Comparative study of short-and long-term results in patients with perihilar cholangiocarcinoma undergoing surgical resection: does the extent and side of resection really affect outcome?

BACKGROUND: The surgical management of perihilar carcinoma (pCCA) is still subject of ongoing debate. To provide more clarity, this study was conducted to evaluate outcomes related to the side and extent of heatectomy in patients with pCAA. METHODS: A total of 32 patients with curative resection for pCCA were identified from our prospective database. Short-and long-term clinical outcome data and histopathological results were compared between right-sided (R-H) and left-sided (L-H) hepatectomy. RESULTS: Nine patients (28.13%) underwent left-sided hepatectomy while a right-sided hepatectomy was accomplished in 23 patients (71.87%). In the R-H group hepatic conditioning of the future liver remnant (FLR) prior to extended resection was necessary in 13 cases (56.52%), and simultaneous pancreaticoduodenectomy was performed in 5 patients (21.74%). The arterial and portal venous reconstruction rates were 17.39% and 11.11% (P=1.00), and 60.87% and 33.33% (P=0.243) in the R-H and L-H groups, respectively. No statistically significant differences in short-term morbidity and mortality between both groups were observed. The rate of R0 resections was comparable (R-H: 78.26% versus L-H: 66.67%; P=0.654) resulting in similar long-term overall and disease-free survival rates after right-and left hepatectomy. CONCLUSIONS: In patients with pCCA, both right- and left-sided resections appear to be safe and feasible options with similar postoperative morbidity and oncologic outcomes. Consecutively, the ideal surgical approach should be patient-tailored based on anatomical considerations and the functional future liver capacity.

Predictive factors of 90-day mortality after curative hepatic resection for hepatocellular carcinoma: a western single-center observational study.

PURPOSE: The aim of this study was to identify predictive risk factors associated with 90-day mortality after hepatic resection (HR) in hepatocellular carcinoma (HCC). METHODS: All patients undergoing elective resection for HCC from a single- institutional and prospectively maintained database were included. Multivariate regression analysis was conducted to identify pre- and intraoperative as well as histopathological predictive factors of 90-day mortality after elective HR. RESULTS: Between August 2004 and October 2021, 196 patients were enrolled (148 male /48 female). The median age of the study cohort was 68.5 years (range19-84 years). The rate of major hepatectomy (≥ 3 segments) was 43.88%. Multivariate analysis revealed patient age ≥ 70 years [HR 2.798; (95% CI 1.263-6.198); p = 0.011], preoperative chronic renal insufficiency [HR 3.673; (95% CI 1.598-8.443); p = 0.002], Child-Pugh Score [HR 2.240; (95% CI 1.188-4.224); p = 0.013], V-Stage [HR 2.420; (95% CI 1.187-4.936); p = 0.015], and resected segments ≥ 3 [HR 4.700; (95% 1.926-11.467); p = 0.001] as the major significant determinants of the 90-day mortality. CONCLUSION: Advanced patient age, pre-existing chronic renal insufficiency, Child-Pugh Score, extended hepatic resection, and vascular tumor involvement were identified as significant predictive factors of 90-day mortality. Proper patient selection and adjustment of treatment strategies could potentially reduce short-term mortality.

Which factors predict tumor recurrence and survival after curative hepatectomy in hepatocellular carcinoma? Results from a European institution.

