Long-term results after semiconstrained distal radioulnar joint arthroplasty: A focus on complications.

Arthroplasty of the distal radioulnar joint (DRUJ) using a semiconstrained DRUJ implant yields good outcomes according to the literature. The aim of this study was to investigate the subjective, clinical and radiographic outcomes with a special focus on complications in nine patients with a mean follow-up of 6years and to compare them with our previously published 3-year follow-up results. No subjective or objective changes were seen between the 3-year and the 6-year follow-up. In the previous study, one implant loosening and two irritations of the superficial branch of the radial nerve occurred. We saw three complications that needed surgery in addition to the three complications already found 3years after surgery. One patient with a large ulna had loosening of the cemented ulnar stem and therefore the prosthesis was explanted. One patient had an allergic reaction to the metal alloy of the prosthesis, which also led to removal. One patient had an ulnar impaction syndrome caused by too-distal placement of the implant that needed revision. Prior studies reported low complication rates. In our study, six complications occurred in four out of nine patients, requiring reoperation including two revisions and two implant removals. A precise surgical technique is mandatory to avoid the otherwise frequent complications and potential implant failures. LEVEL OF EVIDENCE: IV.

Rituximab in routine care of severe active rheumatoid arthritis : A prospective, non-interventional study in Germany.

OBJECTIVE: To assess safety, effectiveness and onset of effect of rituximab (RTX) in routine clinical treatment of severe, active rheumatoid arthritis (RA). METHODS: Prospective, multi-centre, non-interventional study in rheumatological outpatient clinics or private practices in Germany. RTX-naïve adult patients were to receive RTX according to marketing authorisation and at their physician's discretion. Also according to their physician's discretion, patients could receive a second cycle of RTX (re-treatment = treatment continuation). Major outcome was the change in Disease Activity Score based on 28-joints count and erythrocyte sedimentation rate (DAS28-ESR) over 24 weeks and during 6 months of re-treatment. RESULTS: Overall, 1653 patients received at least one cycle RTX; 99.2% of these had received disease-modifying antirheumatic drugs (DMARD) pre-treatment and 75.5% anti-tumor necrosis factor(TNF)­α pre-treatment. After a mean interval of 8.0 months, 820 patients received RTX re-treatment. Mean DAS28-ESR decreased from 5.3 at baseline to 3.8 after 24 weeks (-1.5 [95% confidence interval, CI: -1.6; -1.4]), and from 4.1 at start of cycle 2 to 3.5 at study end (change from baseline: -1.8 [95% CI: -2.0; -1.7]). Improvements in DAS28-ESR and Health Assessment Questionnaire (HAQ) score occurred mainly during the first 12 weeks of RTX treatment, with further DAS28-ESR improvement until week 24 or month 6 of re-treatment. Improvements in DAS28-ESR and EULAR responses were more pronounced in seropositive patients. RF was a predictor of DAS28-ESR change to study end. Safety analysis showed the established profile of RTX. CONCLUSION: RTX was safe and effective in a real-life setting with rapid and sustained improvement in RA signs and symptoms.

[Impact of weather, time of day and season on the admission and outcome of major trauma patients]. / Wie hängen Eintreffen und Outcome schwerer Verletzter im Traumazentrum von Wetter, Tages- und Jahreszeit ab?

