Effect of Kono-S anastomosis on reducing postoperative recurrence rates in Crohn's disease: a systematic review and meta-analysis.

BACKGROUND: Kono-S anastomosis has gained increasing interest although evaluation of its impact on reducing Crohn's recurrence shows conflicting results. This study aimed to evaluate the short- and long-term outcomes for patients with Crohn's disease requiring surgery with Kono-S compared to conventional anastomosis. METHODS: A systematic review and meta-analysis included patients with Crohn's disease treated with bowel resection and Kono-S anastomosis reconstruction versus a comparator arm of conventional anastomosis technique. Recurrence outcomes examined were endoscopic recurrence rates, mean postoperative Rutgeerts score, surgical recurrence, clinical recurrence, and postoperative biologics use. Short-term postoperative outcomes include anastomotic leaks, surgical site infection, postoperative ileus, and mean operative time. RESULTS: A total of 873 studies were identified with 15 remaining after abstract review encompassing 1501 patients, 765 with Kono-S and 736 with conventional anastomosis. Recurrence was significantly lower in the Kono-S arm, with endoscopic recurrence rates of 41% vs 48% (RR 0.86, 95% CI 0.73-1.00, p = 0.05) and surgical recurrence rates of 2.7% vs 21.0% (RR 0.13, 95% CI 0.06-0.30, p < 0.001). There was a significantly lower anastomotic leak rate in the Kono-S arm when compared to conventional anastomosis, 1.7% vs 4.9% (RR 0.37, 95% CI 0.19-0.74, p = 0.005). Mean operative time was similar between both groups. CONCLUSIONS: Kono-S is a safe and feasible anastomotic technique with lower rates of endoscopic and surgical postoperative recurrence. While we await further trials to substantiate this benefit, Kono-S anastomosis should be considered as an important tool in the armamentarium of a surgeon in anastomotic construction to reduce recurrence.

Comprehensive clinical commissioning and validation of the RayStation treatment planning system for proton therapy with active scanning and passive treatment techniques.

PURPOSE: To commission the treatment planning system (TPS) RayStation for proton therapy including beam models for spot scanning and for uniform scanning. METHODS: Tests consist of procedures from ESTRO booklet number 7, the German DIN for constancy checks of TPSs, and extra tests checking the dose perturbation function. The dose distributions within patients were verified in silico by a comparison of 65 clinical treatment plans with the TPS XiO. Dose-volume parameters, dose differences, and three-dimensional gamma-indices serve as measures of similarity. The monthly constancy checks of Raystation have been automatized with a script. RESULTS: The basic functionality of the software complies with ESTRO booklet number 7. For a few features minor enhancements are suggested. The dose distribution in RayStation agrees with the calculation in XiO. This is supported by a gamma-index (3mm/3%) pass rate of >98.9% (median over 59 plans) for the volume within the 20% isodose line and a difference of <0.3% of V95 of the PTV (median over 59 plans). If spot scanning is used together with a range shifter, the dose level calculated by RayStation can be off by a few percent. CONCLUSIONS: RayStation can be used for the creation of clinical proton treatment plans. Compared to XiO RayStation has an improved modelling of the lateral dose fall-off in passively delivered fields. For spot scanning fields with range shifter blocks an empirical adjustment of monitor units is required. The computation of perturbed doses also allows the evaluation of the robustness of a treatment plan.

Three-point transfusion risk score in hepatectomy.

BACKGROUND: Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score. METHODS: A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated. RESULTS: There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66. CONCLUSION: The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.

Doctor, what are my options? A prospective cohort study of an individualized care plan for patients with gastrointestinal cancer.

BACKGROUND: For cancer patients, information about their disease and its treatment is often delivered within a short time period, potentially leading to patient misunderstanding, which can impede optimal patient care. In this 3-part clinical study, we investigated the utility of an individualized care plan for patients with gastrointestinal (gi) cancer starting a new treatment. METHODS: In part 1, a comprehensive literature search identified items for potential inclusion in the care plan. Those items were formatted into a questionnaire. The questionnaire was then administered to patients as a structured interview. In part 2, health care professionals involved in the care of patients with gi cancer evaluated the resulting care plan for content and relevancy. In part 3, a 20-week prospective cohort study (10 weeks using standard of care, 10 weeks using individualized care plans) was conducted. Outcomes were assessed at baseline and at 2-4 weeks after administration of the care plan. RESULTS: In part 1, a 73-item questionnaire was developed and completed by 20 patients in semi-structured interviews. In part 2, long and short versions of the care plan were created. Most health care professionals preferred the long version. Based on their comments, a final version of the care plan was created. The part 3 study enrolled 104 patients. Overall satisfaction scores were significantly higher in the intervention group at baseline (p = 0.010) and follow-up (p = 0.005). Compared with control patients, the intervention cohort also reported significantly higher overall quality of life (p = 0.044) and fewer symptoms of anxiety (p = 0.048) at follow-up. CONCLUSIONS: Provision of an individualized care plan resulted in improvements in outcome measures at both baseline and follow-up. Future studies are needed to confirm these findings.

