Futility: ein Begriff im chirurgischen Alltag?

Zusammenfassung: Ethisch anspruchsvolle Indikationsstellungen bei Patienten, die ihren Willen nicht selbst äußern können, wie beispielsweise schwer demenzkranke Patienten, konfrontieren uns häufig. Es stellt sich hierbei die Frage, ob wir mit operativen Eingriffen eine Übertherapie vollziehen. Der Begriff "futility" der Medizinethik beschreibt Übertherapie, ist allerdings für eine konkrete Anwendung problematisch, da eine exakte Definition fehlt. In der klinischen Situation von schwer demenzkranken, hochbetagten Patienten muss in chirurgischen Abteilungen eine Aufarbeitung von medizinischem Hintergrund, Lebensumständen des Patienten und belegtem oder mutmaßlichem Patientenwillen erfolgen mit dem Ziel, Indikationen individualisiert zu stellen. Nur so können diese Patienten optimal versorgt werden, eine klare Kommunikation über Behandlungsziele mit Angehörigen stattfinden sowie eine Vermeidung eines "burn out" bei den Behandelnden erreicht werden. Von großem Nutzen ist hierbei eine enge Zusammenarbeit mit Medizinethiker

The presence of programmed death 1 (PD-1)-positive tumor-infiltrating lymphocytes is associated with poor prognosis in human breast cancer

Programmed death 1 (PD-1) is a co-inhibitory receptor in the CD28/CTL-4 family, and functions as a negative regulator of the immune system. Tumor-infiltrating lymphocytes (TIL) in many epithelial cancers express PD-1, suggesting that antitumor immunity may be modulated by the PD-1/PD-L1 signaling pathway, and promising results from two recent clinical trials with monoclonal antibodies targeting PD-1 or PD-L1 confirm the clinical relevance of this pathway in human cancer. To explore the role of PD-1+ TIL in human breast cancer, we performed immunohistochemistry studies on a tissue microarray encompassing 660 breast cancer cases with detailed clinical annotation and outcomes data. PD-1+ TIL were present in 104 (15.8%) of the 660 breast cancer cases. Their presence was associated with tumor size, grade, and lymph node status, and was differentially associated with the intrinsic subtypes of breast cancer. In univariate survival analyses, the presence of PD-1+ TIL was associated with a significantly worse overall survival (HR=2.736, p<0.001). In subset analyses, the presence of PD-1+ TIL was associated with significantly worse overall survival in the luminal B HER2− subtype (HR=2.678, p<0.001), the luminal B HER2+ subtype (HR=3.689, p<0.001), and the basal-like subtype (HR=3.140, p<0.001). This is the first study to demonstrate that the presence of PD-1+ TIL is associated with poor prognosis in human breast cancer, with important implications for the potential application of antibody therapies targeting the PD-1/PD-L1 signaling pathway in this diseas

Spritzenabszesse bei intravenös Drogenabhängigen: Häufigkeit assoziierter Komplikationen in Abhängigkeit der Lokalisation

Zusammenfassung: Hintergrund: Haut- und Weichteilabszesse sind bei intravenös Drogenabhängigen der häufigste Hospitalisationsgrund. Zu den mit Spritzenabszessen assoziierten Komplikationen gehören septische Arthritiden, septische Thrombosen und Embolien, lokale Schädigung von umliegenden Strukturen, periphere Ischämie durch intraarterielle Injektion, Pseudoaneurysmata von Venen und Arterien und die nekrotisierende Fasziitis. Material und Methode: Wir führten eine retrospektive Studie von 108Hospitalisationen bei 85Patienten mit insgesamt 130Abszessen in Hinblick auf die aufgetretenen Komplikationen durch. Ergebnisse: Fünfundfünfzig Prozent der Abszesse waren an der unteren Extremität lokalisiert. Die Komplikationsrate an dieser Lokalisation war mit 12/71 (16,9%) signifikant höher (p=0,0005) als an der oberen Extremität mit 0/55. Abszesse an der unteren Extremität führten zu einer signifikant längeren Hospitalisationsdauer als solche an der oberen Extremität (8,5 vs. 4,2Tage, p=0,005) und damit zu höheren Kosten. Schlussfolgerung: Bei der Behandlung von Spritzenabszessen der unteren Extremität muss an das erhöhte Risiko assoziierter Komplikationen gedacht werden. In den Beratungsstellen durchzuführende präventive Maßnahmen könnten durch Vermeiden von Injektionen an den unteren Extremitäten zu einer Verminderung der durch den Drogenkonsum verursachten Kosten führe

