[Severe small bowel involvement and chronic intestinal pseudo-obstruction in systemic sclerosis (scleroderma): Pathophysiological, diagnostic and therapeutic basis, including parenteral nutrition]. / Atteinte sévère de l'intestin grêle et pseudo-obstruction intestinale chronique au cours de la sclérodermie systémique : bases physiopathologiques, diagnostiques et thérapeutiques, dont la nutrition parentérale.

Gastrointestinal involvement in systemic sclerosis can be severe, reaching the critical point of chronic intestinal pseudo-obstruction, secondary to major disorders of small bowel motility. It is associated with some clinical and biological characteristics, in particular the positivity of anti-fibrillarin/U3RNP antibodies. Chronic intestinal pseudo-obstruction (CIPO) is complicated by a small intestinal bacterial overgrowth that requires cyclic antibiotic therapy. CIPO leads to a reduction of the food intake, due to painful symptoms, nausea and vomiting caused by meals, and ultimately to severe malnutrition. Meal splitting is often transiently effective and patients require exogenous nutritional support, mostly parenteral. Systemic sclerosis is not an obstacle to initiation and long-term continuation of parenteral nutrition and central venous catheter implantation is not associated with an increased risk of cutaneous or infectious complications. However, continuation of long-term parenteral nutrition requires monitoring in an expert nutrition center in order to adapt nutritional volumes and intakes and to limit potentially fatal cardiac and hepatobiliary complications. In addition to nutrition, prokinetic treatments, whose side effects must be known, can be associated. Invasive procedures, whose risk-benefit ratio must be carefully assessed, can also be used to treat symptoms exclusively.

Inferring the diurnal variability of OH radical concentrations over the Amazon from BVOC measurements.

The atmospheric oxidation of biogenic volatile organic compounds (BVOC) by OH radicals over tropical rainforests impacts local particle production and the lifetime of globally distributed chemically and radiatively active gases. For the pristine Amazon rainforest during the dry season, we empirically determined the diurnal OH radical variability at the forest-atmosphere interface region between 80 and 325 m from 07:00 to 15:00 LT using BVOC measurements. A dynamic time warping approach was applied showing that median averaged mixing times between 80 to 325 m decrease from 105 to 15 min over this time period. The inferred OH concentrations show evidence for an early morning OH peak (07:00-08:00 LT) and an OH maximum (14:00 LT) reaching 2.2 (0.2, 3.8) × 106 molecules cm-3 controlled by the coupling between BVOC emission fluxes, nocturnal NOx accumulation, convective turbulence, air chemistry and photolysis rates. The results were evaluated with a turbulence resolving transport (DALES), a regional scale (WRF-Chem) and a global (EMAC) atmospheric chemistry model.

Mismatch repair deficiency, chemotherapy and survival for resectable gastric cancer: an observational study from the German staR cohort and a meta-analysis.

PURPOSE: In a post hoc analysis of the MAGIC trial, patients with curatively resected gastric cancer (GC) and mismatch repair (MMR) deficiency (MMRd) had better median overall survival (OS) when treated with surgery alone but worse median OS when treated with additional chemotherapy. Further data are required to corroborate these findings. METHODS: Between April 2013 and December 2018, 458 patients with curatively resected GC, including cancers of the esophagogastric junction Siewert type II and III, were identified in the German centers of the staR consortium. Tumor sections were assessed for expression of MLH1, MSH2, MSH6 and PMS2 by immunohistochemistry. The association between MMR status and survival was assessed. Similar studies published up to January 2021 were then identified in a MEDLINE search for a meta-analysis. RESULTS: MMR-status and survival data were available for 223 patients (median age 66 years, 62.8% male), 23 patients were MMRd (10.3%). After matching for baseline clinical characteristics, median OS was not reached in any subgroup. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd and MMRp had a HR of 0.67 (95% CI 0.13-3.37, P = 0.63) and 1.44 (95% CI 0.66-3.13, P = 0.36), respectively. The meta-analysis included pooled data from 385 patients. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd had an improved OS with a HR of 0.36 (95% CI 0.14-0.91, P = 0.03), whereas those with MMRp had a HR of 1.18 (95% CI 0.89-1.58, P = 0.26). CONCLUSION: Our data support a positive prognostic effect for MMRd in GC patients treated with surgery only and a differentially negative prognostic effect in patients treated with perioperative chemotherapy. MMR status determined by preoperative biopsies may be used as a predictive biomarker to select patients for perioperative chemotherapy in curatively resectable GC.

