Adequate Treatment Decisions Research Articles

Early risk stratification of patients after successfully resuscitated out-of-hospital cardiac arrest without ST-segment elevation - the TOMAHAWK risk score

Abstract Background Mortality after out-of-hospital cardiac arrest (OHCA) remains high. Early risk stratification is crucial to make adequate treatment decisions. Existing OHCA risk scores are either medically outdated, limited to registry data, small cohorts, certain healthcare systems only or include complex calculations. Purpose The aim of this study was to develop an easy-to-use, readily available risk prediction score for short-term mortality in patients with successfully resuscitated OHCA without ST-segment elevation, derived from the TOMAHAWK (Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation) trial. Methods The risk score was developed using a backward stepwise regression analysis. The risk score was externally validated in the COACT (Coronary Angiography after Cardiac Arrest Trial) cohort, which included patients with shockable rhythms only. Results Development and validation of the risk score was performed across 50 centres in three countries. Five variables emerged as independent predictors for 30-day mortality and were used as risk score parameters: age ≥72 years, known diabetes, unshockable initial electrocardiogram rhythm, time until return of spontaneous circulation ≥23 minutes and admission serum lactate level above 7.9 mmol/L. Between 1 and 4 points were attributed to each variable, leading to a score with three risk categories: low (0 to 2), intermediate (3 to 6) and high (7 to 10). The observed 30-day mortality rates were 23.6%, 68.8% and 86.2%, respectively (p<0.001) with a very good discrimination at an area under the curve of 0.82. Kaplan-Meier analysis revealed a stepwise increase in mortality between the different risk score categories (p<0.001 for low vs. intermediate, intermediate vs. high and low vs. high; see Figure). External validation in the COACT cohort showed short-term mortality rates of 23.1% (score 0 to 2), 44.8% (score 3 to 6) and 78.9% (score 7 to 10), respectively (each p<0.001). Conclusion The TOMAHAWK risk score can be easily calculated in daily clinical practice and is strongly correlated with mortality in patients with successfully resuscitated OHCA without ST-segment elevation. It may help stratify patient risk for short-term mortality and facilitate clinical decision making.

Early risk stratification of patients with acute myocardial infarction complicated by severe cardiogenic shock - The ECLS-SHOCK Risk Score

Abstract Background Prognosis after acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains dismal. Timely risk stratification is crucial to make adequate treatment decisions. Existing CS scores are limited to either registry data, included not readily available parameters (such as coronary flow after revascularisation, cystatin C or interleukin-6), or are not tailored to patients with AMI-CS. Purpose The aim of this study was to develop a readily available and easy-to-use risk prediction tool for 30-day mortality in patients with severe AMI-CS derived from the ECLS-SHOCK (Extracorporeal Life Support in Infarct-Related Cardiogenic Shock) trial. Methods Backward stepwise regression analysis was used to develop the risk score across 43 centres in two countries. Results Five variables emerged as independent predictors for 30-day mortality and were used as risk score parameters: age ≥69 years, female sex, ≥3 known cardiovascular risk factors (i.e., hypertension, dyslipidaemia, diabetes, smoking or known vascular disease), baseline arterial lactate ≥7.1 mmol/L and performed resuscitation. Between 1 and 7 points were attributed to each variable, resulting in a score with three risk categories: low (0 to 1), intermediate (2 to 3) and high (4 to 7) (Figure). The observed 30-day mortality rates were 23%, 50% and 80% in each risk category (p<0.001) with a good discrimination at an area under the curve of 0.75. A stepwise increase in mortality between the different risk score categories was observed in Kaplan-Meier analyses (p<0.001 for low vs. intermediate, intermediate vs. high and low vs. high; see Figure). Conclusion The ECLS-SHOCK risk score can be easily and promptly calculated in daily clinical practice and correlated with mortality in patients with severe AMI-CS. It may help stratify patient risk for short-term mortality and facilitate early clinical decision making.

Comparison of the AO/OTA 1996/2007 and 2018 pelvic ring fracture classifications.