BACKGROUND AND OBJECTIVES: The potential association of external factors such as time of day, lunar phases or specific weather conditions on the daily management and outcome of trauma emergencies remains under debate. We undertook this trauma centre investigation to detect possible worthwhile factors of influence in order to optimize the organizational structure of trauma admissions. MATERIALS AND METHODS: Retrospective cohort analysis over the years 2010-2013, including all emergency trauma admissions with a new injury severity score (NISS) ≥8 (major trauma) treated in a teaching hospital in the lowland of Switzerland (uni- and multivariable analysis; p < 0.05). RESULTS: During the study period, 1178 major trauma patients were admitted to the hospital. The mean age of trauma victims was 53 ± 23 and the average ISS was 14 ± 8. More patients arrived within the summer months than during the rest of the year (p < 0.001). Higher energy trauma was found to correlate with higher daytime temperature, longer duration of sunshine (each p < 0.001), and change in weather conditions (p = 0.008). In contrast, snowfall and lunar phases did not demonstrate any association with the number or characteristics of trauma admissions. Multivariable analysis demonstrated that altogether longer sunshine, higher minimum daytime temperature and lower air humidity, compared to the previous day, accounted for 31 % of major trauma admissions. We could not find any impact of the investigated external factors on the outcome of patients. CONCLUSIONS: The study shows a significant relationship between specific weather conditions, such as higher daytime temperature or change in circulation, and the admission of major trauma patients. Due to the small effect in our setting, our results do not implicate any according change in the management of resources. Nevertheless, for hospitals in other geographic or more exposed weather regions, such effects could indeed be relevant and therefore should be tested.

Structural and congenital heart disease interventions: the role of three-dimensional printing.

Advances in catheter-based interventions in structural and congenital heart disease have mandated an increased demand for three-dimensional (3D) visualisation of complex cardiac anatomy. Despite progress in 3D imaging modalities, the pre- and periprocedural visualisation of spatial anatomy is relegated to two-dimensional flat screen representations. 3D printing is an evolving technology based on the concept of additive manufacturing, where computerised digital surface renders are converted into physical models. Printed models replicate complex structures in tangible forms that cardiovascular physicians and surgeons can use for education, preprocedural planning and device testing. In this review we discuss the different steps of the 3D printing process, which include image acquisition, segmentation, printing methods and materials. We also examine the expanded applications of 3D printing in the catheter-based treatment of adult patients with structural and congenital heart disease while highlighting the current limitations of this technology in terms of segmentation, model accuracy and dynamic capabilities. Furthermore, we provide information on the resources needed to establish a hospital-based 3D printing laboratory.

[The first biologic for rheumatoid arthritis: factors influencing the therapeutic decision]. / Das erste Biologikum bei rheumatoider Arthritis: Einflussfaktoren auf die Therapieentscheidung.

BACKGROUND AND AIMS: Biologics (disease modifying antirheumatic drugs, bDMARD) have been in use in Germany for the treatment of rheumatoid arthritis (RA) since 2001, usually after failure of at least one conventional synthetic (cs)DMARD. We analyzed temporal changes in factors that influence the decision for either a first bDMARD or a further csDMARD. MATERIAL AND METHODS: We analyzed data from 9513 bDMARD-naive RA patients in the German biologics register RABBIT who switched to a new therapy. For three recruitment periods (2001-2003, 2004-2006 and 2009-2015) factors influencing the therapeutic decision were analyzed by means of machine learning methods and logistic regression analysis. RESULTS: In all recruitment periods the number of previous csDMARDs, high dosages of glucocorticoids (>7.5 mg/day) and a higher DAS28 (>5.1) were significantly associated with the decision for a first bDMARD. Over time, the chance of receiving a bDMARD increased in patients with moderate disease activity, moderate glucocorticoid dosages (5-7.5 mg/day) and those with comorbidities, such as congestive heart failure or prior malignancy. Men had a higher chance of receiving a bDMARD than women only in the first recruitment period. Private health insurance, high education and gainful employment were significantly associated with more frequent prescription of bDMARDs in all recruitment periods. DISCUSSION: The time-dependent changes in the impact of disease activity, concomitant drugs, gender and comorbidity on the prescription of bDMARDs mirror the increasing therapeutic options and the growing experience in the application of the new substances in patients at higher risk. The influence of demographic and social factors may reflect safety concerns in patients at increased risk of adverse events but also the need to economize drug costs..

Stereochemistry of Fuscumol and Fuscumol Acetate Influences Attraction of Longhorned Beetles (Coleoptera: Cerambycidae) of the Subfamily Lamiinae.

