Pre-operative Assessment of Shoulder Pathologies on MRI by a Radiologist and an Orthopaedic Surgeon.

Introduction: Pathologies of the shoulder, i.e. rotator cuff tears and labral injuries are very common. Most patients receive MRI examination prior to surgery. A correct assessment of pathologies is significant for a detailed patient education and planning of surgery. Materials and methods: Sixty-nine patients were identified, who underwent both, a standardised shoulder MRI and following arthroscopic shoulder surgery in our hospital. For this retrospective comparative study, the MRIs were pseudonymised and evaluated separately by an orthopaedic surgeon and a radiologist. A third rater evaluated images and reports of shoulder surgery, which served as positive control. Results of all raters were then compared. The aim was an analysis of agreement rates of diagnostic accuracy of preoperative MRI by a radiologist and an orthopaedic surgeon. Results: The overall agreement with positive control of detecting transmural cuff tears was high (84% and 89%) and lower for partial tears (70-80%). Subscapularis tears were assessed with moderate rates of agreement (60 - 70%) compared to intra-operative findings. Labral pathologies were detected mostly correctly. SLAP lesions and pulley lesions of the LHB were identified with only moderate agreement (66.4% and 57.2%) and had a high inter-rater disagreement. Conclusion: This study demonstrated that tears of the rotator cuff (supraspinatus, infraspinatus) and labral pathologies can be assessed in non-contrast pre-operative shoulder MRI images with a high accuracy. This allows a detailed planning of surgery and aftercare. Pathologies of the subscapularis tendon, SLAP lesions and biceps instabilities are more challenging to detect correctly. There were only small differences between a radiologic and orthopaedic interpretation of the images.

Stage based recipient and donor outcome in twin-to-twin transfusion syndrome treated by fetoscopic laser surgery using Solomon technique.

OBJECTIVE: To evaluate twin survival stratified by Quintero stage in patients with twin-to-twin transfusion syndrome (TTTS) after Solomon laser treatment. METHODS: Single center cohort of consecutive twin pregnancies treated with Solomon laser for TTTS. Preoperative Quintero stage, perioperative characteristics and obstetric factors were related to neonatal survival of the recipient and donor at discharge. Determinants of twin survival were evaluated using univariate, logistic regression and cumulative survival probability analyses. RESULTS: Of 402 twins with TTTS, 80 (19.9%) had stage I, 126 (31.3%) stage II, 169 (42%) stage III and 27 (6.7%) stage IV. Post laser TAPS or recurrent TTTS occurred in 19 (4.7%) patients and 11 (2.7%) required repeat laser. Preterm premature rupture of membranes occurred in 150 (37.3%) patients and median gestational age of delivery 32+1 weeks. In 303 (75.4%) both twins were alive at discharge; [66 (82.5%) in stage I, 101 (80.2%) in stage II, 114 (67.5%) in stage III and 22 (81.5%) in stage IV, p=0.062]. Compared to recipients, donor survival was only lower in stage III (155 (91.7%) recipients vs 118 (69.8%) donors, Chi square 24.685, p<0.0001). Larger intertwin size discordance and umbilical artery (UA) end-diastolic velocity (EDV) determined donor demise (Nagelkerke R2 0.38, P<0.001). Overall, spontaneous post laser donor demise accounted for the majority (39.5%) of all losses. Cumulative donor survival decreased from 92% to 65% with size discordance >30% and 48% when UA EDV was absent (p<0.001). CONCLUSION: Solomon laser achieves TTTS resolution and double survival in a high proportion of cases. Recipient and donor survival is comparable unless there is significant size discordance and placental dysfunction. This degree of unequal placental sharing, typically found in stage III, is the primary factor preventing double survival due to a higher rate of donor demise. This article is protected by copyright. All rights reserved.

Prognostic influence of mechanical cardiopulmonary resuscitation on survival in patients with out-of-hospital cardiac arrest undergoing ECPR on VA-ECMO.

