Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice.

INTRODUCTION: The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment. METHODS: A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. RESULTS: Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large. CONCLUSION: The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Bedside hyperspectral imaging indicates a microcirculatory sepsis pattern - an observational study.

INTRODUCTION: Microcirculatory alterations are key mechanisms in sepsis pathophysiology leading to tissue hypoxia, edema formation, and organ dysfunction. Hyperspectral imaging (HSI) is an emerging imaging technology that uses tissue-light interactions to evaluate biochemical tissue characteristics including tissue oxygenation, hemoglobin content and water content. Currently, clinical data for HSI technologies in critical ill patients are still limited. METHODS AND ANALYSIS: TIVITA® Tissue System was used to measure Tissue oxygenation (StO2), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI) in 25 healthy volunteers and 25 septic patients. HSI measurement sites were the palm, the fingertip, and a suprapatellar knee area. Septic patients were evaluated on admission to the ICU (E), 6 h afterwards (E+6) and three times a day (t3-t9) within a total observation period of 72 h. Primary outcome was the correlation of HSI results with daily SOFA-scores. RESULTS: Serial HSI at the three measurement sites in healthy volunteers showed a low mean variance expressing high retest reliability. HSI at E demonstrated significantly lower StO2 and NPI as well as higher TWI at the palm and fingertip in septic patients compared to healthy volunteers. StO2 and TWI showed corresponding results at the suprapatellar knee area. In septic patients, palm and fingertip THI identified survivors (E-t4) and revealed predictivity for 28-day mortality (E). Fingertip StO2 and THI correlated to SOFA-score on day 2. TWI was consistently increased in relation to the TWI range of healthy controls during the observation time. Palm TWI correlated positively with SOFA scores on day 3. DISCUSSION: HSI results in septic patients point to a distinctive microcirculatory pattern indicative of reduced skin oxygenation and perfusion quality combined with increased blood pooling and tissue water content. THI might possess risk-stratification properties and TWI could allow tissue edema evaluation in critically ill patients. CONCLUSION: HSI technologies could open new perspectives in microcirculatory monitoring by visualizing oxygenation and perfusion quality combined with tissue water content in critically ill patients - a prerequisite for future tissue perfusion guided therapy concepts in intensive care medicine.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex.

PURPOSE: The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions. METHODS: A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done. RESULTS: Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred. CONCLUSION: Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance. LEVEL OF EVIDENCE: Therapeutic IV.

[Peak timing for complications after spine surgery]. / Komplikationen im zeitlichen Verlauf nach einer operativen Wirbelsäulenversorgung.

BACKGROUND: Spine surgeries can pose many complications; however, peak timing of post-operative complications in the field of spine surgery is still not sufficiently delineated in the literature as yet. Nevertheless the determination of peak timing of post-operative complications has a significant influence on patient education and post-operative follow-up. MATERIALS AND METHODS: This single-center study analyzed the medical records of 1179 patients that underwent spinal instrumentation between 2010 and 2015 at 3, 6, 12, 24 and 36 months postoperatively. Complications were analyzed according to their time of onset. RESULTS: Of the 1179 patients included, 199 (16.9%) underwent revision surgery due to a complication. Peak timing for complications (72.9%) occurred within the first 3 months after surgery. Infection was the most common reason for revision surgery (42.7%) and most infections occurred within the first 3 months after surgery (early infections) (91.8% of infections). Peak timing for material failure occurred in the second post-operative year (46% of all detected prosthesis failures) (2.5% of all complications). DISCUSSION: Peak timing of post-operative complications post spinal instrumentation occurs as early on as within the first 3 months after surgery and post-operative infections remain the most common post-operative complication overall. Nonetheless, regular and long-term postoperative clinical and radiological follow-up is crucial, since in particular prosthesis failure has its peak timing in the second post-operative year.

Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis.

