Oil gland and oil pores in billfishes: in search of a function

Billfishes are well known for their distinctive elongated rostra, i.e. bills. The functional significance of billfish rostra has been frequently discussed and the recent discovery of an oil gland (glandula oleofera) at the base of the rostrum in swordfish, Xiphias gladius, has added an interesting facet to this discussion regarding the potential co-evolution of gland and rostra. Here, we investigated the oil gland and oil pores (through which the oil is brought to the skin surface) of four billfish species - swordfish, Atlantic blue marlin (Makaira nigricans), Indo-Pacific sailfish (Istiophorus platypterus) and striped marlin (Kajikia audax) - and provide detailed evidence for the presence of an oil gland in the last three. All four species had a high density of oil pores on the forehead which is consistent with the hypothesis of hydrodynamic benefits of the oil. The extension of the pores onto the front half of the rostrum in sailfish and striped marlin, but not in swordfish or blue marlin, suggests that the oil may have additional functions. One such function could be linked to the antibacterial and anti-inflammatory properties of the oil. However, the available evidence on predatory rostrum use (and hence the likelihood of tissue damage) is only partly consistent with the extension of pores on rostra across species. We conclude that the oil gland probably serves multiple, non-mutually exclusive functions. More detailed information on rostrum use in blue marlin and swordfish is needed to better link behavioural and morphological data with the aim of accomplishing a full comparative analysis.

Budget impact analysis of gene expression tests to aid therapy decisions for breast cancer patients in Germany

OBJECTIVES

Many women with early-stage, hormone receptor-positive breast cancer may not benefit from adjuvant chemotherapy. Gene expression tests can reduce chemotherapy over- and undertreatment by providing prognostic information on the likelihood of recurrence and, with Oncotype DX, predictive information on chemotherapy benefit. These tests are currently not reimbursed by German healthcare payers. An analysis was conducted to evaluate the budget impact of gene expression tests in Germany.

MATERIALS AND METHODS

Costs of gene expression tests and medical and non-medical costs associated with treatment were assessed from healthcare payer and societal perspectives. Costs were estimated from data collected at a university hospital and were combined with decision impact data for Oncotype DX, MammaPrint, Prosigna and EndoPredict (EPclin). Changes in chemotherapy use and budget impact were evaluated over 1 year for 20,000 women.

RESULTS

Chemotherapy was associated with substantial annual costs of EUR 19,003 and EUR 84,412 per therapy from the healthcare payer and societal perspective, respectively. Compared with standard care, only Oncotype DX was associated with cost savings to healthcare payers and society (EUR 5.9 million and EUR 253 million, respectively). Scenario analysis showed that both women at high clinical but low genomic risk and low clinical but high genomic risk were important contributors to costs.

CONCLUSIONS

Oncotype DX was the only gene expression test that was estimated to reduce costs versus standard care in Germany. The reimbursement of Oncotype DX testing in standard clinical practice in Germany should be considered.

Neonatal lumbar puncture: are clinical landmarks accurate?

BACKGROUND

The intercristal line (ICL), defined by the superior aspect of the iliac crest, is used to clinically identify the entry point for lumbar puncture (LP) in neonates. Accepted practice is to insert the needle at the L3/4 or L4/5 intervertebral space.

AIM

To investigate the vertebral level crossed by the ICL as determined by manual palpation and the ability of manual palpation to reliably identify a specified intervertebral space.

METHOD

A total of 30 term neonates were recruited. Paediatricians identified and marked the ICL and the intervertebral space above, with babies in left lateral position. The anatomical positions of both points and the end of the conus medullaris were confirmed using ultrasonography.

RESULTS

The ICL was marked from L2/3 to L5/S1. In 25 babies (83%), the ICL was identified at the desired vertebral level between L3/4 and L4/5. The intervertebral space above this line was marked between L1/2 to L4/5. The potential site for LP was identified higher than intended in 11 cases (36%). The end of the conus medullaris ranged from L1 to L3 terminating at L2 or lower in 11 cases (36%).

