Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results

INTRODUCTION

Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects.

METHODS

We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates.

RESULTS

Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup.

CONCLUSIONS

Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

Scrotal Hematoma Precipitated by Centrifuge Training in a Fighter Pilot with an Asymptomatic Varicocele

BACKGROUND

Varicocele is quite common in the general population, affecting up to 15% of men. It is not considered disqualifying for the pilot's training program of the Israeli Air Force as long as there are no related symptoms or associated pathologies. During combat flight, increased venous pressure due to acceleration forces and anti-G straining maneuvers, used to counteract high gravitational G forces, can theoretically aggravate the venous blood pooling in varicocele, leading to rupture.

CASE REPORT

We describe a case of a young fighter-jet pilot presenting with a painful inguinal hematoma extending to the scrotum a day after participating in centrifuge training. Sonographic examination demonstrated dilated spermatic veins and intratesticular varicocele along with subcutaneous thickening of the scrotal wall consistent with hematoma.

DISCUSSION

The effects of high G loads on blood flow in spermatic veins, and especially in varicocele, still need to be determined. Varicocele rupture has been described in relation to increased intra-abdominal pressure and could theoretically occur during anti-G straining maneuvers. Such an acute adverse event during combat flight can be detrimental to flight safety and the pilot's well-being.

The relative contribution of urine extravasation to elevate plasma creatinine levels in acute unilateral ureteral obstruction

INTRODUCTION

Rising levels of plasma creatinine in the setting of acute unilateral ureteral obstruction (AUUO) often reflects acute renal failure, mandating kidney drainage. We hypothesize that re-absorption of peri-renal urine extravasation (PUE), a common result of UUO, contributes significantly to the elevation in plasma creatinine, rendering the latter an inaccurate benchmark for renal function. We explored this hypothesis in a rat model of AUUO and PUE.

METHODS

In total, 20 rats were equally divided into 4 groups. Groups 1 and 2 underwent unilateral ligation of the ureter with infiltration of rat's urine (index group) or saline (control) into the peri-renal space. Two additional control groups underwent peri-renal injection of either urine or saline without AUUO. Plasma creatinine levels were determined immediately prior to the procedure (T0), and hourly for 3 hours (T1, T2 and T3). Renal histology was investigated after 3 hours.

RESULTS

Rats in the index group had a significantly greater increase in plasma creatinine levels over 3 hours compared to all other groups (p < 0.05). At T3, average plasma creatinine levels for the index group increased by 96% (0.49 ± 0.18 mg/dL) compared to 46% (0.23 ± 0.06 mg/dL increase) in the AUUO and saline group, and less than 15% rise in both the non-obstructed control groups. Our study limitations includes lack of spontaneous PUE and intraperitoneal surgical approach.

CONCLUSIONS

Absorption of peri-renal urine in the presence of AUUO is a significant contributor to rising plasma creatinine levels, beyond those attributable to the obstruction alone, and may overestimate the extent of the true renal functional impairment.

[Injuries in children and adolescents in emergency services]

BACKGROUND

A differentiated knowledge of trauma in children and adolescents is essential for the treatment of injured minors. The aim of this study was to present the focus of treatment in trauma emergency services.

MATERIAL AND METHODS

Over a period of 2 years all acutely injured children and adolescents (n = 4784) in the emergency service were analyzed prospectively. The data were analyzed according to sex, age, date of examination, indications for x-ray imaging, diagnosis and therapy.

RESULTS

Seasonal differences in the treatment spectrum were detected. In total 34.4 % of the patients presented with bruises/contusions, 23 % wounds, 19.9 % fractures, 14.9 % sprains/strains/ligament ruptures, 4.1 % craniocerebral trauma, 1.5 % dislocations, 1.1 % muscle/tendon injuries and 0.9 % burns. Of the patients 60 % underwent an x-ray examination and 8.3 % were hospitalized. Different injuries were found in the different age groups. Most fractures (25.7 %) were found at the distal forearm and most osteosyntheses (22.5 %) were also carried out at this anatomical location.