Pelvic ring fractures may present with relevant mechanical and haemodynamic instability. Classifications of the bony or ligamentous injuries of the pelvic ring are well established. The most common classifications used analyse the injury mechanisms and the resulting instability of the pelvic ring structure. Fracture classifications should be simple and easy to use, comprehensive, andradiographically and anatomically based, resulting in a hierarchical alphanumeric order of types and subtypes and thereby allow adequate treatment decisions based on a high degree of inter- and intraobserver reliability. In 2018 a new AO/OTA pelvic ring fracture and dislocationclassification was published that combined the most commonly used "historical" classification schemes, e.g. the Tile/AO classification and the classification according to Young and Burgess. Compared with these older classifications, several relevant changes were integrated in the 2018 edition. The changes between the AO/OTA 1996/2007 and 2018 classifications were analysed in detail. Overall, several problems were identified regarding the type-B pelvic ring injury classification. These changes may result in difficulties in classifying pelvic ring injuries and thereby prevent relevant comparisons between former and future clinical studies on pelvic injuries.Level of Evidence: V.

Acute bacterial sinusitis: current concepts in antibiotic therapy

Acute rhinosinusitis is a widespread pathology faced by both outpatient doctors and otorhinolaryngologists in hospitals. At the same time, only understanding of the principles for diagnosing various forms of sinusitis, in particular, the criteria for bacterial sinusitis, provides the adequate treatment decisions. Antibacterial therapy plays a key role in the treatment of patients with acute bacterial sinusitis. Additionally, there is an increasing frequency of the antibiotic resistance of the main bacterial pathogens in the respiratory group of diseases. Both in Russian and foreign clinical guidelines, the so-called lines of antibacterial therapy are clearly identified. Strict adherence to the national recommendations and a thorough analysis of clinical and anamnestic data allows a rational approach to the choice of an antibacterial drug. There is an increase in the rate of uncontrolled and inadequate antibacterial therapy, particularly using of penicillins and short course of macrolides, over the last decade. Such trend is dangerous due to the increased risks for the development of the antibiotic resistance to those groups of antibiotics. Use of dispersible forms is one of the key point of the strategies to overcome the antibiotic resistance. The most important features of dispersible forms of antibiotics are prevented destruction in the stomach and maximal absorption in the upper parts of small intestine. It allows to increase the bioavailability of the drug and to minimize the impact on the intestinal microbiome, which reduces the incidence of common adverse reactions from the gastrointestinal tract. According to literature, oral administration of dispersible forms of drugs allows to reach the plasma concentrations similar to those in parenteral administration.

Terrible triad injuries

The complex injury pattern of aposterior elbow dislocation with concomitant radial head and coronoid fractures is usually referred to as a terrible triad injury. Due to the concomitant compromise of several osteoligamentous structures of the elbow joint relevant for stability, these injuries pose aparticularly major challenge to the treating trauma surgeons. For this reason, acareful preoperative analysis of all relevant injury components is mandatory in order to make an adequate treatment decision. In most cases, surgical treatment addressing all elements relevant for stability is necessary to achieve astable and congruent elbow joint. Only this enables early functional follow-up treatment and minimizes the complication rate. Delayed or even insufficient treatment with persistent (sub)dislocation must be avoided at all costs, otherwise there is ahigh risk of serious posttraumatic functional disorders of the elbow with rapid progression of osteoarthritis.

Asthma and Allergy: Unravelling a Tangled Relationship with a Focus on New Biomarkers and Treatment.

Asthma is a major driver of health care costs across ages. Despite widely disseminated asthma-treatment guidelines and a growing variety of effective therapeutic options, most patients still experience symptoms and/or refractoriness to standard of care treatments. As a result, most patients undergo a further intensification of therapy to optimize symptom control with a subsequent increased risk of side effects. Raising awareness about the relevance of evaluating aeroallergen sensitizations in asthmatic patients is a key step in better informing clinical practice while new molecular tools, such as the component resolved diagnosis, may be of help in refining the relationship between sensitization and therapeutic recommendations. In addition, patient care should benefit from reliable, easy-to-measure and clinically accessible biomarkers that are able to predict outcome and disease monitoring. To attain a personalized asthma management and to guide adequate treatment decisions, it is of paramount importance to expand clinicians’ knowledge about the tangled relationship between asthma and allergy from a molecular perspective. Our review explores the relevance of allergen testing along the asthma patient’s journey, with a special focus on recurrent wheezing children. Here, we also discuss the unresolved issues regarding currently available biomarkers and summarize the evidence supporting the eosinophil-derived neurotoxin as promising biomarker.

