Primary Ureteroscopy without Pre-Stenting for Proximal Ureteral Stones-Is It Feasible?

BACKGROUND

Primary ureteroscopy with laser lithotripsy is the treatment of choice for distal ureteral stones. However, in cases of proximal ureteral stones, some urologists recommend the preliminary insertion of a ureteral stent and deferred ureteroscopy. We aimed to evaluate the necessity of preliminary ureteral stent insertion in the management of proximal ureteral stones by comparing the surgical outcomes of patients undergoing primary ureteroscopy with laser lithotripsy for proximal vs. distal ureteral stones.

METHODS

Medical records of patients who underwent ureteroscopy between 2016 and 2017 in our institution were retrospectively reviewed. Data collected included demographic data, stone size, renal function, intra- and post-operative complications, and stone-free rate (SFR). Patients were divided into two groups: proximal ureteral stones and distal ureteral stones.

RESULTS

The cohort included 241 patients who underwent ureteroscopy. Among them, 106 had a proximal ureteral stone. The median age was 51 (IQR 41-65) years. Patients who underwent ureteroscopy for proximal ureteral stones were significantly older (p = 0.007). The median stone's maximal diameter was 7 (5-10) mm. The complication rate and stone-free rate (SFR) were similar in both groups (p = 0.657 and p = 1, respectively). The prevalence of post-procedural ureteral stent insertion was higher among patients who underwent ureteroscopy for proximal ureteral stones: 92.5% vs. 79.3% (p = 0.004).

CONCLUSIONS

Our study concludes that primary ureteroscopy with laser lithotripsy for proximal ureteral stones is a valid and feasible treatment with a similar surgical outcome compared to distal ureteral stones. Preliminary ureteral stent insertion seems to be unnecessary.

Quality of life with tandem ureteral stents compared to percutaneous nephrostomy for malignant ureteral obstruction

PURPOSE

Malignant ureteral obstruction (MUO) is treated with kidney decompression by a percutaneous nephrostomy (PCN) or internal ureteral stents. The objective of this study was to compare quality of life (QoL) with a PCN compared to tandem ureteral stents (TUS) in cases of MUO.

METHODS

We reviewed the medical records of patients with MUO who were treated by PCN/TUS in our institution between June 2019 and May 2020. Patients were asked to fill out a QoL questionnaire, a tube-symptoms questionnaire, report a general health scale, and asked for a drain preference if they had experience with both drains. Scores of both groups were compared and predictors of all QoL and tube-symptoms measures were searched using multivariate analysis.

RESULTS

Seventy-four patients with a PCN and 30 with TUS were included in the study. No statistically significant difference was found in all QoL and tube-symptoms measurements between the two drains. Type of drain was not found to be a predictor of QoL or tube-related symptoms. Eighty-four percent of patients (11/13) who have experience with both types of drains preferred TUS.

CONCLUSION

TUS and PCN for relief of MUO have a negative and similar effect on various areas of QoL and urinary symptoms. Most patients who had experience with both types of drains preferred TUS over PCN. In this patient population with a grim prognosis, this negative effect must be communicated to patients, and calculated against the potential benefits of drainage.

Comparison of long-term results following ureteroscopic stone fragmentation with removal versus stone dusting without removal

Purpose:

To compare long-term results following ureteroscopic stone fragmentation and removal versus stone dusting.

Methods:

We conducted a retrospective analysis of patients who underwent ureteroscopy for renal calculi at two high-volume tertiary centres between 2012 and 2013, therefore allowing long-term follow-up. The surgeons differed in their technique, some performing dusting for the most part and the others fragmentation. Inclusion criteria were stone free at the first follow-up and the sole use of laser lithotripsy is either by dusting or by fragmentation. Operative and post-operative data as well as re-treatment rates were compared between the groups. Stone-free rates and long-term stone recurrence rates were analysed by a single radiologist blinded to the treatment technique.

