Gynaecologists estimate and experience laparoscopic hysterectomy as more difficult compared with abdominal hysterectomy

The level of difficulty of various types of hysterectomy differs and may influence the choice of either approach. When surgeons consider one specific approach to hysterectomy as more difficult, they may be reluctant to perform this type of hysterectomy. The main objective of this study was to investigate the potential different levels of difficulty for laparoscopic and abdominal hysterectomy. Furthermore, the accuracy of estimating the level of difficulty was examined. In a randomized controlled trial between laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH), gynaecologists were asked to record the preoperatively estimated and postoperatively experienced level of difficulty on a Visual Analogue Scale (VAS). Differences between LH and AH were examined and the correlation between the estimated uterine weight on bimanual palpation and the actual uterine weight was calculated. A difference on the VAS of three points or more (ΔVAS ≥ 3) was considered clinically relevant. In 72 out of 76 cases, both VAS scores were recorded. LH was estimated and experienced as significantly more difficult as compared with AH. In 13 (18%) cases, ΔVAS was ≥3, equally distributed between LH (n = 6) and AH (n = 7). Eleven of these 13 cases had a positive ΔVAS ≥3, meaning that surgery was experienced as more difficult than it was estimated. Surgeon’s estimation of uterine size correlated well with the actual uterine weight. LH is considered as more difficult than AH, which might be a reason for its slow implementation. In a large proportion of cases, gynaecologists seem to be able to estimate the level of difficulty of hysterectomy accurately.     

Combined Radiochemotherapy with Paclitaxel in the Treatment of Malignant Glioma

Background: Paclitaxel is a radiosensitizing agent that shows a synergistic effect with radiation in malignant glioma cells. A phase I/II trial was performed in order to evaluate both feasibility and outcome of combined radiochemotherapy in malignant glioma. Patients and Methods: 56 patients were included in the trial. Paclitaxel was administered on days 1-4, 15-18 and 29-32 18 to 24 hours prior to irradiation. Radiotherapy with 60 Gy in conventional fractionation was initiated on day 2. 31 patients were included in a dose-escalation trial starting with 20 mg/m²/d and increasing up to 60 mg/m²/d in 10-mg steps. Additional 25 patients were treated with 50 mg/m²/d. Results: The regimen was very well tolerated with minimal subjective impairment such as sickness or weakness. Maximal tolerable dose was 50 mg/m²/d, with neutropenia being the dose-limiting toxicity. There were four allergic reactions and five thromboembolisms; furthermore, one patient with a normal blood count died due to pneumonia. The median survival was 12 months, and significantly favorable factors were a young age, a lower tumor grade (grade 3) and a complete resection. Varying the paclitaxel dose had no influence on outcome. Conclusions: Combined radiochemotherapy with paclitaxel in the treatment of malignant glioma was well tolerated. Maximal tolerable dose was 50 mg/m²/d. There was no increase in survival compared with results reported in the literature. Hintergrund: Paclitaxel ist eine strahlensensibilisierende Substanz, die auch bei Gliomzellen eine synergistische Wirkung zeigt. Wir führten eine Phase-I/II-Studie durch, um die Toxizität und erste Ergebnisse der kombinierten postoperativen Radiochemotherapie bei malignen Gliomen zu evaluieren. Patienten und Methode: 56 Patienten wurden in die Studie eingeschlossen. Paclitaxel wurde an den Tagen 1-4, 15-18 und 29-32 18 bis 24 Stunden vor der Bestrahlung gegeben. Diese erfolgte mit 60 Gy in konventioneller Fraktionierung ab Ta 2. 31 Patienten nahmen an der Dosiseskalationsstudie teil, die mit Paclitaxel 20mg/m²/d bis 60 mg/m²/d in 10-mg-Schritten durchgeführt wurde. Weitere 25 Patienten wurden mit 50 mg/m²/d behandelt. Ergebnisse: Das Regime wurde sehr gut vertragen. Es trat keine Übelkeit oder Reduktion des Allgemeinzustandes auf. Die maximal tolerable Dosis war 50 mg/m²/d. Dosislimitierend war eine Grad-4-Neutropenie bei 60 mg/m²/d (Tabelle 1). Vier allergische Reaktionen und fünf thromboembolische Ereignisse waren zu verzeichnen. Ein Patient starb an einer Pneumonie bei normalem Blutbild. Das mediane Überleben betrug 12 Monate. Signifikant günstige prognostische Faktoren waren junges Patientenalter, Grad-3-Tumoren (Abbildung 1) und komplette Resektion (Abbildung 2). Die Paclitaxeldosis hatte keinen Einfluss auf das Therapieergebnis. Schlussfolgerung: Die kombinierte Radiochemotherapie mit Paclitaxel war gut verträglich. Die maximal tolerable Dosis betrug 50 mg/m²/d. Im Vergleich zu Literaturdaten konnte keine Verbesserung des Überlebens festgestellt werden.     