[Avoidance-endurance fast screening (AE-FS) : Content and predictive validity of a 9­item screening instrument for patients with unspecific subacute low back pain]. / Avoidance-Endurance Fast-Screen (AE-FS) : Inhalts- und Vorhersagevalidität eines 9­Item-Screeninginstruments für Patienten mit unspezifischen subakuten Rückenschmerzen.

BACKGROUND: Among screening measures to assess psychosocial risk factors (yellow flags) for chronic low back pain (LBP) economic tools which address dysfunctional endurance pain responses besides emotional distress and fear-avoidance pain processing are rare. Targeting contrasting types of pain processing might improve stratified patient counselling. OBJECTIVE: The aim of the study was to develop a short screening method, based on the avoidance-endurance model of pain and to investigate the prognostic validity for pain intensity, disability and physical function. MATERIAL AND METHODS: A prospective observational study was carried out on 144 patients with subacute LBP (<3 months) from 7 general practitioners and 5 orthopedic practices. The 9­item avoidance-endurance fast screening (AE-FS) was derived from a previous 37-item screening using correlational and receiver operating curve (ROC) analyses and the agreement of subgrouping was calculated using Cohen's kappa. Primary outcomes were assessed after 6 months by mail in 124 patients (86%). Endpoints were pain intensity and disability. RESULTS: The classification of subgroups as high and low risk by both measures had considerable agreement with a value of 0.71 (Cohen's Kappa). The sensitivity to predict pain intensity >2 was high (82%) as was the positive predictive value (80%) but the negative predictive value was moderate (61%). The ROC (AUC) characteristics (95% confidence interval CI) were 0.70 (0.60-0.80) for pain intensity and for limitations in the pain disability index (PDI) 0.70 (0.55-0.87). DISCUSSION: The 9­item AE-FS displayed sufficient prognostic validity for all three outcomes in a sample of primary care patients with subacute LBP. The differentiation of the high-risk patients into fear-avoidance and endurance-related pain processing enables the physician to provide an individualized counselling with the aim of a healthy balance between stress and relaxation.

Startle modulation by heat pain with varying threat levels in chronic pain patients and pain-free controls.

BACKGROUND: Empirical evidence suggests that affective responses to pain are changed in chronic pain. The investigation of startle responses to pain might contribute to clarifying whether such alterations also expand to motivational defensive reactions. We aimed at comparing startle responses to tonic heat pain with high threat (HT) or low threat (LT) in patients with chronic musculoskeletal pain and controls. As pain-related anxiety and catastrophizing are typically elevated in chronic pain, we expected to find stronger startle responses in patients specifically under experimental HT. METHODS: Patients with chronic musculoskeletal, preferentially, back pain (N = 19) and matched pain-free controls (N = 19) underwent two pain-related threat conditions (high and low) in balanced order. Only, in the HT condition, 50% of the trials were announced to include a short further noxious temperature increase at the end. Startle responses to loud tones were always assessed prior to a potential temperature increase in the phase of anticipation and were recorded by surface electromyogram. RESULTS: Surprisingly, we observed no differences in startle responses and ratings of emotional and pain responses between patients and controls despite significantly higher pain-related anxiety and catastrophizing in the patients. Overall, startle was potentiated in the HT condition, but only in participants who started with this condition. CONCLUSION: Our results suggest that, in general, patients with pain are not more responsive emotionally to experimental threat manipulations despite elevated pain anxiety and catastrophizing. Instead, exaggerated responses in patients might be triggered only by individual concerns relating to pain, which are not sufficiently mirrored by our threat paradigm.

[R1 resection for gastric carcinoma]. / R1-Resektion beim Magenkarzinom.