CONCLUSION

Knowledge of the frequency and age dynamics is essential for competent treatment of injuries in children and adolescents. Analysis of the reality of the treatment in emergency services allows a much better evaluation of the requirements with respect to this clientele. The collected data can serve as a basis for the development of major capability foci, training concepts, treatment algorithms as well as prevention measures.

[The posterocentral approach to the posterior tibial plateau]

OBJECTIVE

An anatomically preformed approach to the posterior tibial plateau is described. In avulsion fractures of the posterior cruciate ligament (PCL), the aim is to restore stability of the knee joint with functional treatment, while in posterior shearing tibial plateau fractures the aim is to restore anatomical dorsal alignment of the tibia.

INDICATIONS

Avulsion fracture the PCL, posterior shearing tibial plateau fracture.

CONTRAINDICATIONS

Knee infection, compartment syndrome, joint instability, and osteoarthritis in avulsion fractures of the PCL.

OPERATION TECHNIQUE

Supine position, L-shaped skin incision, dissection of the fascia, protection of the sural nerve, separation of the gastrocnemial heads, identification of the neurovascular bundle, retraction of the gastrocnemial heads. Fixation of the bony avulsion using screws. In tibial plateau fractures, dissection of the soleus and popliteus muscle, fracture reduction, and plate fixation.

POSTOPERATIVE MANAGEMENT

Due to the approach no specific treatment necessary. PCL: functional treatment, with knee brace full weight bearing possible, without 20 kg weight bearing using crutches for 4-6 weeks, tibia: CT for postoperative result and planning of the ventral osteosynthesis after about 5 days, then weight bearing 20 kg and functional treatment for 8-12 weeks.

RESULTS

A total of 33 patients were operated using a posterocentral approach, 22 had a posterior shearing tibial plateau fracture, and 11 an avulsion fracture of the PCL. Temporary hypesthesia around the scar, at the lateral foot, and lateral lower leg were observed in 3 patients, each having one (area supplied by the sural nerve). In 3 cases screw tips at the anterior proximal tibia were palpable. The posterocentral approach reveals a low complication rate due to the anatomical approach.

Vergleichend chemische Untersuchungen der Inhaltsstoffe der Pygidialwehrblasen von Carabiden

In Ergänzung zu früheren Arbeiten wurden die Inhaltsstoffe der Pygidialwehrblasen von 69 verschiedenen Laufkäferarten durch Dünnschichtchromatographie, Hochspannungs-Elektrophorese, Gaschromatographie, Massen- und IR-Spektroskopie untersucht. Es zeigte sich, daß neben Ameisensäure, Methacrylsäure und Tiglinsäure auch n-Undecan sowie teilweise n-Decan und n-Tridecan gespeichert werden kann. Als weitere Sekretbestandteile konnten iso-Valerian- und iso-Buttersäure sowie p-Benzochinon, 2-Methyl-p-benzochinon und 2-Methyl-3-methoxy-p-benzochinon und m-Kresol nachgewiesen werden.

Protonenübertragungsreaktionen zweibasischer Säuren in wäßriger Lösung: 3-Hydroxypyridin / Proton Transfer Reactions of Dibasic Acids in Aqueous Solution: 3-Hydroxypyridine

Proton transfer in aqueous solutions of 3-hydroxypyridin (3HP) has been studied by tempera­ture jump relaxation and ultrasound absorption techniques. Two chemical relaxations have been observed. In the range pK1<pH<pK2 the slower of the two processes corresponds to proton transfer between the N and O atoms. A mechanism is proposed which describes the pH and con­centration dependence of the relaxation time measured. Proton transfer involves two types of pro­cesses which operate in parallel: I. pseudomonomolecular, by consecutive diffusion-controlled protonation and deprotonation steps, and 2. bimolecular by diffusion-controlled proton transfer between the neutral 3HP molecule and its corresponding cation or anion. There is no evidence for direct monomolecular proton transfer within the hydration shell of the molecule (k→ ~ k← < 2 × 1O3 sec-1).

