Prophylaxis of heterotopic ossification in patients sedated after polytrauma: medical and ethical considerations

BACKGROUND AND PURPOSE: Heterotopic ossification (HO) often follows acetabular fractures after multitrauma. Irradiation is a mean for prophylaxis. We established a standard procedure in our hospital for patients under sedation, when obtaining informed consent for HO prophylaxis is impossible. PATIENTS AND METHODS: We reviewed current scientific evidence, calculated the risks of radiation and presented the ethical and legal framework. The subject was scrutinised by an interdisciplinary panel. RESULTS: Irradiation is the most effective means for prophylaxis and has few adverse effects in adult patients with fractures of the acetabulum. The lifetime risk of radiation-induced cancer or infertility are insignificant. CONCLUSIONS: Informed consent for irradiation should be obtained before operation whenever possible. When this cannot be done prophylaxis can be postponed for a maximum of 3 days in order to obtain consent. If the patient is not able to communicate within this period, prophylactic irradiation should be given after consulting the relatives. The patient must be informed as soon as possible

Predictors of state-of-the-art management of early breast cancer in Switzerland

Background: The aim of this study was to investigate predictors of state-of-the-art management of early breast cancer in Switzerland. Patients and methods: The study included 3499 women aged 25-79 years diagnosed with invasive breast cancer stages I-IIIA in 2003-2005. Patients were identified through population-based cancer registries and treated in all kinds of settings. Concordance with national and international recommendations was assessed for 10 items covering surgery, radiotherapy, systemic adjuvant therapy and histopathology reporting. We used multivariate logistic regression to identify independent predictors of high (10 points) and low (≤7 points) concordance. Results: In one-third of the patients, management met guidelines in all items, whereas in about one-fifth, three or more items did not comply. Treatment by a surgeon with caseload in the upper tercile and team involved in clinical research were independent predictors of a high score, whereas treatment by a surgeon with a caseload in the lower tercile was associated with a low score. Socioeconomic characteristics such as income and education were not independent predictors, but patient's place of residence and age independently predicted management according to recommendations. Conclusion: Specialization and involvement in clinical research seem to be key elements for enhancing the quality of early breast cancer management at population leve

Die Radio-Onkologie - eine wichtige Säule in der Krebstherapie

Ihre Wurzeln hat die Strahlentherapie in der Radiologie. Ihre Zukunft liegt jedoch in der Zusammenarbeit mit der medizinischen Onkologie und der Chirurgie. Die Strahlentherapie ist eine wichtige Säule in der Krebstherapie. Wenn es um Forschungsgelder geht, steht die Radio-Onkologie jedoch wesentlich schlechter da als die medizinische Onkologie

Intra-epidermal evoked potentials: A promising tool for spinal disorders?

OBJECTIVES To test the robustness and signal-to-noise ratio of pain-related evoked potentials following intra-epidermal electrical stimulation (IES) compared to contact heat stimulation in healthy controls, and to explore the feasibility and potential added value of IES in the diagnosis of spinal disorders. METHODS Pain-related evoked potentials induced by IES (custom-made, non-invasive, concentric triple pin electrode with steel pins protruding 1 mm from the anode, triangularly separated by 7-10 mm respectively) and contact heat stimulation were compared in 30 healthy subjects. Stimuli were applied to four different body sites. Two IES intensities, i.e., high (individually adapted to contact heat painfulness) and low (1.5 times pain threshold), were used. Additionally, a 40-year-old patient with unilateral dissociated sensory loss due to a multi-segmental syringohydromyelia was assessed comparing IES and contact heat stimulation. RESULTS Both IES and contact heat stimulation led to robust pain-related evoked potentials recorded in all healthy subjects. Low intensity IES evoked potentials (14.1-38.0 µV) had similar amplitudes as contact heat evoked potentials (11.8-32.3 µV), while pain ratings on the numeric rating scale were lower for IES (0.8-2.5, compared to 1.5-3.9 for contact heat stimulation). High intensity IES led to evoked potentials with higher signal-to-noise ratio than low intensity IES and contact heat stimulation. The patient case showed impaired pain-related evoked potentials in segments with hypoalgesia for both IES modes. IES evoked potentials were preserved, with delayed latencies, while contact heat evoked potentials were abolished. CONCLUSION IES evoked robust pain-related cortical potentials, while being less painful in healthy controls. The improved signal-to-noise ratio supports the use of IES for objective segmental testing of nociceptive processing. This was highlighted in a spinal syndrome case, where IES as well as contact heat stimulation reliably detected impaired segmental nociception

Notch1 is required for neuronal and glial differentiation in the cerebellum.

