[Palliative care guidelines in uro-oncology]. / Leitliniengerechte palliativmedizinische Therapie in der Uroonkologie.

Palliative care is an integral part in the treatment of patients in uro-oncology. The German S3 guideline palliative care for patients with incurable cancer is an essential working basis for physicians and healthcare workers. In addition to basic recommendations in palliative care, the guideline provides evidence-based advice in a symptom-oriented approach. Basic knowledge in palliative care is recommended for every urologist who is treating uro-oncologic patients.

Effect of one year krill oil supplementation on depressive symptoms and self-esteem of Dutch adolescents: A randomized controlled trial.

INTRODUCTION: Observational studies have shown a relationship between omega-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) and depression in adolescents. However, n-3 LCPUFA supplementation studies investigating the potential improvement in depressive feelings in adolescents from the general population are missing. METHODS: A one-year double-blind, randomized, placebo controlled krill oil supplementation trial was conducted in two cohorts. Cohort I started with 400 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or placebo, after three months this increased to 800 mg EPA and DHA per day, whilst cohort II started with this higher dose. Omega-3 Index (O3I) was monitored via finger-prick blood measurements. At baseline, six and 12 months participants completed the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Rosenberg Self Esteem questionnaire (RSE). Adjusted mixed models were run with treatment allocation/O3I as predictor of CES-D and RSE scores. RESULTS: Both intention-to-treat and assessing the change in O3I analyses did not show significant effects on CES-D or RSE scores. CONCLUSION: There is no evidence for less depressive feelings, or higher self-esteem after one year of krill oil supplementation. However, due to a lack of adherence and drop-out issues, these results should be interpreted with caution.

Correction to: Exploring the association between whole blood Omega-3 Index, DHA, EPA, DPA, AA and n-6 DPA, and depression and self-esteem in adolescents of lower general secondary education.

The original version of this article unfortunately contained a mistake. Title was incorrect.

Exploring the association between whole blood Omega-3 Index, DHA, EPA, DHA, AA and n-6 DPA, and depression and self-esteem in adolescents of lower general secondary education.

PURPOSE: Depression is common in adolescents and long-chain polyunsaturated fatty acids (LCPUFA) are suggested to be associated with depression. However, research in adolescents is limited. Furthermore, self-esteem has never been studied in relation to LCPUFA. The objective here was to determine associations of depression and self-esteem with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), Omega-3 Index (O3I), n-6 docosapentaenoic acid (n-6 DPA, also called Osbond acid, ObA), n-3 docosapentaenoic acid (DPA), and arachidonic acid (AA) concentrations in blood of adolescents attending lower general secondary education (LGSE). METHODS: Baseline cross-sectional data from a krill oil supplementation trial in adolescents attending LGSE with an O3I ≤ 5% were analysed using regression models built with the BayesFactor package in R. Fatty acids and O3I were determined in blood. Participants filled out the Centre for Epidemiologic Studies Depression (CES-D) scale and the Rosenberg Self-Esteem scale (RSE). RESULTS: Scores indicative of depression (CES-D ≥ 16) were found in 29.4% of the respondents. Of all fatty acids, we found extreme evidence [Bayes factor (BF) > 100] for a weak negative association between ObA and depression score [- 0.16; 95% credible interval (CI) - 0.28 to - 0.04; BF10 = 245], and substantial evidence for a weak positive association between ObA and self-esteem score (0.09; 95% CI, - 0.03 to 0.20; BF10 = 4). When all fatty acids were put in one model as predictors of CES-D or RSE, all of the 95% CI contained 0, i.e., no significant association. CONCLUSION: No evidence was found for associations of DHA, EPA and O3I with depression or self-esteem scores in LGSE adolescents with O3I ≤ 5%. The associations of higher ObA status with lower depression and higher self-esteem scores warrant more research.

A protocol for a randomised controlled trial investigating the effect of increasing Omega-3 index with krill oil supplementation on learning, cognition, behaviour and visual processing in typically developing adolescents.