BACKGROUND: Bracing constitutes the mainstay treatment for mild scoliosis. The 3D reconstruction of the spine using low-dose stereoradiographic imaging (LSI) is increasingly being used to determine the true shape of the deformity and to assess the success of bracing. OBJECTIVE: The aim of the study was to validate the measurement of 3D spinopelvic parameters and vertebral rotation in the setting of bracing treatment via a reliability study conducted in adherence to the guidelines for reporting reliability and agreement studies (GRRAS). MATERIAL AND METHODS: Full spine stereoradiographs of patients with adolescent idiopathic scoliosis (AIS) who underwent Chêneau bracing were retrospectively analyzed. The 3D reconstruction was performed by two experienced operators in a blinded manner and randomized order. Rotation of every vertebra was computed in the coronal, sagittal and axial planes. Sagittal spinopelvic parameters were evaluated. All measurements were statistically compared to determine agreement of the measurement of brace correction using the intraclass correlation coefficient (ICC). RESULTS: In this study, 45 patients (81% females) aged 12.5 ± 2 years were included. The mean absolute difference was less than 3.5° for all measured angles, less than 4 mm for sagittal vertical axis (SVA) and less than 1.5 mm for lateral pelvic shift. The ICC was high for all parameters (ICC >0.81). Despite the overall high reliability, the reliability of axial rotation was lower in the upper and middle thoracic spine and the lower lumbar spine. CONCLUSION: Brace wearing during full spine LSI acquisition does not affect spinal measurements. The LSI under bracing treatment produces reliable measurements of spinopelvic parameters as well as vertebral rotation. These reproducible 3D data enable spine surgeons to assess the true shape of the deformity, to quantify rotation of each vertebra and enhance the understanding of the efficacy of bracing treatment.

Fumaric acid ester-induced T-cell lymphopenia in the real-life treatment of psoriasis.

BACKGROUND: Fumaric acid esters (FAEs) are used to treat psoriasis and are known to cause lymphopenia in roughly 60% of the patients. Much remains to be elucidated about the biological effects of FAEs on lymphocytes. OBJECTIVE: To evaluate the influence of long-term FAE (Fumaderm® ) treatment on peripheral blood CD4+ and CD8+ T cells, CD19+ B cells and CD56+ natural killer (NK) cells in psoriasis. METHODS: In this single-centre retrospective observational subcohort study, we obtained leucocyte and lymphocyte subset counts before initiating FAE therapy in 371 psoriasis patients (mean age, 47.8 years; 63.3% males) and monitored them during treatment (mean treatment duration, 2.9 years). Multiparametric flow cytometry was used for immunophenotyping. RESULTS: FAEs significantly reduced the numbers of CD4+ T, CD8+ T, CD19+ B and CD56+ NK cells. Among lymphocyte subsets, the mean percentage reduction from baseline was always highest for CD8+ T cells, with a peak of 55.7% after 2 years of therapy. The risk of T-cell lymphopenia increased significantly with the age of the psoriasis patients at the time that FAE therapy was initiated. It was significantly decreased for the combination therapy with methotrexate and folic acid (vitamin B9) supplementation. Supporting evidence was found suggesting that T-cell lymphopenia enhances the effectiveness of FAE therapy. CONCLUSIONS: Monitoring distinct T-cell subsets rather than just absolute lymphocyte counts may provide more meaningful insights into both the FAE treatment safety and efficacy. We therefore suggest optimizing pharmacovigilance by additionally monitoring CD4+ and CD8+ T-cell counts at regular intervals, especially in patients of middle to older age. Thus, further prospective studies are needed to establish evidence-based recommendations to guide dermatologists in the management of psoriasis patients who are taking FAEs and who develop low absolute T-cell counts.

The impact of a cervical dysplasia diagnosis on individual cancer prevention habits over time: a bicentric case-control study.