Hypofractionated radiotherapy combined with targeted therapy or immunotherapy: Dutch survey on current practice, knowledge and challenges

IntroductionWith the introduction of tyrosine kinase inhibitors and systemic antibodies, including immune checkpoint inhibitors, the survival of advanced-stage cancer patients has improved for many tumor types. These patients are increasingly referred for radiotherapy, but it is unclear whether radiotherapy combined with these drugs is safe. No international guidelines exist on whether or how to combine these drugs with radiotherapy. Therefore, we investigated the current clinical practice in the Netherlands regarding hypofractionated radiotherapy in patients using targeted drugs and immunotherapy. Materials and methodsWe sent a survey to all 21 Dutch radiotherapy institutes. Dedicated radiation oncologists, medical oncologists and pulmonologists were asked to fill out the survey. The questions explored their familiarity with the combination of targeted drugs and immunotherapy with radiotherapy, the encountered clinical difficulties and factors influencing treatment decisions. ResultsThe survey was filled out by 54 respondents from 19 different institutes. The median annual number of patients per radiation oncologist referred for radiotherapy when using targeted drugs or immunotherapy was 10 and 15, respectively. Despite this high number, only 11% of the radiation oncologists stated that they had sufficient information (resources) for adequate treatment decision making. Among all physicians, 44% stated that there was insufficient knowledge within their institute regarding this topic. Only 17% stated that there was a multidisciplinary protocol available. The application of radiotherapy treatment adaptations (technique, dose, fractionation, field size) varied widely. Generally, there seemed to be no consensus regarding the expected toxicity of combined drug-radiotherapy treatments and the expected risk of tumor flare upon temporary drug discontinuation. ConclusionThere is no consensus amongst involved medical specialties on expected toxicity. Consequently, it is necessary to perform clinical studies examining the safety of combined drug-radiotherapy treatments, to add radiotherapy to phase I-III clinical trials for new drugs and to incorporate outcomes into multidisciplinary, evidence-based guidelines.

Prognostic Value of Quantitative [18F]FDG-PET Features in Patients with Metastases from Soft Tissue Sarcoma.

Background: Prognostic biomarkers are pivotal for adequate treatment decision making. The objective of this study was to determine the added prognostic value of quantitative [18F]FDG-PET features in patients with metastases from soft tissue sarcoma (STS). Methods: Patients with metastases from STS, detected by (re)staging [18F]FDG-PET/CT at Leiden University Medical Centre, were retrospectively included. Clinical and histopathological patient characteristics and [18F]FDG-PET features (SUVmax, SUVpeak, SUVmean, total lesion glycolysis, and metabolic tumor volume) were analyzed as prognostic factors for overall survival using a Cox proportional hazards model and Kaplan–Meier methods. Results: A total of 31 patients were included. SUVmax and SUVpeak were significantly predictive for overall survival (OS) in a univariate analysis (p = 0.004 and p = 0.006, respectively). Hazard ratios (HRs) were 1.16 per unit increase for SUVmax and 1.20 per unit for SUVpeak. SUVmax and SUVpeak remained significant predictors for overall survival after correction for the two strongest predictive clinical characteristics (number of lesions and performance status) in a multivariate analysis (p = 0.02 for both). Median SUVmax and SUVpeak were 5.7 and 4.9 g/mL, respectively. The estimated mean overall survival in patients with SUVmax > 5.7 g/mL was 14 months; otherwise, it was 39 months (p < 0.001). For patients with SUVpeak > 4.9 g/mL, the estimated mean overall survival was 18 months; otherwise, it was 33 months (p = 0.04). Conclusions: In this study, SUVmax and SUVpeak were independent prognostic factors for overall survival in patients with metastases from STS. These results warrant further investigation of metabolic imaging with [18F]FDG-PET/CT in patients with metastatic STS.

Clinical and economic impact of current ALK rearrangement testing in Spain compared with a hypothetical no-testing scenario

