Visual Impairment and Functional Classification in Children with Cerebral Palsy.

BACKGROUND: Cerebral palsy (CP) is the most common motor impairment in childhood and often accompanied by a broad spectrum of comorbidities. Data are sparse concerning visual impairment (VI) and functional classification among CP children. OBJECTIVE: The objective of this study was to analyze the prevalence of VI among children with CP and to investigate a possible association between VI and Gross Motor Function Classification System (GMFCS) and the Bimanual Fine Motor Function (BFMF). METHODS: In this hospital-based study, records of 200 children with CP aged 2 to 17 years were reviewed. RESULTS: Overall, VI was found in 59.5% of children with CP. Prevalence of VI was higher when compared with non-CP children. A correlation between GMFCS as well as BFMF and severity of VI was found. Children with severe CP were at greater risk for severe VI, especially cerebral VI compared with children with mild CP. CONCLUSION: VI is a significant problem in children with CP and is correlated with motor function. Children with CP should undergo detailed ophthalmologic and orthoptic assessment to enable early intervention.

Variability in lymph node irradiation in patients with breast cancer-results from a multi-center survey in German-speaking countries.

PURPOSE: Lymph node irradiation in breast cancer has gained complexity due to recently published studies and technical innovations which then led to changes in international guidelines. We sought to determine real-time variability in lymph node irradiation in clinical practice in German-speaking countries. METHODS: The Department of Radiation Oncology, Technical University of Munich (TUM), developed an online-based questionnaire focusing on the indication, target definition, and treatment technique of lymph node irradiation in patients with breast cancer. The invitation to participate in the survey was sent to members of the German Society of Radiation Oncology (DEGRO) by e­mail. The results of the survey were exported from the online platform into SPSS for a detailed analysis. RESULTS: In total, 100 physicians completed the questionnaire between 05/2019 and 06/2019. Despite the existence of several treatment and contouring guidelines, we observed large variability of lymph node irradiation: The guideline recommendation for internal mammary irradiation is not consistently implemented in clinical practice and irradiation of the axilla after positive SLNB (sentinel lymph node biopsy) or ALND (axillary lymph node dissection) is handled very differently. Furthermore, in most clinics, the ESTRO (European Society for Therapeutic Radiology and Oncology) contouring consensus is not used, and PTV (planning target volume) definitions and margins vary considerably. CONCLUSION: Further clinical studies should be performed with a particular focus on radiotherapy for lymphatic drainage to support and amend the existing guidelines. These studies should establish a more standardized treatment of the lymph node regions in clinical practice. Quality assurance should enforce broad implementation of consensus recommendations.

Prognostic factors in stereotactic body radiotherapy of lung metastases.

PURPOSE: The aim of this study was to evaluate prognostic factors in patients with lung metastases who undergo lung stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS: A total of 87 patients with 129 lung metastases who underwent SBRT between November 2004 and May 2012 were enrolled in this retrospective study. The patient collective consisted of 54 men (62.1%) and 33 women (37.9%); the median age was 65 years (range 36-88). The Karnofsky performance index was ≥70% (median 90%) for all cases, but one (60%). Adverse effects were categorized using the CTCAE 4.0 classification system. Retrospective analyses regarding patients' characteristics, progression-free survival (PFS), overall survival (OS), disease-specific survival (DSS), and local tumor control rates (LTC) were performed. RESULTS: On univariate and multivariate analysis OS, DSS, and PFS were significantly (p < 0.05) better for patients with ≤3 lung metastases; no extrathoracic metastases at the time of the SBRT; a gross tumor volume (GTV) <7.7 cm3 and patients that received a staging that included positron emission tomography with fluorine 18 fluorodeoxyglucose/computed tomography (FDG-PET/CT) imaging. Furthermore, a longer OS was observed if newly diagnosed metastases during follow-up were limited to the lung (median survival: 43.7 months versus 21.7 months; p = 0.023). CONCLUSION: The number and pattern of metastases, and the size of the target volume are strong predictors for the outcome of patients receiving SBRT of lung tumors. FDG-PET/CT should be part of pretherapeutic staging before SBRT.

Impact of 68Ga-PSMA-PET imaging on target volume definition and guidelines in radiation oncology - a patterns of failure analysis in patients with primary diagnosis of prostate cancer.