CONCLUSIONS

There are wide variations in the positions of the ICL and potential LP site. Using the ICL to guide LP does not appear to be accurate, raising the possibility of potential spinal cord damage.

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients

INTRODUCTION

Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease.

MATERIAL AND METHODS

To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015.

RESULTS

A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials.

CONCLUSION

The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.

Impact of Patient and Procedure Mix on Finances of Perinatal Centres - Theoretical Models for Economic Strategies in Perinatal Centres

Introduction: In Germany, cost and revenue structures of hospitals with defined treatment priorities are currently being discussed to identify uneconomic services. This discussion has also affected perinatal centres (PNCs) and represents a new economic challenge for PNCs. In addition to optimising the time spent in hospital, the hospital management needs to define the "best" patient mix based on costs and revenues. Method: Different theoretical models were proposed based on the cost and revenue structures of the University Perinatal Centre for Franconia (UPF). Multi-step marginal costing was then used to show the impact on operating profits of changes in services and bed occupancy rates. The current contribution margin accounting used by the UPF served as the basis for the calculations. The models demonstrated the impact of changes in services on costs and revenues of a level 1 PNC. Results: Contribution margin analysis was used to calculate profitable and unprofitable DRGs based on average inpatient cost per day. Nineteen theoretical models were created. The current direct costing used by the UPF and a theoretical model with a 100 % bed occupancy rate were used as reference models. Significantly higher operating profits could be achieved by doubling the number of profitable DRGs and halving the number of less profitable DRGs. Operating profits could be increased even more by changing the rates of profitable DRGs per bed occupancy. The exclusive specialisation on pathological and high-risk pregnancies resulted in operating losses. All models which increased the numbers of caesarean sections or focused exclusively on c-sections resulted in operating losses. Conclusion: These theoretical models offer a basis for economic planning. They illustrate the enormous impact potential changes can have on the operating profits of PNCs. Level 1 PNCs require high bed occupancy rates and a profitable patient mix to cover the extremely high costs incurred due to the services they are legally required to offer. Based on our theoretical models it must be stated that spontaneous vaginal births (not caesarean sections) were the most profitable procedures in the current DRG system. Overall, it currently makes economic sense for level I PNCs to treat as many low-risk pregnancies and neonates as possible to cover costs.

Culture of Individually Required Number of 2-Pronuclei-Stage Oocytes - Patient Participation in Decision-Making is in Accordance with the Aim of Avoiding Surplus Embryo Freezing

Background: The aim of this study was to evaluate how many embryos will develop if more than 3 2-pronuclei-stage oocytes (2-PNOs) are cultured at the patient's request and in accordance with the Germany Embryo Protection Law. Methods: A total of 106 cycles of patients undergoing their 1st, 2nd or 3rd cycle of IVF or ICSI treatment in 2010 were prospectively included in the study. In each individual case, a decision was taken prior to treatment about the number of 2-PNOs to be cultured after each cycle. Results: Ninety female patients were treated for a total of 106 cycles. A mean of two to six 2-PNOs were cultivated for a period of between 3 and 6 days for each patient. After culture, no viable embryo was identified for 5 patients (4.7 %), a single viable embryo was identified for 37 cycles (34.7 %), and 2 viable embryos were identified for 52 cycles (48.8 %). Eleven patients (10.3 %) had 3 viable embryos after a further 11 cycles and 1 patient had 4 viable embryos in a single cycle. Ten of the patients with 3 embryos each opted to have all 3 embryos transferred in the same cycle. This meant that a single embryo from one patient with 3 viable embryos and a single embryo of the patient with 4 viable embryos were cryopreserved after culture. The pregnancy rate was 19 % per embryo transfer and 25 % per blastocyst transfer (20 pregnancies in total). All cryopreserved embryos were transferred in a subsequent cycle. Discussion: Based on this study it is possible to make a statement about the number of viable embryos which should be cultivated to obtain, at best, two embryos for transfer without running an unacceptably high risk of producing too many embryos which would then need to be cryopreserved. Only 12 patients (13.3 %) had more than 2 viable embryos. The number of supernumerary pre-implantation-stage embryos was acceptably low (only 2 patients had additional viable embryos, 2.2 %). This means that it is possible to fulfil the wishes of individual patients while complying with the German Embryo Protection Law.

