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Kuchen T.,University of Zürich | Straumann A.,Swiss EoE Clinic | Straumann A.,University of Basel | Safroneeva E.,University of Bern | And 6 more authors.
Allergy: European Journal of Allergy and Clinical Immunology | Year: 2014

Background Long-lasting food impactions requiring endoscopic bolus removal occur frequently in patients with eosinophilic esophagitis (EoE) and harbor a risk for severe esophageal injuries. We evaluated whether treatment with swallowed topical corticosteroids is able to reduce the risk of occurrence of this complication. Methods We analyzed data from the Swiss EoE Cohort Study. Patients with yearly clinic visits, during which standardized assessment of symptoms, endoscopic, histologic, and laboratory findings was carried out, were included. Results A total of 206 patients (157 males) were analyzed. The median follow-up time was 5 years with a total of 703 visits (mean 3.41 visits/patient). During the follow-up period, 33 patients (16 % of the cohort) experienced 42 impactions requiring endoscopic bolus removal. We evaluated the following factors regarding the outcome 'bolus impaction' by univariate logistic regression modeling: swallowed topical corticosteroid therapy (OR 0.503, 95%-CI 0.255-0.993, P = 0.048), presence of EoE symptoms (OR 1.150, 95%-CI 0.4668-2.835, P = 0.761), esophageal stricture (OR 2.832, 95%-CI 1.508-5.321, P = 0.001), peak eosinophil count >10 eosinophils/HPF (OR 0.724, 95%-CI 0.324-1.621, P = 0.433), blood eosinophilia (OR 1.532, 95%-CI 0.569-4.118, P = 0.398), and esophageal dilation (OR 1.852, 95%-CI 1.034-3.755, P = 0.017). In the multivariate model, the following factors were significantly associated with bolus impaction: swallowed topical corticosteroid therapy (OR 0.411, 95%-CI 0.203-0.835, P = 0.014) and esophageal stricture (OR 2.666, 95%-CI 1.259-5.645, P = 0.01). Increasing frequency of use of swallowed topical steroids was associated with a lower risk for bolus impactions. Conclusions Treatment of EoE with swallowed topical corticosteroids significantly reduces the risk for long-lasting bolus impactions. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

PubMed | Medicine and Radiation Oncology PA, Howard University, Center Val dAurelle, University of Nice Sophia Antipolis and 10 more.
Type: | Journal: Frontiers in oncology | Year: 2014

Patients with left-sided breast cancer are at risk of cardiac toxicity because of cardiac irradiation during radiotherapy with the conventional 3-dimensional conformal radiotherapy technique. In addition, many patients may receive chemotherapy prior to radiation, which may damage the myocardium and may increase the potential for late cardiac complications. New radiotherapy techniques such as intensity-modulated radiotherapy (IMRT) may decrease the risk of cardiac toxicity because of the steep dose gradient limiting the volume of the heart irradiated to a high dose. Image-guided radiotherapy (IGRT) is a new technique of IMRT delivery with daily imaging, which may further reduce excessive cardiac irradiation. Preliminary results of IGRT for cardiac sparing in patients with left-sided breast cancer are promising and need to be investigated in future prospective clinical studies.

PubMed | Southwest PET CT Institute, Medicine and Radiation Oncology PA, Howard University, Center Val dAurelle and 9 more.
Type: | Journal: Frontiers in oncology | Year: 2015

Conventional radiotherapy for cervical cancer relies on clinical examination, 3-dimensional conformal radiotherapy (3D-CRT), and 2-dimensional intracavitary brachytherapy. Excellent local control and survival have been obtained for small early stage cervical cancer with definitive radiotherapy. For bulky and locally advanced disease, the addition of chemotherapy has improved the prognosis but toxicity remains significant. New imaging technology such as positron-emission tomography and magnetic resonance imaging has improved tumor delineation for radiotherapy planning. Image-guided radiotherapy (IGRT) may decrease treatment toxicity of whole pelvic radiation because of its potential for bone marrow, bowel, and bladder sparring. Tumor shrinkage during whole pelvic IGRT may optimize image-guided brachytherapy (IGBT), allowing for better local control and reduced toxicity for patients with cervical cancer. IGRT and IGBT should be integrated in future prospective studies for cervical cancer.