BackgroundCurrently biomarkers play an essential role in diagnosis, treatment, and management of cancer. In non-small cell lung cancer (NSCLC) determination of biomarkers such as ALK, EGFR, ROS1 or PD-L1 is mandatory for an adequate treatment decision. The aim of this study is to determine the clinical and economic impact of current anaplastic lymphoma kinase testing scenario in Spain.MethodsA joint model, composed by decision-tree and Markov models, was developed to estimate the long-term health outcomes and costs of NSCLC patients, by comparing the current testing scenario for ALK in Spain vs a hypothetical no-testing. The current distribution of testing strategies for ALK determination and their sensitivity and specificity data were obtained from the literature. Treatment allocation based on the molecular testing result were defined by a panel of Spanish experts. To assess long-term effects of each treatment, 3-states Markov models were developed, where progression-free survival and overall survival curves were extrapolated using exponential models. Medical direct costs (expressed in €, 2019) were included. A lifetime horizon was used and a discount rate of 3% was applied for both costs and health effects. Several sensitivity analyses, both deterministic and probabilistic, were performed in order test the robustness of the analysis.ResultsWe estimated a target population of 7628 NSCLC patients, including those with non-squamous histology and those with squamous carcinomas who were never smokers. Over the lifetime horizon, the current ALK testing scenario produced additional 5060 and 3906 life-years and quality-adjusted life-years (QALY), respectively, compared with the no-testing scenario. Total direct costs were increased up to € 51,319,053 for testing scenario. The incremental cost-effectiveness ratio was 10,142 €/QALY. The sensitivity analyses carried out confirmed the robustness of the base-case results, being the treatment allocation and the test accuracy (sensitivity and specificity data) the key drivers of the model.ConclusionsALK testing in advanced NSCLC patients, non-squamous and never-smoker squamous, provides more than 3000 QALYs in Spain over a lifetime horizon. Comparing this gain in health outcomes with the incremental costs, the resulting incremental cost-effectiveness ratio reinforces that testing non-squamous and never-smoker squamous NSCLC is a cost-effective strategy in Spain.

Improving Interdisciplinary Communication: Barriers and Facilitators for Implementation of Standardized Structured Reporting in Oncology.

Standardized structured reporting (SSR) improves quality of diagnostic cancer reporting and interdisciplinary communication in multidisciplinary team (MDT) meetings, resulting in more adequate treatment decisions and better health outcomes. However, use of SSR varies widely among pathologists, but might be encouraged by MDT members (MDTMs). Our objectives were to identify barriers and facilitators (influencing factors) for SSR implementation in oncologic pathology from the perspective of MDTMs and their determinants. In a multimethod design, we identified influencing factors for SSR implementation related to MDT meetings, using 5 domains: (1) innovation factors, (2) individual professional factors, (3) social setting factors, (4) organizational factors, and (5) political and legal factors. Four focus groups with MDTMs in urologic, gynecologic, and gastroenterologic oncology were conducted. We used an eSurvey among MDTMs to quantify the qualitative findings and to analyze determinants affecting these influencing factors. Twenty-three MDTMs practicing in 9 oncology-related disciplines participated in the focus groups and yielded 28 barriers and 28 facilitators in all domains. The eSurvey yielded 211 responses. Main barriers related to lack of readability of SSR: difficulties with capturing nuances (66%) and formulation of the conclusion (43%); lack of transparency in the development (50%) and feedback processes of SSR templates (38%); and lack of information exchange about SSR between pathologists and other MDTMs (45%). Main facilitators were encouragement of pathologists' SSR use by MDTMs (90%) and expanding the recommendation of SSR use in national guidelines (80%). Oncology-related medical discipline and MDT type were the most relevant determinants for SSR implementation barriers. Although SSR makes diagnostic reports more complete, this study shows important barriers in implementing SSR in oncologic pathology. The next step is to use these factors for developing and testing implementation tools to improve SSR implementation.

Current aspects of neurogenic dysfunctions of the lower urinary tract in multiple sclerosis

HintergrundIn der Routine steht man vor der Aufgabe, neurogene Störungen des unteren Harntraktes (NLUTD) bei Patienten mit Multipler Sklerose (MS) frühzeitig zu erkennen und adäquat zu therapieren. Verschiedene nationale Leitlinien geben dazu sehr unterschiedliche praktische Empfehlungen.Ziel der ArbeitErarbeitung eines einfachen, studienbasierten Algorithmus zum Nachweis von NLUTD bei Patienten mit MS, aus dem sich therapeutische Konsequenzen ableiten lassen.Material und MethodeAls direktes Ergebnis zweier multidisziplinärer Konferenzen wurde eine prospektive, multizentrische Studie initiiert. Deren Ziel war es, statistisch relevante Parameter für die Routinediagnostik von NLUTDs zu identifizieren. Als Goldstandard dienten Auffälligkeiten in der Urodynamik. In drei weiteren Konsensuskonferenzen wurden die Ergebnisse der Studie diskutiert, ein diagnostischer Algorithmus entwickelt und eine Erstlinientherapie konsentiert.Ergebnisse und DiskussionDer vorgeschlagene Algorithmus ermöglichte das Erkennen einer NLUTD bei Patienten mit MS mithilfe von 4 statistisch signifikanten Prädiktoren: (1) dem Restharnvolumen, (2) der Anzahl der Harnwegsinfektionen (HWI) innerhalb der letzten 6 Monate, (3) der standardisierten Miktionsfrequenz und (4) dem Vorhandensein/Fehlen einer Harninkontinenz. Gestützt auf den Algorithmus benötigen ca. 75 % der Patienten keine urodynamische Untersuchung zur First-line-Therapieentscheidung. In 25 % der Fälle sind urodynamische Untersuchungen unerlässlich. Für die Routine notwendigen Assessments sind: die Anamneseerhebung, eine Restharnbestimmung, ein Miktionstagebuch und eine Uroflowmetrie (optional).