[The DRG responsible physician in trauma and orthopedic surgery. Surgeon, encoder, and link to medical controlling]

BACKGROUND

Precise coding is an essential requirement in order to generate a valid DRG. The aim of our study was to evaluate the quality of the initial coding of surgical procedures, as well as to introduce our "hybrid model" of a surgical specialist supervising medical coding and a nonphysician for case auditing.

MATERIALS AND METHODS

The department's DRG responsible physician as a surgical specialist has profound knowledge both in surgery and in DRG coding. At a Level 1 hospital, 1000 coded cases of surgical procedures were checked.

RESULTS

In our department, the DRG responsible physician who is both a surgeon and encoder has proven itself for many years. The initial surgical DRG coding had to be corrected by the DRG responsible physician in 42.2% of cases. On average, one hour per working day was necessary.

CONCLUSION

The implementation of a DRG responsible physician is a simple, effective way to connect medical and business expertise without interface problems. Permanent feedback promotes both medical and economic sensitivity for the improvement of coding quality.

A method for 3D-reconstruction of a muscle thick filament using the tilt series images of a single filament electron tomogram

Myosin interacting-heads (MIH) motifs are visualized in 3D-reconstructions of thick filaments from striated muscle. These reconstructions are calculated by averaging methods using images from electron micrographs of grids prepared using numerous filament preparations. Here we propose an alternative method to calculate the 3D-reconstruction of a single thick filament using only a tilt series images recorded by electron tomography. Relaxed thick filaments, prepared from tarantula leg muscle homogenates, were negatively stained. Single-axis tilt series of single isolated thick filaments were obtained with the electron microscope at a low electron dose, and recorded on a CCD camera by electron tomography. An IHRSR 3D-recontruction was calculated from the tilt series images of a single thick filament. The reconstruction was enhanced by including in the search stage dual tilt image segments while only single tilt along the filament axis is usually used, as well as applying a band pass filter just before the back projection. The reconstruction from a single filament has a 40 Å resolution and clearly shows the presence of MIH motifs. In contrast, the electron tomogram 3D-reconstruction of the same thick filament - calculated without any image averaging and/or imposition of helical symmetry - only reveals MIH motifs infrequently. This is - to our knowledge - the first application of the IHRSR method to calculate a 3D reconstruction from tilt series images. This single filament IHRSR reconstruction method (SF-IHRSR) should provide a new tool to assess structural differences between well-ordered thick (or thin) filaments in a grid by recording separately their electron tomograms.

Thermopower enhancement by encapsulating cerium in clathrate cages

The increasing worldwide energy consumption calls for the design of more efficient energy systems. Thermoelectrics could be used to convert waste heat back to useful electric energy if only more efficient materials were available. The ideal thermoelectric material combines high electrical conductivity and thermopower with low thermal conductivity. In this regard, the intermetallic type-I clathrates show promise with their exceedingly low lattice thermal conductivities. Here we report the successful incorporation of cerium as a guest atom into the clathrate crystal structure. In many simpler intermetallic compounds, this rare earth element is known to lead, through the Kondo interaction, to strong correlation phenomena including the occurrence of giant thermopowers at low temperatures. Indeed, we observe a 50% enhancement of the thermopower compared with a rare-earth-free reference material. Importantly, this enhancement occurs at high temperatures and we suggest that a rattling-enhanced Kondo interaction underlies this effect.

[On differentiation of cod (Gadus morhua L.) groups in Baltic Sea]

Using the AGP*, PGI-1*, PGI-2*, LDH*, IDH*, and PGM* allozyme markers, the differentiation of cod groups during the spawning period in Baltic Sea was evaluated. It was shown that cod samples from the eastern and western parts of Baltic Sea (being statistically significantly different from the cod samples from the Norwegian Sea, Barents Sea, and the Skagerrak Strait) demonstrated a high degree of identity (I = 0.99-1.0), which could be associated with the observed from the beginning of the present millennium increased migration of cod from eastern Baltic regions to the waters of Bornholm basin, and the distribution of the part of migrants from Bornholm basin to Arkona basin.

