Surgery and Environmental Influence as Risk-Factors for the Development of Deep Vein Thrombosis in Animal Experiments

The aim of this experimental study was to determine whether deep vein thrombosis (DVT) in animals occurs after osteosynthesis of the femur, and whether a postoperative drop in air pressure increases the frequence of DVT Thus, osteosynthesis of the femur was performed in 10 New Zealand rabbits. Postoperatively a drop in air pressure of 300 hPA was induced. After 40 h in the pressure cabin ascending phlebography was performed (Group A). In a control-group of 10 other rabbits surgery was performed without postoperative drop in air pressure (Group B) while in a second control only the drop in air pressure was induced without surgery (Group C).

The phlebographic studies showed DVT in 4 out of 10 rabbits in group A. In group B there was no demonstrable DVT while in group C one ease of DVT was seen. The difference between group A and group B and C is statistically significant. In conclusion, a rapid drop in air pressure seems to have significant impact on the pathogenesis of DVT in rabbits after osteosynthesis of the femur.

Volume Distribution and Ultrastructure of Platelets in Acute Hog Cholera

Hog cholera is an excellent model to study virus related haemorrhagic diatheses of man, since coagulation parameters and morphology of swine platelets are quite similar to those of man. 15 pigs were infected with hog cholera virus. The volume distribution curves of platelets, immediately stabilized with glutaraldehyde after sampling, indicates a right shift of their peaks after infection, which is due to increase in number of megathrombocytes and aggregates. Electron microscopy shows from the first day p.i. an increase in number of giant platelets, and thrombocytes with multiple dense granules including “bull’s eyes”, more mitochondria, endoplasmic reticulum and Golgi apparatus. These findings indicate an accelerated thrombocytopoiesis, in which more immature platelets appear in the blood stream. The other changes (dilatation of surface connecting system, increase of dense tubular system and microtubuli, formation of aggregates) are obviously due to a release-reaction, following adsorption and phagocytosis of the virus by the platelets. The studies reveal that in the beginning of acute hog cholera platelets already are directly damaged by the virus. Since thrombocytopoiesis cannot match the severe and progredient destruction of platelets, from the second day p.i. marked thrombocytopenia develops. Together with virus-induced endothelial lesions and disseminated intravascular coagulation, as described by us, it causes the haemorrhagic diathesis, typical for terminal stages of acute hog cholera.

Measurement of the ν μ energy spectrum with IceCube-79: IceCube Collaboration

IceCube is a neutrino observatory deployed in the glacial ice at the geographic South Pole. The ν μ energy unfolding described in this paper is based on data taken with IceCube in its 79-string configuration. A sample of muon neutrino charged-current interactions with a purity of 99.5% was selected by means of a multivariate classification process based on machine learning. The subsequent unfolding was performed using the software Truee. The resulting spectrum covers an E ν -range of more than four orders of magnitude from 125 GeV to 3.2 PeV. Compared to the Honda atmospheric neutrino flux model, the energy spectrum shows an excess of more than 1.9 σ in four adjacent bins for neutrino energies E ν ≥ 177.8 TeV . The obtained spectrum is fully compatible with previous measurements of the atmospheric neutrino flux and recent IceCube measurements of a flux of high-energy astrophysical neutrinos.

[Safety culture in orthopedics and trauma surgery : Course concept: interpersonal competence by the German Society for Orthopaedics and Trauma (DGOU) and Lufthansa Aviation Training]

Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3‑column model.

[Reorientation of Medical Procedures Covered by Statutory Accident Insurance]

As of 01/01/2014, the German Statutory Accident Insurance (DGUV) has reorganized inpatient medical procedures. The central element of reorientation is the reorganization of the catalogue of types of accidents and type of medical procedures of hospitalized injured patients in 3 care stages. In addition, the reorientation also concentrates on hospitals with the highest performance and the best qualification and also focuses on severe and most severe injuries.This reorientation is also based on the White Paper of the German Society for Trauma Surgery (DGU), especially on the Trauma Network DGU. The new regulations will be implemented by the state associations of the German Statutory Accident Insurance.The hierarchy of care depends on established admission criteria and the severity of injury. This structuring also refers to special competence in the field of rehabilitation and will lead to the strengthening of multidisciplinary rehabilitation management and workplace-related modules of the healthcare. Overall, the accident insurance institution will place increased demands on their network partners.