Hauschild O.,Albert Ludwigs University of Freiburg | Konrad G.,Kreiskrankenhaus Erding | Audige L.,AO Clinical Investigation and Documentation | De Boer P.,York Hospital | And 3 more authors.
Archives of Orthopaedic and Trauma Surgery | Year: 2013

Introduction: Aim of this study was to evaluate outcomes of operative as compared to conserveative treatment for two-part humerus fractures at the surgical neck. Methods: Data from a prospective multi-centre cohort study on four treatment options (conservative treatment and three implants, i.e. LPHP, PHILOS and PHN) for proximal humerus fractures were evaluated in this post hoc analysis. All patients with two-part fractures of the surgical neck (AO types A2, n = 54 and A3, n = 110) were identified and included for the analysis. All operatively treated patients were gathered and compared to those receiving conservative treatment. Primary outcome parameters were pain, range of motion and absolute and relative Constant scores at 3, 6 and 12 months following injury and coronal plane alignment at 12 months. Results: Operative (n = 133) and non-operative (n = 31) groups were comparable with regard to all parameters assessed including mean age (62.9 vs. 65.6, P = 0.479), gender (27 vs. 29 % male, P = 0.826) and fracture distribution (65 vs. 77 % A3 type, P = 0.207). 26 of the 31 conservatively treated and 103 of the 133 operatively treated patients (84 and 77 %, respectively) were available for final follow-up. There was a continuous improvement for all outcome parameters in both treatment groups (P < 0.001). Operative treatment resulted in a more effective reduction of pain at 3 months (51 vs. 76 % reporting pain at fracture site, P = 0.03) and a reduction of coronal plane malalignment. Both range of motion and Constant scores were, however, comparable in both groups at all follow-up visits. Relative and absolute Constant scores were generally excellent at final follow-up (74 vs. 74, P = 0.528 and 89 vs. 91, P = 0.494, respectively). Conclusions: Both non-operative treatment and operative treatment using modern implants (LPHP, PHILOS and PHN) can be considered safe and effective treatment options for two-part fractures of the proximal humerus. Operative treatment may result in better range of motion and reduced pain in the early postoperative course of treatment. © 2013 Springer-Verlag Berlin Heidelberg.

Guckenberger M.,Julius Maximilians University | Bachmann J.,Julius Maximilians University | Wulf J.,Lindenhofspital | Mueller G.,Julius Maximilians University | And 5 more authors.
Radiotherapy and Oncology | Year: 2010

Purpose: To evaluate outcome of radiotherapy for locally recurrent cervical and endometrial cancer. Materials and methods: Nineteen patients were treated for a locally recurrent cervical (n = 12) or endometrial (n = 7) cancer median 26 months after initial surgery (n = 18) or radiotherapy (n = 1). The whole pelvis was irradiated with 50 Gy conventionally fractionated radiotherapy (n = 16). Because of large size of the recurrent cancer (median 4.5 cm) and peripheral location (n = 12), stereotactic body radiotherapy (SBRT; median 3 fractions of 5 Gy to 65%) was used for local dose escalation instead of (n = 16) or combined with (n = 3) vaginal brachytherapy. Results: After median follow-up of 22 months, 3-year overall survival was 34% with systemic progression the leading cause of death (7/10). Median time to systemic progression was 16 months. Three local recurrences resulted in a local control rate of 81% at 3 years. No correlation between survival, systemic or local control and any patient or treatment characteristic was observed. The rate of late toxicity > grade II was 25% at 3 years: two patients developed a grade IV intestino-vaginal fistula and one patient suffered from a grade IV small bowel ileus. Conclusion: Image-guided SBRT for local dose escalation resulted in high rates of local control but was associated with significant late toxicity. © 2009 Elsevier Ireland Ltd. All rights reserved.

