Mapping distribution of brain metastases: does the primary tumor matter?

PURPOSE: Prior reports on the location and sizes of brain metastases almost entirely focus on patients with primary breast and pulmonary cancer. This is the first study comparing multiple other types of cancer that metastasize to the brain. METHODS: This monocentric retrospective study includes 369 untreated patients with 3313 intraaxial brain metastases. Following semi-manual segmentation of metastases on post-contrast T1WI, cumulative spatial probability distribution maps of brain metastases were created for the whole group and for all primary tumors. Furthermore, mixed effects logistic regression model analysis was performed to determine if the primary tumor, patient age, and patient sex influence lesion location. RESULTS: The cerebellum as location of brain metastases was proportionally overrepresented. Breast and pulmonary cancer caused higher number of brain metastases to what would normally be expected. Multivariate analyses revealed a significant accumulation of brain metastases from skin cancer in a frontal and from breast and gastrointestinal cancer in a cerebellar location. CONCLUSION: Distribution of brain metastases is very heterogeneous for the distinct primaries, possibly reflecting the diversity of mechanisms involved in brain metastases formation. In daily clinical practice distribution patters may be beneficial to predict the primary cancer site, if unknown.

[Hiatus hernia : Standards and controversies in diagnostics and treatment]. / Hiatushernie : Standards und Kontroversen in Diagnostik und Therapie.

A hiatus hernia is defined as a transdiaphragmatic protrusion/migration of the intrabdominal contents through the esophageal hiatus of the diaphragm. The classification of hiatus hernias is based on anatomical morphological differentiation (types I-IV). The leading symptoms and psychological stress vary with respect to the symptoms, e. g. reflux and compression symptoms. Gastroscopy and multichannel intraluminal impedance pH measurement are obligatory preoperative functional diagnostics. A distinction is made between frequent type I hernia (antireflux surgery), symptomatic paraesophageal, thoracic and mixed hernia types (II-IV). Surgical indications exist in symptomatic type II-IV hernias. Hiatal mesh augmentation reduces recurrences. The complication potential of synthetic meshes must be taken into account. Biological implants show no advantages.

Local Mode Analysis: Decoding IR Spectra by Visualizing Molecular Details.

Integration of experimental and computational approaches to investigate chemical reactions in proteins has proven to be very successful. Experimentally, time-resolved FTIR difference-spectroscopy monitors chemical reactions at atomic detail. To decode detailed structural information encoded in IR spectra, QM/MM calculations are performed. Here, we present a novel method which we call local mode analysis (LMA) for calculating IR spectra and assigning spectral IR-bands on the basis of movements of nuclei and partial charges from just a single QM/MM trajectory. Through LMA the decoding of IR spectra no longer requires several simulations or optimizations. The novel approach correlates the motions of atoms of a single simulation with the corresponding IR bands and provides direct access to the structural information encoded in IR spectra. Either the contributions of a particular atom or atom group to the complete IR spectrum of the molecule are visualized, or an IR-band is selected to visualize the corresponding structural motions. Thus, LMA decodes the detailed information contained in IR spectra and provides an intuitive approach for structural biologists and biochemists. The unique feature of LMA is the bidirectional analysis connecting structural details to spectral features and vice versa spectral features to molecular motions.

Biweekly pegylated liposomal doxorubicin in patients with relapsed ovarian cancer: results of a multicenter phase-II trial.

BACKGROUND: The obvious benefit of pegylated liposomal doxorubicin (PLD) for tumour control in recurrent ovarian cancer is frequently offset by severe palmar-plantar erythrodysesthesia (PPE). There is evidence that dose reduction from 50 to 40 mg/m(2) reduces the incidence of PPE without compromising cytotoxic activity. We set out to investigate whether biweekly application further improves the therapeutic index of PLD. PATIENTS AND METHODS: Patients with recurrent ovarian cancer after surgery and adjuvant chemotherapy with platinum and taxane compounds were eligible to participate in this multi-institutional phase II study. PLD was administered at a dose of 20 mg/m(2) every two weeks. Eligible patients had ECOG performance status of < or =2, and sufficient organ function. We employed an optimized two-stage design to test the hypothesis that biweekly application of PLD reduces the frequency of grade III and IV PPE from 25% to 10%. Response and survival were addressed descriptively. RESULTS: Between October 2001 and February 2004, 64 patients with median age of 59 (range 38-81) years were recruited onto this trial. We evaluated 553 (median 7, range 1-25) courses of PLD treatment. Most patients were in their third or fourth line of chemotherapy. PPE was noted in 30 patients (47.6%), but only three participants progressed to grade 3 severity (4.7%, 95% confidence interval 1.0-13.1%). Partial response, stable disease, and tumour progression were observed in 5, 13, and 24 patients, respectively. Median overall and progression-free survival were 18.2 (range, 1.4-34.0) and 4.3 (range 0.5-22.3) months. CONCLUSIONS: Biweekly PLD may reduce the incidence of PPE while retaining efficacy in relapsed ovarian cancer. Our data support the need for a randomized trial to strengthen these assumptions.

