In a single-center, randomized trial involving 361 patients, the use of routine computed tomography after the removal of a chronic hematoma had no advantage over CT performed only in patients with ...clinical deterioration.
2003
Background: Terminology to describe extent of resection in glioblastoma is inconsistent across clinical trials. A surgical classification system for glioblastoma was previously proposed based ...upon the absolute residual contrast-enhancing (CE) tumor (in cm
3
) and the relative reduction of CE tumor (in percentage) on postoperative MRI. Class 0 was defined as ‘supramaximal CE resection’ (also including removal of non-CE tumor), class 1 as ‘maximal CE resection’, class 2 as ‘submaximal CE resection’, and class 3 as ‘biopsy’. We aimed to (I) explore the prognostic utility of the proposed classification system and (II) define how much non-CE tumor needs to be removed to translate into a survival benefit. Methods: An international Response Assessment in Neuro-Oncology (RANO) group was formed, entitled RANO resect. The members of the RANO resect group retrospectively searched the databases from seven neuro-oncological centers in the USA and Europe for patients with newly diagnosed glioblastoma. Clinical characteristics, volumetric information from pre- and postoperative MRI, and outcome were collected. Kaplan-Meier survival analysis and log-rank test were applied to calculate survival, and Cox’s proportional hazard regression model to adjust for multiple variables. Significance level was set at p ≤ 0.05. Results: We encountered 1021 patients with newly diagnosed glioblastoma, including 1008 IDHwt patients. 744 IDHwt patients were treated with radiochemotherapy per EORTC 26981/22981 following surgery. Among such homogenously treated patients, higher extent of resection was favorably associated with outcome: patients with ‘maximal CE resection’ (class 1) had superior outcome compared to patients with ‘submaximal CE resection’ (class 2) or ‘biopsy’ (class 3) (median OS: 20 versus 16 versus 10 months; p = 0.001). Similar findings were made when assessing progression (median PFS: 9 versus 8 versus 5 months; p = 0.001). Extensive resection of non-CE tumor (≥60% of non-CE tumor removed and ≤5 cm
3
residual non-CE tumor) provided an additional survival benefit in patients with complete CE resection (class 1), thus defining class 0 (‘supramaximal CE resection’) (median OS: 29 versus 20 months; p = 0.003). Smaller pre-operative tumor volumes were associated with larger extent of resection. The favorable prognostic effect of CE resection was conserved in a multivariate analysis when stratifying for molecular and clinical markers including pre-operative tumor volume and MGMT promotor status ( p = 0.001). Conclusions: The proposed classification system for extent of surgery in glioblastoma is highly prognostic and may serve for stratification and design of clinical trials. Removal of non-CE tumor beyond the CE tumor borders translates into additional survival benefit in glioblastomas, providing a rationale to explicitly denominate such a 'supramaximal CE resection.'
Juden und Nichtjuden nach der Shoah Stefanie Fischer, Nathanael Riemer, Stefanie Schüler-Springorum / Stefanie Fischer, Nathanael Riemer, Stefanie Schüler-Springorum
2019
eBook
The series European-Jewish Studies reflects the international network and competence of the Moses Mendelssohn Center for European Jewish studies (MMZ). Thanks to the highly interdisciplinary ...character of the series, which is edited in collaboration with the Selma Stern Center for Jewish Studies Berlin- Brandenburg, particular emphasis is placed on the way in which history, the humanities and cultural sciences approach the subject, as well as on fundamental intellectual, political and religious questions that inspire Jewish life and thinking today, and have influenced it in the past. The CONTRIBUTIONS publish excellent monographs and anthologies on the entire spectrum of themes from Jewish studies. The series is peer-reviewed.
In the process of developing and implementing innovative implant technologies the consideration of patient preferences can be beneficial for patients, doctors and developers. Nevertheless, in ...existing literature, there is still scarce knowledge of patients' perspectives on long-term implant care. In this study, three discrete choice experiments (DCEs) were conducted in the context of cochlear implants (CI,
= 92), glaucoma implants (GI,
= 21) and cardiovascular implants (CVI,
= 23), examining the relative importance of attributes of long-term implant care from the patients' perspective. The participants chose between differently shaped options for implant-related care. The attributes of these care options were generated and selected based on previous literature reviews, group discussions and a diary study with patients. The choice data were analyzed via binary logit regression. In CI-DCE, the technological compatibility of the implant with newer implant models, accessories or devices from other manufacturers was highly valued by participants, whereas in GI-DCE the (in)dependency on glaucoma medication post-implantation had the greatest influence on participants' choice behavior. In CVI-DCE, the attribute with the highest relative importance related to the means of securing long-term treatment success. In all three DCE, shared decision making was relatively important for participants. Our results emphasized the importance of an adequate transfer of technological advancements in implant care for promoting patient benefits, such as the availability of comprehensible, understandable, high-quality information about current developments. Similarly, promoting technological health literacy and further pushing the technological compatibility, durability and safety of implants are directions for future implant development in accordance with patients' preferences. Therefore, the participation of implant wearers in the development process is encouraged.
The continuous development of medical implants offers various benefits for persons with chronic conditions but also challenges an individual’s, and the healthcare system’s, ability to deal with ...technical innovation. Accessing and understanding new information, navigating healthcare, and appraising the role of the implant in body perceptions and everyday life requires health literacy (HL) of those affected as well as an HL-responsive healthcare system. The interconnectedness of these aspects to ethically relevant values such as health, dependence, responsibility and self-determination reinforces the need to address HL in implant care. Following a qualitative approach, we conducted group discussions and a diary study among wearers of a cochlear, glaucoma or cardiovascular implant (or their parents). Data were analysed using the documentary method and grounded theory. The data reveal the perceptions of implant wearers regarding the implant on (1) the ability to handle technical and ambiguous information; (2) dependence and responsibility within the healthcare system; and (3) the ethical aspects of HL. Knowing more about the experiences and values of implant wearers is highly beneficial to develop HL from an ethical perspective. Respective interventions need to initially address ethically relevant values in counselling processes and implant care.