Neo-adjuvant chemoradiotherapy and multivisceral resection to optimize R0 resection of locally recurrent adherent colon cancer.

BACKGROUND: Neo-adjuvant chemoradiotherapy reduces local recurrence in rectal cancer, but there is a paucity of evidence regarding its role for colon cancer. The aim of this study was to evaluate the feasibility and outcomes of a neo-adjuvant chemoradiotherapy (NCRT) approach for locally recurrent adherent colon cancer (LRACC). METHODS: All patients with non-metastatic LRACC treated with NCRT and multi-visceral resection (MVR) from January 2000 to July 2010 were included. The primary outcome was the rate of R0 resection (negative microscopic margins). Secondary outcomes were toxicities, post-operative morbidity and mortality, local recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: Fifteen patients were identified. Nine primary cancers were located in the sigmoid and 4 in the left colon. Patients were treated with 45-50 Gy in 25 daily fractions and concurrent 5-FU infusion (225 mg/m(2)/day). En-bloc MVR included between 2 and 5 adjacent organs/structures. All but two resulted in R0 resection. One patient had a complete pathologic response and one had minimal residual tumour cells in the resected specimen. Post-operative major morbidity was 33.3%. No mortality occurred. At a median follow-up of 54 months, there were 2 local, 1 regional, and 2 distant lung recurrences. No grade 3 or 4 acute or late toxicities were observed. 5-year OS and DFS were 90.0% and 63.5% respectively. CONCLUSIONS: NCRT followed by MVR is a feasible option for the treatment of highly selected LRACC to achieve R0 resection, while maintaining acceptable treatment toxicity. Short-term oncological results appear satisfactory, including good local control.

[Incidence of complications of the screw osteosynthesis of odontoid process fractures]. / Inzidenz von Komplikationen der Schraubenosteosynthese von Frakturen des Dens axis, Literaturübersicht, Germany.

In this retrospective clinical study the incidence of complications in 58 consecutive, with anterior screw fixation stabilized patients after fractures of the odontoid process is evaluated. In 51 patients the fracture has been defined as type II according to Anderson, in 6 patients an oblique type II fracture was present and one patient showed a cephalad type III fracture. Preoperatively, in only 19 % of the patients (n = 11) no dislocation of the dens occurred. 32 patients were treated with single screw osteosynthesis, in 26 patients two screws were implanted. Significant complications with clinical relevance were registered in 14 patients (24 %), in 10 cases (17 %) an operative reintervention was required. Intraoperatively, in one patient a rupture of the carotid artery while winding around the motor drill occurred and in another case a complete malplacement of the screw posteriorly to the odontoid process was observed. A clearly excentric positioning of the implant was evaluated in 5 patients with a consecutive high rate of implant migration (n = 3). Two patients died perioperatively not related to the cervical injury. Postoperatively, one patient with a wound infection due to an iatrogenic perforation of the esophagus required reoperation as well as 4 patients with instability because of implant migration. Patients beyond the age of 65 years (n = 3) were significantly overrepresented in that group. In one case, the secondary intervention was caused by a pseudarthrosis of the dens axis. Complications without any relevance to the clinical and functional long term result were fusions in malposition of the odontoid process in 14 patients (24 %) and 10 (17 %) marginal screw perforations laterally. Differences in the use of one or two screws have not been observed in this study, although the investigations showed a tendency between marginal lateral screw perforations and double screw osteosynthesis and an increasing number of complications in the geriatric cohort.

Perfusion abnormalities of kidney parenchyma: microvascular imaging with contrast-enhanced color and power Doppler ultrasonography--preliminary results.

The purpose of this study was to evaluate the feasibility of microvascular imaging using contrast-enhanced color and power Doppler sonography. Ten patients with a focal lesion of the kidney were examined. Three patients were investigated with the polymeric butylcyanacrylate-based contrast agent SHU 563A, and the remaining patients were investigated with the galactose-based agent Levovist. It was possible to observe the microvascularization with Levovist during the blood pool phase of the agent over a period of 1 to 3 s at 1 min and 2 min after injection. With SHU 563A, microvascular imaging was possible 0.50 s after injection and lasted for 10.35 min. No intratumoral signals were seen in cysts (n = 6) and the investigated abscess. Weak intratumoral polychromatic effects were observed in both renal cell carcinomas in this series. Metastasis could be differentiated from healthy parenchyma due to lack of the polychromatic effect. SHU 563A is appropriate for performing microvascular imaging. The Levovist-induced polychromatic effects are smaller, of shorter duration, and observable only during the blood pool phase; thus, the expected diagnostic benefit is limited.