A narrative review of lung cancer cytology in the times of coronavirus: what physicians should know.

In the modern era of personalized and precision medicine, lung cancer management needs to be carried out in a multidisciplinary manner. Among other disciplines, also cytopathology is key in diagnosis and treatment management of these patients. Indeed, cytopathology specimens are often the only source of available tissue material for morphological diagnosis and molecular purposes in order to guarantee an adequate treatment decision making, since surgical resection specimens are not available when lung cancer is diagnosed at advanced disease stages. Today, as an effect of the current severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic, cytopathology is reorganizing and reshaping many of its procedures and workflows, in order to ensure the safety of cytopathologists and laboratory personnel. In particular, careful attention should be paid on biosafety procedures when pulmonary cytological specimens are handled. In addition, also molecular cytopathology, that provides relevant information on the molecular status and on the potential sensitivity to target treatments, is undergoing major changes. In this setting, fully automated technologies, requiring minimal hands-on work, may be a valid option. The aim of this narrative review is to keep updated all the different professional figures involved in lung cancer management and treatment on how SARS-CoV-2 is modifying lung cancer cytopathology.

The Neurological Examination in Telemedical Consiles in Stroke Diagnosis

Over the past years, the importance of telemedicine has increased considerably in patient care, also in Germany. In the case of acute neurological symptoms telemedical consultations between rural clinics and expert neurologists in medical centers may shorten the door to needle time and contribute to an adequate treatment decision. Using applied conversation analytic methods we examine the interplay of talking, examining and professional perceiving in a triadic face to screen and face to face constellation. The interactional jobs as well as the multimodal and multimedial practices used by the participants within the collaborative engagement in neurological testing form the central issues of the present paper.

A RETROSPECTIVE ANALYSIS OF 597 ORAL VASCULAR ANOMALIES DIAGNOSED IN A BRAZILIAN POPULATION

Objective To perform an oral vascular anomalies (OVAs) retrospective analysis in a Brazilian population, in order to investigate its frequency distribution, demographic peculiarities and clinical-pathology characteristics. Study Design Data about the sex, age, race, clinical characteristics, location, and histopathologic diagnosis were extracted from cases recorded as OVAs in a reference center in the period between 1970 and 2016. Then, a database was created for analysis in the SPSS 20.0 system, in which they were submitted to a descriptive analysis. Results A total of 14,560 records were analyzed, of which 597 cases were histologically confirmed as OVA, indicating a 4.1% incidence. The lesions were grouped as the following: pyogenic granuloma (n = 454), hemangioma of childhood (n = 57), vascular malformation (n = 37), lymphangioma (n = 20), hemangiolymphangioma (n = 10), vascular thrombus (n = 7), hemangioendothelioma (n = 5), Kaposi sarcoma (n = 5), angiofibroma (n = 1), and hemangioendotheliosarcoma (n = 1). The patients’ sociodemographic profile was predominantly women (64.2%) and white people (48.2%), with a greater occurrence between the second and fourth decades of life. The majority was located in the gingiva or alveolar ridge (42.9%), presenting a red color (50.9%), sessile implantation (42%), soft consistency (44.5%), nodular appearance (38.3%), nonhemorrhagic (42.9%), and asymptomatic (32.8%). Conclusions These lesions particularities knowledge is important for a correct diagnosis and adequate treatment decision.