Introduction: The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (ECPR) in selected patients after out-of-hospital cardiac arrest (OHCA) is an established method if return of spontaneous circulation cannot be achieved. Automated chest compression devices (ACCD) facilitate transportation of patients under ongoing CPR and might improve outcome. We thus sought to evaluate prognostic influence of mechanical CPR using ACCD in patients presenting with OHCA treated with ECPR including VA-ECMO. Methods: We retrospectively analyzed data of 171 consecutive patients treated for OHCA using ECPR in our cardiac arrest center from the years 2016 to 2022. A Cox proportional hazards model was used to identify characteristics related with survival. Results: Of the 171 analyzed patients (84% male, mean age 56 years), 12% survived the initial hospitalization with favorable neurological outcome. The primary reason for OHCA was an acute coronary event (72%) followed by primary arrhythmia (9%) and non-ischemic cardiogenic shock (6.7%). In most cases, the collapse was witnessed (83%) and bystander CPR was performed (83%). The median time from collapse to VA-ECMO was 81 min (Q1: 69 min, Q3: 98 min). No survival benefit was seen for patients resuscitated using ACCD. Patients in whom an ACCD was used presented with overall longer times from collapse to ECMO than those who were resuscitated manually [83 min (Q1: 70 min, Q3: 98 min) vs. 69 min (Q1: 57 min, Q3: 84 min), p = 0.004]. Conclusion: No overall survival benefit of the use of ACCD before ECPR is established was found, possibly due to longer overall CPR duration. This may arguably be because of the limited availability of ACCD in pre-clinical paramedic service at the time of observation. Increasing the availability of these devices might thus improve treatment of OHCA, presumably by providing efficient CPR during transportation and transfer.

Gender disparities in patients undergoing extracorporeal cardiopulmonary resuscitation.

Introduction: The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (eCPR) has emerged as a treatment option for selected patients who are experiencing refractory cardiac arrest (CA). In the light of increasing availability, the analyses of outcome-relevant predisposing characteristics are of growing importance. We evaluated the prognostic influence of gender in patients presenting with out-of-hospital cardiac arrest (OHCA) treated with eCPR. Methods: We retrospectively analysed the data of 377 consecutive patients treated for OHCA using eCPR in our cardiac arrest centre from January 2016 to December 2022. The primary outcome was defined as the survival of patients until they were discharged from the hospital, with a favourable neurological outcome [cerebral performance category (CPC) score of ≤2]. Statistical analyses were performed using baseline comparison, survival analysis, and multivariable analyses. Results: Out of the 377 patients included in the study, 69 (21%) were female. Female patients showed a lower prevalence rate of pre-existing coronary artery disease (48% vs. 75%, p < 0.001) and cardiomyopathy (17% vs. 34%, p = 0.01) compared with the male patients, while the mean age and prevalence rate of other cardiovascular risk factors were balanced. The primary reason for CA differed significantly (female: coronary event 45%, pulmonary embolism 23%, cardiogenic shock 17%; male: coronary event 70%, primary arrhythmia 10%, cardiogenic shock 10%; p = 0.001). The prevalence rate of witnessed collapse (97% vs. 86%; p = 0.016) and performance of bystander CPR (94% vs. 85%; p = 0.065) was higher in female patients. The mean time from collapse to the initiation of eCPR did not differ between the two groups (77 ± 39 min vs. 80 ± 37 min; p = 0.61). Overall, female patients showed a higher percentage of neurologically favourable survival (23% vs. 12%; p = 0.027) despite a higher prevalence of procedure-associated bleeding complications (33% vs. 16%, p = 0.002). The multivariable analysis identified a shorter total CPR duration (p = 0.001) and performance of bystander CPR (p = 0.03) to be associated with superior neurological outcomes. The bivariate analysis showed relevant interactions between gender and body mass index (BMI). Conclusion: Our analysis suggests a significant survival benefit for female patients who obtain eCPR, possibly driven by a higher prevalence of witnessed collapse and bystander CPR. Interestingly, the impact of patient age and BMI on neurologically favourable outcome was higher in female patients than in male patients, warranting further investigation.

Unresectable Hepatic Metastasis of Uveal Melanoma: Hepatic Chemosaturation with High-Dose Melphalan-Long-Term Overall Survival Negatively Correlates with Tumor Burden.

