On the dose sensitivity of a new CDMAM phantom

For the technical quality assurance of breast cancer screening protocols several phantoms have been developed. Their dose sensitivity is a common topic often discussed in literature. The European protocol for the quality control of the physical and technical aspects of mammography screening suggests a contrast-detail phantom like the CDMAM phantom (Artinis Medical Systems, Elst, NL). The CDMAM 3.4 was tested with respect to its dose sensitivity and compared to other phantoms in a recent paper. The CDMAM 4.0 phantom provides other disc diameters and thicknesses adapted more closely to the image quality found in modern mammography systems. This motivates a comparison of the two generations using the same exposure parameters. We varied the time-current (mAs) within a range of clinically used values (40-140 mAs). All evaluations were done using automatic evaluation software provided by Artinis (for CDMAM 4.0) and the National Coordinating Centre for the Physics of Mammography, Guildford UK (CDMAM 3.4). We compared the relative dose sensitivity with respect to the different diameters and also computed the IQFinv parameter, which averages over the diameters as suggested in the manual for the phantom. The IQFinv parameter linearly depends on dose for both phantoms. The CDMAM 4.0 shows a more monotonous dependence on dose, the total variation of the threshold thicknesses as functions of the dose are significantly smaller than with the CDMAM 3.4. As the automatic evaluation shows rather different threshold thicknesses for the two phantoms, conversion factors for human to automatic readout have to be adapted.

Flavor Ratio of Astrophysical Neutrinos above 35 TeV in IceCube

A diffuse flux of astrophysical neutrinos above 100 TeV has been observed at the IceCube Neutrino Observatory. Here we extend this analysis to probe the astrophysical flux down to 35 TeV and analyze its flavor composition by classifying events as showers or tracks. Taking advantage of lower atmospheric backgrounds for showerlike events, we obtain a shower-biased sample containing 129 showers and 8 tracks collected in three years from 2010 to 2013. We demonstrate consistency with the (fe:fμ:fτ)⊕≈(1:1:1)⊕ flavor ratio at Earth commonly expected from the averaged oscillations of neutrinos produced by pion decay in distant astrophysical sources. Limits are placed on nonstandard flavor compositions that cannot be produced by averaged neutrino oscillations but could arise in exotic physics scenarios. A maximally tracklike composition of (0:1:0)⊕ is excluded at 3.3σ, and a purely showerlike composition of (1:0:0)⊕ is excluded at 2.3σ.

Development of a general analysis and unfolding scheme and its application to measure the energy spectrum of atmospheric neutrinos with IceCube: IceCube Collaboration

We present the development and application of a generic analysis scheme for the measurement of neutrino spectra with the IceCube detector. This scheme is based on regularized unfolding, preceded by an event selection which uses a Minimum Redundancy Maximum Relevance algorithm to select the relevant variables and a random forest for the classification of events. The analysis has been developed using IceCube data from the 59-string configuration of the detector. 27,771 neutrino candidates were detected in 346 days of livetime. A rejection of 99.9999 % of the atmospheric muon background is achieved. The energy spectrum of the atmospheric neutrino flux is obtained using the TRUEE unfolding program. The unfolded spectrum of atmospheric muon neutrinos covers an energy range from 100 GeV to 1 PeV. Compared to the previous measurement using the detector in the 40-string configuration, the analysis presented here, extends the upper end of the atmospheric neutrino spectrum by more than a factor of two, reaching an energy region that has not been previously accessed by spectral measurements.

Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique

INTRODUCTION

Muscular recovery of structural integrity after arthroscopic Bankart repair using the para- and trans-musculotendinous three-portal technique has not been investigated.

MATERIALS AND METHODS

Twenty-seven athletes [mean age 26.9 years, (group 1; G1)] were prospectively and longitudinally monitored after arthroscopic Bankart repair using the three-portal technique by magnetic resonance imaging (MRI) and specific clinical muscular testing. The muscular integrity was assessed at the subscapularis (SSC) for the para-tendinous anteroinferior portal, the supraspinatus (SSP) for the trans-tendinous suprabicipital portal, and the infraspinatus (ISP) for the trans-tendinous posterior portal. Muscular atrophy was assessed by standardized ratios of transverse and vertical diameters for the SSC and ISP, as defined by cross-sectional area ratios for the SSP. Fatty infiltration was assessed by signal intensity analysis for the upper and lower SSC, SSP, and upper ISP as a ratio with the lower ISP. These parameters were analyzed for pre-operative (T0), 1-year (T1), and 2-year status (T2), and compared to 27 healthy volunteers [mean age 29.4 years, (group 2, G2)].