[Early Results of Adjuvant Topical Treatment of Recurrent Osteomyelitis with Absorbable Antibiotic Carriers]

Background Treatment of musculoskeletal infections principally consists of radical surgical debridement and systemic administration of antibiotics. Additional local antibiotic therapy is not yet generally established, and lacks evidence-based proof of efficacy. Nonetheless, there are a variety of practical approaches, as most specialised departments are unwilling to forego this option. The established polymethylmetacrylate (PMMA) carrier system has a number of practical disadvantages. This has led to the increased use of absorbable carrier systems, and those based on calcium sulphate have given particularly encouraging results. In this article, we present our experience with this procedure in the treatment of osteomyelitis. There is currently no standard procedure or algorithm for the use of local antibiotic carriers in the treatment of recurrent osteomyelitis. Material and Methods Between February 2014 and May 2015, a total of 93 patients were treated with an absorbable carrier of topical antibiotics based on calcium sulphate. These patients had suffered from a recurrence of osteomyelitis that had been unsuccessfully treated by the primary implantation of a PMMA chain and systemic antibiotics. The treatment algorithm consisted of radical debridement, followed by implantation of a commercial PMMA chain. If no remission of the infection was observed, the chains were surgically removed and replaced with an absorbable carrier system and antibiotics chosen in accordance with the resistogram. Pursuant to the classification of Cierny and Mader, 10 patients were classified as type I, 5 as type II, 55 as type III and 23 as type IV. The mean follow-up period was 11 months. Two carrier systems, Osteoset® and Herafill®, were purchased from Wright Medical Technology Inc., Arlington, TN, USA and Heraeus Medical GmbH, Wehrheim, Germany, respectively. These were used as supplied for tobramycin and gentamycin. In the case of Osteoset, it was also possible to add an additional arbitrary, water-soluble antibiotic. Systemic administration of antibiotics was carried out in parallel in accordance with the resistogram. Results The most common clinical entities were femoral (36 %) and tibial (29 %) osteitis. Vancomycin (38 %) and tobramycin (38 %) were the most frequently used topical antibiotics, followed by gentamycin (17 %), ceftriaxone (4 %), fosfomycin (2 %) and colistin (1 %). Systemic administration of antibiotics was carried out in parallel, in accordance with the resistogram. In 85 % of all patients, remission was achieved. Infections with methicillin-resistant Staphylococcus aureus (MRSA; 62 %) and Pseudomonas aeruginosa (43 %) showed significantly poorer remission rates. The bacterial spectrum was primarily composed of Staphylococcus aureus (28 %), Staphylococcus epidermidis (22 %), Pseudomonas aeruginosa (7 %) and Enterococcus faecalis (5 %), as well as Escherichia coli and Klebsiella oxytoca (4 %). Conclusion Topical adjuvant antibiotic therapy based on an absorbable carrier system offers an expedient extension of the treatment of osteomyelitis. The remission rate of 85 % for recurrent infections encouraged the use of a therapeutic alternative for many patients. We developed an algorithm for the treatment of osteomyelitis, which includes the application of local antibiotics with different compositions and absorbable carriers. We present early results of successful treatment of patients with recurrent osteomyelitis, after futile topical therapy with non-absorbable antibiotic chains.

[Geriatric trauma centers from the idea to implementation. What has been achieved?]

The geriatric trauma working party, a subgroup of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU), focuses on the challenges of geriatric fractures, which are steadily increasing due to demographic changes. Inherent comorbidities implicate perioperative complications leading to loss of mobility and endangered independence followed by an increased burden on the social services. An interdisciplinary approach is required. The geriatric trauma working party defined criteria for interdisciplinary treatment and comprehensive care as well as early rehabilitation in interdisciplinary geriatric fracture centers. By passing an independent audit process these centers can achieve certification as a geriatric trauma center DGU (AltersTraumaZentrum DGU). Certified centers can participate in a recently established geriatric fracture registry which includes an internationally consented data set. Audit and registry enable centers to acquire an international benchmark, ensure permanent improvement in quality and allow participation in health services research.

