Case-control study between extrapleural pneumonectomy and radical pleurectomy/decortication for pathological N2 malignant pleural mesothelioma.

OBJECTIVE: To compare the outcomes of extrapleural pneumonectomy (EPP) and radical pleurectomy/decortication (P/D) for N2 malignant pleural mesothelioma (MM). PATIENTS AND METHODS: In a retrospective case-control study we analysed the results of the 57 patients [49 male and 8 female, median age 59 (range 14-70) years] who underwent radical surgery for MM found to have pathological N2 disease over a 7-year-period. EPP was performed on 45 and P/D on 12 patients. Prognostic factors, postoperative course, pathological data and postoperative survival were analysed. RESULTS: Those in the P/D group were significantly older (median age 62 vs 58 years, p=0.03) than in the EPP group. There was no difference in postoperative hospital stay (p=0.1) nor T stage (p=0.7) between the groups. There were no significant differences in the proportion of patients undergoing some adjuvant therapy in each group (p=0.2). Mean survival from diagnosis was 15 months in the EPP group and 16 months for those who underwent P/D (p=0.4). CONCLUSIONS: Preservation of the lung during radical surgery for N2 MM does not compromise survival even in an older group population. We therefore now have ceased to perform EPP in cases of N2 disease and we make every effort to accurately stage patients with mediastinoscopy to identify them.     

Understanding the minimum clinically important difference: a review of concepts and methods.

BACKGROUND CONTEXT: The effectiveness of spinal surgery as a treatment option is currently evaluated through the assessment of patient-reported outcomes (PROs). The minimum clinically important difference (MCID) represents the smallest improvement considered worthwhile by a patient. The concept of an MCID is offered as the new standard for determining effectiveness of a given treatment and describing patient satisfaction in reference to that treatment. PURPOSE: Our goal is to review the various definitions of MCID and the methods available to determine MCID. STUDY DESIGN: The primary means of determining the MCID for a specific treatment are divided into anchor-based and distribution-based methods. Each method is further subdivided and examined in detail. METHODS: The overall limitations of the MCID concept are first identified. The basic assumptions, statistical biases, and shortcomings of each method are examined in detail. RESULTS: Each method of determining the MCID has specific shortcomings. Three general limitations in the accurate determination of an MCID have been identified: the multiplicity of MCID determinations, the loss of the patient's perspective, and the relationship between pretreatment baseline and posttreatment change scores. CONCLUSIONS: An ideal means of determining the MCID for a given intervention is yet to be determined. It is possible to develop a useful method provided that the assumptions and methodology are initially declared. Our efforts toward the establishment of a MCID will rely on the establishment of specific external criteria based on the symptoms of the patient and treatment intervention being evaluated.     

Skapula- und Glenoidfrakturen

Trauma und Berufskrankheit - Nur 0,4–1% aller Frakturen betreffen die Skapula, die meisten davon können erfolgreich konservativ funktionell behandelt werden. Zur Identifikation der...     

Long-term outcomes evaluation after pars defect repair in adult low-grade isthmic spondylolithesis

Adult low-grade isthmic spondylolisthesis is often treated by posterolateral lumbar fusion (PLF), with a certain rate of complications and non-return to work. Alternatives to fusion, like pars defect repair (PDR), were used with encouraging results in young populations and athletes but their outcomes were rarely evaluated for adult patients. This retrospective study quantitatively analysed the long-term outcomes in adult isthmic spondylolisthesis patients treated by PLF or PDR. At a mean follow-up of 9 years, clinical, socio-professional, radiological data and Stauffer-Coventry score were available for 59 patients (39 cases treated by PLF and 20 treated by PDR). The overall clinical outcomes were comparable in both populations (88% in the PDR and 80% in PLF group 1), with a larger proportion of excellent results (56% vs. 10%) and of return to work in the PDR group. Radiological quantitative analysis highlighted stationary evolution and comparable outcomes for the two groups, except for vertebral slip evolution and adjacent level degeneration rate. Abnormal kinematic patterns outlined for PLF patients 20% of pseudarthrosis and 42% of adjacent levels hypermobility and for PDR ones low mobility for the levels adjacent to instrumented vertebra in 40% of cases. Quantified analysis of biomechanical parameters interpreted altogether with clinical outcome, complications and economic burden of the patient, provided accurate objective data for a better appreciation of global outcome, allowing for a preliminary view on long-term outcomes after PDR in adult low-grade isthmic spondylolisthesis, which were not presented in literature until now.     