INTRODUCTION: The influence of n-3 long-chain polyunsaturated fatty acids (LCPUFA) supplementation on brain functioning is debated. Some studies have found positive effects on cognition in children with learning difficulties, elderly people with cognitive impairment and depression scores in depressed individuals. Other studies have found null or negative effects. Observational studies in adolescents have found positive associations between fish consumption (containing n-3 LCPUFAs) and academic achievement. However, intervention studies in typically developing adolescents are missing. OBJECTIVE: The goal of this study is to determine the influence of increasing Omega-3 Index on cognitive functioning, academic achievement and mental well-being of typically developing adolescents. METHODS AND DATA ANALYSIS: Double-blind, randomised, placebo controlled intervention; 264 adolescents (age 13-15 years) attending lower general secondary education started daily supplementation of 400 mg eicosapentaenoic acid and docosahexaenoic acid (EPA+DHA) in cohort I (n=130) and 800 mg EPA+DHA in cohort II (n=134) or a placebo for 52 weeks. Recruitment took place according to a low Omega-3 Index (<5%). The Omega-3 Index was monitored via a finger prick at baseline and after 3, 6 and 12 months. The supplement dose was adjusted after 3 months (placebo analogously) to reach an Omega-3 Index of 8-11%. At baseline, 6 and 12 months, a neuropsychological test battery, a number of questionnaires and a standardised math test (baseline and 12 months) were administered. School grades were collected. In a subsample, sleep quality and quantity data (n=64) and/or eye-tracking data (n=33) were collected. ETHICS AND DISSEMINATION: Food2Learn is performed according to Good Clinical Practice. All data collected are linked to participant number only. The results will be disseminated on group level to participants and schools. The results will be presented at conferences and published in peer-reviewed journals. The study is approved by the Medical Ethical Committee of Atrium-Orbis-Zuyd Hospital and is registered at the Netherlands Trial Register (NTR4082). TRIAL REGISTRATION NUMBERS: NTR4082 and NCT02240264; Pre-results.

Association between prenatal and current exposure to selected LCPUFAs and school performance at age 7.

INTRODUCTION: Long-chain polyunsaturated fatty acids (LCPUFAs) are important for brain functioning and might, thus, influence cognition and school performance. However, research investigating LCPUFAs relationships with school performance is limited. The objective of this study was to determine the association between levels of the LCPUFAs docosahexaenoic acid (DHA), arachidonic acid (AA), eicosapentaenoic acid (EPA) and n-6 docosapentaenoic acid (Osbond acid, ObA) at study entry, 22 weeks of pregnancy, 32 weeks of pregnancy, at partus, in umbilical cord plasma and child's plasma at age 7 and school performance scores at age 7. METHODS: Data from the Maastricht Essential Fatty Acid Birth cohort (MEFAB) were used for this study. Fatty acid levels of plasma phospholipids were measured in maternal blood plasma at study entry, 22 weeks of pregnancy, 32 weeks of pregnancy and partus. Childs fatty acid levels of plasma phospholipids were measured a in umbilical cord blood plasma, and in blood plasma of the child at age 7. Scores on national standardised tests for spelling, reading and arithmetic at age 7 were obtained via the school (scores were available for 149, 159 and 155 children, respectively). Associations between LCPUFA levels and school performance scores were analysed with categorical regression analyses with correction for covariates (smoking, maternal education, sex, breastfeeding, maternal intelligence, birth weight and BMI at age 7). RESULTS: Significant (p<0.001) associations between DHA level at age 7 and both reading (ß=0.158) and spelling (ß=0.146) were found. Consistent significant negative associations were observed between all maternal DHA plasma levels and arithmetic scores at age 7 (all p<0.001, all ß<-0.019). Additional significant negative associations were observed between maternal LCPUFA plasma levels at study entry and both reading and spelling scores at age 7; these associations were less consistent. CONCLUSION: Plasma DHA levels at age 7 were positively associated with reading and spelling scores at age 7. Consistent significant negative associations between maternal plasma DHA levels and arithmetic scores of the child at age 7 were found. Although this is an observational study, which cannot proof causality, the consistent negative associations observed between maternal plasma DHA levels and the arithmetic scores of the children at age 7 calls upon prudence when considering DHA supplementation during pregnancy.

Secondary prophylaxis of invasive fungal infections with combination antifungal therapy and G-CSF-mobilized granulocyte transfusions in three children with hematological malignancies.

Fungal infections represent a life-threatening complication for patients receiving chemotherapy or undergoing hematopoietic stem cell transplantation. Historically, antifungal monotherapy is associated with a poor outcome. We treated three children with hematological malignancies and proven fungal infections (one cerebral mold infection, one disseminated Candida infection, one naso-pharyngeal mucor infection) with combination antifungal therapy plus granulocyte-colony-stimulation-factor-mobilized granulocyte transfusions as secondary prophylaxis during subsequent neutropenic episodes. With this approach, the fungal infection was effectively treated, and the anticancer therapy was completed without major delay. All children survived the fungal infection and the underlying malignancy. These experiences illustrate the feasibility of this approach using more than one antifungal agent together with immune-therapy in high-risk patients.

[Hip endoprosthesis]. / Hüftendoprothetik.