[Current state of medical care of polytrauma and mass casualty incidents in Germany. Are we well-prepared?]

The white paper on the medical care of the severely injured published in 2006 is a collection of proposals and recommendations concerning structure, organization and equipment for the medical care of severely injured patients. Since its publication 50 networks ( http://www.dgu-traumanetzwerk.de/index ) have been established as part of the trauma network. This and the trauma register have helped to continuously improve the medical care of severely injured patients since 1993 [26]. Numerous studies have documented the progress made in measures required by the trauma network [4, 6]. For example, the mortality rate of severely injured patients has dropped from 25 % to approximately 10 % in the past 15 years. From the register and network data it is difficult to tell how each of these measures is implemented in the participating hospitals, who provides medical treatment to patients when, and how medical care is organized in detail. This is why a survey on medical care for polytrauma and in mass casualty situations was conducted among medical directors in German surgical hospitals who are members of the German Society for Trauma Surgery (DGU). Thanks to the 211 participants (most of whom specialize in orthopedic and trauma surgery) a detailed description of how medical treatment is currently organized and performed could be acquired. The survey showed that care of patients with polytrauma (i.e. medical treatment and management) is important irrespective of the level of training of physicians and of the level of patient treatment in hospitals. The central role of traumatologists was emphasized not only in terms of actual treatment but also as an administrator for organizational and management matters. Almost all hospitals have plans for a mass casualty situation; however, the levels of preparedness show considerable variation. A highly critical view is taken of the new surgical specialists with respect to interdisciplinary and comprehensive emergency medical treatment and casualty care. The survey also revealed the continual conflict between managing costs and maintaining quality and resources. It gives an overview of patient treatment in the transition from preclinical to clinical care and provides insights into the targets achieved, current problems and conflicts.

Constraints on Ultrahigh-Energy Cosmic-Ray Sources from a Search for Neutrinos above 10 PeV with IceCube

We report constraints on the sources of ultrahigh-energy cosmic rays (UHECRs) above 10^{9}  GeV, based on an analysis of seven years of IceCube data. This analysis efficiently selects very high- energy neutrino-induced events which have deposited energies from 5×10^{5}  GeV to above 10^{11}  GeV. Two neutrino-induced events with an estimated deposited energy of (2.6±0.3)×10^{6}  GeV, the highest neutrino energy observed so far, and (7.7±2.0)×10^{5}  GeV were detected. The atmospheric background-only hypothesis of detecting these events is rejected at 3.6σ. The hypothesis that the observed events are of cosmogenic origin is also rejected at >99% CL because of the limited deposited energy and the nonobservation of events at higher energy, while their observation is consistent with an astrophysical origin. Our limits on cosmogenic neutrino fluxes disfavor the UHECR sources having a cosmological evolution stronger than the star formation rate, e.g., active galactic nuclei and γ-ray bursts, assuming proton-dominated UHECRs. Constraints on UHECR sources including mixed and heavy UHECR compositions are obtained for models of neutrino production within UHECR sources. Our limit disfavors a significant part of parameter space for active galactic nuclei and new-born pulsar models. These limits on the ultrahigh-energy neutrino flux models are the most stringent to date.

Minibactenecins ChBac7.Nα and ChBac7. Nβ - Antimicrobial Peptides from Leukocytes of the Goat Capra hircus