[Retroperitoneal recurrence of non-seminomatous testicular tumors: computerized tomography findings before retroperitoneal lymph node excision]. / Retroperitoneale Rezidive nicht-seminomatöser Hodentumoren: Computertomographische Befunde vor retroperitonealer Lymphadenektomie.

PURPOSE: In relapsing testicular cancer, additional chemotherapy is followed by abdominal CT. If residual lesions are found, retroperitoneal lymphadenectomy is considered. We studied retrospectively whether morphological criteria can help in selected cases in deciding about lymphadenectomy by distinguishing between vital tumor, scarring and mature teratoma. METHODS: In 26 patients who had been treated by salvage chemotherapy and retroperitoneal lymphadenectomy for non-seminomatous testicular cancer between 1990 and 1997, abdominal computed tomography and histology were correlated. RESULTS: Histological examination found scarring in 10 patients, vital tumor in 6, mature teratoma in 4, and simultaneous teratoma and vital tumor in 6. A single CT criterion for distinguishing between these histologies was not identified. In two patients with large masses which were partly cystic and partly solid vital tumor and teratoma were verified. Scarrings may be expected in cystic lesions at the level of the renal hilus which are lined by a thin and smooth wall. Size did not matter. CONCLUSION: Accurate differentiation between vital tumor and necrosis was not possible. Before lymphadenectomy CT, however, localised lesions.

[Chronic fatigue syndrome--psychiatric aspects]. / Das chronische Erschöpfungssyndrom--psychiatrische Aspekte.

Diagnosis of the chronic fatigue syndrome depends on various somatic and psychopathological symptoms. Somatic symptoms of the syndrome have been subject of an extensive body of literature. In comparison, psychiatric aspects have caught relatively less attention. Psychiatric aspects of etiological, diagnostic, and therapeutic concepts are essential for evaluation of the syndrome. Application of CDC-criteria to a well known disease does not solve the nosological problem, but may define the syndrome more accurately. In this respect, issues including psychiatric comorbidity and specificity of neuropathological symptoms are discussed. Psychological variables seem to have a high predictor value for time course and outcome of the symptoms. Etiological concepts emphasize on biological or psychosocial factors. Alterations of biological parameters including immune functions, sleep regulation, and hypothalamic-pituary-adrenocortical function have been reported. The role of cultural factors has been discussed extensively. Somatic and psychological stress may result in the same clinical syndrome via psychoimmunological mechanisms. An integrated, interdisciplinary approach to further refine diagnostic criteria, understanding of etiology and development of adequate therapeutic measures seems necessary.

Evidence for normal vitamin D receptor messenger ribonucleic acid and genotype in absorptive hypercalciuria.

Absorptive hypercalciuria (a stone-forming condition) is characterized by gut hyperabsorption of calcium, hypercalciuria, and reduced bone density. Inasmuch as these features implicate enhanced calcitriol action in gut and bone, we analyzed the vitamin D receptor (VDR) gene to ascertain whether an abnormality of this gene marks patients with intestinal hyperabsorption of calcium. We have compared the frequency of a restriction fragment length polymorphism (Bsm I) associated with different alleles of the VDR gene in a group of 33 well characterized absorptive hypercalciuric patients and a group of 36 normal race- and age-matched control subjects. There was no difference between the distribution of the VDR alleles in the patient population when compared with the normal population. The coding region of VDR messenger RNA was also normal, as determined by both DNA sequence analysis and chemical mismatch cleavage analysis of copy DNA from 11 index absorptive hypercalciuric patients. On the basis of these results, we propose that the enhanced intestinal calcium absorption invariably seen in absorptive hypercalciuria and attendant symptoms of this disorder are not attributable to mutations of the VDR and are not linked to a common VDR genotype.

[Anti-cyclic manifestation of asthma bronchiale and schizophrenic psychosis]. / Antizyklische Manifestation von Asthma bronchiale und schizophrener Psychose.

The interaction between the central nervous system and the immune system has been focus of recent research. Whereas cyclic AMP has been described as a link between atopic and affective disorders, a possible link between atopic disorders and schizophrenia has not yet been investigated. A 33-year-old patient showed episodes of allergic-asthmatic and paranoid-catatonic symptoms which appeared in an anticyclic pattern. Biological, clinical and therapeutic aspects are discussed in respect to the interaction between immunological and psychiatric disorders. Cyclic-AMP as a second-messenger is not specific for a certain cell species and might represent a possible link for integrated communication between the nervous and the immune system.