The replacement of a hip joint after osteoarthritis or fracture is today a standard surgical procedure and performed worldwide in about 750,000 cases. Since it is possible to achieve durable anchorage of implants in bone and to effectively treat loss of function and pain of the hip joint, this operation belongs to the most successful in our times.Therefore, a differentiated technology has developed that encompasses modern implant materials, biomechanical knowledge, and surgical techniques. Current standards in this procedure are demonstrated.

[CPM--Continuous Passive Motion: treatment of injured or operated knee-joints using passive movement. A meta-analysis of current literature]. / CPM-Continuous Passive Motion: Behandlung verletzter und operierter Kniegelenke mit Mitteln der passiven Bewegung. Metaanalyse der gegenwärtigen Literatur.

There is still a controversial discussion in literature about the use of motor driven splints in knee surgery--as the principle of continuous passive motion, CPM. For this reason it seemed useful for an evaluation to look through the papers which were published since 1990. It was obvious, that negative results were published often before this year, but this papers are still quoted standard works. In medical data bases subito-doc.de, medscape.com, medica.de and zbmed.de 230 papers were found by search CPM, continuous passive motion and arthromot. Coincidentally there was a search for authors who were already quoted in other papers. 36 papers concerning CPM after knee surgery were utilized. The role of CPM regarding the range of motion, swelling, duration of hospital stay, use of analgesics, costs, postoperative manipulations, wound healing and thrombo embolic complications was evaluated. Although the results of this partial retrospective, partial prospective, sometimes randomized or double blinded studies are in contradiction, there can only be found a trend to better results. New clinical studies for evidence based guidelines in the handling of continuous passive motion after knee surgery are necessary.

Invasive fungal infections are responsible for one-fifth of the infectious deaths in children with ALL.

The following report will discuss in detail all lethal invasive fungal infections (IFI) that occurred in a group of 2021 children with acute lymphoblasic leukaemia (ALL). The German ALL-Berlin-Frankfurt-Muenster (BFM) study group is one of the largest cooperation for the treatment of childhood ALL. Between 1995 and 2000, 2021 children with ALL received chemotherapy according to the German BFM 95 protocols (ALL-BFM 95). This population was retrospectively screened, whether a lethal fungal infection occurred: totally, in this group, 43 of 2021 (2.1%) children died because of infections. Nine of 43 (21%) patients died in the context of an IFI: six fatal Aspergillus infections and three fatal yeast infections were reported. The following report will focus on the nine children with ALL who died from IFI. The underlying risk factors (RF) included neutropenia (seven of nine patients) and steroid medication (nine of nine patients). Seven of nine children had additional medical complications (e.g. liver failure, haemolytic uraemic syndrome and acute renal failure). In six of nine children the fungal infection was progressive despite intravenous antimycotic therapy, three patients received no antifungal therapy, as IFI was not considered. The progression of IFI despite antimycotic therapy illustrates the inherent problems of diagnosis and the need for innovative therapeutic modalities. The high percentage (21%) of death from IFI among lethal infections in paediatric ALL patients illustrates the relevance of fungi in this group of patients. On the contrary, the total number of IFI in paediatric ALL patients remains to be determined, as only lethal infections were included in this report.

Vertebral osteomyelitis and endocarditis of a pacemaker lead due to Granulicatella (Abiotrophia) adiacens.

Systemic infection due to Granulicatella (formerly Abiotrophia), a species of nutrition-deficient gram-positive cocci, is rare. We present the case of a 68-year-old diabetic male who presented with back pain and a history of fever and chills. Imaging studies revealed vertebral osteomyelitis of the Th 10/11 region. Transesophageal echocardiography disclosed a vegetation adjacent to the pacemaker lead and blood cultures grew Granulicatella adiacens. A diagnosis of vertebral osteomyelitis and endocarditis due to G. adiacens was made and the patient improved with bed rest and medical treatment alone. Granulicatella ssp. should always be part of the differential diagnosis of fastidious bacteria in vertebral osteomyelitis and endocarditis.

[Preoperative planning and surgical technic in achieving stability and leg length equality in total hip joint arthroplasty]. / Predoperacní plánování a operacne-technické resení stability a vyrovnání délky koncetin u totální náhrady kycelního kloubu.

One of the prerequisites for a good outcome of total hip arthroplasty is preoperative planning. Using a roentgenogram, the size of an implant, incision level on the femoral neck, depth required for fitting the cup, restoration of the center of hip rotation and, if necessary, correction of length descrepancy between the legs are determined. The preoperative planning based on an X-ray image was introduced by M. E. Müller and, in 1976, was modified by R. Schneider who used a transparent sheet for a template on which all relevant points guiding the surgical procedure are marked, i.e., the right position for implantation of the cup and stem, and incision lines. In uncomplicated cases, however, this approach is not necessary and the "planning principle of parallel lines" developed by L. Spotorno in 1988 can be used instead. The determination of length discrepancy between the legs is derived from a drawing of three reference lines on the roentgenogram. The lines parallel to each other indicace the same length for both legs. If the legs differ in length, the lines will diverge from each other in a way typical for this condition.

