Obstetric and Neonatal Outcomes Following Hospital Transfers of Home Births and Births in Midwife-led Units in Austria.

Introduction: Home births and births in midwife-led units and the associated potential risks are still being debated. An analysis of the quality of results of planned home births and births in midwife-led units which require intrapartum transfer of the mother to hospital provides important information on the quality of processes during births which occur outside hospital settings. The aim of this study was to analyze neonatal and maternal outcomes after the initial plan to deliver at home or in a midwife-led unit had to be abandoned and the mother transferred to hospital. Material and Methods: The method used was an analysis of data obtained from the Austrian Birth Registry. The dataset consisted of singleton term pregnancies delivered in the period from 1 January 2017 to 31 December 2021 (n = 286056). For the analysis, two groups were created for comparison (planned hospital births and hospital births recorded in the Registry as births originally planned as home births or births in midwife-led units but which required a transfer to hospital) and assessed with regard to previously defined variables. Data were analyzed using frequency description, bivariate analysis and regression models. Results: In Austria, an average of 19% of planned home births have to be discontinued and the mother transferred to hospital. Home births and births in midwife-led units which require transfer of the mother to hospital are associated with higher intervention rates intrapartum, high rates of vacuum delivery, and higher emergency c-section rates compared to planned hospital births. Multifactorial regression analysis showed significantly higher risks of poorer scores for all neonatal outcome parameters (Apgar score, pH value, transfer rate). Conclusion: If a birth which was planned as a home delivery or as a delivery in a midwife-led unit fails to progress because of (possible) anomalies, the midwife must respond and transfer the mother to hospital. This leads to a higher percentage of clinical interventions occurring in hospital. From the perspective of clinical obstetrics, it is understandable, based on the existing data, that giving birth outside a clinical setting cannot be recommended.

Liver Transplantation in Recipients With a Positive Crossmatch: A Retrospective Single-Center Match-Pair Analysis.

A positive crossmatch (XM+) is considered a contraindication to solid abdominal organ transplantation except liver transplantation (LT). Conflicting reports exist regarding the effects of XM+ on post-transplant outcomes. The goal of this retrospective single-center analysis is to evaluate the influence of XM+ on relevant outcome parameters such as survival, graft rejection, biliary and arterial complications. Forty-nine adult patients undergoing LT with a XM+ between 2002 and 2017 were included. XM+ LT recipients were matched 1:2 with crossmatch negative (XM-) LT recipients based on the balance of risk (BAR) score. Patient and graft survival were compared using Kaplan-Meier survival analysis and the log-rank test. Comparative analysis of clinical outcomes in XM+ and XM- groups were conducted. Patient and graft survival were similar in XM+ and XM- patients. Rejection episodes did not differ either. Recipients with a strong XM+ were more likely to develop a PCR+ CMV infection. A XM+ was not associated with a higher incidence of biliary or arterial complications. Donor age, cold ischemia time, PCR+ CMV infection and a rejection episode were associated with the occurrence of ischemic type biliary lesions. A XM+ has no effects on patient and graft survival or other relevant outcome parameters following LT.

Passive leg raising in brain injury patients within the neurointensive care unit. A prospective trial.

INTRODUCTION: In critically ill brain-injured patients maintaining balanced fluid management is a crucial part of critical care. Many factors influence the relationship between fluid management, cerebral blood flow and cerebral oxygenation. Passive leg raising (PLR)-induced changes predict fluid responsiveness in the majority of non-neurological ICU patients. In patients with intracranial lesions, PLR testing has been hypothesized to increase intracranial pressure (ICP), although data are lacking. We wanted to investigate the feasibility of PLR with expected intracranial pressure increase, according to the higher cerebral blood volume. This should be self-limiting in patients with intact cerebral autoregulation. MATERIAL AND METHODS: We prospectively included patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH) in this pilot trial. PLR was performed within 48 hours after the initial diagnosis and on days 5-8. All patients had ICP monitoring. Absence of intracranial hypertension (defined as ICP < 25 mm Hg) was considered a positive test result. RESULTS: Ten patients were recruited for this study. The cohort consisted of 6 male patients with TBI and 4 female patients with aSAH. Mean patient age was 55.6 years (range 35-76). Overall, 18 tests could be performed, of which only one had to be terminated due to temporarily elevated ICP. 9 out of 10 patients had no intracranial hypertension during the acute (mean ICP increase 8.45 mm Hg, range 4-16) or during the subacute phase (mean ICP increase 9.12 mm Hg, range 3-18). CONCLUSIONS: PLR is feasible in patients with intracranial pathology to assess fluid responsiveness and provide optimized patient volume management without increasing the risk of persistent intracranial hypertension.