BACKGROUND: High tumor recurrence and dismal survival rates after curative intended resection for hepatocellular carcinoma (HCC) are still concerning. The primary goal was to assess predictive factors associated with disease-free (DFS) and overall survival (OS) in a subset of patients with HCC undergoing hepatic resection (HR). METHODS: Between 08/2004-7/2021, HR for HCC was performed in 188 patients at our institution. Data allocation was conducted from a prospectively maintained database. The prognostic impact of clinico-pathological factors on DFS and OS was assessed by using uni- and multivariate Cox regression analyses. Survival curves were generated with the Kaplan Meier method. RESULTS: The postoperative 1-, 3- and 5- year overall DFS and OS rates were 77.9%, 49.7%, 41% and 72.7%, 54.7%, 38.8%, respectively. Tumor diameter ≥ 45 mm [HR 1.725; (95% CI 1.091-2.727); p = 0.020], intra-abdominal abscess [HR 3.812; (95% CI 1.859-7.815); p < 0.0001], and preoperative chronic alcohol abuse [HR 1.831; (95% CI 1.102-3.042); p = 0.020] were independently predictive for DFS while diabetes mellitus [HR 1.714; (95% CI 1.147-2.561); p = 0.009), M-Stage [HR 2.656; (95% CI 1.034-6.826); p = 0.042], V-Stage [HR 1.946; (95% CI 1.299-2.915); p = 0.001, Sepsis [HR 10.999; (95% CI 5.167-23.412); p < 0.0001], and ISGLS B/C [HR 2.008; (95% CI 1.273-3.168); p = 0.003] were significant determinants of OS. CONCLUSIONS: Despite high postoperative recurrence rates, an acceptable long-term survival in patients after curative HR could be achieved. The Identification of parameters related to OS and DFS improves patient-centered treatment and surveillance strategies.

Treatment-induced neuropathy of diabetes: challenges in diagnosing neuropathic pain, value of sudomotor function testing.

A patient in his 60s was admitted for an extensive neurological work-up due to progressive asymmetrical, distally pronounced pain in both feet and legs. Conventional pain relievers did not help in pain reduction. A Sudoscan revealed small fibre damage in all extremities indicating an underlying neuropathy. The patient had started insulin treatment around 6 months prior to hospitalisation because of a newly diagnosed late-onset diabetes. Due to a rapid drop in glycated haemoglobin (from over 14% to 6% in 4 months), treatment-induced neuropathy of diabetes (TIND) was hypothesised. On increasing the dose of pregabalin and adding duloxetine, the patient reported improvement of symptoms, which further underlined the suspected diagnosis. Hence, in patients with severe hyperglycaemia, changes in glycaemic control should be stepwise and not rapid; however, to date, no guidelines exist how to avoid TIND.

Needs and supporting tools for primary care physicians to improve care of patients with vertigo and dizziness: a national survey.

Background: The diagnostic workup and treatment decisions for vertigo or dizziness in primary care can be challenging due to the broad range of possible causes and limited time and expertise of physicians. This can lead to delays in treatment and unnecessary tests. We aimed to identify the unmet needs of primary care physicians (PCPs) and strategies to improve care for dizzy patients. Materials and methods: An online survey was conducted among board-certified PCPs in Switzerland to explore needs in caring for dizzy patients and potential educational approaches. Results: Based on responses from 152 participating PCPs, satisfaction and confidence were higher in diagnosing (82%) and treating (76%) acute dizziness compared to episodic/chronic cases (63 and 59%, respectively). Younger PCPs had lower diagnostic yield and confidence. Areas for improvement in specialist interactions included communication between physicians (23%/36%; always/often true), shorter waiting times for consultations (19%/40%), more detailed feedback (36%/35%), and consistent patient back referrals (31%/30%). PCPs expressed interest in hands-on courses, workshops, practical guidelines, web-based algorithms, and digital tools such as printed dizzy diaries and apps for follow-up. Conclusion: Enhanced dialog between PCPs and specialists is crucial to address the most common unmet needs. Reducing waiting times for referrals and providing clear instructions to specialists for triage are essential. The findings from this survey will guide the development of tools to improve the diagnosis and treatment of dizzy patients. Younger PCPs, who face higher diagnostic uncertainty, should be prioritized for educational approaches such as hands-on courses, workshops, and practical recommendations.