RESULTS

The structural integrity assessments were performed after 14.8 (T1) and 32.0 months (T2). The SSC analysis revealed no muscular impairments in the upper and lower portions between T0 and T2 or compared to G2. MRI analysis for SSP and ISP showed full muscular recovery without any changes between T0 and T2 or deficits compared to G2. The number of pre-operative dislocations had no influence on the muscular integrity. MR analysis detected signs of overuse syndrome in 15 % at T0, 41 % at T1, and 63 % at T2; 77, 22, and 26 % of patients at T0, T1, and T2, respectively, were symptomatic.

CONCLUSIONS

Arthroscopic Bankart repair using the three-portal technique prevents full muscular integrity for para-tendinous anteroinferior portals at the SSC, the trans-tendinous suprabicipital portal through the SSP, and the trans-tendinous portal through the ISP.

[Medical controlling as medical economical service center. Successful concept for orthopedics and trauma surgery centers?]

The management of patients from administrative admission through the orthopedic-surgical treatment to completion of the billing is complex. Additional challenges originate from the necessity to treat patients in both outpatient and inpatient departments and in more than one medical sector. A superior coordination is essential for a successful cooperation of the various procedures of controlling. The model of a medical controlling department as a service center with effective competence in the management of service and cost, functions as a successful solution to the problem. Central elements of a successful medical economical case management are a well-defined assignment of tasks and definitions of intersections, the integration of health professionals and administrative employees, the utilization of software for process control and the implementation of inlier controlling.

Observation of high-energy astrophysical neutrinos in three years of IceCube data

A search for high-energy neutrinos interacting within the IceCube detector between 2010 and 2012 provided the first evidence for a high-energy neutrino flux of extraterrestrial origin. Results from an analysis using the same methods with a third year (2012-2013) of data from the complete IceCube detector are consistent with the previously reported astrophysical flux in the 100 TeV-PeV range at the level of 10(-8)  GeV cm-2 s-1 sr-1 per flavor and reject a purely atmospheric explanation for the combined three-year data at 5.7σ. The data are consistent with expectations for equal fluxes of all three neutrino flavors and with isotropic arrival directions, suggesting either numerous or spatially extended sources. The three-year data set, with a live time of 988 days, contains a total of 37 neutrino candidate events with deposited energies ranging from 30 to 2000 TeV. The 2000-TeV event is the highest-energy neutrino interaction ever observed.

Clinical use and safety of a novel gentamicin-releasing resorbable bone graft substitute in the treatment of osteomyelitis/osteitis

Objective

A clinical investigation into a new bone void filler is giving first data on systemic and local exposure to the anti-infective substance after implantation.

Method

A total of 20 patients with post-traumatic/post-operative bone infections were enrolled in this open-label, prospective study. After radical surgical debridement, the bone cavity was filled with this material. The 21-day hospitalisation phase included determination of gentamicin concentrations in plasma, urine and wound exudate, assessment of wound healing, infection parameters, implant resorption, laboratory parameters, and adverse event monitoring. The follow-up period was six months.

Results

Systemic exposure to gentamicin after implantation was very low as local gentamicin concentrations were measured in wound exudate after six to ten hours. There were no signs of infectious complication throughout the clinical phase. Four patients had recurrent infections several weeks to months after implantation. The outcome was deemed successful by remission of infection in 16 (80%) of these problematic long-term treated patients. Safety laboratory measurements did not indicate nephrotoxic or hepatotoxic effects.

Conclusions

Local application of calcium sulphate/carbonate bone void filler comprising gentamicin revealed sufficient active local levels of the antibiotic by simultaneous significant low systemic exposure in patients with mostly chronic osteomyelitis/osteitis. The material was safe and well tolerated.

Cite this article: Bone Joint Res 2014;3:223–9.

[Preclinical treatment of multiple trauma : what is important?]

Multiple trauma is still the most common cause of death in the age group below 40 years but rarely occurs in prehospital emergencies in Germany. Therefore, personal experience of emergency physicians in prehospital treatment of multiple trauma is often limited. Priority-based therapy according to standardized algorithms and advances in clinical and intensive care have reduced hospital mortality down to 13 %. Time factors, treatment and transport by Helicopter Emergency Medical Services seem to have had a significant impact on the outcome. The current German multiple trauma S3 guidelines provide algorithms for preclinical treatment. The underlying scientific evidence in this respect is, however, low.