PTP1B expression is an independent positive prognostic factor in human breast cancer

Protein tyrosine phosphatase 1B (PTP1B) is a non-transmembrane protein tyrosine phosphatase that has come into focus as a critical regulator of multiple signaling pathways. The role of PTP1B in breast cancer remains unclear with evidence suggesting that PTP1B can exert both tumor-suppressing and tumor-promoting effects. To better define the role of PTP1B in human breast cancer, and its relationship with HER2, we performed immunohistochemical studies on a large cohort of functionally annotated primary breast cancer specimens. 683 of 1,402 (49%) evaluable primary breast cancers are positive for PTP1B. There is no statistically significant association between PTP1B expression and age, tumor size, T stage, histologic grade, lymph node status, or histological subtype. Of note, there is no significant association between PTP1B expression and HER2 expression (PTP1B expression53.1% in HER2+ cancers vs. 47.5% in HER2− cancers, p=0.0985). However, PTP1B expression is significantly associated with estrogen receptor expression (PTP1B expression50.7% in ER+ cancers vs. 43.1% in ER− cancers, p=0.0137) and intrinsic molecular subtype (PTP1B expression53.9% in the luminal B HER2+ subtype and 37.9% in the basal-like subtype). Of note, multivariate analyses demonstrate that PTP1B is an independent predictor of improved survival in breast cancer (HR 0.779, p=0.006). Taken together, we demonstrate in the largest study to date that (1) PTP1B is commonly expressed in breast cancer, (2) there is no association or functional impact of PTP1B expression in HER2+ breast cancer, and (3) PTP1B expression in breast cancer is associated with significantly improved clinical outcome. Until additional studies are performed, caution should be exercised in using PTP1B inhibitors in human breast cance

A promising new device for the prevention of parastomal hernia.

Parastomal hernia (PSH) is the most frequent long-term stoma complication with serious negative effects on quality of life. Surgical revision is often required and has a substantial morbidity and recurrence rate. The development of PSH requires revisional surgery with a substantial perioperative morbidity and high failure rate in the long-term follow-up. Prophylactic parastomal mesh insertion during stoma creation has the potential to reduce the rate of PSH, but carries the risk of early and late mesh-related complications such as infection, fibrosis, mesh shrinkage, and/or bowel erosion. We developed a new stomaplasty ring (KORING), which is easy to implant, avoids potential mesh-related complications, and has a high potential of long-term prevention of PSH. Here we describe the technique and the first use

Biological traits of European pond macroinvertebrates

Whilst biological traits of river macroinvertebrates show unimodal responses to geographic changes in habitat conditions in Europe, we still do not know whether spatial turnover of species result in distinct combinations of biological traits for pond macroinvertebrates. Here, we used data on the occurrence of 204 macroinvertebrate taxa in 120 ponds from four biogeographic regions of Europe, to compare their biological traits. The Mediterranean, Atlantic, Alpine, and Continental regions have specific climate, vegetation and geology. Only two taxa were exclusively found in the Alpine and Continental regions, while 28 and 34 taxa were exclusively recorded in the Atlantic and Mediterranean regions, respectively. Invertebrates in the Mediterranean region allocated much energy to reproduction and resistance forms. Most Mediterranean invertebrate species had narrow thermal ranges. In Continental areas, invertebrates allocated lesser energy to reproduction and dispersal, and organisms were short lived with high diversity of feeding groups. These characteristics suggest higher resilience. The main difference between ponds in the Alpine and Atlantic regions was their elevation. Alpine conditions necessitate specific adaptations related to rapid temperature fluctuations, and low nutrient concentrations. Even if our samples did not cover the full range of pond conditions across Europe, our analyses suggest that changes in community composition have important impacts on pond ecosystem functions. Consistent information on a larger set of ponds across Europe would be much needed, but their low accessibility (unpublished data and/or not disclosed by authors) remains problematic. There is still, therefore, a pressing need for the incorporation of high quality data sets into a standardized database so that they can be further analyzed in an integrated European-wide manner