The chemical structures of aggregation-sex pheromones of longhorned beetles (Coleoptera: Cerambycidae) are often conserved among closely related taxa. In the subfamily Lamiinae, adult males and females of several species are attracted by racemic blends of (E)-6,10-dimethyl-5,9-undecadien-2-ol (termed fuscumol) and the structurally related (E)-6,10-dimethyl-5,9-undecadien-2-yl acetate (fuscumol acetate). Both compounds have a chiral center, so each can exist in two enantiomeric forms. Males of many species of longhorned beetles only produce one stereoisomer of each pheromone component, and attraction may be reduced by the presence of stereoisomers that are not produced by a particular species. In a previous publication, analysis of headspace volatiles of adult beetles of the lamiine species Astyleiopus variegatus (Haldeman) revealed that males sex-specifically produced (S)-fuscumol and (S)-fuscumol acetate. Here, we describe field trials which tested attraction of this species to single enantiomers of fuscumol and fuscumol acetate, or to blends of enantiomers. We confirmed attraction of A. variegatus to its species-specific blend, but during the course of the trials, found that several other species also were attracted. These included Aegomorphus modestus (Gyllenhall), attracted to (S)-fuscumol acetate; Astylidius parvus (LeConte), attracted to (R)-fuscumol; Astylopsis macula (Say), attracted to (S)-fuscumol; and Graphisurus fasciatus (DeGeer), attracted to a blend of (R)-fuscumol and (R)-fuscumol acetate. These results suggest that chirality may be important in the pheromone chemistry of lamiines, and that specific stereoisomers or mixtures of stereoisomers are likely produced by each species.

Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project.

OBJECTIVE: To introduce a new standardized ultrasound score based on 7 joints of the clinically dominant hand and foot (German US7 score) implemented in daily rheumatologic practice. METHODS: The ultrasound score included the following joints of the clinically dominant hand and foot: wrist, second and third metacarpophalangeal and proximal interphalangeal, and second and fifth metatarsophalangeal joints. Synovitis and synovial/tenosynovial vascularity were scored semiquantitatively (grade 0-3) by gray-scale (GS) and power Doppler (PD) ultrasound. Tenosynovitis and erosions were scored for presence. The scoring range was 0-27 for GS synovitis, 0-39 for PD synovitis, 0-7 for GS tenosynovitis, 0-21 for PD tenosynovitis, and 0-14 for erosions. Patients with arthritis were examined at baseline and after the start or change of disease-modifying antirheumatic drug (DMARD) and/or tumor necrosis factor alpha (TNFalpha) inhibitor therapy 3 and 6 months later. C-reactive protein level, erythrocyte sedimentation rate, rheumatoid factor, anti-cyclic citrullinated peptide, Disease Activity Score in 28 joints (DAS28), and radiographs of the hands and feet were performed. RESULTS: One hundred twenty patients (76% women) with rheumatoid arthritis (91%) and psoriatic arthritis (9%) were enrolled. In 52 cases (43%), erosions were seen in radiography at baseline. Patients received DMARDs (41%), DMARDs plus TNFalpha inhibitors (41%), or TNFalpha inhibitor monotherapy (18%). At baseline, the mean DAS28 was 5.0 and the synovitis scores were 8.1 in GS ultrasound and 3.3 in PD ultrasound. After 6 months of therapy, the DAS28 significantly decreased to 3.6 (Delta = 1.4), and the GS and PD ultrasound scores significantly decreased to 5.5 (-32%) and 2.0 (-39%), respectively. CONCLUSION: The German US7 score is a viable tool for examining patients with arthritis in daily rheumatologic practice because it significantly reflects therapeutic response.

[Treatment results and complications after PFN osteosynthesis]. / Behandlungsergebnisse und Komplikationen nach PFN-Osteosynthese.