Hg-Coordination Studies of Cysteine Containing Oligopeptides

In order to study the interaction of cysteine containing peptide chains with Hg(II) the nuclear quadrupole interaction (NQI) of 199mHg in the Hg complex of the oligopeptide Alanine-Alanine-Cysteine-Alanine-Alanine (AACAA) was determined by time differential perturbed angular correla-tion. Different 199mHg-NQI’s for free and resin-bound AACAA were obtained. Furthermore, the 199mHg-NQI’s are influenced by the Hg:AACAA stoichiometry.

No virological evidence for an influenza A - like virus in European bats

New members of the influenza A virus genus have been detected recently in bats from South America. By molecular investigations, using a generic real-time RT-PCR (RT-qPCR) that detects all previously known influenza A virus subtypes (H1-H16) and a newly developed RT-qPCR specific for the South American bat influenza-like virus of subtype H17, a total of 1571 samples obtained from 1369 individual bats of 26 species from Central Europe were examined. No evidence for the occurrence of such influenza viruses was found. Further attempts towards a more comprehensive evaluation of the role of bats in the ecology and epidemiology of influenza viruses should be based on more intense monitoring efforts. However, given the protected status of bats, not only in Europe, such activities need to be embedded into existing pathogen-monitoring programs.

The importance of genetic susceptibility in Dupuytren's disease

Dupuytren's disease (DD) is a progressive fibromatosis that causes the formation of nodules and cords in the palmar aponeurosis leading to flexion contracture of affected fingers. The etiopathogenesis is multifactorial with a strong genetic predisposition. It is the most frequent genetic disorder of connective tissues. We have collected clinical data from 736 unrelated individuals with DD who underwent surgical treatment from Germany and Switzerland. We evaluated a standardised questionnaire, assessed the importance of different risk factors and compared subgroups with and without positive family history. We found that family history clearly had the strongest influence on the age at first surgery compared to environmental factors, followed by male sex. Participants with a positive family history were on average 55.9 years of age at the first surgical intervention, 5.2 years younger than probands without known family history (p = 6.7 × 10(-8) ). The percentage of familial cases decreased with age of onset from 55% in the 40-49 years old to 17% at age 80 years or older. Further risk factors analysed were cigarettes, alcohol, diabetes, hypertension, and epilepsy. Our data pinpoint the importance of genetic susceptibility for DD, which has long been underestimated.

Forms of energy delivery during cryo-cooled radiofrequency ablation for optimization of the ablation result

PURPOSE

Energy transfer from radiofrequency (RF) applicator to tissue is both precondition and limiting factor. The purpose of this ex vivo study was to examine the influence of form of energy delivery on ablation result during RF ablation with cryo-cooled applicators.

MATERIALS AND METHODS

One hundred eight ablations were performed in ex vivo bovine liver under continuous energy delivery (A), pulsed energy delivery with reduced current during ablation pause (B) and impedance-dependent energy delivery. Maximum ablation time was 20 min. Early termination of ablation in case of loss of conductivity. Optimal ablation parameters were assessed. Short axis diameter of the ablation zone and ablation duration were determined. Ablation results under mode A, B and C were compared with analysis of variance and Tukey-Kramer HSD test. Influence of ablation duration on short axis diameter was evaluated with regression analysis.

RESULTS

Significantly largest short axis diameter (51.1 mm ± SD 2.3; p = 0.01) was reached with impedance-dependent energy delivery (pulsed: 46.1 mm ± SD 5.6; continuous: 44.4 mm ± SD 4.1). Significantly longest ablation duration (1061.6 s ± SD 42.4; p = 0.01) was reached with impedance-dependent energy delivery (pulsed: 815.7 s ± 41.3; continuous: 715.3 s ± SD 82.2). Linear correlation between ablation duration and short axis diameter was calculated (R = 0.7).

CONCLUSION

Modification of energy delivery during RF ablation with cryo-cooled applicators improves energy transfer to tissue and enables larger ablation zones.

KEY POINTS

• Impedance-dependent energy delivery prevents early termination in kryo-based RF-ablation,• Impedance-dependent energy delivery enables larger ablation zones than continuous energy delivery,• Reduced current during ablation pause does not improve ablation results.

