Erkennung eines potenziellen Organspenders in der Intensivmedizin

Summary During a period of 18 months, 1640 patients were treated at the neurosurgical intensive care unit, University Hospital Essen. Of these, 85 patients died. Determination of brain death was performed in 37 cases. An agreement with family members for organ explantation was achieved in 10 cases. The most frequent diseases leading to dissociated brain death were aneurysmatic subarachnoid hemorrhage (38%) and traumatic brain injury (27%).¶ Using selected case reports, we show that even in extreme devastating cases, a specific therapy (e.g., operation) was performed as long as a minimal chance of restitution existed. Unfortunately sometimes a change for fatal outcome appeared early after onset of symptoms or after many days of treatment so that survival with acceptable life-quality was not possible and progradient cerebral herniation occurred. Recognizing of this fatal change and further management will be demonstrated. Zusammenfassung Über einen Zeitraum von 18 Monaten wurden auf der Neurochirurgischen Intensivstation des Universitätsklinikums Essen 1640 Patienten behandelt. Davon verstarben 85 Patienten. Eine Hirntodfeststellung ergab sich bei 37 Betroffenen. In 10 Fällen erfolgte durch die Angehörigen eine Zustimmung zur Organentnahme (27% Zustimmungsrate). Die häufigsten zum dissoziierten Hirntod führenden Erkrankungen waren die aneurysmatische Subarachnoidalblutung (38%) und das Schädel-Hirn-Trauma (27%).¶ Es wird anhand ausgesuchter Fallbeispiele demonstriert, dass selbst bei extrem schlechter Prognose, solange noch eine minimale Chance auf Heilung besteht, eine spezifische Therapie (z.B. Operation) durchgeführt wird. Leider ergibt sich insbesondere bei den o.g. Krankheitsbildern manchmal zu sehr frühem Zeitpunkt oder nach vielen Tagen ein Wendepunkt, der anzeigt, dass ein sinnvolles Überleben nicht mehr möglich ist und es zur progredienten zerebralen Einklemmung kommt. Das Erkennen dieses Wendepunkts im Krankheitsverlauf und das weitere Management werden aufgezeigt.     

Association between race and oncologic outcome following radical prostatectomy for clinically organ-confined prostate cancer: a long-term follow-up study

Purpose

Few studies have evaluated prostate cancer oncologic outcomes in different ethnic groups following radical prostatectomy for clinically organ-confined disease. Existing studies lack long-term outcome data. We conducted this study to assess the impact of racial differences on risk profile and oncologic outcomes in a large cohort of patients with prostate cancer who underwent radical prostatectomy.

Methods

Using our institutional review board-approved prostate cancer database, we retrospectively reviewed the records of 3437 patients who underwent radical prostatectomy with curative intent in our institution between 1987 and 2009. Based on ethnicity, patients were divided into Asian Americans (n?=?133), African Americans (n?=?155) and Caucasians (n?=?3149). Baseline characteristics and oncologic outcomes including biochemical recurrence free, clinical recurrence free and overall survival were compared between the study groups.

Results

A total of 3437 patients with a mean age of 63?±?9.8 years and median follow-up period of 8.7 (range 0.1–24.1) years were included in the analysis. Pathologic stage and the frequency of poorly differentiated cancer were higher in Asian Americans; however, margin status did not differ significantly. Moreover, oncologic outcomes were comparable between different ethnic groups. In multivariate analysis, both pathologic stage and grade were independent predictors of oncologic outcomes, but race was not.

Conclusions

In this large, ethnically diverse long-term follow-up study, we noted that Asian Americans compared to African Americans and Caucasians are more likely to have high risk prostate cancer; however, race was not an independent predictor of oncologic outcome following radical prostatectomy with curative intent.

     

Early mechanical stimulation only permits timely bone healing in sheep

Bone fracture healing is sensitive to the fixation stability. However, it is unclear which phases of healing are mechano‐sensitive and if mechanical stimulation is required throughout repair. In this study, a novel bone defect model, which isolates an experimental fracture from functional loading, was applied in sheep to investigate if stimulation limited to the early proliferative phase is sufficient for bone healing. An active fixator controlled motion in the fracture. Animals of the control group were unstimulated. In the physiological‐like group, 1 mm axial compressive movements were applied between day 5 and 21, thereafter the movements were decreased in weekly increments and stopped after 6 weeks. In the early stimulatory group, the movements were stopped after 3 weeks. The experimental fractures were evaluated with mechanical and micro‐computed tomography methods after 9 weeks healing. The callus strength of the stimulated fractures (physiological‐like and early stimulatory) was greater than the unstimulated control group. The control group was characterized by minimal external callus formation and a lack of bone bridging at 9 weeks. In contrast, the stimulated groups exhibited advanced healing with solid bone formation across the defect. This was confirmed quantitatively by a lower bone volume in the control group compared to the stimulated groups.The novel experimental model permits the application of a well‐defined load history to an experimental bone fracture. The poor healing observed in the control group is consistent with under‐stimulation. This study has shown early mechanical stimulation only is sufficient for a timely healing outcome. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1790–1796, 2018.

