The Appropriate Management Of Osteoporotic Vertebral Compression Fractures : A Single Institute Evaluation Using The VCF Monitor.

From the Department of Orthopaedics and Trauma Surgery, Klinikum Bayreuth, Bayreuth, Germany Osteoporosis-related vertebral compression fractures (OVCF) are commonly seen in clinical practice. Treatment choice is often challenging due to heterogeneity of the patient population. A European multidisciplinary expert panel developed patient-specific recommendations for reatment choice that were embedded in an online evaluation tool (VCF Monitor). This study aimed to evaluate the appropriateness of treatment choice in patients with OVCF in a German hospital. The prospective observational study included 190 patients with OCVF (2013-2015). Using the VCF Monitor, treatment choices were compared with the recommendations of the European expert panel. Treatment choices included balloon kyphoplasty (61%), non-surgical management (36%) and other surgical procedures (3%). Compared to the panel recommendations, 70% of treatment choices were appropriate, 24% uncertain, and 3% inappropriate. Less appropriate choices were partly due to patient preferences. The VCF Monitor proved to be a helpful tool for quality assurance in the management of OVCF.

Physiological factors which influence the performance potential of athletes: analysis of sports medicine performance testing in Nordic combined.

BACKGROUND: The sports medicine performance diagnostics include investigative procedures that supply information on the performance capacity and stamina of an athlete. This creates a foundation for a personalised training plan and enables optimised control of the training process. METHODOLOGY: The study population consisted of 24 male Nordic combined athletes from the national German squad. They were monitored using sports medicine over a period of five winter seasons. The test speeds on the treadmill in m/s are determined at lactate values of 2, 3 and 4 mmol/l in the peripheral blood values to calculate the lactate curve. RESULTS: The higher the test performance expressed as a percentage, the more likely it was that a top position could be achieved. The individual anaerobic threshold and the maximal oxygen uptake increased significantly with an increase in test performance expressed as a percentage. The older the athlete, the better they performed in the overall world cup. When age increased, the test speed [m/s] at lactate values of 2, 3 and 4 mmol/l also increased, along with the test performance expressed as a percentage, the maximal oxygen uptake and the individual anaerobic threshold. A higher BMI proved advantageous in terms of placement in the individual competitions. CONCLUSION: In this study the test speed at a lactate concentration of 4 mmol/l can be recommended as a robuster, more independent from mathematical models and physiologically more valid parameter for performance diagnostics in professional athletes.

An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine.

INTRODUCTION: Percutaneous vertebral augmentation is a common therapeutic approach for osteoporotic or osteolytic vertebral fractures. Due to the variable pedicle anatomy two different approaches, the transpedicular and the extrapedicular approach have been established. In particular, in the middle and upper thoracic spine, percutaneous procedures are challenging because of difficult visualisation of anatomical landmarks and a more unfavourable anatomy with smaller and differently orientated pedicles. MATERIAL AND METHODS: In our cadaveric study we compared the transpedicular and the extrapedicular approach to the thoracic spine. In 26 cadaveric spine specimes, embalmed using Thiel's method, we placed a total of 486 trans- and extrapedicular K-wires through Jamshidi needles in the vertebral bodies T4 - T12 under fluoroscopy. A CT scan was then performed to verify the actual position of the K-wire. Malpositioning was defined as deviation from the planned approach or placement of the K-wire in the spinal canal or outside the vertebral body. Number and direction of malpositionings was recorded. RESULTS: Malpositioning occurred in 68 of 468 K-wires. It was more frequent in the transpedicular (54) than in the extrapedicular (14) approach. Intraspinal malposition was seen more often in the transpedicular approach (n=36) especially in the upper and middle thoracic spine. CONCLUSION: In summary both approaches are relatively safe but in the upper and middle thoracic spine the risk of intraspinal malpositioning seems to be lower when using the extrapedicular approach.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study.

BACKGROUND: Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT). METHODS: In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs. RESULTS: Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups. CONCLUSIONS: Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

TGF-ß Signalling is Suppressed under Pro-Hypertrophic Conditions in MSC Chondrogenesis Due to TGF-ß Receptor Downregulation.