PURPOSE: Annual cervical cancer screening is recommended in Germany as a part of the statutory preventive care. Abnormal results can provoke psychological distress and anxiety, compromising women's adherence. Little is known about how a cervical dysplasia impacts adherence follow-up visits and prevention habits over time. To optimize care strategies, this study aims to identify women at risk for nonadherence to follow-up visits after a screening event. METHODS: Between November 2015 and May 2017, participants with an abnormal Pap smear at the Heidelberg and Leipzig University Hospitals received a four-part questionnaire (sociodemographic data, PHQ-D, self-designed fear and prevention habit questions) at the first consultation (T1) and subsequently after 3 (T2) and 6 (T3) months; healthy controls completed the questionnaire at T1. RESULTS: 132 women with an abnormal Pap smear [with conization: S1 (n = 68, 51.5%), without intervention: S2 (n = 64, 48.5%)] and healthy controls (K, n = 101) generally adhered to gynecological checkups, except S1 6 months after the first diagnosis (S1/T3 - 0.47, signed rank p < 0.0005). Knowledge of primary prevention information, i.e., HPV vaccination, was significantly higher among K (K 58%, S1 29%, S2 44%, Chi-squared p = 0.01) as was vaccine uptake (K 39% versus S1/S2 7% and 17%, respectively, Chi-squared p = 0.0004). Fear of upcoming Pap smears rose significantly over time (S1/T1-S1/T2-S1/T3, Wilcoxon signed-rank test p < 0.001) and was higher among those with conization at T2 (Chi-square test, p = 0.01) and partially accompanied by panic disorders at T1 (Chi-square test p = 0.035). Realization of general preventive habits rose significantly among women without an operative procedure (S2) over the study. CONCLUSION: This study advances the understanding of non-participation in follow-up visits after a dysplasia diagnosis, identifying post-conization women as a special risk group for decreased adherence.

Comparison of chlorhexidine-isopropanol with isopropanol skin antisepsis for prevention of surgical-site infection after abdominal surgery.

BACKGROUND: Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial. METHODS: Between August and October 2014, patients undergoing abdominal surgery received preoperative skin antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174). RESULTS: In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034). CONCLUSION: This study showed a benefit of adding chlorhexidine to alcohol for skin antisepsis in reducing early SSI compared with alcohol alone.

Long-term real-life safety profile and effectiveness of fumaric acid esters in psoriasis patients: a single-centre, retrospective, observational study.

BACKGROUND: Fumaric acid esters (FAEs) are an established systemic treatment for moderate-to-severe psoriasis. However, the long-term clinical safety and effectiveness of continuous FAE monotherapy and combination therapy have not been established. OBJECTIVE: To examine the long-term safety and effectiveness of FAEs as monotherapy and in combination with phototherapy or methotrexate in patients with psoriasis treated at a single centre in Germany. METHODS: This monocentric, retrospective observational study, with a follow-up period of up to 32.5 years, included 859 patients: 626 received FAE monotherapy, 123 received FAEs with concomitant phototherapy and 110 received FAEs with methotrexate. RESULTS: Approximately half of patients (49.0%) reported adverse events (566 total events), most of which involved the gastrointestinal tract. Serious adverse events were reported in 2.3% of patients, but none were deemed to have a causal relationship with any of the treatment regimens. Adverse events leading to treatment discontinuation were observed in 12.9% of patients. A median duration of 1 year was observed in all three treatment subcohorts (P = 0.70) from initiation of FAE treatment to a 50% response rate, where response was defined as achieving a cumulative static Physician's Global Assessment (PGA) score of 'light' and at least a 2-point reduction in baseline PGA. A 50% response rate for the cumulative Psoriasis Area and Severity Index 75 was achieved in the FAE monotherapy subcohort after a median of 3 years of treatment, in the FAEs + phototherapy subcohort after 6.7 years and in the FAEs + methotrexate subcohort after 8.1 years (P = 0.001). CONCLUSION: According to our data, FAEs as monotherapy or in combination with phototherapy or methotrexate are safe and beneficial for long-term clinical use. However, multicentre, randomized controlled trials are required to establish the clinical value of monotherapy versus combination therapy and the optimal treatment duration.

