved imaging techniques but also prognostic and predictive molecular markers. Treatment decisions for patients with mCRC must be evidence-based. Thus, these ESMO consensus guidelines have been developed based on the current available evidence to provide a series of evidence-based recommendations to assist in the treatment and management of patients with mCRC in this rapidly evolving treatment setting.

Excess Mortality in Two-Year Rodent Carcinogenicity Studies

This paper considers the impacts of various patterns of differential or excess mortality on the biological and statistical interpretation of 2-year rodent carcinogenicity studies. It provides suggestions on experimental design that are intended to maximize the value of such studies for carcinogenic risk assessment. Specifically, it recommends dose reduction, possibly to the level of dose cessation, when biologically feasible and considers the merits of termination of the entire study as alternatives to the commonly employed strategy of terminating particular dose groups. It then recommends statistical analysis modifications that are appropriate when these suggestions on experimental design are adopted. One of the recommended modifications is a new statistical test to determine whether a dose group exceeds the maximum tolerated dose (MTD) on the basis of mortality. While the authors provide recommendations for the most commonly occurring exigencies, they acknowledge the need for and strongly support the practice of active engagement of the appropriate regulatory agency, e.g., the FDA, prior to any action.

[Bone marrow edema and atraumatic necrosis of the femoral head : Therapy]

BACKGROUND

An increase in interstitial bony fluid occurs in bone-marrow edema (BME). The exact pathogenetic processes still remain unknown. BME is an unspecific finding that can occur on its own or accompany multiple diseases and pathologies.

GOAL

Literature review and presentation of new guidelines.

MATERIAL AND METHODS

This is a narrative literature review followed by current advice for the therapy of atraumatic osteonecrosis of the hip, based on the recently published S3-guidelines for this disease.

RESULTS AND DISCUSSION

The differentiation of at least 3 different etiologies is proposed (mechanic, reactive and ischemic). Difficult, but important, is the distinction between the mostly painful, but benign entities (BME syndrome, bone bruise) and the progressive pathologies (osteonecrosis, arthritis, CRPS, tumour). Treatment options are dependent on etiology and clinic and can often be symptomatic. Core decompression is the surgical gold standard, leading to immediate pressure relief and therefore reduction in pain. Recently, it was shown that intravenous administration of Iloprost and bisphosphonates are also effective in achieving a reduction of BME and pain, with considerable improvement in the accompanying symptoms. The combination of core decompression and infusion seems to be another possible optimization ofthe therapy, in particular in the treatment of osteonecrosis.