Retarded hand growth due to a hemodialysis fistula in a young girl

Long-term presence of an arteriovenous hemodialysis fistula (AVF) may lead to alterations in hand perfusion. In the case reported here, a 14-year-old girl developed pain associated with hand ischemia 5 years after a successful kidney transplantation. At age 8 years, she required a period of hemodialysis using an autogenous left upper arm AVF. Compared to the healthy right hand, a smaller ischemic left hand was observed in the presence of a patent AVF. Access flow was 1400 ml/min. Seldinger angiography demonstrated a stenotic brachial artery, and duplex measurements indicated a reversed blood flow in the radial artery. AVF ligation abolished the ischemic symptoms. Distal hypotension due to an impaired arterial inflow combined with a low resistance elbow AVF may result in chronic hypoperfusion of acral portions of the extremity and growth retardation. Access ligation is advised in children with an optimal renal transplant function and a patent elbow AVF suffering from lowered distal tissue perfusion.     

Access to kidney transplantation in European adults aged 75–84 years and related outcomes: an analysis of the European Renal Association–European Dialysis and Transplant Association Registry

To what extent access to, and allocation of kidney transplants and survival outcomes in patients aged ≥75 years have changed over time in Europe is unclear. We included patients aged ≥75–84 years (termed older adults) receiving renal replacement therapy in thirteen European countries between 2005 and 2014. Country differences and time trends in access to, and allocation of kidney transplants were examined. Survival outcomes were determined by Cox regression analyses. Between 2005 and 2014, 1392 older adult patients received 1406 transplants. Access to kidney transplantation varied from ~0% (Slovenia, Greece and Denmark) to ~4% (Norway and various Spanish regions) of all older adult dialysis patients, and overall increased from 0.3% (2005) to 0.9% (2014). Allocation of kidney transplants to older adults overall increased from 0.8% (2005) to 3.2% (2014). Seven‐year unadjusted patient and graft survival probabilities were 49.1% (95% confidence interval, 95% CI: 43.6; 54.4) and 41.7% (95% CI: 36.5; 46.8), respectively, with a temporal trend towards improved survival outcomes. In conclusion, in the European dialysis population aged ≥75–84 years access to kidney transplantation is low, and allocation of kidney transplants remains a rare event. Though both are increasing with time and vary considerably between countries. The trend towards improved survival outcomes is encouraging. This information can aid informed decision‐making regarding treatment options.     

Differentiation of breast masses using 3-D sonographic and echo-enhancer-based evaluation of the vascular pattern: initial experiences

To evaluate the potential of combined 3-D B-mode and color Doppler (CD) data sets in the differentiation of breast masses, in 50 patients with histologically proven solid breast lesions, 3-D datasets were acquired. A 3-D display was created and volume calculation of tumors, their periphery and vasculature was performed. Time-intensity curves of enhancement after administration of a contrast agent were analyzed. Volumetry of tumor vasculature yielded no significant differences between malignant and benign tumors regarding vascularization of the center (2.60 vs. 2.88%) and periphery (6.66 vs. 3.78%). Only the mean values for the rise time in the center of the tumor, fibroadenoma (FA): 5.7 s and ductal invasive carcinoma (DIC): 15.8s; p = 0.05, and the time to peak in the periphery, FA: 21.0 s and DIC: 31.6 s; p = 0.03, differed significantly. The 3-D ultrasound (US) technique was of no additional value in differentiating breast masses. The calculation of time-intensity curves after administration of a contrast agent may be helpful in differentiating FA and DIC.     

Phenotype in girls and women with Turner syndrome: Association between dysmorphic features,karyotype and cardio-aortic malformations

Introduction

Turner syndrome (TS) is a genetic disorder characterized by the (partial) absence or a structural aberration of the second sex chromosome and is associated with a variety of phenotypes with specific physical features and cardio-aortic malformations. The objective of this study was to gain a better insight into the differences in dysmorphic features between girls and women with TS and to explore the association between these features, karyotype and cardio-aortic malformations.