BACKGROUND AND OBJECTIVES: Mesenchymal stem cells (MSCs) become hypertrophic in long term despite chondrogenic differentiation following the pathway of growth plate chondrocytes. This terminal differentiation leads to phenotypically unstable cartilage and was mirrored in vitro by addition of hypertrophy inducing medium. We investigated how intrinsic TGF-ß signaling is altered in pro-hypertrophic conditions. METHODS AND RESULTS: Human bone marrow derived MSC were chondrogenically differentiated in 3D culture. At day 14 medium conditions were changed to 1. pro-hypertrophic by addition of T3 and withdrawal of TGF-ß and dexamethasone 2. pro-hypertrophic by addition of BMP 4 and withdrawal of TGF-ß and dexamethasone and 3. kept in prochondrogenic medium conditions. All groups were treated with and without TGFß-type-1-receptor inhibitor SB431542 from day 14 on. Aggregates were harvested for histo- and immunohistological analysis at d14 and d28, for gene expression analysis (rt-PCR) on d1, d3, d7, d14, d17, d21 and d28 and for Western blot analysis on d21 and d28. Induction of hypertrophy was achieved in the pro-hypertrophic groups while expression of TGFß-type-1- and 2-receptor and Sox 9 were significantly downregulated compared to pro-chondrogenic conditions. Western blotting showed reduced phosphorylation of Smad 2 and 3 in hypertrophic samples, reduced TGF-ß-1 receptor proteins and reduced SOX 9. Addition of SB431542 did not initiate hypertrophy under pro-chondrogenic conditions, but was capable of enhancing hypertrophy when applied simultaneously with BMP-4. CONCLUSIONS: Our results suggest that the enhancement of hypertrophy in this model is a result of both activation of pro-hypertrophic BMP signaling and reduction of anti-hypertrophic TGFß signaling.

Treatment of Osteoporotic Vertebral Compression Fractures: Applicability of Appropriateness Criteria in Clinical Practice.

BACKGROUND: Appropriate treatment choice for osteoporotic vertebral compression fractures (OVCF) is challenging due to patient heterogeneity. Using the RAND/UCLA method, an international multidisciplinary expert panel established patient-specific criteria for the choice between non-surgical management (NSM), vertebroplasty (VP), and balloon kyphoplasty (BKP). OBJECTIVES: To assess the applicability of the appropriateness criteria in real-life practice. STUDY DESIGN: Prospective observational study. SETTING: Eight practices of experts who participated in the panel study, including 2 interventional radiologists, one internal medicine specialist, 2 neurosurgeons, and 3 orthopedic/trauma surgeons. Practices were located in Belgium, Germany, Italy, Switzerland, and the United Kingdom. METHODS: Using an online data capture program, participants documented the clinical profile (age, gender, previous VCFs, time since fracture, magnetic resonance imaging (MRI) findings, evolution of symptoms, impact of symptoms on quality of life, spinal deformity, ongoing fracture process, and presence of pulmonary dysfunction) and treatment choice for consecutive patients who consulted them for OVCF. RESULTS: In total 426 patients were included. BKP was the most frequently chosen treatment option (49%), followed by VP (34%) and NSM (14%). When compared with the panel recommendations, inappropriate treatment choices were rare (5% for NSM, 2% for VP, none for BKP). Treatment choice was strongly associated with the clinical variables used in the panel study. Differences in treatment decisions between interventional radiologists and surgeons were largely determined by differences in patient characteristics, with time of clinical presentation being the dominant factor. LIMITATION: The study population was restricted to the practices of the participants of the panel study. CONCLUSION: This international, multi-specialty utilization review showed excellent applicability of, and good adherence with RAND/UCLA-based recommendations on treatment choice in OVCF.

[How do pediatricians vaccinate in Munich? A health care epidemiological study]. / Wie impfen Kinderärzte in München?: eine versorgungsepidemiologische Untersuchung.

OBJECTIVES: The goal was to determine vaccination rates and predictors of vaccination behaviour of pediatricians in Munich, Germany. METHODS: Standardised questionnaires were sent to all 133 office-based pediatricians in Munich. RESULTS: 97 questionnaires (73%) were returned completely. Vaccination rates were sufficiently against diphtheria, tetanus, and poliomyelitis only. The other vaccinations recommended by the national immunisation advisory board (STIKO) were carried out to an insufficient extent. Vaccination rates of measles, mumps, and rubella were low. Parents' informed consent to STIKO's recommendations was the main determining factor of vaccination rates. Physicians' uncertainty in assessing contra-indications correctly was another important reason for insufficient vaccination rates. CONCLUSIONS: The health target of eliminating measles will not likely be reached. STIKO's recommendations as well as periodically vocational training courses, should be more compulsory to physicians. Self-responsibility of patients and parents should be raised by financial incentives on sick funds premiums.

KRAS, EGFR, PDGFR-α, KIT and COX-2 status in carcinoma showing thymus-like elements (CASTLE).