The mechanisms that guide progenitor cell fate and differentiation in the vertebrate central nervous system (CNS) are poorly understood. Gain-of-function experiments suggest that Notch signaling is involved in the early stages of mammalian neurogenesis. On the basis of the expression of Notch1 by putative progenitor cells of the vertebrate CNS, we have addressed directly the role of Notch1 in the development of the mammalian brain. Using conditional gene ablation, we show that loss of Notch1 results in premature onset of neurogenesis by neuroepithelial cells of the midbrain-hindbrain region of the neural tube. Notch1-deficient cells do not complete differentiation but are eliminated by apoptosis, resulting in a reduced number of neurons in the adult cerebellum. We have also analyzed the effects of Notch1 ablation on gliogenesis in vivo. Our results show that Notch1 is required for both neuron and glia formation and modulates the onset of neurogenesis within the cerebellar neuroepithelium

Mit weniger Therapiesitzungen sicher und effizienter ans Ziel

Hypofraktionierung bedeutet in der Strahlentherapie, im Vergleich mit gängigen Therapieschemata in weniger Therapiesitzungen mit höherer Einzeldosis und in der Regel in einer kürzeren Gesamtbehandlungsdauer die Bestrahlung durchzuführen. Hypofraktionierung zur postoperativen Radiotherapie beim brusterhaltend operierten Mammakarzinom wird (wie auch bei anderen onkologischen Indikationen) seit einigen Jahren diskutiert. Gleiche Resultate in Bezug auf lokale Kontrolle und Kosmetik mir kürzerer Behandlungszeit? Auch in Zeiten gesundheitsökonomischer Überlegungen ein „heisses Eisen“

Risk-adapted dental care prior to intensity-modulated radiotherapy (IMRT).

BACKGROUND: At the Clinic for Radiation Oncology at the Zurich University Hospital (UniversitätsSpital Zürich [USZ]), head-and-neck tumor (HNT) patients have been treated with intensity-modulated radiotherapy (IMRT) since 01/2002 (n 〉 800). This method causes less damage to normal tissues adjacent to the tumor, and thus it was possible in the head/neck region to markedly reduce the rate of osteoradionecrosis (ORN), in addition to reducing the rate of severe xerostomia. Based on these results, risk-adapted dental care (RaDC) was adopted by our clinic as the standard mode of pre-IMRT dental treatment. The guidelines as formulated by Grötz et al. were respected. ORN prophylaxis is one of the most important goals of pre-radiotherapy dental care, and the ORN rate is a measurable parameter for the efficacy of dental care, given a certain radiation technique. The aim of the present study was therefore to evaluate the efficacy of RaDC as reflected by the ORN rate of our IMRT patients. MATERIALS AND METHODS: IN August 2006, RaDC was clinically implemented and has been used for all HNT patients prior to IMRT since then. Before that (01/2002-07/2006), dental restorations were performed according to the usual procedure. RESULTS: The rate of grade-2 ORN was similar in the conventionally treated and RaDC groups (2% and 1%, resp.); grade-3 ORN had not occurred by the time the analysis was conducted. As expected, fewer extractions were performed in the RaDC cohort (no extractions in 47% of the RaDC/IMRT cohort vs. 27% in the IMRT cohort receiving conventional dental care). CONCLUSION: After considerably less invasive dental treatment, no higher-grade ORN occurred and no ORN-related jaw resections were required. Based on the present data, risk-adapted minimally invasive dental care is recommended before IMRT