In vivo measurement of dose distribution in patients' lymphocytes: helical tomotherapy versus step-and-shoot IMRT in prostate cancer

In radiotherapy, in vivo measurement of dose distribution within patients'' lymphocytes can be performed by detecting gamma-H2AX foci in lymphocyte nuclei. This method can help in determining the whole-body dose. Options for risk estimations for toxicities in normal tissue and for the incidence of secondary malignancy are still under debate. In this investigation, helical tomotherapy (TOMO) is compared with step-and-shoot IMRT (SSIMRT) of the prostate gland by measuring the dose distribution within patients'' lymphocytes. In this prospective study, blood was taken from 20 patients before and 10 min after their first irradiation fraction for each technique. The isolated leukocytes were fixed 2 h after radiation. DNA double-stranded breaks in lymphocyte nuclei were stained immunocytochemically using anti-gamma-H2AX antibodies. Gamma-H2AX foci distribution in lymphocytes was determined for each patient. Using a calibration line, dose distributions in patients'' lymphocytes were determined by studying the gamma-H2AX foci distribution, and these data were used to generate a cumulative dose–lymphocyte histogram (DLH). Measured in vivo (DLH), significantly fewer lymphocytes indicated low-dose exposure (<40% of the applied dose) during TOMO compared with SSIMRT. The dose exposure range, between 45 and 100%, was equal with both radiation techniques. The mean number of gamma-H2AX foci per lymphocyte was significantly lower in the TOMO group compared with the SSIMRT group. In radiotherapy of the prostate gland, TOMO generates a smaller fraction of patients'' lymphocytes with low-dose exposure relative to the whole body compared with SSIMRT. Differences in the constructional buildup of the different linear accelerator systems, e.g. the flattening filter, may be the cause thereof. The influence of these methods on the incidence of secondary malignancy should be investigated in further studies.     

Ruhigstellung von Frakturen in der präklinischen Notfallmedizin

Notfall + Rettungsmedizin - In Deutschland ereignen sich etwa 2,6&nbsp;Mio. Verkehrsunfälle/Jahr mit einer relevanten Zahl an Extremitäten‑, Becken- und...     

Effect of exercise on amino acid incorporation into myocardial contractile proteins

Amino acid incorporation into myocardial protein was studied in rats after an acute bout of exhaustive swimming. Hearts were removed at exhaustion, 1, 2, or 4 h of recovery and amino acid incorporation measured using [³H] phenylalanine in an isolated perfused heart preparation. Amino acid incorporation into total tissue protein was reduced 30% at exhaustion but returned to normal by 1 h of recovery and showed no further change 4 h post exercise. In the myofibrillar fraction amino acid incorporation decreased slightly after exhaustive exercise but was stimulated by 57% following 2 h recovery. Myosin, electrophoretically fractionated showed an 84% stimulation in phenylalanine incorporation at exhaustion and 112% increase 2 h post exercise. Amino acid incorporation into myosin light chains (LC₁ and LC₂) accounted for most of the increased rate of synthesis. These data suggest that there was a preferential increase in myocardial protein synthesis following exercise which was associated with the myosin light chain components of the contractile proteins.     

Radiochemotherapie beim nichtkleinzelligen Bronchialkarzinom

In order to treat non-small-cell lung cancer, radiotherapy is combined with chemotherapy. Lung complications can be caused by either therapy modality. However, they can be potentiated in combined radiochemotherapy. This case presents an interesting, escalating progress under docetaxel.     

Management of syndesmotic injuries:What is the evidence?

Ankle fractures are accompanied by a syndesmotic injury in about 10% of operatively treated ankle fractures. Usually, the total rupture of the syndesmotic ligaments with an external rotation force is associated with a Weber type B or C fracture or a Maisonneuve fracture. The clinical assessment should consist of a comprehensive history including mechanism of injury followed by a specific physical examination. Radiographs, and if in doubt magnetic resonance imaging, are needed to ascertain the syndesmotic injury. In the case of operative treatment the method of fixation, the height and number of screws and the need for hardware removal are still under discussion. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. A possible solution might be the assessment with intraoperative three-dimensional imaging. The aim of this article is to provide a current concepts review of the clinical presentation, diagnosis and treatment of syndesmotic injuries.     