[Diagnosis and treatment of benign paroxysmal positional vertigo with manual and motorized chairs - Indication and value]. / Abklärung und Behandlung des benignen paroxysmalen Lagerungsschwindels mittels manueller und motorisierter Drehstühle.

Benign paroxysmal positional vertigo (BPPV) is the most frequent cause of episodic vertigo or dizziness. While this diagnosis can be made reliably in most cases by use of targeted history taking followed by provocation maneuvers on the examination couch and subsequent repositioning maneuver, these maneuvers may not be applicable in a subgroup of patients with pre-existing conditions such as musculoskeletal or neurologic disorders. At the same time, part of patients treated on the examination couch will not respond to the repositioning maneuvers. The use of a manual or motorized turntable thus extends both the diagnostic and therapeutic options in BPPV. Thus, it enables patients with disabilities that do not tolerate classic maneuvers on the examination couch access to the required diagnostic procedures and - if needed - provides targeted treatment as well. Furthermore, turntables extend both the diagnostic and the therapeutic spectrum, offering a broader range of repositioning maneuvers in unclear or treatment-refractory cases. In this narrative review potential indications are described and evidence for using turntables in the diagnosis and treatment of BPPV on the turntable is discussed.

Systematic review and meta-analysis of the diagnostic accuracy of spontaneous nystagmus patterns in acute vestibular syndrome.

Objectives: For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside. Methods: MEDLINE and Embase were searched for studies (1980-2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization. Results: Included studies reported on 1,599 patients, with ischemic strokes (n = 747) and acute unilateral vestibulopathy (n = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], p < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, p < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1-100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5-27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, p < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, p = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, p < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, p = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, p < 0.001). Conclusions: (Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.

Triggered episodic vestibular syndrome and transient loss of consciousness due to a retrostyloidal vagal schwannoma: a case report.

Background: Various conditions may trigger episodic vertigo or dizziness, with positional changes being the most frequently identified condition. In this study, we describe a rare case of triggered episodic vestibular syndrome (EVS) accompanied by transient loss of consciousness (TLOC) linked to retrostyloidal vagal schwannoma. Case description: A 27-year woman with known vestibular migraine presented with a 19-month history of nausea, dysphagia, and odynophagia triggered by swallowing food and followed by recurrent TLOC. These symptoms occurred independently of her body position, resulting in a weight loss of 10 kg within 1 year and in an inability to work. An extensive cardiologic diagnostic work-up undertaken before she presented to the neurologic department was normal. On the fiberoptic endoscopic evaluation of swallowing, she showed a decreased sensitivity, a slight bulging of the right lateral pharyngeal wall, and a pathological pharyngeal squeeze maneuver without any further functional deficits. Quantitative vestibular testing revealed an intact peripheral-vestibular function, and electroencephalography was read as normal. On the brain MRI, a 16 x 15 x 12 mm lesion in the right retrostyloidal space suspicious of a vagal schwannoma was detected. Radiosurgery was preferred over surgical resection, as resection of tumors in the retrostyloid space bears the risk of intraoperative complications and may result in significant morbidity. A single radiosurgical procedure (stereotactic CyberKnife radiosurgery, 1 x 13Gy) accompanied by oral steroids was performed. On follow-up, a cessation of (pre)syncopes was noted 6 months after treatment. Only residual infrequent episodes of mild nausea were triggered by swallowing solid food remained. Brain MRI after 6 months demonstrated no progression of the lesion. In contrast, migraine headaches associated with dizziness remained frequent. Discussion: Distinguishing triggered and spontaneous EVS is important, and identifying specific triggers by structured history-taking is essential. Episodes being elicited by swallowing solid foods and accompanied by (near) TLOC should initiate a thorough search for vagal schwannoma, as symptoms are often disabling, and targeted treatment is available. In the case presented here, cessation of (pre)syncopes and significant reduction of nausea triggered by swallowing was noted with a 6-month delay, illustrating the advantages (no surgical complications) and disadvantages (delayed treatment response) of first-line radiotherapy in vagal schwannoma treatment.