Nguyen N.P.,Howard University | Jang S.,University of Arizona | Vock J.,Lindenhofspital | Vinh-Hung V.,University of Geneva | And 7 more authors.
BMC Cancer | Year: 2014

Background: In this study the feasibility of intensity-modulated radiotherapy (IMRT) and tomotherapy-based image-guided radiotherapy (IGRT) for locally advanced esophageal cancer was assessed. Methods: A retrospective study of ten patients with locally advanced esophageal cancer who underwent concurrent chemotherapy with IMRT (1) and IGRT (9) was conducted. The gross tumor volume was treated to a median dose of 70 Gy (62.4-75 Gy). Results: At a median follow-up of 14 months (1-39 months), three patients developed local failures, six patients developed distant metastases, and complications occurred in two patients (1 tracheoesophageal fistula, 1 esophageal stricture requiring repeated dilatations). No patients developed grade 3-4 pneumonitis or cardiac complications. Conclusions: IMRT and IGRT may be effective for the treatment of locally advanced esophageal cancer with acceptable complications. © 2014 Nguyen et al.; licensee BioMed Central Ltd.

Majed A.,Imperial College London | Macleod I.,ImperialCollege Healthcare NHS Trust | Bull A.M.J.,Imperial College London | Zyto K.,Queen Sophia Hospital | And 4 more authors.
Journal of Shoulder and Elbow Surgery | Year: 2011

Hypothesis: This study evaluated several classification systems and expert surgeons' anatomic understanding of these complex injuries based on a consecutive series of patients. We hypothesized that current proximal humeral fracture classification systems, regardless of imaging methods, are not sufficiently reliable to aid clinical management of these injuries. Materials and methods: Complex fractures in 96 consecutive patients were investigated by generation of rapid sequence prototyping models from computed tomography Digital Imaging and Communications in Medicine (DICOM) imaging data. Four independent senior observers were asked to classify each model using 4 classification systems: Neer, AO, Codman-Hertel, and a prototype classification system by Resch. Interobserver and intraobserver κ coefficient values were calculated for the overall classification system and for selected classification items. Results: The κ coefficient values for the interobserver reliability were 0.33 for Neer, 0.11 for AO, 0.44 for Codman-Hertel, and 0.15 for Resch. Interobserver reliability κ coefficient values were 0.32 for the number of fragments and 0.30 for the anatomic segment involved using the Neer system, 0.30 for the AO type (A, B, C), and 0.53, 0.48, and 0.08 for the Resch impaction/distraction, varus/valgus and flexion/extension subgroups, respectively. Three-part fractures showed low reliability for the Neer and AO systems. Discussion: Currently available evidence suggests facture classifications in use have poor intra- and inter-observer reliability despite the modality of imaging used thus making treating these injuries difficult as weak as affecting scientific research as well. This study was undertaken to evaluate the reliability of several systems using rapid sequence prototype models. Conclusion: Overall interobserver κ values represented slight to moderate agreement. The most reliable interobserver scores were found with the Codman-Hertel classification, followed by elements of Resch's trial system. The AO system had the lowest values. The higher interobserver reliability values for the Codman-Hertel system showed that is the only comprehensive fracture description studied, whereas the novel classification by Resch showed clear definition in respect to varus/valgus and impaction/distraction angulation. © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.

Steffen V.,Lindenhofspital | Hertel R.,Lindenhofspital
Journal of Shoulder and Elbow Surgery | Year: 2013

Background: The purpose of this study was to evaluate the long-term results of instability patients treated with iliac crest graft glenoid augmentation. Materials and methods: Retrospective study including 48 consecutive patients (40 male; mean age 25; range, 17-35). There were 20 primary and 28 revision cases. Three patients declined follow-up examination, and 5 lost to >5 years follow-up. Mean follow-up was 9.2 years (range, 5-19). Reconstruction comprised: iliac crest graft, interposition of the labrum on the burred surface of the graft and capsular re-tensioning. We measured the Oxford Shoulder Instability Score (OSIS) and assessed arthrotic changes and atrophy and fatty infiltration of the subscapularis. Results: 8/43 had residual pain, 3/43 had a subjective sensation of instability, 1/43 had a re-dislocation and required re-intervention. The mean OSIS was 18.1 points (12-50) (n = 40). 1/40 developed postoperative subscapularis insufficiency. The mean subscapularis atrophy was 7.4% (37% atrophy to 27% hypertrophy). 2/40 had a relevant fatty infiltration of the SSC muscle stage III to stage IV. 19/40 had mild and 1/40 had a moderate arthrosis. Arthrosis progressed by 1 stage in 7 of 35 shoulders. The mean residual glenoid defect area was 4.0% (0-13.5) and the mean defect width was 8.3% (range, 0-19.2) (n = 40). Conclusion: Glenoid rim reconstruction with iliac crest graft was equally effective for patients with primary repair and for failed previous stabilization. It offered the advantage of an anatomic reconstruction with a comparatively good long-term preservation of the joint line. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