UNLABELLED: Intramedullary implants, such as the proximal femur nails (PFN), are inserted for the treatment of per-, inter- and subtrochanteric fractures. The initial experiences with these PFN, carried out by AO/ASIF in 1996, have been published. PATIENTS AND METHODS: This study makes a systematic examination of the complications and clinical treatment results from 133 patients treated at our clinic from December 1997-2001 with 139 PFN in per-, inter- and subtrochanteric femur fractures. The mean age at the time of surgery was 78.4 years. All fractures were classified according to the AO system. The most frequent injuries were 31 A2.3 fractures (61.2%). All intraoperative image-converter images and all radiographs from the total period of treatment were evaluated retrospectively in accordance with 28 criteria. The degree of osteoporosis was estimated using the Singh classification. RESULTS: A total of 44 (31.7%) complications arose in 31 (23.3%) patients. On 11 occasions, hip screw cut-out was observed. Of these, two cases involved a Z-effect and one an inverted Z-effect. Two patients suffered a femoral neck fracture following removal of the hip screws. There were 38 (27.3%) reoperations required with 13 changes in procedure. In autumn 2002, clinical follow-up examinations were carried out on 65 (48.9%) patients who were assessed according to the Merle d'Aubigné score. A total of 51 (38.3%) patients had died at the time of follow-up. Normal ambulation was achieved by 33.8% of patients, while 64.6% were free of pain. CONCLUSIONS: The PFN is an appropriate implant in cases of per-, inter- and subtrochanteric femur fractures. Anatomical resetting and correct implant positioning are the keys to successful osteosynthesis. The risk of implant failure is highest in the case of multi-fragmentary per- and intertrochanteric fractures in which medial strengthening has been degraded in patients aged over 80 years. The clinical results in elderly patients are unsatisfactory.

ACE inhibition does not exaggerate the blood pressure decrease in the early phase of spinal anaesthesia.

BACKGROUND: This study investigates whether long-term treatment with an angiotensin converting enzyme inhibitor (ACEI) impairs the hemodynamic regulation during the early phase of spinal anaesthesia. METHODS: Forty-two patients undergoing minor surgery were studied. Twenty-one patients were long-term treated (ACEI group), while the other patients served as controls (nonACEI group). All patients received a balanced electrolyte solution (6 ml kg(-1)) 20 min before spinal anaesthesia. RESULTS: Mean arterial blood pressure decreased 19% in both groups within 20 min after spinal anaesthesia. Heart rate did not change in either group. Plasma renin concentration increased from 7.3 +/- 2.1 to 12.8 +/- 4 pg ml(-1) during spinal anaesthesia in nonACEI patients (P < 0.05), whereas an elevated plasma renin level remained unchanged in the nonACEI group. The angiotensin II concentration increased in both groups during spinal anaesthesia (P < 0.05). The vasopressin concentration did not change during spinal anaesthesia in the ACEI group, but increased from 1.2 +/- 0.3 to 2.2 +/- 0.5 pg ml(-1) in patients with ACEI treatment (P < 0.05). The norepinephrine concentration increased transiently 5 min after spinal anaesthesia in both groups, and returned to baseline levels within 15 min. CONCLUSION: Long-term ACEI treatment does not further exaggerate the blood pressure decrease in the early phase of spinal anaesthesia. The increase in vasopressin concentrations in ACEI treated patients seems to be sufficient to compensate for the inhibited renin-angiotensin system. In addition, the transient increase in plasma norepinephrine, which occurs independent of preoperative ACEI treatment, seems to be involved in blood pressure regulation during spinal anaesthesia.

[Kirschner wire transfixation of syndesmosis rupture--an alternative treatment of type B and C malleolar fractures]. / Die Kirschnerdraht-Transfixation der Syndesmosenruptur--Eine alternative Behandlung von Malleolarfrakturen Typ B und C.