BACKGROUND: 68Ga-PSMA-PET-imaging has proven to be a highly sensitive and specific diagnostic element for patients with prostate cancer (PC). Does the standard clinical target volume (CTV) cover the majority of 68Ga-PSMA-PET detected lymph nodes (LNs) in a primary setting? METHODS: 25 out of 159 patients with primary PC who underwent 68Ga-PSMA-PET-imaging were analyzed in the process of this study. These 25 high-risk patients had a total of 126 LNs with positive 68Ga-PSMA-ligand uptake. A standard CTV according to the 'Radiation Therapy Oncology Group' consensus was delineated and LNs were judged whether they were in- or outside of this target volume. With a Pearson correlation we additionally evaluated whether the Gleason score, the prostate-specific antigen (PSA) value or the risk according to the Roach formula correlate with a higher chance of LNs being outside of the CTV in uncommon LN locations. RESULTS: 81 (64.3%) of 126 LNs were covered by the CTV with a complete coverage of all positive LNs inside the respective radiation volume in 11 of 25 patients (44%). LNs that were not covered by the CTV included (para-aortic,) common-iliac, pre-sacral, obturatoric, para-rectal, para-vesical and pre-acetabular locations. In a statistical analysis neither the Gleason score, nor the PSA value, nor the calculated risk with the Roach formula correlated with LNs being inside or outside of the CTV in this patient group. CONCLUSION: 68Ga-PSMA-PET-imaging proves to be a valuable asset for patients and physicians for primary diagnosis and treatment planning. In our study, trusting the RTOG consensus for CTV delineation would have led to up to 35.7% of all LNs not to be included in the clinical radiation volume, which might have resulted in insufficient radiation dose coverage.

Association between erythrocyte membrane fatty acids and biomarkers of dyslipidemia in the EPIC-Potsdam study.

BACKGROUND/OBJECTIVE: Blood proportions of fatty acids (FAs) and FA-ratios reflecting desaturase activity are associated with the risk of chronic diseases like type 2 diabetes mellitus or cardiovascular diseases. Biomarkers of dyslipidemia are considered as potential mediators of this association. We evaluated associations of erythrocyte membrane proportions of individual disease-related polyunsaturated fatty acids (PUFAs), trans-FAs, dairy-derived saturated FAs (SFAs) (15:0, 17:0) and FA-ratios with biomarkers of dyslipidemia (high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, non-HDL-cholesterol, triglycerides). SUBJECTS/METHODS: We conducted a cross-sectional analysis of a subsample (n=1759) of the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. Associations of individual FAs and FA-ratios with plasma biomarkers of dyslipidemia were evaluated by linear multivariable regression. RESULTS: Most notably, FA-ratios reflecting activity of Δ6-desaturase (D6D) and stearoyl-coenzyme A-desaturase (SCD) were positively associated with triglyceride and LDL-cholesterol concentrations (adjusted means (95% confidence interval (CI)) of triglycerides (mg/dl) across D6D tertiles: men--102 (94.7-110), 111 (104-120), 144 (134-156) and women--73.5 (70.0-77.2), 82.9 (79.0-86.9), 94.2 (89.7-98.9)); across SCD tertiles: men--99.0 (91.8-107), 115 (107-124), 144 (134-156) and women--72.4 (69.0-76.0), 81.5 (77.8-85.5), 97.2 (92.6-102)), whereas inverse associations with triglycerides were observed for the estimated Δ5-desaturase (D5D) activity (adjusted means (95% CI) of triglycerides (mg/dl) across D5D tertiles: men--128 (119-138), 121 (113-131), 106 (97.9-114) and women--92.0 (87.6-96.6), 82.8 (78.9-86.9), 75.3 (71.6-79.1), P-values for trend at least 0.0006). Furthermore, we observed generally weaker and less consistent associations of dairy-derived SFAs (mainly 17:0) with triglycerides and HDL-cholesterol. Individual PUFAs and trans-FAs were, if at all, only weakly associated with dyslipidemia markers. CONCLUSIONS: Our findings suggest that triglyceride and LDL-cholesterol concentrations may be mediators that link intake and metabolism of FAs to metabolic risk.