[Post-traumatic rotational deformity of the femur in a patient with paraplegia]. / Posttraumatische Rotationsfehlstellung des Femurs bei einer Patientin mit Paraplegie.

A 37-year old woman with paraplegia sustained a posttraumatic rotational deformity of the femur of 40 degrees after the osteosynthesis of a femur fracture. In the consequence she got several problems in her everyday life, such as problems in handling the wheel-chair and in catheterism. The determination of anteversion of the femoral neck by computed tomography is necessary for quantifying rotational faults and planning of corrective osteotomy. Our patient recuperated as the same level of independence after a subtrochanteric corrective osteotomy as before the fracture of the femur.

[Differences in hip prosthesis implantation in a non-urban region]. / Unterschiede in der Hüftendoprothetik in einer Nicht-Grossstadt-Region.

AIM: The aim of the study was to analyse differences of early results after total hip replacement performed at various hospitals. METHOD: A total of 37 consecutive patients submitted for postoperative rehabilitation were examined. These patients were referred from 18 different hospitals. In an assessment sheet, personal data, age, indication, operating department (surgical or orthopedic), side, length of skin incision and early X-ray presentation with regard to cup angle, position of greater trochanter in relation to head of prosthesis, varus/valgus angle of femoral prosthesis, and cementation were recorded. RESULTS: Of the 37 patients, 26 were female, 11 male. Average age was 62.9 +/- 10.4 years. Degenerative osteoarthritis was present in 23 cases, fractures in 6 cases, there were 6 patients with osteoarthritis following hip dysplasia, 1 pathological fracture, and 1 aseptic necrosis of the femoral head. The skin incision length varied from 8 to 31 cm, averaging to 16.8 +/- 5.3 cm. Implantations were cementless in 20 cases, cemented in 12, and partly cemented in 5 cases. Using a THR-Early-Result-Score of 25 points maximum, # 7 implantations were scored as normal, 16 subnormal, 10 atypical, and 4 highly atypical. CONCLUSION: The data presented show an incidence of 81% non-ideal implantations which is considered surprisingly high. Potential reasons are discussed. It is suggested that efforts to improve the quality of total hip replacements should be made.

A demonstrator for a low-cost, cordless, multi-carrier spread-spectrum system.

Because of the need for spectrally efficient systems for wireless communication, many research activities have been carried out in the area of spread-spectrum techniques. Multi-carrier spread-spectrum (MC-SS) is a new modulation technique with better spectral properties than direct-sequence spread-spectrum (DS-SS). In this paper, a new MC-SS system is introduced. A customized surface acoustic wave (SAW) filter has been designed as a fast analog correlator. A demonstrator testbed has been developed for the 2.4-GHz industrial, scientific, and medical (ISM) band. Experimental measurements of the intermediate frequency (IF) and baseband correlation are presented.

[Experimental stability of a new implant-free fixation technique in ACL replacement]. / Primärstabilität einer implantatfreien Verankerung des Lig.-patellae-Transplantats beim vorderen Kreuzbandersatz.

The purpose of the study is to establish data on the stability of an ACL replacement. In 40 human cadaver knees, either a mid patellar ligament third with a trapezoid bone block on one side was fixed on the femoral side in a 2-diameter drill hole, or a conventional interference screw fixation was applied. Average primary stability amounted to 570 N (+/- 100 N) for the bone-blocking technique, and to 402 N ( +/- 79 N) for the interference screw fixation. When statistically tested by variance analysis, stability was significantly higher for the bone blocking technique than with interference screw fixation (p < 0.05). Thus, when using a mid-patellar ligament third for ACL reconstruction, the new implant-free technique described here appears to be a practical and reliable method for femoral graft fixation.