Prevalence of upper extremity pain in a population of people with paraplegia.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine the prevalence, patterns, and predictors of musculoskeletal pain in the upper extremity joints among wheelchair-dependent individuals with post-traumatic paraplegia. Secondarily, to document most common reported causes of upper extremity pain. SETTING: Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Germany. METHODS: The study was done by means of a structured questionnaire, which was mailed to the individuals who had been treated between 1990 and 2007 for newly sustained or pre-existing, accident-related paraplegia (n = 670). The questionnaire was designed mainly to obtain the information regarding shoulder, elbow, and wrist pain. Additional data included participant demographics, mechanism, level and completeness of injury as well as wheelchair dependence and time since injury. The Frankel classification system was used to define the completeness of injury. RESULTS: Four hundred and fifty-one (67%) questionnaires were included. Pain was reported by approximately 81% of the participants. Of this sample, 61% had shoulder pain, 33% had elbow pain, and 43% had wrist pain, 19% had shoulder, elbow, and wrist pain, 27% had shoulder and elbow pain, 34% had shoulder and wrist pain, 21% had elbow and wrist pain. The main diagnoses were rotator cuff tears for individuals with shoulder pain, epicondylitis for those with elbow pain, and carpal tunnel syndrome for those with wrist pain. The development of shoulder/elbow and wrist pain correlated with age and time since injury. CONCLUSIONS: Age and the length of time since injury correlated with a higher rate of shoulder, elbow, and wrist pain. The completeness of injury, neurological level, and gender were correlated with shoulder, elbow, and wrist pain, respectively.

Fertility preservation: ovarian response to freeze oocytes is not affected by different malignant diseases-an analysis of 992 stimulations.

PURPOSE: To study if ovarian response is affected by the type of disease if fertility preservation is required. METHODS: A registry of the trinational fertility preservation network FertiPROTEKT including 992 patients aged 18-40 years undergoing ovarian stimulation and follicle aspiration for fertility preservation from 1/2007 until 3/2016 was analysed. The number of collected oocytes, days of stimulation, total gonadotropin dosage and gonadotropin dosage per day were evaluated. RESULTS: Total oocyte number was negatively correlated with increasing age (r = 0.237, p < 0.0001). Oocyte numbers were in women < 26 years 15.4 ± 8.8, 26-30 years 13.1 ± 8.5, 31-35 years 12.2 ± 7.7 and 36-40 years 9.9 ± 8.0. Age-adjusted oocyte numbers were not different in women with Hodgkin's lymphoma (12.6 ± 8.8), non-Hodgkin's lymphoma (12.4 ± 8.2), leukaemia (11.7 ± 8.2), sarcoma (11.8 ± 8.2), cerebral cancer (16.5 ± 8.1), gastrointestinal cancer (13.2 ± 8.1) gynaecological cancer (10.8 ± 8.2) and other types of malignancies (15.8 ± 8.1) apart from ovarian cancer with lower oocyte yield (7.3 ± 8.3, p < 0.001) compared to women with breast cancer (13.3 ± 8.8). The total gonadotropin dose used for stimulation was only elevated in Hodgkin's and non-Hodgkin's lymphoma compared to women with breast cancer (p < 0.05). Oocyte yield was lower in women with versus without ovarian cancer (p < 0.0001). CONCLUSIONS: As ovarian response is not affected by the type of cancer, ovarian stimulation can be performed with the same oocyte yield in different malignant diseases. However, oocyte yield is reduced if ovarian surgery is required and in older women.

[Risk factors for the development of rotator cuff tears in individuals with paraplegia : A cross-sectional study]. / Risikofaktoren für Rotatorenmanschettenrupturen bei Paraplegikern : Eine Querschnittstudie.