Reoperation on the thymus. A critique.

Reoperation on the thymus, including even multiple re-resection, is a useful modality in carefully selected patients for recurrent thymoma or for incompletely removed thymus. In the case of MG, reoperation is used for completion of an otherwise incomplete thymectomy, usually by the transcervical method, although it also has been used after primary sternotomy. Interestingly enough, no instances of reoperation after primary VATS thymectomy have been reported yet. Indeed, VATS has been used successfully for reoperation after previous transcervical and trans-sternal thymectomies. In the case of thymoma, there have been an increasing number of reports of reoperation, including multiple procedures, in many cases. It is important to interpret the results of reoperation in the context of the biologic behavior of the thymus tumor. Thus far, no formal guidelines have been established for the follow-up of these patients. It is believed that all cases of thymectomy with or without thymoma and with or without MG should be followed for the lifetime of the patient with periodic examinations and imaging.

[Results of cement-free St. Nabor hip prosthesis implantation and clinical and radiological results after 8 to 10 years]. / Ergebnisse der zementfreien Hüftpfanne St. Nabor. Klinische und radiologische Ergebnisse nach acht bis zehn Jahren.

PURPOSE OF THE STUDY: The aim of the retrospective study was to analyse the medium-term results of the cementless hip prosthesis St. Nabor. METHOD: 46 patients with complete postoperative and radiographic documentation were available for clinical review. The average follow-up was eight years and five months (range from eight years, one month to ten years). The average age at the last follow-up was 60 years. Ten patients showed severe coxarthritis and 32 patients a dysplasia of the acetabulum before surgery. Two patients suffered from a severe osteonecrosis of the femoral head and two patients had fractures of the acetabulum or femoral neck, respectively. RESULTS: The medium-term follow-up for the acetabular component showed a survival rate of 97.8%. The radiographic data visualized one loosening as a result of a low grade infection, 18 months after surgery. There was no migration of the acetabular component according to Sutherland et al. and no protrusion was found. None of the acetabular components showed radiolucent lines or was loose according to radiographic criteria. In comparison to the first post-operative radiograph, 26 of the hips were found with a significant reduction of lacunae, twelve of them showed a complete absence at last follow-up. The overall Harris hip score averaged 92 points (range 58 to 100 points) for the entire group. 41 (92%) of all hips were rated as excellent or good. Two hips (4%) of all hips were rated as fair and two hips (4%) were rated as poor. CONCLUSION: The high rate of good and satisfying results in medium-term follow-up proves this St. Nabor acetabular component system to be an excellent implant in total hip arthroplasty for younger patients with or without dysplasia.

Physician perceptions of HMO care for older persons. Health Maintenance Organization.

OBJECTIVE: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients. DESIGN: A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans. PARTICIPANTS: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts. RESULTS: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies. CONCLUSIONS: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.

The history of surgery of the thymus gland.

The history of surgery of the thymus gland is presented through highlights and landmark publications ranging from prehistoric times to the present day. The evolution of surgical techniques includes transcervical and transthoracic thymectomy along with other techniques such as current thoracoscopic VATS procedures. The significance of myasthenia gravis, autoimmunity, thymic oncology, adjuvant developments, and speculation on the future is discussed.

Recovery of mycobacteria from patients with cystic fibrosis.

Despite decontamination, overgrowth by pseudomonads renders cultural isolation of mycobacteria from respiratory specimens of patients with cystic fibrosis (CF) difficult or impossible. We performed a prospective study by comparing levels of reduction of overgrowth and recovery of mycobacteria using either pretreatment with N-acetyl-L-cysteine (NALC)-NaOH alone or pretreatment with NALC-NaOH and then with oxalic acid. From 406 specimens of 148 CF patients, 11 specimens were positive for mycobacteria, 5 of which grew mycobacteria after decontamination by either procedure. Three specimens grew mycobacteria only after decontamination with NALC-NaOH, whereas three specimens grew mycobacteria only after treatment with NALC-NaOH followed by oxalic acid but were overgrown after decontamination with NALC-NaOH. Thus, inactivation of mycobacteria by the more aggressive oxalic acid treatment offsets its beneficial effect of reducing the proportion of cultures overgrown with microorganisms other than mycobacteria.