[Changes in psychophysiologic status during inpatient rehabilitation in the orthopedics service--a preliminary study]. / Psychophysiologische Befindensveränderungen während einer stationären Rehabilitation im Bereich Orthopädie--eine Erkundungsstudie.

OBJECTIVES: Assessment of non-operative treatment of orthopaedic diseases is sometimes considered difficult. The purpose of this retrospective longitudinal study on the one hand is to evaluate the formal quality of questionnaire data under routine conditions in an in-patient rehabilitation hospital and on the other hand to study the impact of additional psychologic treatment on the outcome of patients who received conservative treatment for chronic orthopaedic diseases. PATIENTS AND METHODS: During a 7-month period, a total of 900 patients received a standardized questionnaire at the beginning and the end of a 4-week inhouse treatment for chronic orthopaedic diseases. A questionnaire handed out to the patients at arrival includes 33 items of psychophysiologic interest. At discharge, a modified questionnaire was used, focussing on the course of complaints during the treatment period, and including additional control-questions for consistency. Return of the questionnaires was voluntary, no pressure was applied, no effort was made to correct inconsistent or missing data. The results presented here are based on 105 orthopaedic patients who returned both questionnaires complete with consistent data. Of these, 44 received additional psychologic treatment by a psychologist, while 61 did not. Participation or non-participation in the psychologic treatment was the grouping variable in this study. RESULTS: For only 189/900 (21%) of the patients taking part in the study complete and consistent questionnaires were available for analysis. For the 105 orthopaedic patients, no significant score differences at arrival between the groups were detected (p = 0.38) using the Mann-Whitney U-test. At discharge, the mean rank sums for the psychological intervention group was 45.7, while it amounted to 58.3 in the control group, indicating significantly stronger improvement of symptoms in the intervention group (p = 0.04). CONCLUSIONS: Under routine conditions without any arrangements to ensure data quality a great amount of incomplete and/or inconsistent data has to be expected. For subsequent studies, this fact has to be taken into account. Irrespective of this aspect, complementary psychologic treatment of certain orthopaedic diseases seems to lead to significantly better results of treatment, as assessed by a psychophysiological questionnaire.

Magnetic resonance imaging and knee stability following ACL reconstruction.

This study was undertaken to determine whether there is a correlation between magnetic resonance imaging (MRI) and clinical success after reconstruction of the anterior cruciate ligament (ACL). In a prospective study, 28 patients underwent clinical and MRI examination 3 to 5 years after ACL reconstruction with either the semitendinosus tendon (n = 15) or patellar ligament (n = 13). Knee stability was assessed both clinically and by KT-1000 arthrometer testing. Magnetic resonance imaging was performed with a 0.2-T dedicated system (Artoscan, Esaote, Italy) including sagittal and oblique coronal T1 and T2-weighted images. Magnetic resonance images were evaluated by two readers with regard to signal intensity and continuity of the ACL reconstruction and presence or absence of posterior cruciate ligament buckling. Knee stability and MRI evaluation were each summarized in a 6-point score. Statistical correlation was checked with the Spearman ranked correlation for testing non-normal distributed samples. Statistical testing of all patients' results together showed a significant correlation with a prediction value of 12%, indicating no significant correlation between clinical results and MRI evaluation. Separate statistical testing of the patellar ligament and semitendinosus patients' results showed no significant correlation in either group at all. Thus, no correlation between clinical stability and MRI could be established. Magnetic resonance images after ACL reconstruction using the techniques mentioned above should be interpreted with caution, as they may not relate to the clinical function of the ligament.

[Reconstruction of acute anterior cruciate ligament rupture by suture and semitendinosus tendon augmentation.]. / Die Rekonstruktion frischer vorderer Kreuzbandrupturen durch Naht und Semitendinosusaugmentation.