Associated factors of estimated desaturase activity in the EPIC-Potsdam study.

BACKGROUND AND AIMS: Altered activity of desaturase enzymes may be involved in the development of metabolic diseases like type 2-diabetes. Desaturase activities might be modifiable by diet and lifestyle-related factors, but no study has systematically investigated such factors so far. We aimed to evaluate the association of demographic, anthropometric, dietary and lifestyle characteristics with estimated Δ5-, Δ6- and Δ9-desaturase activity. METHODS AND RESULTS: A subsample (n = 1782) of the EPIC-Potsdam study was used for a cross-sectional analysis, involving men and women, mainly aged 35-65 years. Fatty acid (FA) product-to-precursor ratios, derived from the FA composition of erythrocyte membrane phospholipids, were used to estimate desaturase activities. Multiple linear regression models were used with estimated Δ5-, Δ6- and Δ9-desaturase activity as outcome and demographic (age, sex), anthropometric (BMI, WHR), dietary intake (FAs, carbohydrates) and lifestyle (physical activity, smoking, alcohol consumption) factors as exposure variables. Alcohol intake was positively associated with estimated Δ6- (explained variance in desaturase activity: 1.52%) and estimated Δ9-desaturase activity (explained variance: 5.53%). BMI and WHR showed a weak inverse association with estimated Δ5-desaturase activity (explained variance: BMI: 1.07%; WHR: 1.02%) and weak positive associations with estimated Δ6-(explained variance: BMI: 1.17%; WHR: 1.19%) and estimated Δ9-desaturase activities (explained variance: BMI: 0.70%; WHR: 0.96%). Age, sex, physical activity, smoking and dietary factors were only weakly associated with the estimated desaturase activities. CONCLUSION: Our findings suggest that alcohol intake as well as obesity measures are associated with the FA ratios reflecting desaturase activity.

Patient assessments of care and utilization in Medicaid managed care: PCCMs vs. PSOs.

States are experimenting with different forms of delivery and financing to make Medicaid expenditures more predictable. Florida Medicaid is experimenting with a relatively new form of managed care, the provider-sponsored organization (PSO). Using the Donabedian structure-process-outcome (SPO) model, patient experiences and utilization in Florida PSOs and primary care case management (PCCM) were compared. The study analyzed Consumer Assessments of Healthcare Providers and Systems (CAHPS) data for 1,257 Medicaid beneficiaries in Florida in 2005. Results showed that beneficiaries in the PSOs had similar ratings and reports of care to those in the PCCM. However, PSOs had lower physician visits compared to the PCCM, indicating potential access barriers to primary care. The PSO's impact on emergency department (ED) utilization and specialist utilization was similar to that of the PCCM. The PSOs may lower costs, but the savings may be due to lower physician utilization rather than better case management. This is important since states that are experimenting with PSOs in their Medicaid programs are looking to these organizations to improve beneficiary care while lowering costs.

Survey response style and differential use of CAHPS rating scales by Hispanics.

BACKGROUND: Previous Consumer Assessments Of Healthcare Providers And Systems (CAHPS) studies have shown that Hispanics report care that is similar to or less positive than for non-Hispanic whites, yet have more positive ratings of care. OBJECTIVE: To examine differential use of the 0-10 rating scales in the CAHPS health plan survey by Hispanic ethnicity and insurance status (Medicaid vs. commercial managed care). DATA: CAHPS 2.0H adult Medicaid and commercial data submitted to the National Committee for Quality Assurance. MEASURES: The dependent variables are the CAHPS 2.0 ratings of care: personal doctor or nurse, specialists, and health care received. Ratings were categorized into 4 levels: 0-4, 5-8, 9, and 10. The independent variable is a 4-level categorical variable: Hispanic Medicaid, Hispanic commercial, (non-Hispanic) white Medicaid, and (non-Hispanic) white commercial. Six potential confounders were controlled: gender, age, education, self-rated health, survey mode, and survey language. ANALYSIS: Multinomial logistic regression was used to test for differences in extreme response styles. RESULTS: Hispanics exhibited a greater tendency toward extreme responding in the CAHPS ratings than non-Hispanic whites-in particular, they were more likely than whites in commercial plans to endorse a "10," and often, scores of 4 or less, relative to an omitted category of "5" to "8." CONCLUSIONS: The observed higher Hispanic ratings may be partially attributed to differences in response style rather than superior care. This suggests caution in the use of central tendency measures and the proportion of 10 ratings when examining racial/ethnic differences in CAHPS ratings of care. It is advisable to consider pooling responses at the top end (eg, 9 and 10) and lower end (eg, 0-6) of the response scale when making racial/ethnic comparisons.