Antimicrobial peptides (AMPs) of neutrophils play an important role in the animal and human host defenses. We have isolated two AMPs (average molecular masses of 2895.5 and 2739.3 Da), with potent antimicrobial activity from neutrophils of the domestic goat (Capra hircus). A structural analysis of the obtained peptides revealed that they encompass N-terminal fragments (1-21 and 1-22) of the proline-rich peptide bactenecin 7.5. The primary structure of caprine bactenecin 7.5 had been previously deduced from the nucleotide sequence, but the corresponding protein had not been isolated from leukocytes until now. The obtained caprine AMPs were designated as mini-batenecins (mini-ChBac7.5N and mini-ChBac7.5N), analogously to the reported C-terminal fragment of the ovine bactenecin 7.5 named Bac7.5mini [Anderson, Yu, 2003]. Caprine mini-ChBac7.5N and mini-ChBac7.5N exhibit significant antimicrobial activity against Gram-negative bacteria, including drug-resistant strains of Pseudomonas aeruginosa, Klebsiella spp., Acinetobacter baumannii at a range of concentrations of 0.5-4 M, as well as against some species of Gram-positive bacteria (Listeria monocytogenes EGD, Micrococcus luteus). The eptides demonstrate lipopolysaccharide-binding activity. Similarly to most proline-rich AMPs, caprine peptides inactivate bacteria without appreciable damage of their membranes. Mini-ChBac7.5N and mini-ChBac7.5N have no hemolytic effect on human red blood cells and are nontoxic to various cultured human cells. Therefore, they might be considered as promising templates for the development of novel antibiotic pharmaceuticals. Isolation of highly active fragments of the antimicrobial peptide from goat neutrophils supports the hypothesis that fragmentation of cathelicidin-related AMPs is an important process that results in the generation of potent effector molecules, which are in some cases more active than full-size AMPs. These truncated AMPs may play a crucial role in host defense reactions.

Coccospheres confer mechanical protection: New evidence for an old hypothesis

Emiliania huxleyi has evolved an extremely intricate coccosphere architecture. The coccosphere is comprised of interlocking coccoliths embedded in a polysaccharide matrix. In this work, we performed in-situ scanning electron microscopy based compression tests and conclude that coccospheres have a mechanical protection function. The coccosphere exhibits exceptional damage tolerance in terms of inelastic deformation, recovery and stable crack growth before catastrophic fracture, a feature, which is not found in monolithic ceramic structures. Some of the mechanical features of the coccospheres are due to their architecture, especially polysaccharide matrix that acts as a kind of bio-adhesive. Our data provide strong evidence for the mechanical protection-hypothesis of coccolithophore calcification, without excluding other functions of calcification such as various biochemical roles discussed in the literature.

STATEMENT OF SIGNIFICANCE

Although bio-mechanics of shell structures like nacre have been studied over the past decade, coccospheres present an architecture that is quite distinct and complex. It is a porous cell structure evolved to protect the living algae cell inside it in the oceans, subjected to significant hydrostatic pressure. Despite being made of extremely brittle constituents like calcium carbonate, our study finds that coccospheres possess significant damage tolerance especially due to their interlocking coccolith architecture. This will have consequences in bio-mimetic design, especially relating to high pressure applications.

Value of 3D-volume rendering in the assessment of coronary arteries with retrospectively ECG-gated multislice spiral CT

Purpose: To assess the diagnostic value and measurement precision of 3D volume rendering technique (3D-VRT) from retrospectively ECG-gated multislice spiral CT (MSCT) data sets for imaging of the coronary arteries.

Material and Methods: In 35 patients, retrospectively ECG-gated MSCT of the heart using a four detector row MSCT scanner with a standardized examination protocol was performed as well as quantitative X-ray coronary angiography (QCA). The MSCT data was assessed on segmental basis using 3D-VRT exclusively. The coronary artery diameters were measured at the origin of each main coronary branch and 1 cm, 3 cm and 5 cm distally. The minimum, maximum and mean diameters were determined from MSCT angiography and compared to QCA.

Results: A total of 353 of 525 (67.2%) coronary artery segments were assessable by MSCT angiography. The proximal segments were more often assessable when compared to the distal segments. Stenoses were detected with a sensitivity of 82.6% and a specificity of 92.8%. According to the Bland-Altmanmethod the mean differences between QCA and MSCT ranged from −0.55 to 1.07 mm with limits of agreement from −2.2 mm to −2.7 mm.

Conclusion: When compared to QCA, the ability of 3D-VRT to quantitatively assess coronary artery diameters and coronary artery stenoses is insufficient for clinical purposes.

