Cytology of the neovagina in transgender women and individuals with congenital or acquired absence of a natural vagina.

OBJECTIVE: The primary objective of this study was to describe the cytological findings of bowel and (penile) skin-lined neovaginas in patients with gender dysphoria (GD) and individuals with a congenital or acquired absence of a natural vagina. The secondary objective was to correlate the cytological findings with clinical characteristics such as oestrogen replacement therapy (ERT). METHODS: A retrospective review of an institutional pathology archive over a 15-year-period was performed to identify cytological samples of neovaginal vaults. The medical and surgical records of the patients identified (n=20) were evaluated. RESULTS: Well-preserved nucleated squamous cells were found in 70% (14/20) of patients. Neovaginal samples showing superficial, intermediate and parabasal cells plus Döderlein flora similar to normal cervical cytology were present in only 10% (2/20). Three samples (15%, 3/20) showed atypical squamous cells of undetermined significance (ASC-US) that were all negative for high-risk human papillomavirus (HR-HPV) types, whereas one case was positive for low-risk (LR) HPV. One patient (5%, 1/20) was diagnosed with an HR-HPV-positive high-grade squamous intraepithelial lesion (HSIL), and one patient (5%, 1/20) had an HR- and LR-HPV-positive low-grade squamous intraepithelial lesion (LSIL). The correlation between the presence of nucleated squamous cells and ERT was significant (P=.032). CONCLUSION: Cytological findings of the neovagina resemble normal cervical cytology with superficial, intermediate and parabasal cells as well as Döderlein bacilli in a minority of cases. Because precancerous lesions and invasive carcinoma may develop in the neovagina, patients with neovaginas should be subject to cancer screening programmes.

Septic shock in children in an urban area in Western Germany--outcome, risk factors for mortality and infection epidemiology.

BACKGROUND: Only sparse data exist about children with septic shock in Europe. The present study aimed to evaluate demographics, treatment, outcome and risk factors for mortality in Western Germany. PATIENTS: Children with septic shock aged 2 months to 17 years. METHODS: In a multi-center retrospective study of 20 children's hospitals data were obtained and analyzed by chart review. Risk factors for mortality were identified and assessed by multivariate regression analysis. RESULTS: Overall mortality in 83 cases with septic shock was 25% (21 patients). Significant risk factors were high PRISM III score, low pH, low arterial systolic blood pressure, presence of disseminated intravascular coagulation and extent of multi-organ failure, but not lactate (p=0.05) and base excess (p=0.065). Mortality in hospitals which treated 10 or more patients (category 1) was 17% and increased to 22% in hospitals which treated 3-6 patients (category 2). In hospitals with only 1 or 2 patients (category 3) mortality rate was 61% (p<0.01 when compared to category 1 or 2). A stepwise increase was also seen in the severely sick patients according to PRISM III (>19): category 1: 23%, category 2: 40%, category 3: 62.5% (p<0.05 for comparison of category 1 and 3). Multivariate analysis of significant risk factors revealed low number of treated patients as the only individual risk factor for mortality. CONCLUSION: Mortality from pediatric septic shock in an urban area in Western Germany is high. Disease severity and treatment in a department with few cases were associated with increased mortality.

Color Doppler ultrasound-guided PTBD with and without metal stent implantation by endoscopic control: prospective success and early adverse event rates.

OBJECTIVE: There are just a few reports on Color Doppler Ultrasound-guided PTBD with and without metal stent implantation by endoscopic control. Ultrasound guidance facilitates percutaneous bile duct access and avoids severe adverse events. Internal biliary drainage rate in PTBD should be as high as possible as endoscopic ultrasound-guided cholangiodrainage (EUCD) offers internal drainage regularly. We report our prospective study analyzing success, internal drainage and adverse event rates. MATERIALS AND METHODS: Between June 2009 and November 2014 overall 63 PTBDs were performed prospectively in 37 patients (18 m, 19f; age on average: 72 years) with benign (9 %) and malignant (91 %) bile duct obstruction. Ultrasound was used in combination with fluoroscopic guidance. Whenever possible, primary or early secondary metal stent implantation via PTBD by endoscopic control was performed as a one step-procedure. RESULTS: 38 of 41 (93 %) initial PTBDs (in four patients PTBD was performed twice) were successful. 22 of 63 PTBDs were follow-up examinations with different interventions. In 34 of 38 successful (89 %) PTBDs, an internal drainage (or metal stent) was implanted. 12 metal stent implantations via PTBD were performed under endoscopic control. Just 2 (5 %) permanent external drainages were inserted. In 63 performed PTBDs 5 (7.9 %) early major adverse events (no severe intrahepatic bleeding) were documented and treated without any procedure related death. When metal stent implantation was performed via PTBD no adverse event was documented. CONCLUSION: Color Doppler guided PTBD is an effective and safe method for biliary drainage avoiding severe adverse events. Primary or early secondary metal stent implantation via PTBD reduces complication risks additionally. Endoscopic control of stent implantation via PTBD is helpful for optimal stent placement.