[The first wave of the German Health Interview and Examination Survey for Adults (DEGS1): sample design, response, weighting and representativeness]

The "German Health Interview and Examination Survey for Adults" (DEGS) is part of the health monitoring program of the Robert Koch Institute (RKI) and is designed as a combined cross-sectional and longitudinal survey. The first wave (DEGS1; 2008-2011) comprised interviews and physical examinations. The target population were 18- to 79-year olds living in Germany. The mixed design consisted of a new sample randomly chosen from local population registries which was supplemented by participants from the "German National Health Interview and Examination Survey 1998" (GNHIES98). In total, 8,152 persons took part, among them 4,193 newly invited (response 42%) and 3,959 who had previously taken part in GNHIES98 (response 62%). 7,238 participants visited one of the 180 local study centres, 914 took part in the interview-only programme. The comparison of the net sample with the group of non-participants and with the resident population of Germany suggests a high representativeness regarding various attributes. To account for certain aspects of the population structure cross-sectional, trend and longitudinal analyses are corrected by weighting factors. Furthermore, different participation probabilities of the former participants of GNHIES98 are compensated for. An English full-text version of this article is available at SpringerLink as supplemental.

Evidence for high-energy extraterrestrial neutrinos at the IceCube detector

We report on results of an all-sky search for high-energy neutrino events interacting within the IceCube neutrino detector conducted between May 2010 and May 2012. The search follows up on the previous detection of two PeV neutrino events, with improved sensitivity and extended energy coverage down to about 30 TeV. Twenty-six additional events were observed, substantially more than expected from atmospheric backgrounds. Combined, both searches reject a purely atmospheric origin for the 28 events at the 4σ level. These 28 events, which include the highest energy neutrinos ever observed, have flavors, directions, and energies inconsistent with those expected from the atmospheric muon and neutrino backgrounds. These properties are, however, consistent with generic predictions for an additional component of extraterrestrial origin.

[Image-guided therapy with closed MRI: an update]

STANDARD RADIOLOGICAL METHODS

Standard imaging modalities for percutaneous minimally invasive therapy are ultrasound, fluoroscopy and computed tomography.

METHODICAL INNOVATIONS

Magnetic resonance imaging is becoming increasingly more popular for minimally invasive procedures. The advantages are high soft-tissue contrast, the possibility of free selection of multiple imaging slices, multiple tools for intrainterventional monitoring and the absence of ionizing radiation for the patient and the interventional radiologist.

ACHIEVEMENTS

Magnetic resonance imaging is a promising imaging modality for minimally invasive procedures. The most common clinical applications are thermoablative procedures for treatment of hepatic, renal and prostatic malignancies.

First evidence of protein profile alteration due to the main cocaine metabolite (benzoylecgonine) in a freshwater biological model

Illicit drugs represent not only a great social problem but are also considered an environmental problem because their use and, often, abuse release large amounts of parent compounds, and especially their metabolites, into freshwaters. One of the most commonly used drugs is cocaine, which is the second most prevalent drug in Europe (accounting for almost 30% of all cocaine users worldwide). Cocaine is rapidly metabolised in humans to benzoylecgonine (35-54%), ecgonine methyl ester (32-49%) and norcocaine (5%), which are eliminated in the urine and are only partially removed by wastewater treatment plants (WWTPs). Because no studies have previously been carried out to evaluate the possible risks due to cocaine and its metabolites in non-target organisms, we applied a multi-disciplinary approach to investigate the possible environmental risk related to benzoylecgonine (BE), the main metabolite of cocaine. Previous studies carried out by means of a biomarker suite and the redox-proteomic approach showed an imbalance of anti-oxidant enzyme activities and several genotoxic effects to be caused by environmental BE concentrations in the freshwater bivalve Zebra mussel (Dreissena polymorpha). This report presents the results obtained in the last step of this study, based on a proteomics analysis. We analysed the protein expression profile in the gills of Zebra mussels exposed to two different concentrations (0.5 and 1 μg/L) of BE for 14 days through 2-DE and mass spectrometry analysis (RP-UPLC ESI-LTQ-Orbitrap). Our results highlight significant changes in some proteins in gill cells whose functions are crucial for overall metabolism. In particular, we detected a probable effect of BE on calcium homeostasis and a consequent imbalance of oxidative stress, as verified for vertebrates.

Promising results after the treatment of simple and complex distal humerus type C fractures by angular-stable double-plate osteosynthesis

INTRODUCTION

The aim of this study was to evaluate the functional results and complications following open reduction and internal fixation of distal humerus type C fractures (AO classification) using an anatomically precontoured, angular-stable double-plate system.

PATIENTS AND METHODS

The study is a retrospective analysis of 45 patients with 46 type C fractures. There was one C1, eight C2 and 31 C3 fractures. Twelve fractures were open (Gustilo classification). Follow-up was performed on 38 patients with 39 fractures (84%) after 14 months (range, 12-22). The mean age was 50 years (range, 14-87). Functional results were evaluated using the Mayo Elbow Performance Score (MEPS); the Disabilities of the Arm, Shoulder and Hand score (DASH); and range-of motion (ROM) measurements. Complications were classified as minor or major, and the postoperative and follow-up X-rays were analyzed.