Sex matching does not impact the outcome after simultaneous pancreas-kidney transplantation.

BACKGROUND: Several studies in solid organ transplantation have shown a correlation between donor and recipient sex mismatch and risk of graft loss. In this study, we aimed to analyze the impact of donor and recipient sex matching on patient and pancreas graft survival in a large single-center cohort. METHODS: We retrospectively analyzed all first simultaneous pancreas-kidney transplants performed between 1979 and 2017 at the Medical University of Innsbruck. RESULTS: Of 452 patients, 54.6% (247) received a sex-matched transplant. Patient survival (P = .86), death-censored pancreas graft survival (dcPGS, P = .26), and death-censored kidney graft survival (dcKGS, P = .24) were similar between the sex-matched and sex-mismatched groups. Patient survival and dcPGS at 1, 5, and 15 years were 95.9%, 90.0%, and 62.1% and 86.1%, 77.1%, and 56.7% in the sex-matched group and 93.6%, 86.2%, and 62.4% and 83.1%, 73.3%, and 54.3% in the sex-mismatched group. Sex matching led to a lower odds of severe postoperative complications (41.2% vs 49.0%; OR 0.57, 95%CI 0.33-0.97; P = .038); however, no increased odds of other adverse postoperative outcomes was detected. CONCLUSION: Our study demonstrates that sex matching reduced the odds of postoperative complications but did not impact other early and late outcome parameters in our cohort.

Primary tumour location affects survival after resection of colorectal liver metastases: A two-institutional cohort study with international validation, systematic meta-analysis and a clinical risk score.

BACKGROUND: Colorectal cancer (CRC) represents a major cause for cancer death and every third patient develops liver metastases (CRLM). Several factors including number and size of metastases and primary tumour lymph-node status have been linked to survival. The primary tumour location along the colo-rectum continuum (sidedness) was analysed in first-line chemotherapy trials, where right-sided CRCs showed decreased survival. This association has not yet been clearly established in patients undergoing resection for CRLM. METHODS: Clinicopathological differences in CRLM resections according to sidedness in two Austrian centres (2003-2016) are described and survival is compared through Kaplan-Meier and multivariable analysis. A risk-score is presented with time-dependent receiver operating curve analysis and international validation in two major hepatobiliary centres. Furthermore, a systematic meta-analysis of studies on primary tumour location and survival after CRLM resection was performed. RESULTS: 259 patients underwent hepatectomy. Right-sided CRC patients (n = 59) more often had positive primary tumour lymph-nodes (76.3%/61.3%;p = 0.043) and RAS-mutations (60%/34.9%;p = 0.036). The median overall and disease-free survival was 33.5 and 9.1 months in right-sided versus 55.5 (p = 0.051) and 12.1 months (p = 0.078) in left-sided patients. In multivariable analysis nodal-status (HR 1.52), right-sidedness (HR 1.53), extrahepatic disease (HR 1.71) and bilobar hepatic involvement (HR 1.41) were significantly associated with overall survival. Sidedness was not independently associated with disease-free survival (HR 1.33; p = 0.099). A clinical risk score including right-sidedness, nodal-positivity and extrahepatic involvement significantly predicted overall (p = 0.005) and disease-free survival (p = 0.027), which was confirmed by international validation in 527 patients (p = 0.001 and p = 0.011). Meta-analysis including 10 studies (n = 4312) showed a significant association of right-sidedness with overall survival after resection (HR 1.55;p<0.001). There was no significant association with disease-free survival (HR 1.22;p = 0.077), except when rectal-cancers were excluded (HR 1.39;p = 0.006). CONCLUSIONS: Patients with liver metastases from right-sided CRC experience worse survival after hepatic resection. Sidedness is a simple yet effective factor to predict outcome.