Exploring the temperature-stress metabolome of Arabidopsis.

Metabolic profiling analyses were performed to determine metabolite temporal dynamics associated with the induction of acquired thermotolerance in response to heat shock and acquired freezing tolerance in response to cold shock. Low-M(r) polar metabolite analyses were performed using gas chromatography-mass spectrometry. Eighty-one identified metabolites and 416 unidentified mass spectral tags, characterized by retention time indices and specific mass fragments, were monitored. Cold shock influenced metabolism far more profoundly than heat shock. The steady-state pool sizes of 143 and 311 metabolites or mass spectral tags were altered in response to heat and cold shock, respectively. Comparison of heat- and cold-shock response patterns revealed that the majority of heat-shock responses were shared with cold-shock responses, a previously unknown relationship. Coordinate increases in the pool sizes of amino acids derived from pyruvate and oxaloacetate, polyamine precursors, and compatible solutes were observed during both heat and cold shock. In addition, many of the metabolites that showed increases in response to both heat and cold shock in this study were previously unlinked with temperature stress. This investigation provides new insight into the mechanisms of plant adaptation to thermal stress at the metabolite level, reveals relationships between heat- and cold-shock responses, and highlights the roles of known signaling molecules and protectants.

Patients with Glanzmann thrombasthenia lacking platelet glycoprotein alpha(IIb)beta(3) (GPIIb/IIIa) and alpha(v)beta(3) receptors are not protected from atherosclerosis.

BACKGROUND: Platelets have been suggested to play a role in the early development of atherosclerosis. As one test of this hypothesis, we assessed whether patients with Glanzmann thrombasthenia who lack platelet glycoprotein alpha(IIb)beta(3) (GPIIb/IIIa) complexes or both alpha(IIb)beta(3) and the more ubiquitous alpha(v)beta(3) cell membrane complexes are protected from development of atherosclerosis. METHODS AND RESULTS: Seven patients with Glanzmann thrombasthenia, 45 to 66 years of age, underwent bilateral carotid artery ultrasonography and screening for risk factors of atherosclerosis. Findings consistent with early atherosclerosis evaluated by measurement of intima-media thickness and presence of atherosclerotic plaques were observed in 6 of the 7 patients. Intima-media thickness values higher than the 75th and 90th percentiles of age- and sex-matched white control subjects of the Atherosclerosis Risk in Communities (ARIC) study were observed in 30 and 8 of 56 carotid artery measurements, respectively. Five of the 6 patients with signs consistent with early atherosclerosis lacked both alpha(IIb)beta(3) and alpha(v)beta(3) complexes and 1 only lacked alpha(IIb)beta(3). CONCLUSIONS: Glanzmann thrombasthenia does not protect affected individuals from development of atherosclerosis.

Vólvulo primario de intestino delgado en el adulto / Primary volvulus of the small intestine in adult

El vólvulo de intestino delgado primario es una condición en la cual existe una torsión de la totalidad o de un segmento del intestino delgado y su mesenterio, sin encontrarse malrotación intestinal, bridas adquiridas o congénitas o cualquier otra condición que facilite que se produzca el vólvulo. En el adulto generalmente ocurre en un segmento del intestino medio. Se presentan 4 casos de vólvulo primario del intestino delgado en el adulto, operado en el Servicio de Urgencia de la Clínica Alemana. Por su escasa frecuencia en nuestro medio, este cuadro presenta una importante dificultad diagnóstica. En todos los casos destaca en su presentación clínica, el comienzo agudo de dolor abdominal de gran intensidad, que no guarda relación con los hallazgos del examen clínico y con escasa repercusión en los estudios complementarios. Los cuatros pacientes fueron sometidos a intervención quirúrgica

Prevalence and risk factors for abdominal aortic aneurysms in older adults with and without isolated systolic hypertension.