Shaping the System - The DRG Evaluation Project of the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG)

Introduction: The German DRG system is annually adapted to the changing services provided. For the further development, the self-governing body and its DRG Institute (InEK) depend on participation of the users. Methods: For one of the DRG evaluation projects initiated by DGGG, cost and performance data for the year 2011 from 16 hospitals were available. After plausibility checks and corrections, analyses for service and cost homogeneity were performed. In cases of inadequate DRG-representation attributes were sought that would make an appropriate reimbursement possible. Conspicuities and potential solutions were checked for clinical plausibility. Results: 44 concrete modification proposals for further development of the G-DRG system were formulated and submitted in due time to the InEK. In addition, 3 modification proposals were addressed to the German Institute for Medical Documentation and Information (Deutsches Institut für Medizinische Dokumentation und Information, DIMDI) for further development of the diagnosis classification ICD-10-GM. For all modification proposals care was taken to minimise misdirected incentives and to reduce the potential for disputes with the cost bearers and their auditors services in settlements. Discussion: The publication of the G-DRG system 2014 shows which modification proposals have been realised. Essentially, an appropriate redistribution of the resources among the gynaecological and obstetrics departments is to be expected. The financial pressure that is caused by the generally inadequate financing of hospitals will not be reduced by a further development of the G-DRG system.

Health Services Research and Health Economy - Quality Care Training in Gynaecology, with Focus On Gynaecological Oncology

In the era of cost increases and reduced resources in the German healthcare system, the value of health services research and health economics is increasing more and more. Health services research attempts to develop concepts for the most effective ways to organise, manage, finance and deliver high-quality care and evaluates the implementation of these concepts with regard to daily routine conditions. Goals are the assessment of benefits and the economic advantages and disadvantages of new and established diagnostic methods, drugs and vaccines. Regarding these goals, it is clear that health services research goes hand in hand with health economics, which evaluates the benefits of diagnostic and therapeutic procedures in relation to the costs. Both scientific fields have focus principally on gynaecology and particularly on gynaecological oncology in Germany, as can be seen by numerous publications. These present several advantages compared with clinical trials - they uncover gaps in health care, question the material, staffing and consequently the financial resources required and they allow the estimation of value and the comparison of different innovations to identify the best options for our patients.

The era of centers: the influence of establishing specialized centers on patients' choice of hospital

PURPOSE

It is considered that establishing accredited specialized centers can serve as a marketing tool. This study investigated whether accredited specialized centers influence patients' choice of hospital.

METHODS

A total of 2,389 patients was included in a questionnaire survey: 468 at the Department of Gynecology, 745 at the certified University Breast Center of Franconia, 1,000 at the University Perinatal Center of Franconia and 176 for whom classification details were lacking.

RESULTS

Among the oncological patients, physicians in private practice played an important role in the choice of hospital (58.4 vs. 25.7%; P < 0.001; OR 4.058). Among obstetric patients, the primary factors were recommendations from family [odds ratio (OR) 0.495], friends (OR 0.218), and previous personal experience of the hospital (OR 0.695). For oncological patients, treatment quality (OR 2.693), availability of a center (OR 1.785), and certification (OR 3.939) were comparatively more important. For obstetric patients, friendliness (OR 0.409) and attractive accommodation (OR 0.153) were more important.

CONCLUSIONS

Physicians are the most important source of recommendations for oncological patients. From the marketing point of view, intensive involvement of local private-practice physicians is necessary. The availability of certified perinatal centers does not currently play any part in patients' choice of hospital.

