Die anteriore Schulterinstabilität ist die häufigste Form der Instabilität des Glenohumeralgelenks und betrifft überwiegend junge aktive Patienten. Die Entscheidung bezüglich konservativer oder operativer Therapie ist komplex und erfordert die Berücksichtigung individueller Risikofaktoren. Ziel dieses Übersichtsartikels ist es, die aktuelle Evidenz zu Indikationsstellung, klinischen Ergebnissen nach konservativer und operativer Therapie sowie Rezidivraten darzustellen. Hieraus können klinische Entscheidungskriterien – unter Berücksichtigung patientenspezifischer Risikofaktoren, Aktivitätsniveau sowie struktureller glenoidaler und humeraler Pathologien – abgeleitet werden. Die konservative Therapie nach erstmaliger anteriorer Schulterluxation umfasst eine kurzzeitige Immobilisation mit anschließender funktioneller Rehabilitation zur Verbesserung der muskulären Stabilisierung und Beweglichkeit der Schulter. Hierdurch kann bei älteren, wenig aktiven Patienten ohne relevante knöcherne Defekte eine signifikante Verbesserung der Funktion und Schmerzreduktion erzielt werden. Junge, sportlich aktive Patienten, insbesondere in Kontakt- und Überkopfsportarten, zeigen jedoch ein deutlich erhöhtes Rezidivrisiko. Dieses kann durch eine frühe operative, primär arthroskopische Stabilisierung reduziert werden. Patientenalter, Aktivitätsniveau, Anzahl vorheriger Luxationen, sowie knöcherne und weichteilige Begleitpathologien sollten hierbei individuell berücksichtigt werden. Somit erfordert die Therapieentscheidung eine individualisierte, risikoadaptierte Evaluation.
Zusammenfassung: Die jüngsten Revisionen der Krankheitsklassifikationssysteme DSM-5 und ICD-11 stärken die Rolle der Neuropsychologie bei der Diagnose neurokognitiver Störungen. Zugleich ist eine gewisse Stagnation der neuropsychologischen Methodenentwicklung auf dem Gebiet der Demenzdiagnostik zu verzeichnen. Vor diesem Hintergrund wurde im Rahmen des computergestützten Wiener Testsystems (WTS) das portable Test-Set Cognitive Functions Dementia (CFD) entwickelt und anhand der hier berichteten multizentrischen Beobachtungsstudie im klinischen Einsatz evaluiert. Bei guter Akzeptanz zeigten sich keine besonderen Anwendungsprobleme. Die 14 Hauptvariablen und 6 Indizes des CFD unterscheiden Demenz-Erkrankte ( n = 131) deutlich von Gesunden ( n = 407) sowie Personen mit Depression (n = 145), leichter kognitiver Störung (n = 57) und Morbus Parkinson ( n = 52). Im Vergleich zum Mini-Mental Status Test (MMST) ist das CFD sensitiver für diskrete Beeinträchtigungen neurokognitiver Funktionen. Die Ergebnisse belegen die Eignung des Test-Sets für die Demenz-Früherkennung und Differenzialdiagnostik Demenz vs. Depression.
When different therapies provide similar cure rates, health-related quality of life (HRQoL) may become crucial for the choice of treatment. In the Positron Emission Tomography-guided Therapy of Aggressive non-Hodgkin Lymphomas (PETAL) trial, we compared six cycles of R-CHOP with or without two extra doses of rituximab in prognostically favorable interim PET (iPET)-negative patients, while eight cycles of R-CHOP were compared with two R-CHOP cycles followed by six cycles of a more intensive protocol in prognostically unfavorable iPET-positive patients. As reported previously, treatment intensification did not improve outcome. HRQoL was assessed using the EORTC QLQ-C30 questionnaire. Pretreatment questionnaires were obtained from 558 out of the 862 participants (64.7%). Pretreatment HRQoL was significantly worse than in the general population. It was associated with age, gender, B symptoms, International Prognostic Index (IPI) and total metabolic tumor volume (TMTV). Physical and cognitive functioning predicted survival independent of IPI or TMTV. During treatment, some domains remained stable (e.g., cognitive functioning, nausea/vomiting), while others improved (e.g., emotional functioning, pain) or deteriorated (e.g., physical functioning, role functioning, fatigue). At the end of treatment, HRQoL was better in patients with controlled disease than in patients with progressive disease and better for iPET-negative patients than for iPET-positive patients. During follow-up, all HRQoL domains returned to levels similar to those reported for the general population. Differences between randomized treatment arms were not observed. The longitudinal data need to be interpreted with caution, because decreasing participation resulted in a selection of patients with increasingly good outcomes. ClinicalTrials.gov no. NCT00554164 (registered 11/5/2007).