Pond research and management in Europe: "Small is Beautiful"

The phrase "Small is Beautiful" was first used by the talented scholar Leopold Kohr (1909 131994), but it becames more popular thanks to the essays of one of his students, the British economist E. F. Schumacher, and it was coined as a response to the socially established idea that "Big is Powerful". It could be argued that this desire for "bigness" explains why current legal frameworks and the conservation planning and management related to standing waters often overlook ponds, despite their well-known value in terms of biodiversity and socio-economic benefits (Oertli et al., 2004; Cereghino et al., 2008). Of course, this is only one of several possible explanations, but it is important to understand that such long-established ideas can have a lasting effect upon the efficiency of our conservation actions. Beyond this social perspective, the history of science can also provide some explanation as to why ponds have been undervalued for so long

Temporal dynamics of aquatic communities and implications for pond conservation

Conservation through the protection of particular habitats is predicated on the assumption that the conservation value of those habitats is stable. We test this assumption for ponds by investigating temporal variation in macroinvertebrate and macrophyte communities over a 10-year period in northwest England. We surveyed 51 ponds in northern England in 1995/6 and again in 2006, identifying all macrophytes (167 species) and all macroinvertebrates (221 species, excluding Diptera) to species. The alpha-diversity, beta-diversity and conservation value of these ponds were compared between surveys. We find that invertebrate species richness increased from an average of 29. 5 species to 39. 8 species between surveys. Invertebrate gamma-diversity also increased between the two surveys from 181 species to 201 species. However, this increase in diversity was accompanied by a decrease in beta-diversity. Plant alpha-, beta and gamma-diversity remained approximately constant between the two periods. However, increased proportions of grass species and a complete loss of charophytes suggests that the communities are undergoing succession. Conservation value was not correlated between sampling periods in either plants or invertebrates. This was confirmed by comparing ponds that had been disturbed with those that had no history of disturbance to demonstrate that levels of correlation between surveys were approximately equal in each group of ponds. This study has three important conservation implications: (i) a pond with high diversity or high conservation value may not remain that way and so it is unwise to base pond conservation measures upon protecting currently-speciose habitats; (ii) maximising pond gamma-diversity requires a combination of late and early succession ponds, especially for invertebrates; and (iii) invertebrate and plant communities in ponds may require different management strategies if succession occurs at varying rates in the two groups

Food-web structure in relation to environmental gradients and predator-prey ratios in tank-bromeliad ecosystems

Little is known of how linkage patterns between species change along environmental gradients. The small, spatially discrete food webs inhabiting tank-bromeliads provide an excellent opportunity to analyse patterns of community diversity and food-web topology (connectance, linkage density, nestedness) in relation to key environmental variables (habitat size, detrital resource, incident radiation) and predators: prey ratios. We sampled 365 bromeliads in a wide range of understorey environments in French Guiana and used gut contents of invertebrates to draw the corresponding 365 connectance webs. At the bromeliad scale, habitat size (water volume) determined the number of species that constitute food-web nodes, the proportion of predators, and food-web topology. The number of species as well as the proportion of predators within bromeliads declined from open to forested habitats, where the volume of water collected by bromeliads was generally lower because of rainfall interception by the canopy. A core group of microorganisms and generalist detritivores remained relatively constant across environments. This suggests that (i) a highly-connected core ensures food-web stability and key ecosystem functions across environments, and (ii) larger deviations in food-web structures can be expected following disturbance if detritivores share traits that determine responses to environmental changes. While linkage density and nestedness were lower in bromeliads in the forest than in open areas, experiments are needed to confirm a trend for lower food-web stability in the understorey of primary forests