[Imaging modalities and therapy options in patients with acute flank pain]. / Bildgebungsmodalitäten und Therapieoptionen bei Patienten mit akutem Flankenschmerz.

The objective of this article is the description of imaging techniques for the evaluation of patients with acute flank pain and suspicion of urolithiasis and the impact of these techniques in the therapy management of patients with calculi.

[IgG4-related systemic disease with autoimmune pancreatitis and lung involvement primarily presenting as pancreatic cancer with pulmonary metastases]. / IgG4-assoziierte Autoimmunpankreatitis und Lungenerkrankung mit der primären, klinischen Präsentation eines pulmonal metastasierten Pankreaskarzinoms.

BACKGROUND: After the first case publication using the term "autoimmune pancreatitis" in 1995 and the successful treatment with steroids we now can distinguish between two clinical und histopathological forms of autoimmune pancreatitis. Type 1 autoimmune pancreatitis (AIP) is usually part of an IgG4-related systemic disease. AIP Typ 2 is an IgG4-independent pancreatic disease. For both entities pancreas cancer is the most important differential diagnosis. CASE REPORT: We report the case of an 82-year-old male patient who primarily presented with obstructive jaundice. Computed tomography (CT) revealed the typical image of a small cancer of the head of the pancreas with pulmonary metastases. After endoscopic drainage of the bile duct a CT-guided biopsy of a pulmonary nodule was performed in which cancer was ruled out. Next the patient was treated with steroids because of "tumour-associated cachexia". In the follow-up the mass in the head of the pancreas like the lung nodules had surprisingly disappeared. In the complete work-up the immune histochemical staining of the lung biopsy revealed subsequently a typical IgG4-associated inflammation. After termination of the therapy the disease relapsed as sclerosing cholangitis. CONCLUSION: The IgG4-related systemic disease with AIP can present as cancer of the pancreas with lung metastases. Extrapancreatic IgG4-positive histopathology and response to therapy with steroids can help to diagnose the disease in complex clinical presentations.

Efflux time of soap bubbles and liquid spheres.

The efflux time, T, of gas from soap bubbles of radius, R, through their blow tube of length, 1, and radius, p, is given by the equation see pdf for equation where eta is the viscosity of the gas and omicron the surface tension of the bubble solution, all in centimeter-gram-second units. Similar relations between time and diameter were established for the flow from one bubble to another or from one bubble within another. The same relations hold for the flow of liquid spheres, suspended in another liquid of equal density, following Plateau's classic method. They have been extended to the flow of spheres to cylinders and catenoids of rotation. In all these cases the driving force is the surface or interfacial tension, creating an excess pressure as defined by Laplace's equation.

Effect of temperature on the life of soap bubbles, and their solidification at low temperature.

Soap bubbles (also films on wire frames) have been solidified at low temperatures. At~-30 degrees C the bubbles still behave normally, that is, they can be expanded by blowing air into them and contract when the air is let out. At ~ -80 degrees C they become glassy, have very little surface tension, and cannot be blown up any more. At ~-120 degrees C they become completely solid. No further change is observed by cooling them to 90 degrees or 77 degrees K.

Soap bubbles: two years old and sixty centimeters in diameter.

Soap bubbles of long life (over 2 years) and large size (over 60 centimeters in diameter, 100 liters volume) have been produced from bubble solutions improved by the addition of water-soluble synthetic organic polymers such as polyvinyl alcohol or polyoxyethylene. The natural life can be defined as the time it takes for the bubble, if left undisturbed, to contract from the original size to a flat film.

Direct high-temperature ohmic heating of metals as liquid pipes.

When a sufficiently high electric current is passed through a liquid metal, the electromagnetic pressure pinches off the liquid metal and interrupts the flow of current. For the first time the pinch effect has been overcome by use of centrifugal acceleration. By rotation of a pipe of liquid metal, tin or bismuth or their alloys, at sufficiently high speed, it can be heated electrically without intermission of the electric current. One may now heat liquid metallic substances, by resistive (ohmic) heating, to 5000 degrees K and perhaps higher temperatures.

Preparing strategic information management plans for hospitals: a practical guideline SIM plans for hospitals: a guideline.