Erni D.,University of Bern | De Kerviler S.,University of Bern | Hertel R.,Lindenhofspital | Slongo T.,University of Bern
Journal of Plastic, Reconstructive and Aesthetic Surgery | Year: 2010

Congenital pseudarthrosis of the tibia (CPT) is caused by an ill-defined, segmental disturbance of periosteal bone formation leading to spontaneous bowing, followed by fracture and subsequent pseudarthrosis in the first 2 years of life. The results of conventional treatment modalities (e.g., bracing, internal and external fixation and bone grafting) are associated with high failure rates in terms of persisting pseudarthrosis, malunion and impaired growth. As a more promising alternative, a more aggressive approach, including wide resection of the affected bone, reconstruction with free vascularised fibula grafts from the healthy contralateral leg and stable external fixation at a very early stage has been suggested. Between 1995 and 2007, 10 children (age 12-31 months, median 20 months) suffering from CPT were treated at our institutions according to this principle. Two patients were treated before a fracture had occurred. The length of the fibula graft was 7-9 cm. End-to-end anastomoses were performed at the level of the distal tibia stump. The follow-up was 80 months (median, range 12 months to 12 years). Radiologic examination at 6 weeks postoperatively showed normal bone density and structure of the transplanted fibula in all cases and osseous consolidation at 19 of the 20 graft/tibia junctions. One nonunion was sucessfully treated with bone grafting and plate osteosynthesis. Pin-tract infection occurred in three patients. Five children sustained graft fractures that were successfully treated with internal or external fixation. Two patients developed diminished growth of the affected limb or foot; all others had equal limb length and shoe size. At long-term follow-up, tibialisation of the transplant had occurred, and normal gait and physical activities were possible in all children. We conclude that in spite of a relatively high complication rate and the reluctance to perform free flap surgery in infants at this young age, the present concept may successfully prevent the imminent severe sequelae associated with CPT. © 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

PubMed | Shoulder Unit Royal National Orthopaedic Hospital, Lindenhofspital, AO Research Institute Davos and University Hospital Freiburg
Type: Journal Article | Journal: Journal of orthopaedic research : official publication of the Orthopaedic Research Society | Year: 2016

Previous studies have suggested clavicular morphology is highly variable, particularly in the lateral retrocurved section. Current clavicle fracture plating systems require three dimensional intra-operative contouring to achieve adequate fit and necessitate variable soft tissue dissection placing fracture perfusion and muscular attachments at risk. The aim of this study was to search for a surgically relevant superficial shape pattern. This is a retrospective CT-based analysis of 174 non-pathological clavicles in 95 adults (45 females, 50 males). Using the principle of cylindrical parameterisation generated 3-D computer models, we identified an implant preferred pathway (IPP), defined as a continuous linear region where the least possible soft tissue disruption would be necessary for plate fixation. The IPP mean form was within 3.04mm (SD1.34) on all clavicles. Clavicle length, and not shape, was found to be the biggest variable (correlation between size and form co-ordinates r=0.99, p<0.05), accounting for 79% of overall variability. This length variation was mainly located in the medial antecurved section. Superior convexity and recurvatum were the main shape variables, however they only contributed 8% and 5% to the overall variation, respectively. Three IPP lengths were shown to match all clavicles when aligned at the acromial end first. In contrast to previous studies, we have shown that the IPP is fairly consistent with respect to the general shape with the exception of length variation which mainly affected the medial antecurved section. 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1216-1223, 2016.Future pre-contoured fracture fixation systems should provide variable length plates with a constant lateral section retrocurve and a variable medial antecurve.

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