Preoperative Assessment of Muscle Mass Using Computerized Tomography Scans to Predict Outcomes Following Orthotopic Liver Transplantation.

BACKGROUND: Sarcopenia is an established risk factor predicting survival in chronically ill and trauma patients. We herein examine the assessment and clinical implication of sarcopenia in liver transplantation (LT). METHODS: Computerized tomography scans from 172 patients waitlisted for LT were analyzed by applying 6 morphometric muscle scores, including 2 density indices (psoas density [PD] and skeletal muscle density [SMD]) and 4 scores based on muscle area (total psoas area, psoas muscle index, skeletal muscle area, and skeletal muscle index). RESULTS: The prevalence of sarcopenia in our cohort ranged from 7.0% to 37.8%, depending on the score applied. Only sarcopenia as defined by the density indices PD and SMD (but not total psoas area, psoas muscle index, skeletal muscle area, or skeletal muscle index) revealed clinical relevance since it correlates significantly with postoperative complications (≥Grade III, Clavien-Dindo classification) and sepsis. Furthermore, sarcopenia predicted inferior patient and graft survival, with low muscle density (PD: <38.5 HU or SMD: <30 HU) representing an independent risk factor in a multivariate regression model (P < 0.05). Importantly, the widely used Eurotransplant donor risk index had a predictive value in nonsarcopenic patients but failed to predict graft survival in patients with sarcopenia. CONCLUSIONS: Sarcopenia revealed by low muscle density correlates with major complications following LT and acts as an independent predictor for patient and graft survival. Therefore, the application of a simple computerized tomography-morphologic index can refine an individual recipient's risk estimate in a personalized approach to transplantation.

Results of Phosphorus Magnetic Resonance Spectroscopy for Brain Metastases Correlate with Histopathologic Results.

BACKGROUND: Brain metastases (BMs) are classically well-circumscribed lesions. Still, the amount of edema in these neoplasms suggests either mechanisms of infiltration or defense. A better understanding of the mechanisms within the edema of BMs seems reasonable to preoperatively identify areas of potential infiltration and resect them. BMs represent tumors with high energy demand and cell turnover; therefore, they qualify for preoperative investigation with phosphorus-31 magnetic resonance spectroscopy (31PMRS), which reveals information about those characteristics. METHODS: Ten patients with BMs were included in this trial. All underwent preoperative standard magnetic resonance imaging with additional 31PMRS. In all patients, 1 voxel within the contrast-enhancing tumor (CE+), 1 voxel at the border (including CE+ areas and surrounding T2-hyperintensive [T2+] areas), and 1 distant voxel purely including T2+ areas were determined by a neuroradiologist and a neurosurgeon. A frameless stereotactic biopsy was performed after craniotomy. Subsequently, the metabolites of the 31PMRS were analyzed and compared with the histopathologic results. RESULTS: Ratios, reflecting resynthesis (CE+/border/T2+: 1.109 ± 0.192/1.112 ± 0.158/1.083 ± 0.097), hydrolysis (0.303 ± 0.089/0.360 ± 0.122/0.321 ± 0.089), energy demand (4.227 ± 2.35/3.453 ± 1.284/3.599 ± 0.833), and membrane turnover (1.239 ± 0.2611/3.453 ± 1.284/3.599 ± 0.283) were calculated and compared intraindividually with a voxel from the contralateral side (resynthesis/hydrolysis/energy demand/membrane turnover: 1.063 ± 0.085/0.335 ± 0.073/3.317 ± 0.7573/0.784 ± 0.186), respectively. Resynthesis showed a trend toward higher ratios in CE+ and border biopsies without reaching statistical significances. This trend was also seen concerning energy demand. Membrane turnover was significantly higher in CE+, border zone, and also in the T2+ areas compared with controls (P > 0.001). CONCLUSIONS: 31PMRS in BMs provides information on metabolic changes in tumor and surrounding edema. There is proof of enhanced metabolism in tissue without histologic tumor manifestation.