Test-re-test reliability and dynamics of the Fukuda-Unterberger stepping test.

Background: The Fukuda-stepping-test (FST), i.e., repetitive walking on the spot while blindfolded, has been proposed as a means to assess the integrity of the vestibular pathways. While its sensitivity to detect abnormalities in patients is limited, it may be useful in studying the physiology of the subjective-straight-ahead (SSA). Considering reported systematic shifts in SSA in humans, we hypothesize that such asymmetries arise from individual differences in the orientation/configuration of the macular organs and in central processing of vestibular input. We hypothesize that such asymmetries are stable over time in individual subjects. Alternatively, such asymmetries may arise from random noise in the sensory/motor systems involved, demonstrating low reproducibility over time. Materials and methods: Twenty-four subjects walked on the spot over 60 s while blindfolded (n = 6 trials per subject). Using an inertial measurement unit (IMU) placed at the chest, angular deviations were recorded and compared to manually-measured final positions. Both static (direction, magnitude) and dynamic (time-to-onset of deviation, pattern of deviations) parameters were retrieved from the yaw slopes. Results: Significant deviations were found in 15/24 participants for the manual measurements (leftwards = 8; rightwards = 7), whereas when using the IMU-sensor 13/24 participants showed significant shifts (leftwards = 9; rightwards = 4). There was a high correlation (0.98) between manually measured rotation angles (average absolute deviations = 58.0 deg ± 48.6 deg; intra-individual variability = 39 deg ± 24 deg) and sensor-based yaw slopes (1.00 deg/s ± 0.88 deg/s; 0.67 deg/s ± 0.41 deg/s). Relevant yaw deviation was detected 22.1 s ± 12.3 s (range = 5.6 s-59.2 s) after the onset of marching (no relevant yaw-deviation in 15/139 measurements), showing a mostly linear behavior over time. Conclusion: We observed significant inter-individual variability in task performance in the FST, reproducing findings from previous studies. With test-re-test reliability being moderate only, but at the same time observing a preference in the side of shifts in most trials and subjects, we conclude that likely both individually varying estimates of straight-ahead and random noise contribute to the pattern of angular deviations observed. Using an IMU-sensory based approach, additional dynamic parameters could be retrieved, emphasizing the value of such a quantitative approach over manual measurements. Such an approach may provide useful additional information to distinguish patients from healthy controls.

Optimizing Growth of the Future Liver Remnant and Making In-Situ Liver Transsection Safe-A Standardized Approach to ISLT or ALPPS.

In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II/III and IVa/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.

Video head impulse testing in patients with isolated (hemi)nodular infarction.

Background: Isolated (hemi)nodular strokes as underlying cause of acute dizziness are rare, thus there are still gaps of knowledge in the clinical presentation of affected patients. Clinical and experimental evidence has suggested that lesions involving the nodulus lead to various vestibulo-ocular deficits including prolonged velocity-storage, periodic-alternating nystagmus, positional nystagmus, abolished suppression of post-rotatory nystagmus by head-tilt and impaired verticality perception. At the bedside, the angular vestibulo-ocular reflex (aVOR), as assessed by the horizontal head-impulse test (HIT), has been reported to be normal, however quantitative assessments of all six semicircular canals are lacking. Objective: The primary aim of this case series was to characterize the spectrum of clinical presentations in isolated (hemi)nodular strokes. Furthermore, based on preliminary observations, we hypothesized that the aVOR is within normal limits in isolated nodular strokes. Methods: We retrospectively included patients with isolated (hemi)nodular stroke on diffusion-weighted MR-imaging from a prospective stroke-registry. All patients received a standardized bedside neuro-otological assessment and quantitative, video-based HIT (vHIT) of all six semicircular canals. Overall ratings of vHIT (normal vs. abnormal function) were performed independently by two reviewers and disagreements were resolved. Results: Between January 2015 and December 2021 six patients with isolated nodular (n = 1) or heminodular (n = 5) ischemic stroke were included. Clinical presentation met diagnostic criteria for acute vestibular syndrome (AVS) in 5/6 patients and for episodic vestibular syndrome (EVS) in 1/6 patients. Ocular motor abnormalities observed included the presence of spontaneous horizontal nystagmus (n = 2), positional nystagmus (5/6), head-shaking nystagmus (3/6), skew deviation (n = 1), and moderate or severe truncal ataxia (5/6). Bedside HIT was normal in all patients and no gaze-evoked or periodic alternating nystagmus was observed. aVOR-gains were within normal range in all patients and overall aVOR-function as assessed by vHIT was rated as normal in all six patients. Conclusions: Using quantitative, video-based testing of the horizontal and vertical aVOR, preserved integrity of the aVOR in (hemi)nodular strokes was confirmed, extending preliminary findings at the bedside. Furthermore, widespread deficits of both ocular stability, postural control and volitional eye movements were observed in our study cohort, being consistent with findings reported in previous studies.