BACKGROUND: CASTLE (Carcinoma showing thymus-like elements) is a rare malignant neoplasm of the thyroid resembling lymphoepithelioma-like and squamous cell carcinoma of the thymus with different biological behaviour and a better prognosis than anaplastic carcinoma of the thyroid. METHODS: We retrospectively investigated 6 cases of this very rare neoplasm in order to investigate the mutational status of KRAS, EGFR, PDGFR-α and KIT, as well as the immunohistochemical expression pattern of CD117, EGFR and COX-2, and possibly find new therapeutic targets. RESULTS: Diagnosis was confirmed by a moderate to strong expression of CD5, CD117 and CK5/6, whereas thyroglobulin, calcitonin and TTF-1 were negative in all cases. Tumors were also positive for COX-2 and in nearly all cases for EGFR. In four cases single nucleotide polymorphisms (SNPs) could be detected in exon 12 of the PDGFR-α gene (rs1873778), in three cases SNPs were found in exon 20 of the EGFR gene (rs1050171). No mutations were found in the KIT and KRAS gene. CONCLUSIONS: All tumors showed a COX-2 expression as well as an EGFR expression except for one case and a wild-type KRAS status. No activating mutations in the EGFR, KIT and PDGFR-α gene could be detected. Our data may indicate a potential for targeted therapies, but if these therapeutic strategies are of benefit in CASTLE remains to be determined. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1658499296115016.

Results of thoracic drainages placed in air rescue.

INTRODUCTION: horax injuries are to be found in approximately 78% amongst all accident victims. Moreover, they implicate an increase in mortality rate. Consequently, an adequate contemporary treatment has to begin preclinically, even if the conditions are less comfortable than in a clinical setting. Emergency doctors need to be familiar with the placement of chest tubes. MATERIALS AND METHODS: From January 1, 2007 to December 31, 2010, emergency doctors of the rescue helicopter site Christoph 20 had to place chest tubes directly at the scene of an accident in 49 patients. These patients were now reidentified, and their clinical course was reevaluated. By means of apparative diagnostics, it was possible to analyze the location of the tubes tip. Following a comparison of the patient, outcome versus the quality of preclinical thoracic discharge could be made. RESULTS: The preclinical placement of a chest tube became necessary mainly because of a blunt thoracic trauma. This was predominantly related to victims of traffic accidents, whereas male victims clearly dominated. Forty-two of those patients received further treatment at the Klinikum Bayreuth hospital, enabling an analysis of the tubes location by CAT (computed axial tomography) scan. Six patients had been discharged on both sides, contributing to 48 tube tips that could be examined concerning their location. Of the 48 chest tubes, 46 had been placed from a lateral approach. The ventral access by Monaldi had only been chosen in two cases. Altogether, nine incorrect placements, mainly within the right interlobe gap, had been detected. CONCLUSIONS: The study collective showed a significant preference to the lateral approach when placing a chest tube at the emergency scene of an accident. In total, a prevalence of 19% incorrect placements could be revealed, meaning the chest tube had either been placed within the lung parenchyma, the interlobe gap, or extrathoracically. Concerning the patient outcome, no statistically significant difference regarding the clinical course after incorrect chest tube placement could be identified.

Criteria for the appropriate treatment of osteoporotic vertebral compression fractures.

BACKGROUND: The heterogeneity of patients with osteoporotic vertebral compression fractures (VCF) necessitates a tailored approach of balancing the benefits and limitations of available treatments. Current guidelines are divergent, sometimes contradictory, and often insufficiently detailed to guide practice decisions. OBJECTIVES: This study aimed at establishing treatment recommendations at the patient-specific level. STUDY DESIGN: Using the RAND/UCLA Appropriateness Method (RAM), the appropriateness of different treatment options for osteoporotic VCFs was assessed. SETTING: The assessment was conducted by a European multidisciplinary panel of 12 experts. METHODS: The appropriateness of non-surgical management (NSM), vertebroplasty (VP), and balloon kyphoplasty (BKP) was determined for 128 hypothetical patient profiles. These were unique combinations of clinical factors considered relevant to treatment choice (time since fracture, MRI findings, impact and evolution of symptoms, spinal deformity, ongoing fracture process, and pulmonary dysfunction). After 2 individual rating rounds and plenary meetings, appropriateness statements (appropriate, inappropriate, and uncertain) were calculated for all clinical scenarios. RESULTS: Disagreement dropped from 31% in the first round to 7% in the second round. Appropriateness outcomes showed specific patterns for the 3 treatments. For three-quarters of the profiles, only one treatment was considered appropriate: NSM 25%, VP 6%, and BKP 45%. NSM was usually appropriate in patients with a negative MRI or a positive MRI without other unfavorable conditions (poor outcomes for the other variables). VP was usually appropriate in patients with a positive MRI, time since fracture ≥ 6 weeks, and no spinal deformity. BKP was recommended for all patients with an ongoing fracture process, and also in most patients with a positive MRI and ≥ 1 other unfavorable factor. LIMITATIONS: The prevalence of the patient profiles in daily practice is yet unknown. CONCLUSION: The panel results may help to support treatment choice in the heterogeneous population of patients with osteoporotic VCF.