Extracellular vesicles (EVs) transport biomolecules that could serve as biomarkers for disease diagnosis and monitoring. The clinical utility of EVs derived from cerebrospinal fluid (CSF) in patients with intradural spinal tumors (IST) has not yet been investigated. Here, we obtained EVs from CSF of adult patients with intraspinal ependymoma (n = 9), meningioma (n = 9), hemangioma (n = 4) and schwannian tumors (n = 7), as well as comparison group (‘CG’, normal pressure hydrocephalus, n = 7), by ultrafiltration. CSF-EVs were characterized by electron microscopy and nanoparticle tracking analysis. EV populations according to the presence of tetraspanins (CD9, CD63, CD81) were measured by imaging flow cytometry (IFCM). CD81+ EVs were more prevalent in the comparison group, meningioma, ependymoma WHO grade 2, and hemangioma, whereas CD9+ EVs were predominant in ependymoma grade 1 and Schwannian tumors. CD63+ EVs per milliliter/CSF differed between ependymoma WHO grades 1 and 2 (FC = 24.6, AUC = 90%, p < 0.05). Based on results from a bead-based multiplex profiling, we selected ITGB1, CD44, CD133 and HLA-DR/DQ/DP for further phenotyping in CSF-EVs using IFCM, in combination with each tetraspanin as double-positive subpopulations. Compared to CG, CD44+ EVs were the most relevant population in CSF from IST patients, followed by ITGB1. Notable differences in absolute (EVs/mL CSF) and relative (percentages of CSF-EVs) levels were: CD44+/CD81+ for ependymoma grade 1 (FC = 196.5 and 34.5; p < 0.01) and grade 2 (%FC = 6.1, p < 0.05); CD44+/CD63+ for meningioma (abs. and %FC > 1000, p < 0.05); ITGB1+/CD81+ for hemangioma (%FC = 4.8, p < 0.05); and ITGB1+/CD9+ for schwannian tumors (abs.FC = 19.8, p < 0.01). In conclusion, we identified distinct EV subpopulations in the CSF of IST patients, potentially facilitating tumor classification.
Background During the covid-19 pandemic, a non-funded, nurse-led quality improvement project on delirium management was in progress on four Stroke Units (SU). Two sites experienced pandemic-related delays; we set out to learn lessons based on the impact for delivering multicentre trials. Methods Secondary analysis of a prospective quality improvement project. We compared data quality from centres with vs. without delay. Unplanned modifications in study management were classified as a) fatal modifications (ending the study), b) serious modifications (requiring a revision of the registration and/or ethic approval, c) moderate modifications (revising study management), d) minor modifications (improving study performance). Local study coordinators summarised lessons learned. Results The study had an overall delay of 14 months. Centres without delay delivered better data quality and had less loss of patients due to missing primary outcome data in 0.3% vs 28.8% in centres with delay (p<0.001). There were no fatal modifications, two serious (exchange of study centre, adding new outcome parameters), six moderate (e.g. delayed start in two centres, change from in-person to virtual meetings), and one minor modification (four local study coordinators taking parental leave). Lessons learned were frequent communication with study coordinators, attention to data quality, protocolisation of recruitment rates, and adapted education in quality improvement projects. Conclusions Pandemic-related disruption can be substantial, with poorer data quality, but only in a few cases were registration and/or ethic approval modifications required. Facilitators are flexible, including changed time frames, frequent virtual communication, and critical reflection.