RESULTS

Thirty-four fractures were considered stable to allow early physical therapy. With a mean MEPS of 85 points, 36 results (36/39 [92%]) were rated as excellent or good. The mean DASH was 22.5 points, and the ROM for extension-flexion was 105° (range, 50-145). Sixteen major complications (eventually coexistent: 6 × implant failure, 3 × non-union, 6 × stiffness, 2 × necrosis capitulum, 4 × failure olecranon osteotomy refixation) and two minor complications were recorded in 17 patients. These adverse events led to 14 revision surgeries (14/39 [36%]). Except for extension deficit, no statistically significant differences were found between the articular simple and articular complex fractures and when comparing the results between patients with and without a major complication.

CONCLUSION

The anatomically precontoured and angular-stable double-plate system provides sufficient immediate postoperative stability to allow early physiotherapy, even in C3-type fractures. Excellent or good results could be achieved in the vast majority of patients, independent on having suffered a complication or not. Complication rates were remarkably high, emphasizing the difficulties associated with this rare type of fracture.

LEVEL OF EVIDENCE

Level IV Retrospective study.

Measurement of atmospheric neutrino oscillations with IceCube

We present the first statistically significant detection of neutrino oscillations in the high-energy regime (>20 GeV) from an analysis of IceCube Neutrino Observatory data collected in 2010 and 2011. This measurement is made possible by the low-energy threshold of the DeepCore detector (~20 GeV) and benefits from the use of the IceCube detector as a veto against cosmic-ray-induced muon background. The oscillation signal was detected within a low-energy muon neutrino sample (20-100 GeV) extracted from data collected by DeepCore. A high-energy muon neutrino sample (100 GeV-10 TeV) was extracted from IceCube data to constrain systematic uncertainties. The disappearance of low-energy upward-going muon neutrinos was observed, and the nonoscillation hypothesis is rejected with more than 5σ significance. In a two-neutrino flavor formalism, our data are best described by the atmospheric neutrino oscillation parameters |Δm(32)(2)|=(2.3(-0.5)(+0.6))×10(-3) eV(2) and sin(2)(2θ(23))>0.93, and maximum mixing is favored.

[Treatment of septic olecranon and patellar bursitis by excision and vacuum-assisted closure therapy]

BACKGROUND

Treatment of septic olecranon and patellar bursitis differs considerably and is currently under discussion. We therefore performed a retrospective study of our patients with septic bursitis in the past 5 years.

PATIENTS AND METHOD

Between March 2007 and February 2012 we treated 79 patients with septic olecranon (n = 43) and patellar (n = 36) bursitis surgically: 61-males, 18 females, age 51 (range: 11-91) years. Four patients had not been treated before, 25 had suffered recurrences after 1-10 previous procedures, and 9 patients had not improved after conservative therapy. 34 patients presented with traumatic rupture or fistula of their bursae. In all cases we performed a radical bursectomy and vacuum-assisted therapy for 4 to 5 days. In addition, patients received systemic antibiotics. We phoned all patients and were successful in 57 cases (72 %). We questioned these patients for range of movement, limitations at work, pain, sensibility disorder, satisfaction with the result and further surgical procedures. In all cases we took tissue specimens for cultures, in 48 preparations histological examination was performed.

RESULTS

Microbiological and histological results are discussed in detail. 40 patients were free of complaints, 15 complained of mild pain, 54 of 57 had unlimited range of motion. Minor discomforts at desk work were reported by 5 of 43 patients, 12 out of 36 patient reported discomfort when performing on their knees. There was no recurrence in the period of investigation.

CONCLUSION

We recommend our treatment concept for septic olecranon and patellar bursitis because patient satisfaction is high and recurrences are reliably avoided. The soft tissue is spared, so that plastic covering procedures are seldom necessary.

[Simple pelvic fracture - presentation of life-threatening complications and their therapy]

The risk of life-threatening bleeding in stable pelvic-ring fractures is often underestimated. The angioembolisation is, in these cases, an important treatment option. Two case reports illustrate the risks of such haemorrhagic complications in stable pelvic-ring fractures and their immediate treatment. The fracture itself can often be treated conservatively and does not require treatment in a trauma centre. However, in the case of haemorrhage complications such treatment seems to be essential.