Results:

Between 2012 and 2013, 669 ureteroscopies were performed at both centres. The study group included 100 patients, which met the inclusion criteria, equally distributed between dusting and fragmentation. The cumulative stone diameter in patients treated with dusting was significantly larger (12.7 mm versus 17 mm, p = 0.006). Operative time was shorter in patients treated with dusting (56 minutes versus 47.2 minutes, p = 0.6). The mean follow-up was 58.9 (standard deviation (SD) 17.2) and 69.4 (SD 13.8) months for the fragmentation and dusting-treated patients, respectively( p = 0.06). The long-term recurrence rate in the fragmentation group was 22% compared to 38% in the dusting group ( p = 0 .08). Most of the patients in the dusting group required a repeat ureteroscopy during their follow-up (28% versus 6%, p = 0.003). A multivariable logistic regression analysis revealed that the fragmentation was not associated with a lower stone recurrence rate when compared to dusting (OR 0.6, 95% CI 0.199-1.810, p = 0.3).

Conclusions:

The recurrence rate of renal stones was not significantly influenced by the choice of surgical techniques. However, dusting was associated with a greater need for repeat ureteroscopy than fragmentation with removal.

Level of evidence:

Not applicable

[UPPER TRACT UROTHELIAL CARCINOMA]

Upper tract urothelial carcinoma is a relatively rare malignancy, but with an increasing prevalence. The main risk factor for the disease is smoking. The most common presentation is hematuria or flank pain. Workup is made by imaging of the upper tract - CTU/MRU (Computed Tomography-Urography/Magnetic resonance (MR) urography) and diagnostic uretero-nephroscopy with biopsy. In the past several years there is major advancement in our understanding of the disease and how to treat it, mainly in nephron-sparing treatments. A risk-stratification is usually conducted according to parameters such as tumor size, distribution, and pathologic diagnosis. The low-risk group is usually offered nephron-sparing treatments such as segmental ureterectomy, endoscopic treatments, and lately - local chemotherapy. The high-risk group is usually offered radical resection of the kidney and ureter, with the possible addition of new-adjuvant and adjuvant treatments. In this article we will review the epidemiology, risk factors, diagnosis, and treatment of this malignancy, with a distinction between the risk groups.

Endoscopic management of upper tract urothelial carcinoma-tips and tricks

Ureteroscopic methods have been rapidly evolving in the last several decades. With advances in flexible devices, optics and laser technologies, the endourologic surgeon has now the tools to treat high-volume tumors, in difficult locations, with good oncologic outcome. This makes radical nephroureterectomy unnecessary in some cases. Endoscopy in the setting of UTUC will surely continue to evolve and become applicable to a wider selection of patients. In this review we describe the surgical technique and provide tips and tricks which we use in our practice of endoscopic retrograde treatment of upper-tract urothelial carcinoma.

Is it safe to use a ureteral access sheath in an unstented ureter?

Background

The aim of this study was to examine ureteral stricture rate after the use of UAS in an unstented ureter and compare complications of smaller vs. larger-caliber UAS.

Methods

We conducted a retrospective analysis of consecutive RIRS for renal stones, with the use of UAS in unstented ureters. We excluded cases with previous ureteroscopies, who carried ureteral stent or nephrostomy, had impacted stones, underwent radiation treatment, or had urinary tract malignancies. The primary outcome was formation of ureteral strictures diagnosed by hydronephrosis in ultrasound test and late secretion in dynamic renal scan. Secondary outcome was stone-free-rate (SFR) and complications. In addition, we compared safety and efficacy of smaller (9.5/11.5Fr) vs. larger-caliber (12/14Fr) UAS.

Results

The cohort included 165 patients with a median follow-up time of 115 days. There was no case of ureteral stricture formation after the use us UAS, despite using a larger-caliber UAS in nearly half the cases. Larger-caliber UAS was not associated with more complications compared to the smaller-caliber one (p = 0.780). SFR was non-significantly higher in the larger-caliber UAS group (p = 0.056), despite having a larger stone burden, and only stone number was associated with SFR (p = 0.003).