The health-related quality of life of male and female heavy smokers

Objectives: Heavy smokers are a segment of the smoking population who are at increased risk of smoking-related morbidity and least likely to achieve cessation. This study identifies the impact of heavy smoking on quality of life by gender and describes the subpopulation for improved targeting.Methods: South Australian representative population data (n = 3010) was used to compare the health-related quality of life status of male and female heavy smokers as assessed by the SF-36.     

Thrombotic Micro‐Angiopathy with Sirolimus‐Based Immunosuppression: Potentiation of Calcineurin‐Inhibitor‐Induced Endothelial Damage?

Thrombotic microangiopathy is a rare but important finding in the context of organ transplantation. Acute renal insufficiency in the setting of hemolysis and thrombocytopenia, a triad that constitutes 'hemolytic uremic syndrome', can be associated with, or triggered by, conditions such as verocytotoxin-producing Escherichia coli, viral infections, malignant hypertension, scleroderma, allograft rejection, lupus erythematosus, pregnancy, and medications including mitomycin C, calcineurin inhibitors, and oral contraceptives. After renal transplantation, it can occur, as either a de novo episode, or recurrent disease. Calcineurin inhibitors have long been associated with post-transplantation thrombotic microangiopathy. Sirolimus has been used as a primary immunosuppressant in patients transplanted with a history of earlier hemolytic-uremic syndrome, and also as rescue therapy in patients with calcineurin-inhibitor-associated thrombotic microangiopathy. We describe four cases where there was significant thrombotic microangiopathy in the context of contemporaneous or contiguous calcineurin inhibitor and sirolimus usage. As the intrarenal cyclosporin concentration is thought to be significantly elevated when cyclosporin and sirolimus are used together, this may explain these findings, and mandates caution in their co-administration.     

Educational level as a modulator of cognitive performance and neuropsychyatric features in Parkinson disease.

OBJECTIVES: To test a possible association between the educational level (EL), cognitive performance, and neuropsychiatric features in Parkinson disease (PD). BACKGROUND: An inverse association has been reported between EL and cognitive dysfunction in patients with senile dementia of Alzheimer type but it is yet unsettled whether education has a similar effect on cognition in PD. METHODS: Seventy-two PD patients (45 males, mean age 68.7+/-11.6 y) underwent a detailed neurologic examination, a battery of neuropsychologic tests, and questionnaires for the evaluation of psychosis, sleep disturbances, and depression. According to the number of educational years, patients were divided into 3 groups: low EL (0 to 8 y), (15 patients), intermediate EL (9 to 12 y) (28 patients), and high EL (>/=13 y) (29 patients). RESULTS: Patients with a higher EL had a better cognitive function and an association was found between the patients' EL and their scores in various neuropsychologic tests mainly those sensitive to frontal lobe dysfunction. Low education was associated with an increased risk for hallucinations and a trend for more depression, delusions, and sleep disturbances. CONCLUSIONS: The association between high educational attainment and the lower risk of cognitive dysfunction suggest that education might modulate cognitive performance in PD.     

A giant fusiform basilar aneurysm treated by bilateral vertebral artery occlusion.

OBJECTIVE AND IMPORTANCE: Fusiform aneurysms of the vertebrobasilar arteries that progressively enlarge causing symptomatic brainstem compression are dangerous and their treatment is difficult. A patient with such an aneurysm treated successfully with staged, microsurgical occlusions of the proximal vertebral arteries is described, and the literature pertaining to this rare condition is briefly reviewed. CLINICAL PRESENTATION: A 48-year-old man with a fusiform basilar trunk aneurysm of uncertain etiology presented initially with transient ischemic attacks (TIAs) of the posterior circulation that ceased with anticoagulation. Four years later he presented again with progressive ataxia, dysphagia and dysphonia due to considerable enlargement of the aneurysm causing brainstem compression. INTERVENTION: Staged microsurgical vertebral artery occlusions proximal to the aneurysm were performed. The second (left) vertebral artery was clipped only after the patient passed its temporary occlusion with an endovascular test balloon. The aneurysm subsequently thrombosed, the distal basilar artery kept patent by a single (left) posterior communicating artery. The patient's clinical condition improved markedly over a number of months as the aneurysm mass atrophied. CONCLUSION: Giant vertebrobasilar aneurysms are rare but treacherous lesions, sometimes justifying aggressive management. Carefully selected patients with progressive and severe symptoms due to brainstem compression may tolerate proximal vertebral artery occlusions, provided there is adequate collateral flow to the basilar termination and all of its perforating branches.