[Interpersonal competence in orthopedics and traumatology : Why technical and procedural skills alone are not sufficient]

Patient safety has increasingly gained significance as criterion which clinics and doctors will be measured against in terms of ethics and finances. The "human factor" moved into focus regarding the question of how to reduce treatment errors in clinical daily routine. Nevertheless, systematic mediation of interpersonal competences only plays a minor role in the catalogue of requirements for medical specialization and professional training. This is the case not only in orthopedics and traumatology, but in other medical fields as well. At the insistence of DGOU and in cooperation with Lufthansa Flight Training, a training model was initiated, comparable to training models used in aviation. In aviation, apart from the training of procedural and technical abilities, regular soft skills training has become standard in the training of all Lufthansa staff. Several studies confirm that by improving communication, interaction, and teamwork skills not only a reduction of intolerable incidents is observed, but also a positive economic effect. Interpersonal competences should be firmly anchored in orthopedics and traumatology and thus be implemented as third post in specialist training.

Searches for Sterile Neutrinos with the IceCube Detector

The IceCube neutrino telescope at the South Pole has measured the atmospheric muon neutrino spectrum as a function of zenith angle and energy in the approximate 320 GeV to 20 TeV range, to search for the oscillation signatures of light sterile neutrinos. No evidence for anomalous ν_{μ} or ν[over ¯]_{μ} disappearance is observed in either of two independently developed analyses, each using one year of atmospheric neutrino data. New exclusion limits are placed on the parameter space of the 3+1 model, in which muon antineutrinos experience a strong Mikheyev-Smirnov-Wolfenstein-resonant oscillation. The exclusion limits extend to sin^{2}2θ_{24}≤0.02 at Δm^{2}∼0.3  eV^{2} at the 90% confidence level. The allowed region from global analysis of appearance experiments, including LSND and MiniBooNE, is excluded at approximately the 99% confidence level for the global best-fit value of |U_{e4}|^{2}.

[Determination of training costs associated with surgical procedures during specialization as an orthopaedic and trauma surgeon]

BACKGROUND

Trauma surgery is a discipline in which the training phase for specialization requires a technical and time-intensive learning curve, including the repetitive training of manual skills. This results in prolonged operation times and thus elevated costs.

OBJECTIVES

The present study retrospectively examines operations in trauma surgery and orthopaedics at a Munich university hospital according to the required curriculum for further specialist training. The duration of procedures at the various training levels and the resulting costs were compared.

MATERIAL AND METHODS

Based on digital surgical records, more than 2,000 surgical interventions were analysed and checked that they fulfilled the practical requirements. Patients with multiple injuries and polytrauma, in addition to irregularly complex cases, were removed from the calculation to ensure high comparability of the individual cases. This yielded more than 1,000+ cases for evaluation. The per-minute cost was calculated to allow for the translation of operating time into costs.

RESULTS

The study shows a prolonged duration of operating time of 19.75 % when the procedure was conducted by residents. This prolongation can be split into 37 subgroups according to body region and type of procedure. The prolongation of operation time could be quantified as a specific prolongation per cluster, in addition to cumulative prolongation. By including the operating costs, the operation-dependent training costs are shown as an exact sum of Euros.

CONCLUSION

Surgical training of residents costs hospitals the appropriate amounts of time and money and reduces the overall number of procedures performed, justifying special consideration of the financing of training hospitals.

[The Significance of Early Reposition in Patients with Visible Malposition of the Upper Ankle Joint]