Posttraumatic and postoperative osteomyelitis: surgical revision strategy with persisting fistula

Introduction

Posttraumatic and postoperative osteomyelitis (PPO) with bacteria colonisation during trauma and associated surgery is an increasing clinical problem. This study investigated the treatment of PPO by surgical revision including irrigation, debridement, and temporary hardware maintenance. In addition, a drainage was inserted as persisting fistula to control osteomyelitis until fracture healing was achieved. Trauma- and osteomyelitis-related factors that influenced the study outcome were determined.

Patients and methods

67 consecutive patients with PPO were included. At onset of PPO, patients had incomplete fracture healing. Patients were subdivided by time of PPO occurrence (acute, subacute or chronic), initial soft tissue trauma, anatomical location, and initial fracture type (AO classification). The study outcome measures included radiographic and clinical follow-up.

Results

59 patients could be followed for an average of 23 months after revision surgery. A bone healing was achieved by 89 % of patients after 14.7 ± 13.4 weeks. Fractures of the lower extremity, open fractures and comminuted C-type fractures took significantly longer to achieve bone healing (p < 0.05 each). Time of PPO occurrence did not influence bone healing. After fracture consolidation, no re-infection was found.

Conclusions

This study showed high rates of bone healing, indicating that this strategy with persisting fistula should be considered as alternative treatment option in patients with PPO.     

Does ATLS trauma training fit into Western countries: evaluation of the first 8 years of ATLS in Germany

Background

With over 2 million certified physicians worldwide, the Advanced Trauma Life Support (ATLS) program is one of the most successful international medical education programs. Germany joined the ATLS program in 2003. Before implementation of the program, there was a controversial discussion as to whether a country like Germany with a long history of trauma care needed ATLS at all. 197 courses with nearly 3,000 providers were performed until December 2010.

Aim

We assessed the course evaluations since the implementation of ATLS in Germany using the participants’ systematic feedback.

Method

During the course, each participant evaluated each presentation, skill station, and simulation on a rating scale from 1 to 4 (1 being the best, 4 being the worst). The participants completed the evaluation forms during the course and before they received their results. The course coordinator made sure that all forms were returned. The feedback forms were collected anonymously and were entered into a database. Statistical analysis was performed using frequencies and mean values.

Results

The cumulative evaluation of all courses revealed an average performance score of 1.39 (1.06–1.86; n = 197). The lectures, skill stations, and simulations were individually evaluated as follows: lectures 1.61 (1.00–2.81; n = 197), skill stations 1.40 (1.00–2.40; n = 197), and surgical skill stations 1.35 (1.00–2.38; n = 197). Practical skills simulation (case scenarios) received the highest grade of 1.24 (1.00–1.57; n = 197). There were no significant changes during the time concerning the results of the evaluation.

Conclusion

The overall assessment showed constantly good and excellent evaluations by the participants over the years. In general, skill stations and simulations performed better than lectures. According to these results, the course format is well accepted by the participants and, therefore, can be recommended to all physicians treating trauma patients. Our results also underline the value of such a course format in an industrial country with an already established trauma system.     

Long-term outcome of femoral derotation osteotomy in children with spastic diplegia

Satisfactory short-term results after femoral derotation osteotomy (FDO) for the treatment of internal rotation gait in cerebral palsy have been reported by various authors. However, there are only a few longer-term studies reporting results 5 years after FDO and these are not in agreement. There are no reports on the clinical course beyond the pubertal growth spurt. 33 children with diplegia (n=59 legs, age: 10.5±3.6 years) and internally rotated gait were examined pre- (E0), 1 year (E1), 3±1 (E2) and 9±2 (E3) years after distal (27 legs) or proximal (32 legs) FDO as part of multilevel surgery, using standardized clinical exam and 3D gait-analysis at all examinations. The amount of intra-operative derotation averaged 25°. ANOVA was used for statistics (p<0.05). Mean hip internal rotation in stance at E0 of 17.3° was significantly changed to 1.0° of external rotation at E1 and was maintained at 4.2° at E3. The same clinical course was found for foot progression angle. The mid-point of passive hip rotation at E0 was 21°. This was significantly decreased to 6° at E1 and showed a small but significant increase reaching 12° at E3. The results of this study showed a good overall correction of internally rotated gait following FDO. These improvements were maintained at long-term follow-up after the pubertal growth spurt. Recurrence was observed in some cases with overall severe deterioration. In those patients persistent dynamic factors leading to recurrence should be further investigated.