Thoracolumbar dorsolateral laminectomy with osteotomy of the spinous process in fourteen dogs

OBJECTIVE: To describe outcome after an alternative unilateral approach to the thoracolumbar spine for dorsal laminectomy. STUDY DESIGN: Retrospective clinical study. ANIMALS: Dogs (n=14) with thoracolumbar spinal cord compression. METHODS: Thoracolumbar spinal cord compression was lateral (6 dogs), dorsal (4), and dorsolateral (4) caused by subarachnoid (7) and synovial cysts (2) and intradural-extramedullary neoplasia (5). All dogs were treated by dorsal laminectomy with osteotomy of the spinous process using a unilateral paramedian approach. The contralateral paraspinal muscles were not stripped from the spinous process and the osteoligamentous complexes were preserved. Retraction of the spinous process and muscles to the contralateral side resulted in complete visualization of the dorsal vertebral arch thereby allowing dorsal laminectomy to be performed. RESULTS: No technique complications occurred. Approximately 75% exposure of the spinal cord (dorsal and lateral compartments) was achieved providing adequate visualization and treatment of the lesions. Transient deterioration of neurologic state occurred in 5 dogs because of extensive spinal cord manipulation. At long-term follow-up, 6 dogs were normal, 6 had clinical improvement, and 2 were unchanged. CONCLUSION: Dorsal laminectomy after osteotomy and retraction of the spinous process may be considered in canine patients with dorsal, dorsolateral, or lateral compression to facilitate adequate decompression of the spinal cord. CLINICAL SIGNIFICANCE: This surgical technique offers an alternative approach to the thoracolumbar spine and spinal cord by a modified dorsal laminectomy that preserves the paraspinal muscle integrity on the contralateral side.

Diagnostic criteria for hematopoietic stem cell transplant-associated microangiopathy: results of a consensus process by an International Working Group

BACKGROUND AND OBJECTIVES: There are no widely accepted criteria for the definition of hematopoietic stem cell transplant -associated microangiopathy (TAM). An International Working Group was formed to develop a consensus formulation of criteria for diagnosing clinically significant TAM. DESIGN AND METHODS: The participants proposed a list of candidate criteria, selected those considered necessary, and ranked those considered optional to identify a core set of criteria. Three obligatory criteria and four optional criteria that ranked highest formed a core set. In an appropriateness panel process, the participants scored the diagnosis of 16 patient profiles as appropriate or not appropriate for TAM. Using the experts' ratings on the patient profiles as a gold standard, the sensitivity and specificity of 24 candidate definitions of the disorder developed from the core set of criteria were evaluated. A nominal group technique was used to facilitate consensus formation. The definition of TAM with the highest score formed the final PROPOSAL. RESULTS: The Working Group proposes that the diagnosis of TAM requires fulfilment of all of the following criteria: (i) >4% schistocytes in blood; (ii) de novo, prolonged or progressive thrombocytopenia (platelet count <50 x 109/L or 50% or greater reduction from previous counts); (iii) sudden and persistent increase in lactate dehydrogenase concentration; (iv) decrease in hemoglobin concentration or increased transfusion requirement; and (v) decrease in serum haptoglobin. The sensitivity and specificity of this definition exceed 80%. INTERPRETATION AND CONCLUSIONS: The Working Group recommends that the presented criteria of TAM be adopted in clinical use, especially in scientific trials.

Drug-eluting or bare-metal stents for large coronary vessel stenting? The BASKET-PROVE (PROspective Validation Examination) trial: study protocol and design

BACKGROUND: Based on a subgroup analysis of 18-month BAsel Stent Kosten Effektivitäts Trial (BASKET) outcome data, we hypothesized that very late (> 12 months) stent thrombosis occurs predominantly after drug-eluting stent implantation in large native coronary vessel stenting. METHODS: To prove or refute this hypothesis, we set up an 11-center 4-country prospective trial of 2260 consecutive patients treated with > or = 3.0-mm stents only, randomized to receive Cypher (Johnson ; Johnson, Miami Lakes, FL), Vision (Abbott Vascular, Abbott Laboratories, IL), or Xience stents (Abbott Vascular). Only patients with left main or bypass graft disease, in-stent restenosis or stent thrombosis, in need of nonheart surgery, at increased bleeding risk, without compliance/consent are excluded. All patients are treated with dual antiplatelet therapy for 12 months. The primary end point will be cardiac death/nonfatal myocardial infarction after 24 months with further follow-up up to 5 years. RESULTS: By June 12, 229 patients (10% of the planned total) were included with a baseline risk similar to that of the same subgroup of BASKET (n = 588). CONCLUSIONS: This study will answer several important questions of contemporary stent use in patients with large native vessel stenting. The 2-year death/myocardial infarction-as well as target vessel revascularization-and bleeding rates in these patients with a first- versus second-generation drug-eluting stent should demonstrate the benefit or harm of these stents compared to cobalt-chromium bare-metal stents in this relevant, low-risk group of everyday patients. In addition, a comparison with similar BASKET patients will allow to estimate the impact of 12- versus 6-month dual antiplatelet therapy on these outcomes.