QUESTION: Shoulder pain and rotator cuff tears are highly prevalent among wheelchair dependent individuals with paraplegia. The purpose of this study was to identify potential risk factors associated with the development of rotator cuff tears in this population. METHODS: A total of 217 wheelchair dependent individuals with paraplegia were included in this cross-sectional study (level of evidence III). The mean age of this population was 47.9 years and the mean duration of wheelchair dependence was 24.1 years. Each individual was asked to complete a questionnaire designed to identify risk factors for rotator cuff tears and underwent a standardized clinical examination with the documentation of the Constant-Murley shoulder outcome score and magnetic resonance imaging (MRI) of both shoulder joints. RESULTS: MRI analysis revealed at least one rotator cuff tear in 93 patients (43%). Multiple logistic regression analysis identified the following factors to be associated with the presence of rotator cuff tear: patient age, duration of spinal cord injury/wheelchair dependence, gender, and wheelchair athletic activity. Neither BMI nor the level of spinal cord injury was found to pose a risk factor in the population studied. With respect to patient age, the risk of developing a rotator cuff tear increased by 11% per annum. In terms of duration of spinal cord injury, the analysis revealed a 6% increased risk per year of wheelchair dependence (OR = 1.06). Females had a 2.6-fold higher risk of developing rotator cuff tears than males and wheelchair sport activity increased the risk 2.3-fold. DISCUSSION: There is a high prevalence of rotator cuff tears in wheel-chair dependent persons with paraplegia. Risk factors such as age, gender, duration of paraplegia, and wheel chair sport activity seem to play an important role in the development of rotator cuff tears.

Two-year development of children conceived by IVM: a prospective controlled single-blinded study.

STUDY QUESTION: Is there a difference in mental development of children conceived by IVM in comparison to IVF or ICSI, independently, at the age of 2 years? SUMMARY ANSWER: No differences could be found in mental development of IVM children compared to IVF and IVM children compared to ICSI as well. WHAT IS KNOWN ALREADY: Only few retrospective or non-controlled studies addressed the health of IVM children and did not show a negative impact of the IVM procedure. STUDY DESIGN, SIZE, DURATION: Prospective controlled single-blinded study including 63 pregnancies (21 per IVM, IVF and ICSI groups) with 70 children expected. Examinations of 62 embryos at first trimester screening, of 57 fetuses at 21st week of pregnancy, of 60 children at birth and of 37 children at their second birthday were performed during the study period from January 2009 until October 2016. Bayley score at the age of 2 was the primary outcome parameter. Data of 40 children after spontaneous conception from a previous prospective unrelated study were further used as control at 2 years examination and compared to the pooled ART group (IVM, IVF and ICSI). PARTICIPANTS/MATERIALS, SETTING, METHODS: Twenty-one IVM pregnancies achieved in the study period were included. For each of them, the following IVF- and ICSI pregnancies were recruited as controls. Ultrasound examinations during pregnancy, examinations of newborns and of children around their second birthday were done by blinded prenatal specialists, pediatricians and neuropediatricians, respectively. MAIN RESULTS AND THE ROLE OF CHANCE: Children conceived after IVM did not show differences during embryonic development, at birth nor in their neuropediatric development at the age of 2 compared to their counterparts after IVF and after ICSI (Bayley score 91.3 ± 21.0 for IVM, 96.8 ± 13.2 for IVF and 103.9 ± 13.1 for ICSI) and of the pooled ART group compared to children after spontaneous conception (96.6 ± 16.4 ART and 103.2 ± 9.4 spontaneous conception). When analyzing singleton pregnancies only, again no differences during pregnancy, at birth and at their 2-year evaluation were detected between IVM versus IVF and IVM versus ICSI. LIMITATIONS, REASONS FOR CAUTION: Due to the small sample size data must be interpreted with caution. To allow a confirmative answer that there are no health risks for children conceived by IVM, large multicenter cohort or registry-based studies are urgently needed. WIDER IMPLICATIONS OF THE FINDINGS: The study adds further information to previous uncontrolled or retrospective studies, which were unable to detect risks for the health of IVM children. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by the 'Deutsche Forschungsgemeinschaft' (DFG): STR 387/4-1. G.R. receives royalties from Pearson Assessment Germany (editor fee for Bayley-III). The other authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas).

BACKGROUND: Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome. METHODS: Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery. RESULTS: Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications. CONCLUSION: None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Post-prostatectomy radiotherapy adversely affects urinary continence irrespective of radiotherapy regime.