Background: Protracted dislocation of the upper ankle joint can lead to substantial damage to the surrounding soft tissue, possibly followed by local complications and longer hospitalisation. Although reposition is usually easy to conduct, it is commonly recommended that this should only be performed by an experienced specialist, as long as there is no neurovascular restriction. There are however no exact data or studies on this problem. The aim of the present study is to examine whether early reposition is of benefit for subsequent treatment. Methods: Retrospective study of all patients in a supra-regional trauma centre during the period from January 2009 to July 2015, with either prehospital reposition of the ankle joint because of visible malposition or documented visible malposition on arrival at hospital. Patients with relevant concomitant injuries elsewhere were excluded. Data on the duration of dislocation were matched with diagnostic findings at the time of hospital admission, the kind of primary care, local complications and the time of hospitalisation, using linear regression analysis and ANOVA calculations. Results: Of a total of 391 patients with a dislocation or a fracture dislocation of the ankle joint within this period, 132 fulfilled the inclusion criteria. These patients were divided into 5 groups on the basis of the time of dislocation. Time to reposition was less than one hour for 39 patients, between one and two hours for 29 patients, between two and six hours for 41 patients, between six and 24 hours for 13 patients and more than 24 hours for 10 patients, all with a visible dislocation. The results on admission showed a significant increase in skin bruises and tension bullae with increasing time of dislocation. A longer time of dislocation was associated with more two stage surgical procedures with external fixators and a decreasing number of single stage procedures. While there was immediate definitive treatment of 79.5 % of the patients in the first group, this figure decreased continuously to 10.0 % in the last group. The number of local complications increased significantly in every group with the duration of dislocation. In particular, the incidence of severe swelling, wound healing disorders, skin necrosis and the need for revision surgery and plastic reconstruction exhibit a significant linear increase within the groups (p < 0.05). The incidence of severe swelling rose from 10.3 % in the first group, to 31.0 % in the second group, to 100 % in the last group. The incidence of wound healing disorders rose from 7.7 to 13.8 to 80 % and the incidence of skin necrosis from 2.6 to 3.5 to 30.0 %. The duration of hospitalisation also exhibited a significant linear increase with group affiliation (p < 0.001), from 8.3 days in the first group to 12.5 days in the second group and 30.5 days in the last group. Conclusion: This study shows the importance of conducting reposition of the ankle joint as soon as possible if there is visible malposition, in order to avoid local complications and longer hospitalisation. If there is visible malposition of the ankle joint, the best procedure is immediate - ideally prehospital - reposition and in-axis splinting, in order to preserve soft tissue.

Minibactenecins ChBac7.Nα and ChBac7. Nβ - Antimicrobial Peptides from Leukocytes of the Goat Capra hircus

Antimicrobial peptides (AMPs) of neutrophils play an important role in the animal and human host defenses. We have isolated two AMPs (average molecular masses of 2895.5 and 2739.3 Da), with potent antimicrobial activity from neutrophils of the domestic goat (Capra hircus). A structural analysis of the obtained peptides revealed that they encompass N-terminal fragments (1-21 and 1-22) of the proline-rich peptide bactenecin 7.5. The primary structure of caprine bactenecin 7.5 had been previously deduced from the nucleotide sequence, but the corresponding protein had not been isolated from leukocytes until now. The obtained caprine AMPs were designated as mini-batenecins (mini-ChBac7.5Nα and mini-ChBac7.5Nβ), analogously to the reported C-terminal fragment of the ovine bactenecin 7.5 named Bac7.5mini [Anderson, Yu, 2003]. Caprine mini-ChBac7.5Nα and mini-ChBac7.5Nβ exhibit significant antimicrobial activity against Gram-negative bacteria, including drug-resistant strains of Pseudomonas aeruginosa, Klebsiella spp., Acinetobacter baumannii at a range of concentrations of 0.5-4 μM, as well as against some species of Gram-positive bacteria (Listeria monocytogenes EGD, Micrococcus luteus). The peptides demonstrate lipopolysaccharide-binding activity. Similarly to most proline-rich AMPs, caprine peptides inactivate bacteria without appreciable damage of their membranes. Mini-ChBac7.5Nα and mini-ChBac7.5Nβ have no hemolytic effect on human red blood cells and are nontoxic to various cultured human cells. Therefore, they might be considered as promising templates for the development of novel antibiotic pharmaceuticals. Isolation of highly active fragments of the antimicrobial peptide from goat neutrophils supports the hypothesis that fragmentation of cathelicidin-related AMPs is an important process that results in the generation of potent effector molecules, which are in some cases more active than full-size AMPs. These truncated AMPs may play a crucial role in host defense reactions.

Comparison of enzyme immunoassays and rapid diagnostic tests for clostridium difficile glutamate dehydrogenase and toxin a + B to toxinogenic culture on a highly selective chromogenic medium