Opiate-receptor antagonist improves metabolic recovery and limits neurochemical alterations associated with reperfusion after global brain ischemia in rats.

Opiate-receptor antagonists improve behavioral, electrophysiologic and/or histologic outcome in various experimental models of central nervous system ischemia. To address the potential mechanism(s) by which opiate-receptor antagonists may exert their protective actions in cerebral ischemia, metabolic and biochemical changes were measured in brain of rats pretreated with the opiate-receptor antagonist nalmefene or vehicle and subjected to 60 min of global ischemia followed by 2 hr of reperfusion. 31P and 1H magnetic resonance spectroscopy were used to follow the metabolic changes during ischemia and reperfusion, after which brain tissue was frozen in situ. Biochemical assays included free fatty acids, thromboxane B2, ascorbate, vitamin E and amino acids. Nalmefene-treated animals showed more rapid and complete recovery of cellular bioenergetic state (as indicated by the phosphocreatine to inorganic phosphate ratio), tissue acidosis and lactate levels during reperfusion than placebotreated controls. Ischemia/reperfusion caused significant increases of fatty free acids and thromboxane, associated with significant decreases of ascorbate and glutamate; nalmefene pretreatment limited each of these changes. The degree of metabolic improvement as reflected by recovery of high energy phosphates and reduction of lactic acidosis were highly correlated with changes in tissue levels of arachidonate and glutamate. Thus, the beneficial effects of opiate-receptor antagonists in cerebral ischemia may be due, in part, to an ability to enhance metabolic recovery with associated, reduction in phospholipid hydrolysis and excitotoxin release.

Effect of medroxyprogesterone and an aorta-derived cell growth inhibitor on B16 melanoma in mice.

An aorta-derived inhibitor of endothelial cell and tumor cell growth and medroxyprogesterone, which depresses collagenase expression in vivo, were tested alone and in combination against B16-F10 melanoma in C57BL/6 mice in such doses that either agent alone had little effect. Together, these agents retarded growth of subcutaneously transplanted tumor cells and reduced the number and size of pulmonary tumors after iv tumor cell injection. Of the treatments used, only the aortic factor administered alone prolonged life in mice with pulmonary tumors.

Studies on the puberty-controlling function of the mediocortical amygdala in the immature female rat.

The puberty-controlling function of the mediocortical amygdala in immature female rats was investigated by lesioning this region at different ages and by studying the effects on the onset of spontaneous and experimentally-induced precocious puberty. At 21 days of age, bilateral lesions in the anterior mediocortical amygdala (AMCA) caused precocious puberty and enhanced the puberty-accelerating effect of bilateral lesions produced simultaneously in the medial preoptic area (MPA). Similar lesions, ineffective on day 26, delayed the onset of puberty when produced on day 32 in otherwise untreated rats. Lesions in the posterior mediocortical amygdala (PMCA) at 26 or 32 days of age postponed puberty in untreated rats and inhibited the advancement of their 1st pubertal ovulation that resulted from damage to the ventromedial-arcuate region (VAH) or daily administration of 0.05 mug estradiol benzoate (EB) per 100 g b.w. The results confirm earlier findings of different gonadotropin-controlling activities of the AMCA and PMCA in immature female rats and suggest maturational changes in the function of both areas. The gonadotropin-inhibiting action exerted by the AMCA at 3 weeks of age is lost when puberty approaches; a gonadotropin-stimulating activity seems to develop in both the AMCA and PMCA.

PIP: Vaginal openings and the 1st pubertal ovulations usually occurred between 38-42 days of age in female Wistar rats. Autopsies were done on the 16th day after vaginal openings were detected, or on the day of vaginal estrus after the 1st pubertal ovulation. For daily long-term treatment with estradiol benzoate sc injections of .05 mcg were given, with higher doses as age advanced. Bilateral lesions were produced by passing an anodal DC of 1 mA through a unipolar platinum electrode. At 21 days of age, bilateral lesions in the anterior mediocortical amygdala (AMCA) caused precocious puberty and enhanced the puberty-accelerating effect of bilateral lesions produced simultaneously in the medial preoptic area. Similar lesions were ineffective on Day 26, but when produced on Day 32 they delayed the onset of puberty. Lesions of the posterior mediocortical amygdala (PMCA) at 26 or 32 days of age delayed puberty and inhibited the advancement of the 1st pubertal ovulation that had resulted from damage to the ventromedial-arcuate region, or by the daily administration of .05 mc of estradiol/benzoate/100 gm body weight. Results showed different gonadotropin-controlling activities of the AMCA and PMCA in prepubertal female rats. The gonadotropin-inhibitory action exerted by AMCA at 3 weeks of age was lost when puberty approached. Maturational changes in the function of both areas seemed to develop.