PURPOSE: To investigate the influence of different postoperative radiotherapy (RT) regimes on post-prostatectomy continence and QoL. METHODS: Men after prostatectomy (RP) and RT were assigned in adjuvant (ART), early salvage (ESRT) and salvage radiotherapy (SRT) groups depending on time of initiation, indication and pre-RT-PSA (≤/>0.5 ng/ml). Continence and QoL outcomes were evaluated by validated questionnaire. Statistical analysis included students t test, Chi square, Fisher's test, ROC- and McNemar-Bowker-Analyses. RESULTS: The mean follow-up was 5.1 years. 33.5, 38.2 and 28.3% received ART, ESRT and SRT, respectively. Mean time to RT was 0.3 (±0.4), 1.8 (±2.5) and 3.3 (±3.6) years respectively. Differences in age at RP (p = 0.54) and RT (p = 0.47) between groups were not significant. Mean-RT-dose was similar (p = 0.70). Differences in continence distribution between groups before (p = 0.56) and after RT (p = 0.38) were not significant. No significant differences were observed for frequency (p = 0.58) or amount (p = 0.88) of urine loss, impact on QoL (p = 0.13) and ICIQ-SF scores (p = 0.69) between groups. Even though no significant difference in post-RT-continence (p = 0.89) was observed in the direct comparison between groups, a significant worsening of long-term continence was observed in all groups (p < 0.001). We found no cutoff and no time-point after RP at which this negative effect of RT on continence became insignificant (AUC = 0.474). A subgroup with apparent local recurrence showed no differences for ICIQ-SF-score (p = 0.155), QoL (0.077), incontinence grade (p = 0.387), frequency (p = 0.182) and amount (p = 0.415) of urine loss. Proportionally more men in this subgroup remembered deterioration of continence after RT (p = 0.029). CONCLUSION: Postoperative RT adversely affects long-term continence; this negative effect is irrespective of time of initiation or indication for RT. These results suggest a need for innovative strategies of prostate cancer therapy with lasting oncological, functional and QoL outcomes.

Surgery is essential in squamous cell cancer of the rectum.

PURPOSE: Squamous cell cancer (SCC) is a rare histological subtype of rectal cancer. It is unclear whether SCC should be treated by multimodal therapy, including surgery, or by chemoradiation alone. The objective of the study was to define an optimal treatment strategy. METHODS: Patients with rectal cancer and SCC histology were identified in the Surveillance Epidemiology and End Results Database between 1990 and 2013. According to treatment, three groups were defined: radiotherapy and surgery (RT/SX), radiotherapy (RT), and surgery (SX). Overall survival (OS) and disease-specific survival (DSS) for localized, regional, and distant disease were assessed using a multivariable Cox regression model. RESULTS: Out of 856,435 colorectal cancer patients, 1747 with SCC of the rectum were eligible. Four hundred and fifty-five were treated with RT/SX, 994 with RT, and 298 with SX. Adjusted hazard ratios (HR) did not differ for OS and DSS in localized disease. In regional disease, OS and DSS were improved for RT/SX compared to RT (HR 0.751, 95% CI 0.566-0.997, P = 0.048 and HR 0.679, 95% CI 0.478-0.966, P = 0.031). In distant disease, OS and DSS were not different. CONCLUSIONS: Multimodal therapy including surgery improved OS and DSS compared to receiving a treatment without surgery for regional disease in rectal SCC. No difference was observed in localized and distant disease. The findings contradict with recent reports favoring definitive chemoradiation.

A randomized controlled trial to assess the effect of a medication plan containing drug administration recommendations on patients' drug knowledge after 2 months.