What neuro-otology specialists need for better care of dizzy patients: a national survey.

Background: A substantial fraction of dizzy patients are assessed by neurologists and ear-nose-throat (ENT) physicians. With the differential diagnosis being broad and often different specialties involved, we aimed to assess the interaction with generalists from the specialists' perspective to identify limitations and needs and to define strategies for improvement in patient care and education by the specialist. Methods: One hundred eleven board-certified neurologists (n = 62) and ENT physicians (n = 49) working in Switzerland participated in an online survey. Here, we focused on limitations faced in the diagnostic workup and treatment of the dizzy patient and potential strategies to improve the standard of care and the interaction between generalists and specialists. Descriptive statistical analyses were performed. We hypothesized that those specialists applying modern concepts in history-taking and bedside examination techniques reach a specific diagnosis more often and request fewer referrals. Results: Specialists indicated higher confidence in reaching a specific diagnosis for patients presenting with acute dizziness than episodic/chronic dizziness (80% vs. 60%) at the first consultation. Knowledge of the timing-and-trigger concept [odds ratio (OR) = 0.81 (0.67-0.98), p = 0.034], as well as of subtle oculomotor/vestibular signs [OR = 0.80 (0.68-0.94), p = 0.007] was predictive of the self-reported probability of reaching a specific diagnosis in patients with episodic/chronic dizziness, while no such differences were observed in the care of acutely dizzy patients. Further referrals of acutely dizzy patients were significantly higher in neurologists than in ENT physicians (17% vs. 10%, p < 0.001) and in specialists located in the Latin part of Switzerland [OR = 2.84 (1.63-4.93), p < 0.001], while this was not the case for patients with episodic/chronic dizziness. Identified unmet needs included regular communication between physicians (27%/53%; always/often true) and sufficiently detailed information on the previous workup from the referrals (27%/53%). Specialists expressed most interest in hands-on courses/workshops, webinars, and practical guidelines for education. Conclusion: In our survey, bedside state-of-the-art assessments were key in reducing the fraction of unclear dizzy cases. Several gaps were identified that should be addressed. Specifically, referring physicians should provide more comprehensive details regarding urgency, prior diagnostics, and treatment. Specifically, when promoting the knowledge of neurologists and ENT physicians, this should be preferentially done by offering a combination of hands-on courses and webinars.

Heading Direction Is Significantly Biased by Preceding Whole-Body Roll-Orientation While Lying.