Dental treatment under general anesthesia in adults with special needs at the University Hospital of Dental Prosthetics and Restorative Dentistry of Innsbruck, Austria: a retrospective study of 12 years.

OBJECTIVES: Special needs patients are prone to insufficient oral care and subsequent caries or periodontitis. The aim of this retrospective study was the assessment of demand for restorative therapy and tooth extractions under general anesthesia in adults with intellectual and/or physical disablement (IPD) or psychiatric disorders (PDs) with inherent dentist phobia at the University Hospital of Innsbruck with regard to demographic factors. MATERIALS AND METHODS: A total of 444 consecutive cases of scheduled dental general anesthesia (DGA) in adults from 2003 to 2014 were included. From patient files, demographic data, the presence of either IPD or a PD, attested by a mandatory certificate, and restorative therapy and tooth extractions performed under DGA were obtained. Data analysis was carried out by means of descriptive and comparative statistics. RESULTS: Four hundred two cases (mean age 37.5 ± 13.87 years) assigned to 283 individuals with IPD and 42 cases (mean age 36.09 ± 13.03 years) assigned to 39 individuals with PDs arose in the observed period. Patients with PDs required significantly more restorations (in 7.98 ± 5.4 versus 5.34 ± 4.41 teeth; p = 0.002; Mann-Whitney U test) and extractions (of 4.86 ± 4.51 versus 2.6 ± 3.96 teeth; p < 0.001; Mann-Whitney U test) than patients with IPD. CONCLUSIONS: Demand for dental treatment was high in the collective of special needs patients. Oral health status was worse in patients with PDs than in patients suffering IPD. CLINICAL RELEVANCE: While in patients with severe disablement, DGA presents the only treatment option, specific preventive programs should be implemented for patients with minor disablement or dentist phobia. In these patients, alternative approaches should be promoted.

Radiologic complete response (rCR) in contrast-enhanced magnetic resonance imaging (CE-MRI) after neoadjuvant chemotherapy for early breast cancer predicts recurrence-free survival but not pathologic complete response (pCR).

BACKGROUND: Patients with early breast cancer (EBC) achieving pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) have a favorable prognosis. Breast surgery might be avoided in patients in whom the presence of residual tumor can be ruled out with high confidence. Here, we investigated the diagnostic accuracy of contrast-enhanced MRI (CE-MRI) in predicting pCR and long-term outcome after NACT. METHODS: Patients with EBC, including patients with locally advanced disease, who had undergone CE-MRI after NACT, were retrospectively analyzed (n = 246). Three radiologists, blinded to clinicopathologic data, reevaluated all MRI scans regarding to the absence (radiologic complete remission; rCR) or presence (no-rCR) of residual contrast enhancement. Clinical and pathologic responses were compared categorically using Cohen's kappa statistic. The Kaplan-Meier method was used to estimate recurrence-free survival (RFS) and overall survival (OS). RESULTS: Overall rCR and pCR (no invasive tumor in the breast and axilla (ypT0/is N0)) rates were 45% (111/246) and 29% (71/246), respectively. Only 48% (53/111; 95% CI 38-57%) of rCR corresponded to a pCR (= positive predictive value - PPV). Conversely, in 87% (117/135; 95% CI 79-92%) of patients, residual tumor observed on MRI was pathologically confirmed (= negative predictive value - NPV). Sensitivity to detect a pCR was 75% (53/71; 95% CI 63-84%), while specificity to detect residual tumor and accuracy were 67% (117/175; 95% CI 59-74%) and 69% (170/246; 95% CI 63-75%), respectively. The PPV was significantly lower in hormone-receptor (HR)-positive compared to HR-negative tumors (17/52 = 33% vs. 36/59 = 61%; P = 0.004). The concordance between rCR and pCR was low (Cohen's kappa - 0.1), however in multivariate analysis both assessments were significantly associated with RFS (rCR P = 0.037; pCR P = 0.033) and OS (rCR P = 0.033; pCR P = 0.043). CONCLUSION: Preoperative CE-MRI did not accurately predict pCR after NACT for EBC, especially not in HR-positive tumors. However, rCR was strongly associated with favorable RFS and OS.