Conclusions

These data suggest that the use of UAS during RIRS in an unstented ureter is safe and does not involve ureteral stricture formation after one procedure. Furthermore, the use of wider sheaths was not found to be associated with higher complications rate.

Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study

BACKGROUND

To compare quality of life (QoL) indices between ureteral stent (DJS) and nephrostomy tube (PCN) inserted in the setting of acute ureteral obstruction.

METHODS

Prospective bi-centered study. Over the span of 2 years, 45 DJS and 30 PCN patients were recruited. Quality of life was assessed by 2 questionnaires, EuroQol EQ-5D and 'Tube symptoms' questionnaire, at 2 time points (at discharge after drainage and before definitive treatment).

RESULTS

Patients' demographics and pre-drainage data were similar. There were no clinically significant differences in patient's recovery between the groups, including post procedural pain, defeverence, returning to baseline renal function, and septic shock complications. More DJS patients presented to the emergency room with complaints related to their procedure compared to PCN patients. At first, DJS patients complained more of urinary discomfort while PCN patients had worse symptoms relating to mobility and personal hygiene, with both groups achieving similar overall QoL score. At second time point, PCN patients' symptoms ameliorated while symptoms in the DJS group remained similar, translating to higher overall QoL score in the PCN group.

CONCLUSIONS

The two techniques had a distinct and significantly different impact on quality of life. Over time, PCN patients' symptoms relieve and their QoL improve, while DJS patients' symptoms persist. Specific tube related symptoms, and their dynamics over time, should be a major determinant in choosing the appropriate drainage method, especially when definitive treatment is not imminent.

Practice patterns of ureteral access sheath during ureteroscopy for nephrolithiasis: a survey among endourologists worldwide

Background

The use of ureteral access sheath (UAS) during ureteroscopy is controversial. We aimed to explore practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists worldwide.

Methods

A 15-question survey was designed using the SurveyMonkey® platform. The questions covered the background and professional experience of the potential respondents, indications for UAS insertion, UAS caliber and possible complications associated with its use.

The questions were anonymously tabulated in order to determine practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists.

The survey was then distributed via e-mail to all the Endourological Society members.

Results

216 members responded. 99.53% of the respondents practice as endourologists, 63.4% are fellowship trained and 74.4% are at least 6 years post-fellow. 73.2% practice in an academic facility. 77.3% perform at least 100 ureteroscopies annually. 46 and 76% routinely use UAS for the treatment of ureteral and kidney stones, respectively. In both cases, the 12/14 access sheath is the most common. 42% use UAS in primary ureteroscopy. 90.3% believe that a double J stent insertion is not mandatory prior to UAS insertion. 79.1% think the use of UAS does not increase postoperative complications rate, and if the latter does encounter, then most likely it is either a ureteral stricture (93.2%) or pain (48%).

Conclusions

UAS is commonly used by highly skilled endourologists during ureteroscopy. 12/14 UAS is mostly used. Ureteral stricture and post-operative pain are proposed as possible complications following UAS introduction, however pre-stenting is not mandatory as overall low complication rate is expected.

Major histocompatibility complex genes partly explain early survival in house sparrows

Environmental factors and genetic incompatibilities between parents have been suggested as important determinants for embryonic mortality and survival. The genetic set-up of the immune system, specifically the highly polymorphic major histocompatibility complex (MHC) may also influence individual resistance to infections. MHC proteins are important for an appropriate adaptive immune response and enable T-cells to separate 'self' from 'non-self'. Here we investigate the importance of MHC functional diversity for early development in birds, more specifically, if offspring survival and body mass or size depends on number of different functional MHC alleles, specific functional MHC alleles or similarity of MHC alleles in the parents. Unhatched eggs are common in clutches of many bird species. In house sparrows (Passer domesticus), embryo and nestling mortality can exceed 50%. To control for environmental factors, our study was carried out on an aviary population. We found that one specific functional MHC allele was associated with reduced nestling survival, which was additionally supported by lower body mass and a smaller tarsus when nestlings have been 6 days old. Another allele was positively associated with tarsus length at a later nestling stage (nestlings 12 days old). These results indicate that MHC alleles might influence pathogen resistance or susceptibility.