Rationale and design of a randomized, double-blind, parallel-group study of terutroban 30 mg/day versus aspirin 100 mg/day in stroke patients: the prevention of cerebrovascular and cardiovascular events of ischemic origin with terutroban in patients with a history of ischemic stroke or transient ischemic attack (PERFORM) study

BACKGROUND: Ischemic stroke is the leading cause of mortality worldwide and a major contributor to neurological disability and dementia. Terutroban is a specific TP receptor antagonist with antithrombotic, antivasoconstrictive, and antiatherosclerotic properties, which may be of interest for the secondary prevention of ischemic stroke. This article describes the rationale and design of the Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic Attack (PERFORM) Study, which aims to demonstrate the superiority of the efficacy of terutroban versus aspirin in secondary prevention of cerebrovascular and cardiovascular events. METHODS AND RESULTS: The PERFORM Study is a multicenter, randomized, double-blind, parallel-group study being carried out in 802 centers in 46 countries. The study population includes patients aged > or =55 years, having suffered an ischemic stroke (< or =3 months) or a transient ischemic attack (< or =8 days). Participants are randomly allocated to terutroban (30 mg/day) or aspirin (100 mg/day). The primary efficacy endpoint is a composite of ischemic stroke (fatal or nonfatal), myocardial infarction (fatal or nonfatal), or other vascular death (excluding hemorrhagic death of any origin). Safety is being evaluated by assessing hemorrhagic events. Follow-up is expected to last for 2-4 years. Assuming a relative risk reduction of 13%, the expected number of primary events is 2,340. To obtain statistical power of 90%, this requires inclusion of at least 18,000 patients in this event-driven trial. The first patient was randomized in February 2006. CONCLUSIONS: The PERFORM Study will explore the benefits and safety of terutroban in secondary cardiovascular prevention after a cerebral ischemic event.

Virtual implant planning in the edentulous maxilla: criteria for decision making of prosthesis design

OBJECTIVES To evaluate prosthetic parameters in the edentulous anterior maxilla for decision making between fixed and removable implant prosthesis using virtual planning software. MATERIAL AND METHODS CT- or DVT-scans of 43 patients (mean age 62 ± 8 years) with an edentulous maxilla were analyzed with the NobelGuide software. Implants (≥3.5 mm diameter, ≥10 mm length) were virtually placed in the optimal three-dimensional prosthetic position of all maxillary front teeth. Anatomical and prosthetic landmarks, including the cervical crown point (C-Point), the acrylic flange border (F-Point), and the implant-platform buccal-end (I-Point) were defined in each middle section to determine four measuring parameters: (1) acrylic flange height (FLHeight), (2) mucosal coverage (MucCov), (3) crown-Implant distance (CID) and (4) buccal prosthesis profile (ProsthProfile). Based on these parameters, all patients were assigned to one of three classes: (A) MucCov ≤ 0 mm and ProsthProfile≥45(0) allowing for fixed prosthesis, (B) MucCov = 0-5 mm and/or ProsthProfile = 30(0) -45(0) probably allowing for fixed prosthesis, and (C) MucCov ≥ 5 mm and/or ProsthProfile ≤ 30(0) where removable prosthesis is favorable. Statistical analyses included descriptive methods and non-parametric tests. RESULTS Mean values were for FLHeight 10.0 mm, MucCov 5.6 mm, CID 7.4 mm, and ProsthProfile 39.1(0) . Seventy percent of patients fulfilled class C criteria (removable), 21% class B (probably fixed), and 2% class A (fixed), while in 7% (three patients) bone volume was insufficient for implant planning. CONCLUSIONS The proposed classification and virtual planning procedure simplify the decision-making process regarding type of prosthesis and increase predictability of esthetic treatment outcomes. It was demonstrated that in the majority of cases, the space between the prosthetic crown and implant platform had to be filled with prosthetic materials.