To compare Clostridium. (C.) difficile toxin A/B and glutamate dehydrogenase (GDH) enzyme immunoassays or rapid diagnostic tests to toxinogenic culture on recently described highly selective agar plates. Five hundred consecutive samples sent in for C. difficile diagnostics were tested by toxin A/B enzyme immunoassay (EIA) and rapid diagnostic test (RDT), GDH EIA and RDT, and culture on chromID C. difficile plates for 48 hrs, with toxin testing from culture if the toxin EIA from feces was negative. Samples with discordant results from EIA and RDT were submitted to C. difficile-specific 16S rRNA gene and tcdB PCR. Ninety-two, 88, 31, and 37 samples were positive by GDH EIA, GDH RDT, toxin A/B EIA, and toxin A/B RDT respectively. Seventy-four samples were positive by culture, 54 culture-positive samples were subjected to repeat toxin testing, with an additional 29 samples positive. Thus, there were 60 C. difficile toxin A/B positive samples in total (12 %). Single-step screening with GDH EIA, GDH RDT, toxin A/B EIA, and toxin A/B RDT would have missed seven (12 %), 11 (18 %), 29 (48 %) or 27 (45 %) of all positive samples respectively. Single-step screening with GDH or toxin A/B tests from feces misses a significant proportion of patients compared to toxinogenic culture, putting these patients at risk from undiagnosed C. difficile infection. More data are needed to establish the clinical significance of a positive toxinogenic culture result in the absence of detectable toxin A/B in feces.

[The Summer School of the German Society for Orthopaedics and Traumatology - A Success Story]

Background: It has been known for several years that orthopaedic and trauma clinics suffer from a shortage of young people, due to the substantial loss in attractiveness. The Youth Forum OU has been addressing this problem for many years, by initiating many projects such as the Summer School to counteract this trend. The purpose of this research is to evaluate the success of Summer Schools since 2009. Methods: The Youth Forum OU performed a survey in December 2014 to answer the research question on the basis of an internet-based poll of the student participants in all Summer Schools between 2009 and 2014. Following data cleansing, 121 students and former students were included in the survey. Results: Seventy-two completed questionnaires were collected and included in the evaluation. The survey included 40 % of Summer School participants, with a mean age of 27.3 years (SD ± 2.95); 50 % were female. Participation in the Summer School helped 50 % of the respondents to decide to start advanced study in orthopaedics and/or traumatology (OU). One third of these Summer School participants had already finished a university degree; 100 % are now residents in orthopaedics and/or traumatology. Regardless of prior plans, 87.2 % of participants are now residents in OU. Thirty-three are still students: 78.8 % have already decided to work in OU. The survey also served to identify the factors positively and negatively associated with OU. Unfavourable factors included the reputation of OU, and the difficulty of reconciling family and work. Favourable factors included surgical work and personal experience during university studies. Discussion: The aim of this study was to evaluate whether the efforts of the Youth Forum OU, the German Society for Orthopaedics and Traumatology (DGOU) and the local hospitals lead to increased interest in OU. The answer to this question is positive. This is particularly true for those students who did not plan to become an orthopaedic or trauma surgeon before participating in a Summer School. In conclusion, the efforts to recruit residents for OU by using Summer Schools were successful. Moreover, this research offers approaches to counteract the loss of attractiveness of OU.

[Registries of the German Society for Orthopaedics and Trauma : Overview and perspectives of the DGU and DGOOC registries]

The register network of the German Society for Orthopaedics and Trauma (DGOU) consists of 14 registries that cover the various fields of traumatology and elective orthopedics. In addition to registries that focus on implants and types of diseases without age limitations, there are also registries dealing with special diseases in children and adolescents as well as the special needs of elderly patients with fractures. The registries serve as instruments for outcome research and quality assurance and can be used to develop treatment recommendations on a high level of evidence. The objective of the network is to exchange experience that facilitates the establishment of new registers, to pool expertise and to conserve resources.

Human phosphodiesterase 4D7 (PDE4D7) expression is increased in TMPRSS2-ERG-positive primary prostate cancer and independently adds to a reduced risk of post-surgical disease progression

Background:

There is an acute need to uncover biomarkers that reflect the molecular pathologies, underpinning prostate cancer progression and poor patient outcome. We have previously demonstrated that in prostate cancer cell lines PDE4D7 is downregulated in advanced cases of the disease. To investigate further the prognostic power of PDE4D7 expression during prostate cancer progression and assess how downregulation of this PDE isoform may affect disease outcome, we have examined PDE4D7 expression in physiologically relevant primary human samples.