An association between abdominal aortic aneurysm (AAA) and atherosclerotic disease has been recognized and may be due to shared risk factors. A consistent relation between blood pressure and AAA has not been found. AAA was compared between those with and without isolated systolic hypertension (ISH) and prevalence of aortic atherosclerosis was evaluated. Abdominal aortic ultrasound was performed in 266 people, 143 with ISH and 123 age-similar controls. AAA was defined as an infrarenal aortic diameter of > or = 3.0 cm or an infrarenal-to-suprarenal diameter ratio of > or = 1.2. The average age of participants was 73 years. Overall prevalence of AAA was 9.4%, 11.9% in those with ISH and 6.5% among normotensives (p = 0.134). Multivariate analysis revealed male gender (p <0.001), higher low-density lipoprotein (p <0.001), higher pulse pressure (p = 0.032), and current smoking (p = 0.012) to be independent predictors of AAA. When evaluating aortic atherosclerosis, those with AAA had significantly larger diameters of the iliac arteries along with greater intimamedia thickness of the iliac arteries. Those with and without aneurysms had a similar prevalence of plaque (89% to 96%), but measured plaques tended to be larger among those with than without AAA (p <0.001). Progression of AAA after 1 year was observed in 8 participants, with a mean diameter change of 3.42 mm. AAA was found to be independently associated with pulse pressure but not with systolic blood pressure. Patients with AAA also had greater wall thickness and greater diameter of the iliac arteries, which are probably associated with the underlying disease process.

A perinatal ethics committee on abortion: process and outcome in thirty-one cases.

PIP: The US Supreme Court's June 1992 decision to uphold most of Pennsylvania's law restricting access to abortion confirms that while abortion is still permitted in the US, it is being increasingly regulated. Individual institutions may, however, find ways to permit access to abortion. One hospital formed a mandatory, prospective perinatal ethics committee (PEC) in May 1987 to develop clinical guidelines with which to consider and decide requests by physicians for their patients seeking abortions. The authors obtained the consent of this PEC to study its membership, processes, case outcomes, and clinical decision making. Understanding PEC processes and outcomes may help other institutions to decide whether to institute similar mechanisms. Specifically, the investigators determined the backgrounds and abortion-related beliefs of PEC members and obstetric and gynecology department members, whether the PEC affects the number of abortions performed, how PEC members decide in individual cases, and whether requesting physicians find the PEC helpful. All eleven PEC members and 58 of the 65 medical staff ob/gyn physicians returned background surveys. Study results are presented. Overall, the PEC appeared to function as an affirming regulatory body for second-trimester, medically-indicated terminations and for certain personal choice terminations. Institutional interests were well-served by the PEC and with the assurance of informed consent, the interests of some patients were also well served.^ieng

[Knee joint hemarthrosis. An absolute indication for operation?]. / Der Kniegelenkshämarthros. Absolute Indikation zur Operation?

The degree of severity of an injury of the knee joint is estimated mainly on the basis of the history given by the patient, stability testing and hemarthrosis. Once these are known the surgeon usually decides whether an arthroscopy should be done or not. In a group of 365 patients who had undergone arthroscopy after acute knee injury, we made a retrospective check of the indications. The purpose of the study was to evaluate the sensitivity of hemarthrosis as an indicator of severe injury of the knee joint necessitating operative treatment. For stability testing we used the varus and valgus stress test, the Lachman test, the Anterior drawer test, the pivot shift test and the anterior drawer test with medial and lateral rotation. The Lachman test was repeated under general anesthesia in the majority of patients just before the arthroscopy. The results were evaluated retrospectively with the aid of electronic data processing. In nearly 70% of cases the arthroscopy was indicated because of positive signs of instability together with a typical history provided by the patient or hemarthrosis. In another 27%, the hemarthrosis was the sole reason for the surgeon's decision to perform an arthroscopic investigation of the injured knee joint. In 80.5% of all cases the clinical diagnosis of lesion of the anterior cruciate ligament (ACL) or combined injury to ligaments and menisci was confirmed by the arthroscopy. In addition to this group, in another 10.8% we found other severe lesions necessitating by operation.(ABSTRACT TRUNCATED AT 250 WORDS)