WHAT IS KNOWN AND OBJECTIVE: Patients' drug administration errors are often promoted by poor drug knowledge resulting from inadequate oral or written information. It has previously been shown that a medication plan enhanced with graphical and textual information on drug handling (enhanced medication plan) proved to immediately increase patients' drug knowledge. This study aimed to evaluate the effect of the enhanced medication plan on drug knowledge in outpatients after 2 months (intervention group) compared to patients with a simple medication plan with standard information (control group). METHODS: We recruited patients using ≥5 drugs in four family practices in Germany. After inclusion, patients' knowledge on handling of their drugs was assessed using three questions from a standardized catalog. Thereafter, patients were randomized to the intervention or control group. After 2 months, drug knowledge was reassessed with three different questions from the same standardized catalog. RESULTS AND DISCUSSION: Of 120 enrolled patients, 75% of participants in the control group (42/60 patients) and 78% of participants in the intervention group (46/60; P = 0·71) completed the study. Baseline drug knowledge was similar in both groups (43·7% vs. 40·6% correct answers). After 2 months, patients' drug knowledge showed an absolute increase of 23·2% in the intervention group (P < 0·01) and was unchanged in the control group (46·0%; P = 0·70). WHAT IS NEW AND CONCLUSION: The enhanced medication plan outperformed the effect of a simple medication plan and persistently increased the fraction of correct answers of polypharmacy patients. This demonstrates that the enhanced medication plan may be a useful tool in promoting drug knowledge.

Return to sports and work after partial shoulder replacement surgery.

BACKGROUND: Shoulder hemiarthroplasty is a particularly attractive treatment option in young active patients, where revision surgery is an issue and a glenoid replacement might be necessary in the long run. These patients often ask about the possibility of returning to sport and work after surgery. OBJECTIVE: The purpose of this investigation was to analyze whether patients undergoing shoulder hemiarthroplasty (HSA) are able to successfully return to sports activities and work after surgery. MATERIALS AND METHODS: This study included 42 patients treated with HSA. Two subgroups were built: patients who had participated in sports less than 5 years prior to surgery (group A: n = 29, 69%) and those who had not done so (group B: n = 13, 31%). Evaluation was based on a questionnaire asking about types of sports, frequency of sports activity, and the time taken to return to sports and work, as well as about limitations in occupational life. RESULTS: Patients' mean age at the time of surgery was 56.3 ± 12.7 years in group A and 66.9 ± 13.8 years in group B. Mean follow-up was 5.5 years (range 2.5-12 years). In group A, 18 patients (62%) had participated in sports up to the time of surgery and 12 (41%) had returned to the same level of sports activity at final follow-up. The rate of return to preoperative sports activity was 67%. Swimming was one of the most favorable sports (92%). Of the cohort patients, 2 (5%) had to change their profession due to surgery. Most patients were retired at follow-up. CONCLUSION: Patients who were sportingly active prior to HSA were able to return to sports after surgery in 67% of cases. This study confirms that patients treated by hemiarthroplasty of the shoulder joint can return to sports and work, even at medium-term follow-up.

Impact of Everolimus and Low-Dose Cyclosporin on Cytomegalovirus Replication and Disease in Pediatric Renal Transplantation.

In order to investigate the hypothesis that the mammalian target of rapamycin inhibitor everolimus (EVR) shows anticytomegalovirus (CMV) activity in pediatric patients, we analyzed the impact of EVR-based immunosuppressive therapy on CMV replication and disease in a large cohort (n = 301) of pediatric kidney allograft recipients. The EVR cohort (n = 59), who also received low-dose cyclosporin, was compared with a control cohort (n = 242), who was administered standard-dose cyclosporin or tacrolimus and an antimetabolite, mostly mycophenolate mofetil (91.7%). Multivariate analysis revealed an 83% lower risk of CMV replication in the EVR cohort than in the control cohort (p = 0.005). In CMV high-risk (donor+/recipient-) patients (n = 88), the EVR-based regimen was associated with a significantly lower rate of CMV disease (0% vs. 14.3%, p = 0.046) than the standard regimen. In patients who had received chemoprophylaxis with (val-)ganciclovir (n = 63), the CMV-free survival rates at 1 year and 3 years posttransplant (100%) were significantly (p = 0.015) higher in the EVR cohort (n = 15) than in the control cohort (n = 48; 1 year, 75.0%; 3 years, 63.3%). Our data suggest that in pediatric patients at high risk of CMV, an EVR-based immunosuppressive regimen is associated with a lower risk of CMV disease than a standard-dose calcineurin inhibitor-based regimen.

Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.

OBJECTIVES: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial. BACKGROUND: PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications. METHODS: A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up. RESULTS: From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters. CONCLUSIONS: The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.