GOAL OF SURGERY: Restoration of normal knee function. INDICATIONS: Acute avulsion of the anterior cruciate ligament (ACL) from its femoral origin. CONTRAINDICATIONS: Mid substance and remote tears. POSITIONING AND ANAESTHESIA: Supine. Knee flexed, hip bent to 30 degrees . General or regional anaesthesia. SURGICAL TECHNIQUE: Step 1: Arthroscopy to confirm site of rupture, meniscus repair if necessary. Step 2: Mobilisation of semitendinosus tendon, left attached distally. Step 3: Mini-arthrotomy, securing of ACL stump with atraumatic suture. Step 4: Transfer of ST-tendon through 5 mm drill holes through tibial head and lateral femoral condyle. Step 5: Fixation of tendon and ACL-sutures with staple at the exit of the femoral drill hole. POSTOPERATIVE MANAGEMENT: Knee orthosis for 6 weeks, CPM, physiotherapy. ROM day 0-2: 0-10-10 degrees ; day 3-11: 0-0-60 degrees , day 12-42: 0-0-90 degrees . Increase of weight bearing 10 kg/week from operation date. Bicycling and running permitted 3 months post-op. Full sport activity after muscle power has reached that of opposite side. LMW heparin until full weight bearing. POSSIBLE COMPLICATIONS: Thrombosis. Embolism. Infection. Failure of reconstruction. Osteoarthritis. RESULTS: During 1 year, 116 patients were operated. Follow-up after 42 to 57 months (average 52 months) included 95 patients (82%). Of these, 76 underwent full examination (average age 33 1/2 years, 20-49 years), 11 answered a questionnaire, 8 had suffered re-injury. Average Lysholm score was 92 points (+/-13). Tegner activity scale amounted to 7.2 points pre-injury, 7.1 points at follow-up. Anterior translation (KT 1000 arthrometer testing at 89 N) was identical to opposite side in 25 patients, less than 2 mm in 14, up to 4 mm in 19, up to 6 mm in 15, more that 6 mm in 3 patients. Pivot shift was negative or trace 73 times, and positive in 3 patients. ROM was full in 54 patients, 17 times the flexion was limited up to 10 degrees . Ten times extension lag was less than 5 degrees , and twice between 5 and 10 degrees .

Surgical treatment for myeloma of the bone. A retrospective analysis of 22 cases.

In a retrospective study, 22 patients treated surgically for solitary or multiple myeloma between 1980 and 1993 were analysed. The main complaint was pain. A fracture was observed in 7 cases and motor-sensory impaired neurology due to spinal compression in 3. Apart from incisional biopsies, tumour resections, reductions (with and without stabilization by osteosynthesis) and endoprotheses were performed either at the extremities or on the spine. In addition, radiation and chemotherapy were included in the therapeutical concept. Early mobilization was achieved in all cases, and the 5-year survival rate (Kaplan-Meier method) was 48%. The results presented in this study demonstrate that a variety of surgical interventions can be of importance in the treatment of myeloma of the bone, ranging from biopsy or even curative resections in selected cases to endoprosthetic replacement. Thus, good functional results can be achieved and maintained over often long survival times.

[Unusual late complications following total hip endoprosthesis]. / Ungewöhnliche Spätkomplikation nach Totalendoprothese der Hüfte.

A cementless total hip replacement was implanted in a 52-year-old male patient with coxarthrosis. Rapid cranial migration of the cup and ectopic ossification were subsequently observed. Five years after the original operation, revisional arthroplasty had to be performed to replace the cup. At surgery a large amount of granulomatous tissue and the tip of a deep drainage tube were found. Interposed between the polyethylene inlay and the femoral head of the prosthesis, the drain had not been visible on any of the radiographic controls. The X-ray control performed immediately after the first procedure revealed that the drain had been slung around the neck of the prosthesis stem, a procedure preferred by some surgeons. When the drain was removed, the tip must have been caught between the polyethylene inlay and the femoral head of the prosthesis. It is not clear whether the loosening of the cup was ultimately caused by the increased wear due to the presence of the drain tip. However, in light of this finding we no longer sling the drain around the prosthesis shaft, but lay it along the neck of the femoral component in the same direction as it is routed out transcutaneously.

Bone formation in coralline hydroxyapatite. Effects of pore size studied in rabbits.