[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]

BACKGROUND

In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity.

OBJECTIVES

In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated.

MATERIAL AND METHODS

Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification.

RESULTS

Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS.

DISCUSSION

Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

[Emergency radiographs in injured children and adolescents]

BACKGROUND

Adequate interpretation of radiographs of injured children and adolescents is key for appropriate treatment. For the purposes of structuring in-hospital education and training, conventional radiographs obtained in the emergency department (ED) should be analyzed.

MATERIAL AND METHODS

A total of 10,232 radiographs of children and adolescents (0-17 years old) were analyzed retrospectively. Data was analyzed according to sex, age, time, radiograph, and type of insurance.

RESULTS

The male to female ratio was 3:2. In all, 76% of all radiographs were processed during on-call duty hours. Radiographs of the ankle were ordered most at a rate of 11%. Radiographs of the skull, wrist, finger, and ankle stood out from the sum of all radiographs and together accounted for 40%.

CONCLUSION

Radiographs of injured children are analyzed predominantly during on-call duty hours. Frequently mandated radiographs should be diagnosed accurately and standard injuries should be well known. Particular attention should be directed to the typical injury patterns of the ankle joint.

[X‑ray of the thoracic and lumbar spine in injured children and adolescents : Incidence, fracture rates and therapeutic consequences]

INTRODUCTION

Usually, conventional radiographs are appropriate for injuries in the region of the thoracic and lumbar spine (TLS) in children and adolescents. The aim of our study was to determine the incidence of trauma-associated radiographic findings in this anatomical region and to present the therapeutic consequences.

MATERIAL AND METHODS

In a retrospective cohort study (2007-2015) of a level 1 trauma center all children and adolescents (0-17 years) with a TLS-trauma, in which conventional radiographs were performed anteroposterior and lateral as the initial imaging modality, were included.

RESULTS

In 396 children and adolescents conventional radiographs were performed, but only 5.6 % suffered a fracture. Conventional radiographs were performed in 188 cases of the thoracic spine, in 43 cases in the thoracolumbar junction and in 255 cases in the lumbar spine. On average, children and adolescents with fractures were 12.5 (5-17) years old. Fractures were classified as 38.7 % A1.1, 51.6 % A1.2, and 9.7 % were fractures of the transverse process. B and C fractures could not be detected. Of all fractures, 80 % were found in the mid-thoracic spine and the thoracolumbar junction. All fractures could be treated conservatively.

CONCLUSION

With 5.6 % TLS-injuries in children and adolescents, the study revealed a low fracture rate in a highly radiosensitive region. With regard to an expected stable fracture morphology and the absent surgical consequences, the indication for emergency radiographs should be provided restrictively.

Chronopharmacology of β-Adrenoceptor-Blocking Drugs: Pharmacokinetic and Pharmacodynamic Studies in Rats

Specific and nonspecific effects and the pharmacokinetic behavior of β-adrenoceptor-blocking drugs of different Iipophilicity (atenolol, bupranolol, carazolol, metoprolol, ox-prenolol, practolol, propranolol, sotalol) were investigated in L-D-synchronized male rats as a function of treatment time. The studies revealed that pharmacodynamic effects on heart rate, cardiac noradrenaline turnover, and motor activity as well as pharmacokinetic parameters of racemic mixtures of β-receptor blockers display temporal variations with more pronounced pharmacological effects and shorter elimination half-lives in the dark span. Studies with the isomers of bupranolol and practolol indicate no stereospecificity in the central depressant effect; the kinetic behavior of, for example, propranolol, however, exhibits stereospecificity. The results demonstrate the importance of circadian rhythms in modifying the effects and kinetics of drugs. These findings may have therapeutic implication in human subjects.

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.