INTRODUCTION: Percutaneous hepatic perfusion with melphalan (PHP-M) for hepatic metastasis of uveal melanoma (LMUM) achieves high local response rates, but the individual clinical benefit is poorly defined. We aimed to determine cofactors of response and clinical outcomes including the probability of long-term (5-years) overall survival (OS) in PHP-M-treated patients with LMUM. Patients and Methods. We retrospectively reviewed clinicopathological, radiological, and outcome data of 19 patients with unresectable LMUM treated with 43 PHP-M (median 2 PHP-M) between 2014 and 2019. Tumor response and adverse events were evaluated using RECIST 1.1 and the Clavien-Dindo classification. Kaplan-Meier methods and Cox regression hazard proportional models were used. RESULTS: Of 19 patients, 10 (53%) achieved a partial response (PR) and 9 (47%) had stable disease (SD). There was no progressive disease (PD) and no adverse events exceeding Clavien-Dindo grade IV. Median OS was 16.7 months after the first PHP-M treatment and 26.4 months after initial diagnosis. Low hepatic tumor volume (median of 10 mL vs. 150 mL) was an independent predictor of favorable OS (hazard ratio (95% confidence interval): 0.190 (0.041, 0.893); p < 0.05), and female patients were at a lower risk compared with males (0.146 (0.017, 1.240)). Estimates of the overall survival were 0.213 (0.0449, 1) from first imaging (95% confidence interval) to 5 years and 0.793 (0.609, 1) and 0.604 (0.380, 0.960) for 1 and 2 years after chemosaturation, respectively. Discussion. PHP-M for nonresectable LMUV provides a safe and locally efficient liver-directed procedure that offers patients a chance for long-term OS, especially for patients with a low hepatic tumor burden.

[Ligament bracing--augmented cruciate ligament sutures: biomechanical studies of a new treatment concept]. / "Ligament bracing"--die augmentierte Kreuzbandnaht: Biomechanische Grundlagen für ein neues Behandlungskonzept.

BACKGROUND: In the context of acute knee dislocations, suture repair of ruptured cruciate ligaments leads to good clinical results in 80% of cases. Disadvantages are low primary stability and subsequently secondary elongation of the sutured ligaments. In the present study, we compared primary stability of suture repair, reinforced by different suture augments, to cruciate ligament reconstruction. OBJECTIVE: The concept of ligament bracing with transosseous suture repair of the cruciate ligaments and additional suture augmentation is biomechanically superior to cruciate ligament reconstruction. MATERIAL AND METHODS: A total of 42 porcine knee joints divided into seven groups were examined. The stability of four different suture/augmentation combinations were compared to cruciate ligament reconstruction with human hamstring tendons. The investigational setup consisted of testing 1000 cycles with 20 N to 154 N load in a.-p. translation and 60° flexion. Elongation and load to failure were measured. RESULTS: Neither reconstruction (3.13 ± 1.65 mm; 362 ± 51 N) nor augmented suture repair (1.89-2.5 mm; 464-624 N) achieved the primary stability of the intact cruciate ligament (0.63 ± 0.34 mm, 1012 ± 91 N). In comparison to ligament reconstruction, all four augmented suture repairs showed minor elongation in the cyclic test and a higher load to failure. The isolated suture repair showed poor results (6.79 ± 4.86 mm, 177 ± 73 N). CONCLUSION: Augmented suture repair provides significantly higher stability compared with isolated suture repair and reconstruction with hamstring tendons. The concept of ligament bracing could be a promising future treatment option in acute knee dislocations. Clinical results remain to be seen.

[Morbidity, mortality, and overall survival after radical cystectomy: comparison of single-center results with the literature and a nomogram]. / Morbidität, Mortalität und Gesamtüberleben nach radikaler Zystektomie: Abgleich eigener Daten mit der Literatur und einem Nomogramm.