After completing ORIF of the lateral malleolus, the standard technique for fixation of the syndesmosis involves placement of a 3.5 mm locking screw across the fibula to the tibia. Alternative there is a possibility to make the transfixation with two 1.6 mm Kirschner wires introduced obliquely across the distal tibiofibular syndesmosis. No early removing of the implant is necessary. This retrospective study was conducted on a total of 50 cases of Weber type B or C malleolar fractures with syndesmotic rupture between 1988 and 1996. In 45 patients (90%) there is no complication seen for the transfixation, but in five patients a Kirschner wire dislocation was observed. We were able to review 36 of these patients after a median follow-up of 8.3 years (range 5-12 years). The results were evaluated using objective, subjective and roentgenographic criteria. Subjective rating had 29 patients (81%) with very good or good results. Good radiological results were found in 29 patients (81%). Concluding of this results the Kirschner wires transfixation is a technical simple method with good or very good results.

Organic Pillared Clays.

Commonly used organophilic clays are modified by alkylammonium cations which hold apart the aluminosilicate layers permanently. The cations fill the interlayer space and are contemplated as flexible pillars, resulting from the mobility of the alkyl chains. Therefore, the interlayer distance varies depending on the layer charge and on the alkyl chain length. Contrary to these cations, rigid pillaring cations guarantee a constant interlayer distance without occupying the interlayer by themselves and show special adsorption properties such as hydrophilic behavior contrary to the generally hydrophobic ones. Smectites were modified by flexible organic cations, e.g., dimethyldioctadecylammonium, and by rigid ones, e.g., tetraphenylphosphonium. Their adsorption properties are compared. Our investigations showed improved adsorption properties for rigid organic cations on smectites using 2-chlorophenol as pollutant. Best adsorption results are achieved using pillaring cations in combination with low charged smectites, especially at low pollutant concentrations. The properties of organic modified smectites are discussed by a pollution intercalation model. The intercalation process of an organic pollutant into an organic modified smectite is expressed by a two-step Born-Haber cycle process: (i) the formation of an adsorbing position by layer expansion and (ii) the occupation of the adsorbing position by the pollutant. The first step of the formation of the adsorbing position is an endothermal transition state which lowers the total intercalation energy and therefore worsens the adsorption behavior. Thus, an already expanded organophilic smectite will show improved adsorption behavior. The formed adsorbing position state on organic modified smectites is comparable to the pillared state of inorganic pillared clays. Copyright 2001 Academic Press.

Vasculitis of the female genital tract with clinicopathologic correlation: a study of 46 cases with follow-up.

Forty-six cases of vasculitis affecting the female genital tract are described; only 41 similar cases have been previously reported, either as case reports or small series. The age range of the patients was from 22 to 80 years, and most of them presented with abnormal bleeding or were being treated conditions unrelated to the vasculitis. There were 39 hysterectomy specimens (26 of which were derived from total abdominal hysterectomies) and seven specimens of the cervix only. The vasculitis was confined to the cervix in 30 of the 46 cases; in 24 of these, the entire uterus was available for examination. In 23 cases, only a single vessel was involved, and in the other 23 there was more extensive vessel involvement. In all cases, the involved vessels were arterioles and small arteries. In 42 cases, the arteritis was of the polyarteritis nodosa (PAN) type, and in four, of the giant cell type (GCA). Follow-up ranged from < 1 year to 23 (mean, 3) years. Systemic manifestations were previously diagnosed or subsequently developed in only four patients, three with PAN and one with GCA; in each of them, the genital tract vasculitis was found only in the cervix (in one of these, however, the specimen was a loop excision of the cervix and the rest of the uterus was not assessable). The three patients with PAN subsequently developed extragenital PAN (one case), PAN and rheumatoid arthritis (one case), or PAN and polymyalgia rheumatica (one case). The patient with GCA had previously documented temporal arteritis and temperomandibular arthritis. The findings in this series and in previously reported cases indicate that vasculitis of the female genital tract is only rarely associated with systemic vasculitis.

HLA-DR/DQ interaction in patients with erosive rheumatoid arthritis presenting articular and extraarticular disease manifestations.