Advanced production scheduling for batch plants in process industries

An Advanced Planning System (APS) offers support at all planning levels along the supply chain while observing limited resources. We consider an APS for process industries (e.g. chemical and pharmaceutical industries) consisting of the modules network design (for long–term decisions), supply network planning (for medium–term decisions), and detailed production scheduling (for short–term decisions). For each module, we outline the decision problem, discuss the specifi cs of process industries, and review state–of–the–art solution approaches. For the module detailed production scheduling, a new solution approach is proposed in the case of batch production, which can solve much larger practical problems than the methods known thus far. The new approach decomposes detailed production scheduling for batch production into batching and batch scheduling. The batching problem converts the primary requirements for products into individual batches, where the work load is to be minimized. We formulate the batching problem as a nonlinear mixed–integer program and transform it into a linear mixed–binary program of moderate size, which can be solved by standard software. The batch scheduling problem allocates the batches to scarce resources such as processing units, workers, and intermediate storage facilities, where some regular objective function like the makespan is to be minimized. The batch scheduling problem is modelled as a resource–constrained project scheduling problem, which can be solved by an efficient truncated branch–and–bound algorithm developed recently. The performance of the new solution procedures for batching and batch scheduling is demonstrated by solving several instances of a case study from process industries.

The FReedom from Ischemic Events-New Dimensions for Survival (FRIENDS) registry: design of a prospective cohort study of patients with advanced peripheral artery disease.

BACKGROUND Advanced lower extremity peripheral artery disease (PAD), whether presenting as acute limb ischemia (ALI) or chronic critical limb ischemia (CLI), is associated with high rates of cardiovascular ischemic events, amputation, and death. Past research has focused on strategies of revascularization, but few data are available that prospectively evaluate the impact of key process of care factors (spanning pre-admission, acute hospitalization, and post-discharge) that might contribute to improving short and long-term health outcomes. METHODS/DESIGN The FRIENDS registry is designed to prospectively evaluate a range of patient and health system care delivery factors that might serve as future targets for efforts to improve limb and systemic outcomes for patients with ALI or CLI. This hypothesis-driven registry was designed to evaluate the contributions of: (i) pre-hospital limb ischemia symptom duration, (ii) use of leg revascularization strategies, and (iii) use of risk-reduction pharmacotherapies, as pre-specified factors that may affect amputation-free survival. Sequential patients would be included at an index "vascular specialist-defined" ALI or CLI episode, and patients excluded only for non-vascular etiologies of limb threat. Data including baseline demographics, functional status, co-morbidities, pre-hospital time segments, and use of medical therapies; hospital-based use of revascularization strategies, time segments, and pharmacotherapies; and rates of systemic ischemic events (e.g., myocardial infarction, stroke, hospitalization, and death) and limb ischemic events (e.g., hospitalization for revascularization or amputation) will be recorded during a minimum of one year follow-up. DISCUSSION The FRIENDS registry is designed to evaluate the potential impact of key factors that may contribute to adverse outcomes for patients with ALI or CLI. Definition of new "health system-based" therapeutic targets could then become the focus of future interventional clinical trials for individuals with advanced PAD.

Optional course "Homeopathically potentised substances: placebos or effective?" for medical students at the University of Bern, Switzerland

Background Apart from compulsory lectures on classical homeopathy (CH), traditional Chinese medicine/acupuncture, neural therapy and anthroposophically extended medicine (AEM), our institute at the University of Bern offers several optional practical courses for medical students. The aim of this course during autumn 2011 and spring 2012 was to discuss basic research, observational and clinical studies in the fields of CH and AEM, so that students i) learned how to read and appraise scientific publications, ii) learned how complementary medicine can be investigated with scientific methods, and iii) were able to form their own opinion about the possible specific effects and effectiveness of homeopathically potentised substances. Methods Introductory lectures on AEM, CH and study design were given to 12 second year medical students. The students appraised 12 research articles and presented the results in class, followed by discussions with experts in the fields of basic and clinical research from our institute. A company producing homeopathic remedies was visited and students could practise potentization procedures and trituration. At the end of the course, students compiled posters with arguments in favour of and against specific effects and effectiveness as well as their own conclusions. The course was evaluated using a written questionnaire with closed and open questions. Results Previous knowledge about CH and AEM was scarce among the students. It slightly increased during the course, and the course itself fostered their interest on the topic. This course was chosen by most students, because they were genuinely interested in the topic (and not because other courses they had wanted to visit were fully booked). The students especially valued the discussions, the various perspectives presented to them, and experiencing a potentization process. Conclusion Medical students were interested to learn more about homeopathically potentised substances. The contradictory study results made it difficult for them to form their own opinion. Apart from appraising articles, the students would have liked to meet and talk to patients.