     

Enhanced Endoscopy in Bladder Cancer

Purpose of Review

Endoscopy coupled with targeted resections represents a cornerstone in the diagnosis, staging, and treatment of patients with bladder cancer. Direct visualization can be challenging and imprecise due to patient-, tumor-, and surgeon-specific factors. We will review contemporary endoscopic technologies and techniques used to improve our ability to safely identify and resect malignant lesions in patients with bladder cancer.

Recent Findings

Enhanced endoscopic imaging technology may improve detection rates for bladder cancer throughout the upper and lower urinary tract, which may lead to improvements in recurrence and progression rates for non-muscle invasive bladder cancer (NMIBC). New techniques including narrow-band imaging (NBI), photodynamic diagnosis (PDD), Storz Professional Image Enhancement System (SPIES), optical coherence tomography (OCT), and others have shown benefit and may further improve our ability to detect and stage bladder tumors.

Summary

Enhanced endoscopy technologies have already demonstrated value in improving the sensitivity of bladder cancer detection and early results suggest they may improve short- and long-term oncologic outcomes.

     

The Role of Surgery in Metastatic Bladder Cancer: A Systematic Review

Context

The role of surgery in metastatic bladder cancer (BCa) is unclear.

Anti-MDA5 Antibody Spectrum in Western World

Purpose of Review

Anti-melanoma differentiation-associated gene 5 (anti-MDA5) is a novel and highly specific myositis-associated autoantibody, which defines a unique phenotype among patients with dermatomyositis (DM).

Recent Findings

Anti-MDA5 was originally characterized in Japan in DM patients with hallmark cutaneous features and no proximal muscle weakness and termed clinically amyopathic DM (CADM). Anti-MDA5 has characteristic cutaneous manifestations which include tender palmar papules and cutaneous ulcerations, along with an increased frequency of interstitial lung disease (ILD) that can be rapidly progressive (RPILD) and fatal.

Summary

This review will highlight the clinical significance of anti-MDA5 autoantibodies in Caucasian DM patients.

     

Design and finite element analysis of a novel smart clamper for aortic cross-clamping in minimally invasive surgery

Aortic cross-clamping is a critical action during heart surgeries which may cause some injuries to the wall of the artery. These injuries may have both short-term and long-term adverse effects on the artery function. Appropriate clampers can properly occlude the artery and decrease the extent of injury. Thus, developing a model for evaluation of such clampers is inevitable. In this paper, a finite element model of the aorta is presented; then, different mechanisms of clamping are investigated. In this regard, a numerical model of aortic cross-clamping by three types of clampers has been implemented with consideration of nonlinear behavior of two-layer artery, residual stress in aorta, and calcification. These three clamper models are commercial Chitwood clamper and linear mechanism clamper with and without balloon. Using the obtained results, comparative analysis was performed between the proposed clamper design and the commercial one. Based upon the analysis, it was concluded that the designed clamper, linear mechanism clamper with balloon, helps to distribute the stress uniformly in different layers of the aorta, which results in better performance of the clamping procedure and causes less injury in the aorta, especially when there is calcification.     

Association of the GNB3 825T-allele with better survival in patients with glioblastoma multiforme

Purpose

Genotypes of the C825T polymorphism of the GNB3 gene encoding the G protein β3 subunit were recently associated with the prognosis of different malignomas. We investigated potential associations of GNB3 genotypes with survival of patients with glioblastoma multiforme (GBM).

Methods

One hundred and sixty-one patients suffering from GBM were retrospectively investigated. Inclusion criteria were availability of DNA and a follow-up of at least 24 months. The results were evaluated with respect to the basic clinical data, type of surgical intervention, MGMT promoter methylation, adjuvant therapy, and survival.

Results

After 2 years of first diagnosis, 128 (79.5%) of the 161 patients had died, 33 (20.5%) were alive. Kaplan–Meier curves revealed a significant higher rate of survival for homo- and heterozygous T-allele carriers (P = 0.019) with 38.5 and 25.3%, respectively, but only 11.6% for homozygous C-allele carriers. Multivariable Cox regression identified the heterozygous (hazard ratio 3.3, 95% CI 1.3–8.0, P = 0.010), as well as homozygous GNB3 825 C-allele (hazard ratio 3.7, 95% CI 1.5–9.1, P = 0.004) as an independent negative prognostic factor for 2-year survival according to the GNB3 825 TT genotype reference group.

Conclusions

Our data suggest an association of the GNB3 825TT genotype and better survival in patients with GBM.