In the present study we have analysed the effect of HLA-DRB1 and -DQB1 alleles on disease progression and genetic predisposition among 201 RA patients. We clearly confirm the association of RA with HLA class II alleles sharing the (Q)R/KRAA amino acid (AA) cassette in the third hypervariable region (HVR3) of the DR beta-chain. The HVR3 (Q)R/KRAA motif was significantly overrepresented among RA patients (79% vs. 40%, P < 0.001), with one third of the patients homozygous (28% vs. 6.7%, P < 10(-9)) and the number of rheumatoid factor positive (RF+) patients was significantly increased among HVR3 (Q)R/KRAA homozygous in comparison to HVR3 (Q)R/KRAA negative individuals. Erosive disease defined by the Larsen Score and personal disability determined using the Health Assessment Questionnaire (HAQ) was significantly increased among patients positive for the HVR3 motif with the worst outcome among HVR3 (Q)R/KRAA homozygous patients. In contrast, there was no association of the shared HVR3 AA cassette and disease severity in the majority of patients presenting systemic (extraarticular) disease. Homozygosity for the shared HVR3 motif was only marginally increased among patients presenting 'severe' extraarticular disease in comparison to patients with articular disease (33% vs. 43%, P = ns). Similarly, patients with nodular disease were not more often homozygous for the HVR3 (Q)R/KRAA motif. Furthermore, we observed no HLA-DR independent association of DQB1 alleles among HVR3 (Q)R/KRAA positive patients and controls. Our analysis supports the predominant role of HLA-DR for genetic susceptibility to RA. In the clinical setting, however, HLA-DR typing may be limited to assess the individual risk of patients for disease progression.

Activity of high-dose cyclophosphamide in the treatment of childhood malignant gliomas.

Seventeen patients less than or equal to 20 years of age with newly diagnosed (n = 10) or recurrent (n = 7) malignant gliomas (anaplastic astrocytoma and glioblastoma multiforme) were treated with cyclophosphamide in association with hematopoietic cytokines (GM-CSF or G-CSF). Cyclophosphamide was given at a dose of 2 g/m2 daily for 2 days at 4-week intervals. Toxicity consisted of grade IV neutropenia and thrombocytopenia in 95% and 48% of cycles, respectively. There were no cyclophosphamide-related cardiac, pulmonary, or urothelial toxicities observed. Four of 10 patients with newly diagnosed disease demonstrated responses (three complete and one partial responses; one CR was only of 2 months duration). None of the seven patients with recurrent tumors demonstrated a response. We conclude that high-dose cyclophosphamide warrants further evaluation in children with newly diagnosed malignant glioma.

Development of polyarthritis after insertion of silicone breast implants followed by remission after implant removal in 2 HLA-identical sisters bearing rheumatoid arthritis susceptibility genes.

We describe 2 HLA-identical sisters who both received silicone breast implants and subsequently developed polyarticular arthritis and neurologic symptoms. In both patients, HLA typing revealed 3 alleles typically associated with rheumatic diseases: HLA-DRB1*0405 and HLA-DQB1*0302 (associated with RA), and HLA-DRB4*01 (associated with mixed connective tissue disease and autoimmune reactions in patients with silicone breast implants. After removal of the implants, rheumatic as well as neurologic symptoms improved dramatically in both patients. One patient achieved complete remission. The other patient, who initially had more progressive disease, retained mild residual symptoms, but had significant improvement in radiological erosions. We believe that our cases support the theories that silicone may act as a triggering factor in genetically susceptible individuals, and that silicone may represent an adjuvant for the development of autoimmune disease. We discuss the possibility that a manifested spectrum of symptoms after silicone exposure might be more specific for a patient's genetic background than unique for silicone.

Response of recurrent medulloblastoma to low-dose oral etoposide.