Ontogenetic scaling of foot musculoskeletal anatomy in elephants

This study quantifies the shape change in elephant manus and pes anatomy with increasing body mass, using computed tomographic scanning. Most manus and pes bones, and manus tendons, maintain their shape, or become more gracile, through ontogeny. Contrary to this, tendons of the pes become significantly more robust, suggesting functional adaptation to increasingly high loads. Ankle tendon cross-sectional area (CSA) scales the highest in the long digital extensor, proportional to body mass(1.08+/-0.21), significantly greater than the highest-scaling wrist tendon (extensor carpi ulnaris, body mass(0.69+/-0.09)). These patterns of shape change relate to the marked anatomical differences between the pillar-like manus and tripod-like pes, consistent with differences in fore- and hindlimb locomotor function. The cartilaginous predigits (prepollux and prehallux) of the manus and pes also become relatively more robust through ontogeny, and their pattern of shape change does not resemble that seen in any of the 10 metacarpals and metatarsals. Their CSAs scale above isometry proportional to body mass(0.73+/-0.09) and body mass(0.82+/-0.07) respectively. We infer a supportive function for these structures, preventing collapse of the foot pad during locomotion.

The distribution, density and three-dimensional histomorphology of Pacinian corpuscles in the foot of the Asian elephant (Elephas maximus) and their potential role in seismic communication

Both Asian (Elephas maximus) and African (Loxodonta africana) elephants produce low-frequency, high-amplitude rumbles that travel well through the ground as seismic waves, and field studies have shown that elephants may utilize these seismic signals as one form of communication. Unique elephant postures observed in field studies suggest that the elephants use their feet to 'listen' to these seismic signals, but the exact sensory mechanisms used by the elephant have never been characterized. The distribution, morphology and tissue density of Pacinian corpuscles, specialized mechanoreceptors, were studied in a forefoot and hindfoot of Asian elephants. Pacinian corpuscles were located in the dermis and distal digital cushion and were most densely localized to the anterior, posterior, medial and lateral region of each foot, with the highest numbers in the anterior region of the forefoot (52.19%) and the posterior region of the hindfoot (47.09%). Pacinian corpuscles were encapsulated, had a typical lamellar structure and were most often observed in large clusters. Three-dimensional reconstruction through serial sections of the dermis revealed that individual Pacinian corpuscles may be part of a cluster. By studying the distribution and density of these mechanoreceptors, we propose that Pacinian corpuscles are one possible anatomic mechanism used by elephants to detect seismic waves.

The effect of body condition on ovarian activity of free ranging tropical jennies (Equus asinus)

Serial ultrasonography was performed on seven jennies to study the effect of seasonally fluctuating body condition on ovarian activity during the dry, short rainy and long rainy seasons. Kendall Tau correlations and differences of least square mean values were compared. A distinct seasonal pattern was observed both in body condition and ovarian activity. The mean (+/-SD) Body Condition Score (BCS) was lowest during the dry season 2.6 +/- 0.45 when compared with 3.5 +/- 0.52 and 3.9 +/- 0.58 during the short and long rainy seasons, respectively. The mean (+/-SD) number of total follicles was also proportionally low 7.3 +/- 1.6 during the dry season compared with 9.6 +/- 2.4 and 11.3 +/- 3.3 found during the short and the long rainy seasons, respectively. The BCS was positively correlated to the total number of follicles and the diameter of the largest follicle during all seasons. Periods of increasing BCS and transition between seasons with both increasing and decreasing body conditions were strongly correlated to the number and size of ovarian follicles. Seasonal fluctuation in the body condition was found to be the result of variation in feed resource and ovarian activity was also closely following this seasonal pattern. The improvement in body condition has generally, a positive impact on emergence of small growing follicles there by having influence on the total count of ovarian follicles.

[Prevalence of anti-Yersinia antibodies in European brown hares in North-Rhine Westphalia, Germany]

Yersinia (Y.) pseudotuberculosis infections may lead to significant lethality in European brown hare (Lepus europaeus, Pallas) populations especially during the cold and wet seasons. In recent decades, also Y. enterocolitica was isolated from hares found dead. Consequently, a Western-blot technique proved to be valuable for the detection of antibodies against all pathogenic Yersinia isolates was applied to monitor the prevalence of antibodies in hare populations in North-Rhine Westphalia, Germany. A total of 89.6% of the 230 animals tested was seropositive. Further investigations should be performed to elucidate the role of subclinical yersiniosis in the decline of European brown hare populations in Germany.