Methods:

About 1405 patient samples across 8 publically available qPCR, Affymetrix Exon 1.0 ST arrays and RNA sequencing data sets were screened for PDE4D7 expression. The TMPRSS2-ERG gene rearrangement status of patient samples was determined by transformation of the exon array and RNA seq expression data to robust z-scores followed by the application of a threshold >3 to define a positive TMPRSS2-ERG gene fusion event in a tumour sample.

Results:

We demonstrate that PDE4D7 expression positively correlates with primary tumour development. We also show a positive association with the highly prostate cancer-specific gene rearrangement between TMPRSS2 and the ETS transcription factor family member ERG. In addition, we find that in primary TMPRSS2-ERG-positive tumours PDE4D7 expression is significantly positively correlated with low-grade disease and a reduced likelihood of progression after primary treatment. Conversely, PDE4D7 transcript levels become significantly decreased in castration resistant prostate cancer (CRPC).

Conclusions:

We further characterise and add physiological relevance to PDE4D7 as a novel marker that is associated with the development and progression of prostate tumours. We propose that the assessment of PDE4D7 levels may provide a novel, independent predictor of post-surgical disease progression.

Treatment strategies for partial chronic instability of the distal syndesmosis: an arthroscopic grading scale and operative staging concept

INTRODUCTION

The aim of this study was to evaluate three different anatomical reconstruction techniques for the partial chronic isolated instability of the syndesmosis based on own arthroscopic classification criteria.

MATERIALS AND METHODS

A retrospective study was conducted to review 32 patients (15 female, 17 male; average age 41; range 18-71) with isolated partial chronic instability of the syndesmosis. During the arthroscopic examination of the patient, the instability of the syndesmosis was assessed by inserting a dissector of defined size into the distal tibiofibular joint. The lateralization of the fibula in the distal tibiofibular joint was then semi-quantitatively evaluated and classified. In all cases, open reconstructive surgery was carried out at the same time. Depending on the grading of the instability assessed arthroscopically (Grades I-III), one of three different anatomical reconstruction techniques was performed: suture of the anterior inferior tibiofibular ligament (AITFL), ligament repair using periosteal flaps, or autogenous plantaris tendon graft. Patients in all three groups were treated with a screw and an additional preassembled suture-button device. At 8 weeks after surgery, the screw was removed and full weight bearing was allowed. Clinical and radiological follow up were obtained at an average time of 17 months after surgery. Clinical evaluation of the reconstruction techniques was assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) and the Weber Score.

RESULTS

The median AOFAS score was significantly higher than before surgery for all three groups. In addition, the Weber score was significantly lower in all three groups than before surgery, indicating substantial improvement. There were no complications after the arthroscopies and the reconstructive surgeries. But in two cases, suture granuloma occurred within the 17-month window, which was treated with a revision operation and removal of the suture-button device.

CONCLUSION

Depending on the arthroscopic classification of the partial chronic instability of the syndesmosis, the three different anatomical reconstruction techniques potentially provide appropriate treatment options based on the grade of injury.

Evidence for Astrophysical Muon Neutrinos from the Northern Sky with IceCube

Results from the IceCube Neutrino Observatory have recently provided compelling evidence for the existence of a high energy astrophysical neutrino flux utilizing a dominantly Southern Hemisphere data set consisting primarily of ν(e) and ν(τ) charged-current and neutral-current (cascade) neutrino interactions. In the analysis presented here, a data sample of approximately 35,000 muon neutrinos from the Northern sky is extracted from data taken during 659.5 days of live time recorded between May 2010 and May 2012. While this sample is composed primarily of neutrinos produced by cosmic ray interactions in Earth's atmosphere, the highest energy events are inconsistent with a hypothesis of solely terrestrial origin at 3.7σ significance. These neutrinos can, however, be explained by an astrophysical flux per neutrino flavor at a level of Φ(E(ν))=9.9(-3.4)(+3.9)×10(-19)  GeV(-1) cm(-2) sr(-1) s(-1)(E(ν)/100  TeV(-2), consistent with IceCube's Southern-Hemisphere-dominated result. Additionally, a fit for an astrophysical flux with an arbitrary spectral index is performed. We find a spectral index of 2.2(-0.2)(+0.2), which is also in good agreement with the Southern Hemisphere result.