Consultation on UTUC, Stockholm 2018 aspects of diagnosis of upper tract urothelial carcinoma

PurposeTo summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers.MethodsA scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018.ResultsTumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice.ConclusionsCorrect grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Multiresistant Bacteria - Antibiotic Prescription and Antibiotics of Last Resort

Ascertaining critical indications for antibiotics and rational prescribing can delay and minimize the spread of antibiotic resistance. Room for improvement lies in particular in a stricter indication, in shortening antibiotic treatment and in initiating more targeted therapies with narrow-spectrum drugs. Not all infections due to multidrug-resistant organisms require treatment with reserve drugs. Detailed susceptibility testing together with enhanced knowledge of pharmacokinetics and -dynamics are needed for adequate treatment decisions. There are some new drugs with interesting spectrum of activity in development. The problem of antimicrobial resistance in human medicine, however, must also be seen in the context of "One Health" interactions between various systems including environmental issues and food production.

Risk Stratification for Patients in Cardiogenic Shock After Acute Myocardial Infarction

BackgroundMortality in cardiogenic shock (CS) remains high. Early risk stratification is crucial to make adequate treatment decisions. ObjectivesThis study sought to develop an easy-to-use, readily available risk prediction score for short-term mortality in patients with CS, derived from the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock) trial. MethodsThe score was developed using a stepwise multivariable regression analysis. ResultsSix variables emerged as independent predictors for 30-day mortality and were used as score parameters: age >73 years, prior stroke, glucose at admission >10.6 mmol/l (191 mg/dl), creatinine at admission >132.6 μmol/l (1.5 mg/dl), Thrombolysis In Myocardial Infarction flow grade <3 after percutaneous coronary intervention, and arterial blood lactate at admission >5 mmol/l. Either 1 or 2 points were attributed to each variable, leading to a score in 3 risk categories: low (0 to 2), intermediate (3 or 4), and high (5 to 9). The observed 30-day mortality rates were 23.8%, 49.2%, and 76.6%, respectively (p < 0.0001). Validation in the IABP-SHOCK II registry population showed good discrimination with an area under the curve of 0.79. External validation in the CardShock trial population (n = 137) showed short-term mortality rates of 28.0% (score 0 to 2), 42.9% (score 3 to 4), and 77.3% (score 5 to 9; p < 0.001) and an area under the curve of 0.73. Kaplan-Meier analysis revealed a stepwise increase in mortality between the different score categories (0 to 2 vs. 3 to 4: p = 0.04; 0 to 2 vs. 5 to 9: p = 0.008). ConclusionsThe IABP-SHOCK II risk score can be easily calculated in daily clinical practice and strongly correlated with mortality in patients with infarct-related CS. It may help stratify patient risk for short-term mortality and might, thus, facilitate clinical decision making. (Intraaortic Balloon Pump in Cardiogenic Shock II [IABP-SHOCK II]; NCT00491036)

Advances in MRI around metal.

4 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:972-991.

Plexiform schwannoma involving the trachea and recurrent laryngeal nerve: a case report.

Plexiform schwannoma is an infrequent variant of schwannoma characterized grossly and microscopically by multi-nodular growth. Although plexiform schwannoma has such growth patterns, it is a benign tumor as well as a conventional schwannoma. It rarely infiltrates adjacent organs or arises from the organ itself. In this report, we describe a case in which plexiform schwannoma involved the tracheal wall and left recurrent laryngeal nerve to a great extent. As it was expected to be difficult to achieve complete resection even if the longer tracheal resection were performed, we preserved the trachea and resected as much of the tumor as possible. This report is thought to be the first to describe plexiform schwannoma infiltrating or growing from the trachea. Although the treatment decisions we made might be controversial, we believed we could make an accurate diagnosis and adequate treatment decision through surgery.Electronic supplementary materialThe online version of this article (doi:10.1186/s40792-015-0070-0) contains supplementary material, which is available to authorized users.

Therapy of recurrent or metastatic head and neck squamous cell carcinoma : highlights of the ASCO Meeting 2014

The treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M-HNSCC) requires exceptional interdisciplinary cooperation within the treatment team, as many factors need to be taken into account to come to an adequate treatment decision. Most of these patients need to be treated in a palliative concept, as comorbidities and prior oncologic treatment limit the treatment options. Inhibitors of epidermal growth factor receptor (EGFR) in combination with platinum and 5-fluorouracil (5-FU) may be considered as standard. However, survival rates are poor and new therapeutic approaches and substances are therefore tested continuously. At the annual meeting of the American Society of Clinical Oncology (ASCO) in2014, numerous studies on first- and second-line treatment of R/M-HNSCC were presented. A selection is discussed in this paper, including a report about the combined therapy of cetuximab with established chemotherapies, new results from protocols including small molecules and investigations of mTOR inhibitors.