Background: After a prolonged static whole-body roll-tilt, a significant bias of the internal estimates of the direction of gravity has been observed when assessing the subjective visual vertical. Objective: We hypothesized that this post-tilt bias represents a more general phenomenon, broadly affecting spatial orientation and navigation. Specifically, we predicted that after the prolonged roll-tilt to either side perceived straight-ahead would also be biased. Methods: Twenty-five healthy participants were asked to rest in three different lying positions (supine, right-ear-down, and left-ear-down) for 5 min ("adaptation period") prior to walking straight-ahead blindfolded for 2 min. Walking was recorded with the inertial measurement unit sensors attached to different body locations and with sensor shoe insoles. The raw data was segmented with a gait-event detection method. The Heading direction was determined and linear mixed-effects models were used for statistical analyses. Results: A significant bias in heading into the direction of the previous roll-tilt position was observed in the post-adaptation trials. This bias was identified in both measurement systems and decreased again over the 2-min walking period. Conclusions: The bias observed further confirms the influence of prior knowledge on spatial orientation and navigation. Specifically, it underlines the broad impact of a shifting internal estimate of direction of gravity over a range of distinct paradigms, illustrating similar decay time constants. In the broader context, the observed bias in perceived straight-ahead emphasizes that getting up in the morning after a good night's sleep is a vulnerable period, with an increased risk of falls and fall-related injuries due to non-availability of optimally tuned internal estimates of the direction of gravity and the direction of straight-ahead.

Quality of Life in Patients with Pancreatic Cancer before and during the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease 19 (COVID-19) substantially affects cancer patients due to adverse outcomes and disruptions in cancer care. Recent studies have indicated the additional stress and anxiety burden arising from the pandemic and impairing quality of life in this vulnerable group of patients. However, patients with cancer represent a heterogenous group. Therefore, we conducted a study on patients with pancreatic cancer, requiring demanding surgical interventions and chemotherapy regimens due to its aggressive tumor biology, to explore the pandemic's impact on quality of life within this homogenous cohort. METHODS: In a descriptive observational study, the quality of life of patients who had undergone pancreatic surgery for tumor resection at our institution between 2014 and the beginning of the pandemic in March 2020 was assessed. For HRQoL measurement, we used the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), comparing their situation before the pandemic and since its beginning. An additional self-developed questionnaire was applied to assess the life circumstances during the pandemic. RESULTS: Our cohort included 26 patients. Scores from the survey in HRQoL revealed no significant changes over time between before and during the pandemic. A medium deterioration in HRQoL was apparent in social functioning, as well as a small deterioration in role functioning and emotional functioning. Worries concerning a potential impact of COVID-19 on personal health were expressed. Psychological limitations in QoL were mainly attributed to the pandemic, whereas physical limitations in QoL were rather associated with the underlying disease of pancreatic cancer. CONCLUSION: The COVID-19 pandemic is causing considerable social and emotional distress among pancreatic cancer patients. These patients will benefit from psychological support during the pandemic and beyond. Long-time survivors of pancreatic cancer, such as those included in our cohort, appear to have improved resilience facing the psychosocial challenges of the pandemic. For pancreatic cancer, surgical care is considered the cornerstone of treatment. Prolonged delays in healthcare cause serious damage to mental and physical health. To date, the longer-term clinical consequences are not known and can only be estimated. The potential tragic outcome for the vulnerable group of pancreatic cancer patients highlights the urgency of timely healthcare decisions to be addressed in the future.

Vestibular performance in high-level soccer and ice hockey players: Sport-specific norm values and implications.