Background
Risk communication is a core aspect of a physician’s work and a fundamental prerequisite for successful shared decision-making. However, many physicians are not able to adequately ...communicate risks to patients due to a lack of understanding of statistics as well as inadequate management of conflicts of interest (COI).
Objective
To evaluate the effects of an integrated curriculum encompassing COI and shared decision-making on the participants’ risk communication competence, that is, their competence to advise patients on the benefits and harms of diagnostic or therapeutic interventions.
Design
A rater-blind randomized controlled trial with a 30 (± 1)-week follow-up conducted from October 2016 to June 2017 at two German academic medical centers.
Participants
Sixty-three medical students in their fourth or fifth year.
Interventions
Participants received either a newly developed 15-h curriculum or a course manual adapted from teaching as usual.
Main Measures
Primary outcome: change in risk communication performance in a video-observed structured clinical examination (VOSCE).
Key Results
Participants were 25.7 years old on average (SD 3.6); 73% (46/63) were female. Increase in risk communication performance was significantly higher in the intervention group with post-intervention Cohen’s
d
of 2.35 (95% confidence interval (CI) 1.62 to 3.01,
p
< 0.01) and of 1.83 (CI 1.13 to 2.47,
p
< 0.01) 30 (± 1) weeks later. Secondary outcomes with the exception of frequency of interactions with the pharmaceutical industry also showed relevant improvements in the intervention as compared with the control group (
d
between 0.91 and 2.04 (
p
< 0.001)).
Conclusions
Our results show that an integrated curriculum encompassing COI and risk communication leads to a large and sustainable increase in risk communication performance. We interpret the large effect sizes to be a result of the integration of topics that are usually taught separately, leading to a more effective organization of knowledge.
Trial Registration:
The trial is registered in the International Clinical Trials Registry with the trial number DRKS00010890.
With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks ...concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest.
After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.
We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.
CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.
Transsexualism describes the condition when a person's psychological gender differs from his or her biological sex and is commonly thought to arise from a discrepant cerebral and genital sexual ...differentiation. This review intends to give an extensive overview of structural and functional neurobiological correlates of transsexualism and their course under cross-sex hormonal treatment. Research in this field enables insight into the stability or variability of gender differences and their relation to hormonal status. For a number of sexually dimorphic brain structures or processes, signs of feminisation or masculinisation are observable in transsexual individuals, which, during hormonal treatment, partly seem to further adjust to characteristics of the desired sex. Still, it appears the data are quite inhomogeneous, mostly not replicated and in many cases available for male-to-female transsexuals only. As the prevalence of homosexuality is markedly higher among transsexuals than among the general population, disentangling correlates of sexual orientation and gender identity is a major problem. To resolve such deficiencies, the implementation of specific research standards is proposed.
Communication and interprofessional collaboration with patients diagnosed with cancer is challenging. Structured communication training has not yet been integrated into postgraduate medical ...education. The aim of this study was to evaluate the feasibility of an 80-teaching unit interprofessional communication training (ICT), as recommended in the National Cancer Plan, at a clinic with a uro-oncological focus.
A needs assessment was conducted using focus groups and individual interviews. Learning objectives were aligned with (inter)national learning objective catalogs. The ICT was developed using the six-step approach according to Kern and design-based research. Utilization and acceptance were evaluated. The ICT comprised six face-to-face workshops (50 teaching units) and team supervision sessions (10 teaching units). Six defined settings were identified for the individual workplace-based training (20 teaching units): Ward rounds, handover, reporting of medical findings, admission and discharge interviews, and a freely choosable setting.
Physician participation rates in the workshops were 83.0% and nursing participation rates were 58.3%. Utilization of the workplace-based training was 97%. The physicians evaluated the ICT very positively. All participants felt better prepared for discussions with patients and relatives. For continuity, physicians were trained as mentors.
The implementation of an ICT with 80 teaching units is successfully feasible in a urological clinic and leads to a sustainable improvement of the communication culture, among other things through mentor training.
Type D personality, as with formal mental disorders, is linked to increased mortality in coronary heart disease (CHD). Our aim was to determine the prevalence of mental disorders among depressed CHD ...patients with and without Type D personality.
Depressive symptoms (HADS, HAM-D), Type D personality (DS-14) and mental disorders based on DSM-IV (SCID I and II) were assessed. Results were calculated by Kruskal-Wallis tests, Fisher's exact tests and logistic regression analyses.
570 CHD patients were included (age 59.2±9.5years; male 78.9%, HADS-D depression 10.4±2.5; HAM-D 11.3±6.6; Type D 60.1%). 84.8% of patients with Type D personality and 79.3% of non-Type D patients suffered from at least one mental disorder (p=0.092), while 41.8% of Type D positives and 27.8% of Type D negatives had at least two mental disorders (p=0.001). Patients with Type D personality significantly more often had social phobia odds ratio (95% confidence interval): 3.79 (1.1 to 13.12); p=0.035, dysthymia 1.78 (1.12 to 2.84); p=0.015, compulsive 2.25 (1.04 to 4.86); p=0.038 or avoidant 8.95 (2.08 to 38.49); p=0.003 personality disorder.
Type D personality among depressed CHD patients is associated with more complex and enduring mental disorders. This implies higher treatment demands.
ISRCTN 76240576; NCT00705965
PDF