The results reported in the literature in the context of an R1 situation for a resected gastric carcinoma are not uniform. An R1 situation worsens the prognosis for the long-term survival of patients. This is significant especially for low T stages and lymph node metastasis with 0-≤3 lymph node metastases. In higher tumor stages with extensive lymph node metastases, the survival difference between R0 and R1 resections is lower and frequently no longer significant. The frequency of R1 resection is approximately 5% (range 1.8-9%) and for adenocarcinoma of the esophagogastric junction (AEG tumors)> 10%. The data are mainly related to the oral and aboral resection line but there are only a few specifications on the circumferential margin. The risk of an infiltrated resection line increases with the size of the tumor (>5 cm), T3+4 and pN2/pN3 stages. Poorly differentiated signet ring cell or mucinous adenocarcinomas and carcinomas of the Bormann type 3+4 also lead to an increased R1 rate. In order to achieve an R0 resection, an intraoperative frozen section is the standard approach. Immediate reoperation should be performed in the case of tumor infiltration. If an R1 resection is detected only in the definitive histology, surgical re-excision to achieve an R0 resection is the standard approach in publications. Nevertheless, a reoperation is rare. Only 1 study showed 122 patients with 100% re-operations, which were successfully performed in 50 patients (41% R0). For the R0 group, median survival was extended from 18 months to 23 months. There are only sporadic literature data and no evidence for postoperative additive treatment (chemotherapy, radiotherapy and radiochemotherapy).

Evolution and complications after surgery for spine deformation in patients with Parkinson's disease.

INTRODUCTION: Surgical treatment of spinal deformity is high risk in patients suffering from Parkinson's disease (PD). Several series have already reported a high rate of complications. However, none of these studies included more than 40 patients and none of the risk factors of complications were described. The aim of this study was to describe the rate and risk factors of revision surgery as well as the clinical outcome at the last visit in a large multicenter study of PD patients operated for spinal deformities. METHODS: A multicenter retrospective study included arthrodesis for spinal deformity in patients with PD. Clinical and surgical data including revision surgeries were collected. Assessment of functional outcomes at last follow-up was classified in 3 grades and spinal balance was assessed on anteroposterior and lateral plain X-rays of the entire spine. RESULTS: Forty-eight patients were included. Median age was 67 years old (range 41-80). Median follow-up was 27 months. The rate of surgical revision was 42%. Eighty per cent of revisions were performed for chronic mechanical complication. Global results were considered to be good in 17 patients (35%), doubtful in 17 patients (35%) and a failure in 14 patients (30%), for the whole series. CONCLUSIONS: The results of surgery for spinal deformities in patients with Parkinson disease vary with a high rate of complications and revisions. Nevertheless, these results should be seen in relation to the natural progression of these spinal deformities once spinal imbalance has developed. The association between preoperative clinical balance and final outcome suggests that early surgery can probably play a role in treatment. LEVEL OF EVIDENCE: Level IV (e.g. case series).

Does Certification as Bariatric Surgery Center and Volume Influence the Outcome in RYGB-Data Analysis of German Bariatric Surgery Registry.

AIM: To examine the association between the certification as bariatric surgery center and volume and patient outcome, data collected in the German Bariatric Surgery Registry were evaluated. All data were registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg. METHODS: Data collection began in 2005 for all bariatric procedures in an online database. Participation in the quality assurance study is required for all certified bariatric surgery centers in Germany. Descriptive evaluation and matched pairs analysis were performed. Patients were matched via propensity score taking into account BMI, age, and incidence of comorbidities. RESULTS: During the period from 2005 to 2013, 3083 male and 10,639 female patients were operated on with the RYGB primary approach. In Centers of Competence (77.2 %) and non-accredited hospitals (76.3 %), the proportion of female patients was significantly lower than in Centers of Reference/Excellence (78.7 %; p = 0.002). The mean age in Centers of Reference/Excellence (41.2 years) was significantly lower than in Centers of Competence (43.2 years; p < 0.05). Propensity score analysis was performed to compare matched patients with regard to BMI, age, and incidence of comorbidities. The rate of general and surgical postoperative complications and mortality rate was significantly lower in certified Centers of Reference/Excellence compared to Centers of Competence with 29 and non-certified hospitals. CONCLUSION: There is evidence of improved patient outcome in certified bariatric surgery centers with higher volume. The study supports the concept of certification. There are different factors which can and cannot be preoperatively modified and influence the perioperative outcome.