OBJECTIVES: Quantitative vestibular testing in athletes after sports-related concussion (SRC) has become more popular due to accompanying injuries of the peripheral-vestibular organs that require targeted treatment. Sports-specific normative values are currently not available. Taking into account potential adaptational mechanisms, we obtained sports-specific, age- and peak-head-velocity-corrected normative values of peripheral-vestibular function and postural-stability in football (soccer, FB) and ice-hockey (IH) players. DESIGN: Retrospective single-center case-control study. METHOD: Pre-seasonal angular vestibulo-ocular reflex (aVOR) gains and cumulative-saccadic-amplitudes were obtained using the video-head-impulse test and performance in the balance-error-scoring-system (BESS) was recorded and compared in high-level FB-players (n = 510, 197 females) and IH-players (n = 210, males only) (age-range = 13-39y) and in healthy normals (n = 49, 22 females). Statistical analysis was performed using a generalized linear model. RESULTS: aVOR-gain values were significantly higher for FB-players than for IH-players (1.07 ±â€¯0.21 vs. 0.98 ±â€¯0.13, p < 0.001) and controls (1.07 ±â€¯0.21 vs. 0.97 ±â€¯0.17, p < 0.001). Significant age-related changes in aVOR-gains were only observed for the anterior and posterior canals in the IH-players. Cumulative-saccadic-amplitudes were clearly below established cut-off values (0.73°/trial). BESS scores were significantly higher in IH-players than in FB-players (15.4 ±â€¯5.1 vs. 11.2 ±â€¯4.9, p < 0.001). CONCLUSIONS: The significantly better performance of the FB players in the vertical aVOR-gains and the BESS compared to the IH-players could be related to sports-specific differences influencing visuo-vestibular and balance performance. Therefore, we recommend using the established normative aVOR-gain values for high-level FB-players, whereas in IH obtaining individual pre-seasonal (baseline) aVOR-gain values is proposed. Further studies should add sports-specific normative aVOR-gain values for IH and other sports.

Socioeconomic Impact of Recurrent Primary Spontaneous Pneumothorax: Should Video-Assisted Thoracoscopic Surgery Be Considered at First Episode of Primary Spontaneous Pneumothorax?

BACKGROUND: Current guidelines recommend video-assisted thoracoscopic surgery (VATS) for recurrent primary spontaneous pneumothorax (PSP) and for cases with persistent air leak after chest tube treatment. The socioeconomic impact of recurrent PSP on the healthcare system is insufficiently reported. METHODS: Ninety-six patients treated for PSP between 01/2010 and 01/2020 were included. Forty-eight patients underwent primary VATS, while the second group received chest tube (CT) treatment only. Length of hospital stay (LOS), duration of chest tube, prolonged air leak, postoperative complications, recurrences and treatment costs were analyzed. RESULTS: Prolonged air leaks were evident in 12.5% and 22.9% patients of the VATS and CT group, respectively. Ten (20.8%) patients in the CT group underwent VATS for persistent air leakage. During follow-up, the VATS group recurred at 8.3% compared to 52.1% in the CT group. The total cost of treatment per patient, including treatment cost due to recurrence, was EUR 1.501 in the VATS group and EUR 2.233 in the CT group. CONCLUSIONS: Primary treatment of PSP by CT is associated with an increased socioeconomic burden for patients and the healthcare system due to high recurrence rates. This burden may be reduced if VATS is considered at the first episode of PSP.

Peridural Anesthesia and Cancer-Related Survival after Surgery for Pancreatic Cancer-A Retrospective Cohort Study.

BACKGROUND: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. METHODS: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox's proportional hazard regression model. RESULTS: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio [HR] 0.884, 95% confidence interval [CI] 0.398-1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144-1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. CONCLUSION: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma.

Negative myoclonus as the leading symptom in acute cefepime neurotoxicity.

An 86-year-old woman was diagnosed with hospital-acquired pneumonia with Pseudomonas aeruginosa and treated with cefepime adjusted to her renal clearance. After 4 days, she developed acute-onset negative myoclonus without signs of altered mental status. After ruling out an acute intracranial haemorrhagic or ischaemic stroke as well as other metabolic and endocrine causes of negative myoclonus, the antibiotic was switched to piperacillin/tazobactam due to a suspicion of cefepime neurotoxicity. The patient improved within 24 hours and her symptoms fully resolved within 4 days. These observations suggest a link of the negative myoclonus to acute cefepime neurotoxicity, which may occur without or with minimal alteration of mental status, thus extending its spectrum of clinical presentation.