The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke.

BACKGROUND: Malignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome. METHODS: A cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3. RESULTS: Median age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P = 0.0003) and was associated with a worse outcome (P < 0.0001) after exceeding a cutoff volume of 300 cm3. CONCLUSIONS: Volumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.

Supervised versus autonomous exercise training in breast cancer patients: A multicenter randomized clinical trial.

BACKGROUND: There is a well-known correlation between obesity, sedentary lifestyle, and breast cancer incidence and outcome. The Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT) exercise study was a multicenter, randomized clinical trial and assessed the feasibility and efficacy of physical training in 50 breast cancer patients undergoing aromatase inhibitor treatment. METHODS: Postmenopausal, estrogen receptor-positive breast cancer patients under aromatase inhibitor treatment were randomized 1:1 to counseling and unsupervised training for 48 weeks (unsupervised arm) or counseling and a sequential training (supervised arm) with a supervised phase (24 weeks) followed by unsupervised physical training (further 24 weeks). Primary endpoint was the individual maximum power output on a cycle ergometer after 24 weeks of exercise. A key secondary endpoint was the feasibility of achieving 12 METh/week (metabolic equivalent of task hours per week). RESULTS: Twenty-three patients (92%) in the unsupervised arm and 19 patients (76%) in the supervised arm with early-stage breast cancer completed the study. After 24 weeks, the supervised arm achieved a significantly higher maximum output in watt (mean 132 ±  standard deviation [SD] 34; 95% confidence interval [CI] 117-147) compared to baseline (107 ± 25; 95%CI 97-117; P = 0.012) with a numerically higher output than the unsupervised arm (week 24 115 ± 25; 95%CI 105-125; P = 0.059). Significantly higher METh/week was reported in the supervised arm compared to the unsupervised arm during the whole study period (week 1-24 unsupervised: 18.3 (7.6-58.3); supervised: 28.5 (6.7-40.1); P = 0.043; week 25-48; P = 0.041)). CONCLUSION: This trial indicates that patients in an exercise program achieve higher fitness levels during supervised than unsupervised training.

Accuracy Validation of Neuronavigation Comparing Headholder-Based System with Head-Mounted Array-A Cadaveric Study.

BACKGROUND: Neuronavigation is widely used for intracranial neurosurgical procedures and is commonly based on the standard reference array being fixed to the headholder. Some cases require the reference array to be attached directly to the head. The aim of this cadaveric study was to compare operational accuracy of a head-mounted reference array with the standard headholder-based system. METHODS: Navigation accuracy was evaluated with 10 cadaveric specimens. Each specimen was prepared with 8 titanium microscrews that served as reference points on the external skull, and computed tomography was performed. Registration of all specimens was done using surface matching with infrared laser on three-dimensional reconstructed high-resolution computed tomography. In all 10 specimens, the head-mounted reference array and headholder-based system were compared by 10 repetitive measurements. The deviation was evaluated for each screw and compared using nonparametric Mann-Whitney U test between groups and screws. A Bland-Altman plot was generated for comparison. RESULTS: A total of 1600 measurements were conducted. Mean deviation was 1.97 mm (95% confidence interval, 1.90-2.03 mm) with the head-mounted reference array and 2.10 mm (95% confidence interval, 2.04-2.18 mm) with the headholder based system. There was no significant difference between methods in 9 of 10 specimens. In 1 specimen, the head-mounted array was superior. The deviation in either method showed a significant correlation, indicating high pertinence for registration (P < 0.001). CONCLUSIONS: Navigation with the head-mounted reference array demonstrated comparable accuracy to the headholder-based system and can be used without reduced accuracy. Careful registration is mandatory.