Quality of life after gamma knife radiosurgery treatment in patients with a vestibular schwannoma: the patient’s perspective

This study evaluates the impact of gamma knife radiosurgery (GKRS) on the quality of life (QOL) of patients with a sporadic vestibular schwannoma (VS). This study pertains to 108 VS patients who had GKRS in the years 2003 through 2007. Two different QOL questionnaires were used: medical outcome study short form 36 (SF36) and Glasgow benefit inventory (GBI). Radiosurgery was performed using a Leksell 4C gamma knife. The results of the QOL questionnaires in relation to prospectively and retrospectively gathered data of the VS patients treated by GKRS. Eventually, 97 patients could be included in the study. Their mean tumor size was 17 mm (range 6–39 mm); the mean maximum dose on the tumor was 19.9 Gy (range 16–25.5 Gy) and the mean marginal dose on the tumor was 11.1 (range 9.3–12.5 Gy). SF36 scores showed results comparable to those for a normal Dutch population. GBI showed a marginal decline in QOL. No correlation was found between QOL and gender, age, tumor size, or radiation dose. Increased audiovestibular symptoms after GKRS were correlated with a decreased GBI score, and decreased symptoms were correlated with a higher QOL post-GKRS. In this study shows that GKRS for VS has little impact on the general QOL of the VS patient. However, there is a wide range in individual QOL results. Individual QOL was influenced by the audiovestibular symptoms. No predictive patient, tumor, or treatment factors for QOL outcome after GKRS could be determined. Comparison with microsurgery is difficult because of intra group variability.     

Conservative treatment of a posterior intercostal lung herniation: a case report

Introduction patients: A rare posterior intercostal lung herniation was diagnosed after a coughing spell by computed tomography and treated conservatively. Two years later, there were no specific complications or progression of the herniation.

Methods, results and conclusions: There is no consensus on the indications for surgery and optimal treatment of this disorder.     

Approach for valuating the influence of laboratory simulation

ObjectiveThe aim of this investigation was to determine the fracture resistance of zirconia fixed partial dentures (FPDs) after laboratory simulation. Failure type and failure rates during simulation were compared to available clinical data for estimating the relevance of the simulation.Methods32 FPDs were fabricated of a zirconia ceramic and a corresponding ceramic veneer. The FPDs were adhesively bonded on human molars and artificial aging was performed for investigating the survival rate during thermal cycling and mechanical loading (TCML1; 3.6 Mio × 50 N ML). Survival rates were compared to available clinical data and the TCML parameter “mastication force” was adapted accordingly for a second TCML run (TCML2; 3.6 Mio × 100 N ML). The fracture resistance of the FPDs which survived TCML was determined. FPDs were examined without TCML (control) or after TCML according to literature (1.2 Mio × 50 N ML). Data were statistically analyzed (Mann–Whitney U-test) and curve fitting/regression analysis of the survival rates was performed.ResultsTCML reduced survival rates down to 63%. Failures during TCML were chipping off of the veneering ceramic, no zirconia framework was damaged. Under clinical conditions comparable failures (chipping) are reported. The clinical survival rate (～10%) is lower compared to TCML data because of the short period of observation. The fracture resistance after TCML was significantly reduced from 1058 N (control) to values between 320 and 533 N.ConclusionThe results indicate that TCML with 1.2 Mio × 50 N provides a sufficient explanatory power. TCML with prolonged simulation time may allow the definition of a mathematical model for estimating future survival rates.     

P300 and treatment effect of modafinil on fatigue in multiple sclerosis.

To evaluate the value of visual and auditory P300 for predicting the response of multiple sclerosis-related fatigue to modafinil treatment, 33 patients were treated with 100 mg modafinil once daily for 4 weeks, following a 4-week baseline phase and an optional 8-week extension phase. The main clinical outcome parameter was a decrease in the fatigue visual analogue score (VAS) before and after 4 weeks of treatment. Patients with shorter auditory P300 latency at baseline were more likely to benefit from modafinil treatment. Auditory P300 latency predicted treatment response with a specificity of 76% and a sensitivity of 75% at a cut-off latency of 350 ms. Visual P300 latency could not be used to predict treatment response. Baseline auditory P300 latency predicted treatment response, whereas visual P300 latency did not. Clinical improvement did not correlate with changes in either visual or auditory P300.     

Rationality,practice variation and person‐centred health policy: a threshold hypothesis

Variation in practice of medicine is one of the major health policy issues of today. Ultimately, it is related to physicians' decision making. Similar patients with similar likelihood of having disease are often managed by different doctors differently: some doctors may elect to observe the patient, others decide to act based on diagnostic testing and yet others may elect to treat without testing. We explain these differences in practice by differences in disease probability thresholds at which physicians decide to act: contextual social and clinical factors and emotions such as regret affect the threshold by influencing the way doctors integrate objective data related to treatment and testing. However, depending on a theoretical construct each of the physician's behaviour can be considered rational. In fact, we showed that the current regulatory policies lead to predictably low thresholds for most decisions in contemporary practice. As a result, we may expect continuing motivation for overuse of treatment and diagnostic tests. We argue that rationality should take into account both formal principles of rationality and human intuitions about good decisions along the lines of Rawls' ‘reflective equilibrium/considered judgment’. In turn, this can help define a threshold model that is empirically testable.     

Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis

IntroductionThe aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.MethodsMedline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.ResultsIn total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).ConclusionsThis systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0795-y) contains supplementary material, which is available to authorized users.