[ProFI reduction of pediatric pulled elbow]

BACKGROUND

Pulled elbow is a common injury in children under the age of 5 years which is usually treated by manual reduction. Supination of the forearm is recommended as opposed to pronation or other maneuvers. The author has developed a manipulative intervention for reduction of pulled elbow in young children on the basis of the pronation technique and called ProFI reduction.

PATIENTS AND METHODS

The ProFI method was performed on 41 children and the group was analyzed prospectively according to effectiveness of the ProFI repositioning.

RESULTS

Among the 41 children the initial diagnosis was incorrect in 7 cases (17%) and in 11 children (27%) more than one doctor's visit was necessary to reposition successfully. Repositioning with the ProFI method was immediately successful in all cases.

CONCLUSION

The application of the ProFI method as a modified pronation technique was shown to provide excellent effectiveness with respect to the patients treated.

Pre- and post-pandemic prevalence of antibodies to the 2009 pandemic influenza A (H1N1) virus in Austrian adults

Antibody prevalence to the 2009 pandemic influenza A (H1N1) virus was determined in a sample of the Austrian population to assess the post-pandemic seropositivity rate, the infection attack rate, and the proportion of subclinical infections during the 2009/2010 influenza pandemic in Austrian adults. A total of 480 sera from individuals aged between 18 and 57 years from all nine federal states of Austria were collected between April and June 2010. Information on demographic characteristics, vaccination history, and history of suspected or verified influenza virus infection was ascertained. Antibodies were determined using a commercial ELISA and compared with 80 age-matched adult sera collected before the pandemic began. The overall seropositivity rate was 28% and was highest among young adults aged 18-29 years, followed by adults aged 50-57 years. Among seropositive unvaccinated individuals, infection was asymptomatic in more than 80%. Extrapolation to the overall Austrian adult population indicates that more than 1.3 million persons aged 18-57 years became infected in 2009. Compared with the pre-pandemic seropositivity rate, the infection rate was highest among young adults but low in those aged 30-57 years. Among 69 individuals previously vaccinated with the 2009 pandemic influenza A (H1N1) virus, 71% had specific antibodies. The study demonstrates that infection rates based on surveillance of clinical cases considerably underestimated the infection attack rate during the 2009 H1N1 pandemic in Austria and that vaccination against this virus elicited long-lasting seropositivity in more than 70% of adults.

Delays in diagnosis in early trauma care: evaluation of diagnostic efficiency and circumstances of delay

BACKGROUND

Trauma centers, trauma management concepts, damage control surgery and the integration of whole-body CT scanning into early trauma care have reduced mortality in traumatized patients significantly. However, some injuries are still initially missed. In this study, the diagnostic efficiency of early trauma care and the circumstances of delays in diagnosis were evaluated.

MATERIALS AND METHODS

Initially missed diagnoses in 111 traumatized patients were recorded retrospectively. "Primary diagnoses" after the emergency room (ER) phase including CT scanning with immediate data evaluation were compared to "secondary diagnoses" after a secondary survey of the CT data, as well as to discharge diagnoses. Circumstances of delay were assessed according to injury severity score (ISS), hospital admission, mechanism of injury, diagnostics, treatment, time in the intensive care unit, hospitalization and mortality.

RESULTS

73% of the patients arrived at the ER during on-call hours. In 23% of all patients, diagnoses were missed after the ER phase, while in 12% of the patients diagnoses were missed after the secondary survey of the CT data. One half of the missed diagnoses were almost impossible to detect; the other half were judged to be acceptable. During on-call hours, 9% more patients with delays in diagnosis were observed. Injury severity in patients with delays in diagnosis was significantly higher than in patients without.

CONCLUSIONS

Although diagnostic quality in early trauma care has improved, some diagnoses are initially missed. Severely injured patients with life-threatening or potentially life-threatening injuries arriving at the ER during on-call hours were at higher risk for delays in diagnosis. A secondary evaluation of acquired CT data and repetitive examinations are essential.