We analyzed osseous reactions in the rabbit femoral condyle to coralline hydroxyapatite bone substitutes of various pore sizes by radiology and histology. The results were compared to bone repair of empty cavities and to integration of allografts. Spontaneous bone repair of the empty cavities took approximately 12 weeks, while integration of the cryopreserved allografts occurred after 9 weeks. However, no signs of new bone formation were found with the 200 microns pore size hydroxyapatite. In contrast, there was substantial production of bone within the 500 microns pore size implants at 12 and 26 weeks. Our results indicate that the pore size of the coralline hydroxyapatite influenced the development of bone in the implants in the cancellous bone bed of the rabbit femoral condyle. The results also show that spontaneous bone repair should be taken into consideration when the integration of implants is evaluated.

[Initial clinical results with heat-treated homologous bone transplants]. / Erste klinische Ergebnisse mit wärmebehandelten homologen Knochentransplantaten.

Several ways for HIV inactivation in bone allografts are being discussed. These methods must be efficient, but they must not compromise biologic properties of the allografts. According to animal studies, moderate heat treatment of bone allografts in a 65 degrees C waterbath has no adverse effects on osseointegration. A clinical follow-up study of 49 patients with heat treated bone allografts was conducted. 37 patients with conventional cryopreserved allografts were included in the study as controls. Average follow-up time was 27 months. Results were evaluated by clinical and X-ray examination, using a modified radiologic score. No significant differences in the two groups were detected, except for a slight retardation in bony integration of the heat treated allografts between week 39 and 52 postoperatively. Complication rates were 11.4% vs. 10.7%. In conclusion, moderate heat treatment of bone allografts appears to be a practicable and safe method to improve safety in bone transplantation in clinical practice. In addition to the known guide lines for bone banking heat treating of allografts should be further improved in order to minimize the low remaining risk of infection which exists despite of the three months test.

[Results of surgical treatment of posterior knee instability]. / Ergebnisse der operativen Behandlung posteriorer Knieinstabilitäten.

A retrospective study was performed to evaluate the outcome of operative treatment of posterior cruciate ligament (PCL) lesions in 115 patients operated on between 1980 and 1989. Follow-up was possible in 89 patients at 18-124 months postoperatively (average 76 months). In 65 re-examination was possible, while 24 patients returned a questionnaire. The results of patients who were operated on in the acute state were superior to those with chronic instabilities (Lysholm 79.9 +/- 18.5 vs 64.3 +/- 22.1; Tegner 5.7 +/- 2.3 vs 4.2 +/- 2.2; instrumented posterior drawer 5.3 +/- 3.5 mm vs 5.9 +/- 3.8 mm). On the other hand, the preoperative scores of symptomatic patients with chronic instabilities (Lysholm 38.8 +/- 22.0; Tegner 2.1 +/- 1.7) were clearly lower. Extraarticular procedures (Hughston) slightly improved symptoms in posterolateral instabilities. Olecranization of the patella had no influence on the results. Interpretation of the data is difficult as there was no matched group of patients with nonoperative treatment. A reviews of the literature suggests that isolated PCL tears are best treated with conservative management. Only in cases where associated ligamentous injuries require operative treatment should PCL reconstruction be performed. Chronic posterior instabilities should be treated operatively only if the patients are severely symptomatic. However, complete restoration of knee stability was usually not achieved with the techniques presented in this paper.

[Possibilities for HIV inactivation in homologous bone transplants]. / Möglichkeiten zur HIV-Inaktivierung homologer Knochentransplantate.

Recently, the availability of bone allografts has declined dramatically, due to the three-month HIV test which is often difficult to obtain. Accordingly, there is a search for methods to inactivate HIV in bone allografts without compromising the biologic quality of the grafts. Chemical substances require long exposure and desorption times, to ensure that no toxic agents remain within the bone before actual transplantation. X-ray inactivation leads to complete loss of any osteoinductive properties of the allografts, according to some authors. In addition, the high doses that are necessary are difficult to apply. Autoclaving has been practiced in some instances, but all experimental results and some more recent clinical observations warn that osteoinductive properties of the allografts are lost during the autoclaving process. Lower temperatures (56 degrees C) are sufficient to warrant inactivation of HIV, and some experimental results and preliminary clinical observations indicate that moderate heat treatment of bone allografts in a water bath may become a useful method for virus inactivation of bone allografts.