PURPOSE: The outcome for patients with recurrent medulloblastoma has historically been poor, with most patients dying of disseminated disease. Here, we report on seven patients with recurrent medulloblastoma, most heavily pretreated with a variety of chemotherapeutic agents, including parenteral etoposide (VP-16), who showed responses to the administration of repeated courses of low-dose oral VP-16. PATIENTS AND METHODS: Seven patients age 4 to 16 years were treated with VP-16 after neuroradiographic and clinical evidence of tumor progression. Six had received prior irradiation. All seven had been pretreated with a variety of chemotherapeutic agents and schedules, including parenteral VP-16. VP-16 was administered orally as repeated 21-day courses at 50 mg/m2/d with a 7-day interval between courses. Evaluation consisted of neuroradiographic and clinical examination after completion of every two courses of therapy. Complete blood cell counts were performed weekly. RESULTS: The major toxicity of oral VP-16 was hematologic, with two patients requiring platelet transfusions due to thrombocytopenia and two requiring RBC transfusions. All seven patients developed treatment-related neutropenia. Two patients were supported with granulocyte colony-stimulating factor (G-CSF) between courses. One patient developed infectious epididymitis after course 2 and required intravenous antibiotics; this illness was complicated by Clostridium difficile colitis. There was one episode of fever associated with neutropenia. There were no treatment-related deaths. Of seven patients assessed, six have demonstrated partial responses (PRs) and the remaining patient had stable disease (SD). CONCLUSION: This report demonstrates the activity of oral VP-16 in the treatment of a small cohort of pretreated patients with recurrent medulloblastoma. This form of administration of oral VP-16 was well tolerated and produced modest toxicity.

Treatment of patients with pineoblastoma with high dose cyclophosphamide.

The outcome for patients with pineoblastoma has historically been very poor, with most patients dying of disseminated disease despite irradiation. Furthermore, the low incidence of this tumor has hindered progress toward defining better treatment strategies. Here we report the activity and toxicity of cyclophosphamide administered as a single agent at a dose schedule of 2 g/m2/day for 2 successive days at monthly intervals for a maximum of four courses. Eight patients were evaluated, six newly diagnosed and two recurrent. Amongst the six newly diagnosed patients, there were three patients demonstrating partial responses, and three had stable disease throughout the cyclophosphamide treatment period. All six patients are alive and disease free after further therapy. One patient with recurrent disease demonstrated tumor progression on cyclophosphamide, and the other had stable disease throughout the cyclophosphamide treatment period. Both patients subsequently died of progressive disease. The major toxicity of high dose cyclophosphamide was hematopoietic, with one patient requiring a dose reduction after three courses due to prolonged thrombocytopenia. One patient was also withdrawn from treatment with cyclophosphamide due to impaired pulmonary function. This study demonstrates the activity of high dose cyclophosphamide in the treatment of pineoblastoma and may serve as basis for the design of future studies of this tumor.

[Management of lateral type B malleolar fracture with penetrating wires, cerclage and hemicerclage]. / Versorgung der lateralen Malleolarfraktur Typ B mit Spickdrähten, Cerclagen und Hemicerclagen.

In this retrospective study 52 cases of malleolar fractures type B, that were treated with Kirschner wires, cerclages and hemicerclages, between 1981 and 1991 at the Männedorf Hospital, were compiled and completed with the corresponding synopsis. The results show that the osteosynthesis technique, in certain cases, is absolutely justifiable and represents a reliable alternative to tensile screw osteosynthesis. This procedure of osteosynthesis is a good method in comminuted fractures as well as osteoporotic bone, in which the screws grip badly. A minimum of osteosynthesis material is implanted in precarious soft tissue conditions. As in the tensile screw osteosynthesis, the removal of the material can be done ambulatory under local anaesthetic with stab incision. The functional after-treatment is not recommended. We suggested a postoperative plaster of Paris treatment for 6 weeks (2 weeks without and 4 weeks with strain). As the postoperative course shows comparable results, osteosynthesis of the lateral malleolar fracture type B with Kirschner wires, cerclages and hemicerclages represents a good variation to plate osteosynthesis and tensile screw osteosynthesis.