BACKGROUND: Overall survival (OS) after radical cystectomy is determined. It is investigated retrospectively whether prediction is possible using a nomogram. A comparison with published data from "high-volume" centers is performed. PATIENTS AND METHODS: Data of 100 consecutive radical cystectomies performed between 2006 and 2012 were collected. Age, ASA score, tumor stage, urinary diversion, and Clavien score were recorded. The OS after 2 and 5 years was recorded (Kaplan-Meier analysis) and the nomogram-based predictive accuracy was calculated. RESULTS: Median age was 70.8 years. A T≤2, T3, T4, N+ stage was present in 40, 37, 23, and 43%, respectively. Urinary diversion: neobladder, conduit, and ureterostomy were performed in 35, 53, and 12%. The 30-day mortality was 1%. At follow-up, there were 95 patients with a median observation time of 19.8 months. The 2- and 5-year OS were 0.68 and 0.45 (Kaplan-Meier analysis) and 0.65 and 0.39, respectively (nomogram). A significant correlation was observed (rs=0.79; rs=0.80). Compared to published "high-volume" series, no relevant differences concerning morbidity, mortality, and OS were observed. However, there are significant differences concerning the characteristics of "high-volume centers". CONCLUSION: In this series, the OS can be predicted by a multivariate nomogram. The results are comparable with published data. There is no clear definition of a "high-volume center".

[Late preterms: the influence of foetal gender on neonatal outcome]. / Late preterms: Auswirkungen des fetalen Geschlechts auf das neonatologische Outcome.

BACKGROUND: The group of the so-called late preterms (infants born at 34 0/7-36 6/7 weeks gestational age) has been underestimated with respect to their neonatal outcome. Among infants born before the 29th week of pregnancy, a gender-specific difference in favour of females regarding morbidity became evident. The aim of this study is to investigate whether these findings are transferable to the group of late preterms. METHODS: The neonatal outcome of 528 consecutive singletons, born at 34 0/7-36 6/7 weeks gestational age and requiring intensive care, was examined. RESULTS: Neonatal complications have been particularly analysed with regard to gender-specific differences. Boys (n=292) were significantly more frequently affected by sepsis (3.8 vs. 0.9%; p=0,0314, x²-test). Girls had significantly longer stays in the neonatal intensive care unit (median 12 (Q1:8; Q3:17) vs. 11 (6;16) days; p=0.0149, t-test). In a multiple logistic regression model, male gender and premature rupture of membranes were borderline significant with respect to the occurrence of sepsis - boys had a 4.4-fold risk (OR=0.228 [95% CI: 0.050-1.041]; p=0.0564) and premature rupture of membranes had a 3.5-fold risk (OR=3.462 [0.938-12.779]; p=0.0623). Strong cause variables for the length of stay in the neonatal intensive care unit were birth weight, gestational age and premature rupture of membranes after adjustment. CONCLUSION: The influence of foetal gender on the neonatal outcome in the late preterm group (34 0/7-36 6/7 gestational age) has been relativised.

A prospective randomised phase III trial of adjuvant chemotherapy with 5-fluorouracil and leucovorin in patients with stage II colon cancer.

The purpose of this trial was to investigate the efficacy of adjuvant chemotherapy with 5-fluorouracil (5-FU) and leucovorin (LV) in stage II colon cancer. Patients with stage II colon cancer were randomised to either adjuvant chemotherapy with 5-FU/LV (100 mg m(-2) LV+450 mg m(-2) 5-FU weekly, weeks 1-6, in 8 weeks cycles x 7) or surveillance only. Five hundred patients were evaluable for analyses. After a median follow-up of 95.6 months, 55 of 252 patients (21.8%) have died in the 5-FU/LV arm and 58 of 248 patients (23.4%) in the surveillance arm. There was no statistically significant difference in overall survival (OS) between the two treatment arms (hazard ratios, HR 0.88, 95% CI 0.61-1.27, P=0.49). The relative risk for tumour relapse was higher for patients on the surveillance arm than for those on the 5-FU/LV arm; however, this difference was not statistically significant (HR 0.69, 95% CI 0.45-1.06, P=0.09). Consequently, disease-free survival (DFS) was not significantly different between the two trial arms. In conclusion, results of this trial demonstrate a trend to a lower risk for relapse in patients treated with adjuvant 5-FU/LV for stage II colon cancer. However, in this study with limited power to detect small differences between the study arms, adjuvant chemotherapy failed to significantly improve DFS and OS.