OBJECTIVES: Systematic information management in hospitals demands for a strategic information management plan (SIM plan). As preparing a SIM plan is a considerable challenge we provide a practical guideline that is directly applicable when a SIM plan is going to be prepared. METHODS: The guideline recommends a detailed structure of a SIM plan and gives advice about its content and the preparation process. It may be used as template, which can be adapted to the individual demands of any hospital. RESULTS: The guideline was used in several hospitals preparing a SIM plan. Experiences showed that the SIM plans could be prepared very efficiently and timely using the guideline, that the proposed SIM plan structure suited well, that the guideline offers enough flexibility to meet the requirements of the individual hospitals and that the specific recommendations of the guideline were very helpful. CONCLUSIONS: Nevertheless, we must strive for a more comprehensive theory of strategic information management planning which -- in the sense of enterprise architecture planning -- represents the intrinsic correlations of the different parts of a SIM plan to a greater extent.

Reverse genetic screening reveals poor correlation between morpholino-induced and mutant phenotypes in zebrafish.

The widespread availability of programmable site-specific nucleases now enables targeted gene disruption in the zebrafish. In this study, we applied site-specific nucleases to generate zebrafish lines bearing individual mutations in more than 20 genes. We found that mutations in only a small proportion of genes caused defects in embryogenesis. Moreover, mutants for ten different genes failed to recapitulate published Morpholino-induced phenotypes (morphants). The absence of phenotypes in mutant embryos was not likely due to maternal effects or failure to eliminate gene function. Consistently, a comparison of published morphant defects with the Sanger Zebrafish Mutation Project revealed that approximately 80% of morphant phenotypes were not observed in mutant embryos, similar to our mutant collection. Based on these results, we suggest that mutant phenotypes become the standard metric to define gene function in zebrafish, after which Morpholinos that recapitulate respective phenotypes could be reliably applied for ancillary analyses.

Results of breast conserving therapy for early breast cancer and the role of mammographic follow-up.

PURPOSE: The following article is a review of 23 years of breast-conserving therapy in our hospital. This study was performed to assess and improve the follow-up care of women with early breast cancer and to evaluate whether or not biannual mammogram is useful. METHODS AND MATERIALS: Between 1972 and December 1995, 3072 women with pathological size pT1 and pT2 breast cancer were treated with conservative surgery and radiation therapy. Eighty-five patients developed a recurrence in the treated breast as the first site of failure, 12 of which had positive axillary nodes. In the following patient study, those with an noninvasive recurrence were excluded. A retrospective assessment of the entire mammographic course was made, starting with the mammogram at the time of original diagnosis to the mammogram of the recurrence. RESULTS: In our study group the probability for local failure ranged from 1 to 2% per year. At 5 and 10 years the actuarial rates were 5 and 10%. The median time to recurrence was 41 months (range 8-161). Twenty-six (31%) recurrences were detected by mammography alone, 10 (12%) by clinical examination only, and 35 (41%) by both methods. For the patients with an ipsilateral recurrence, the overall actuarial 5- and 10-year survival after treatment was 87 and 70%, respectively. The 5-year actuarial rate of survival from salvage mastectomy was 61%. CONCLUSION: Considering the high percentage of recurrences detectable by mammography and the possibility of detection within a short-term interval, we think biannual mammographic follow-up is appropriate for the first years following breast-conserving therapy.

Reversal of hypoxemia by inhaled nitric oxide in children with severe hepatopulmonary syndrome, type 1, during and after liver transplantation.

BACKGROUND: The hepatopulmonary syndrome with profound hypoxemia is a rare but severe complication for children with liver cirrhosis. It can be reversed by liver transplantation (LT), which is now regarded as a good indication. However, previous reports have described cases of transient or fatal deteriorations of intrapulmonary shunting after pediatric liver transplantation with dramatically worsening hypoxemia. METHODS AND RESULTS: A similar case during and after LT in a 4-year-old girl with severe hepatopulmonary syndrome is described with prompt reversal of hypoxemia by inhaled nitric oxide, which was discontinued definitely until day 14 after LT. CONCLUSIONS: During or after LT, worsening hypoxemia may be improved by using inhaled nitric oxide in pediatric patients undergoing liver transplantation for liver cirrhosis and hepatopulmonary syndrome. The mechanisms are unclear, but may involve mismatching lung ventilation-perfusion. However, additional clinical reports are necessary before accepting these results.

Osteoprotegerin and receptor activator of nuclear factor-kappaB ligand (RANKL) in the serum of healthy adults.

AIMS: Osteoprotegerin and the receptor activator of the nuclear factor-kappaB ligand (RANKL) are decisive factors for maintaining the balance between bone formation and bone resorption. As new, sensitive ELISAs have been developed recently, reference serum ranges should be established to use these analytes for possible diagnostic purposes. METHODS: Measurements were performed in serum samples of 142 healthy adults (82 women, 60 men) between 20 and 70 years of age (mean age: 46 years) using ELISA kits from Immundiagnostik, Bensheim, Germany. RESULTS: Serum concentrations of osteoprotegerin were age and gender independent and showed a Gaussian distribution, while RANKL concentrations were also age independent but differed between males and females, with a non-Gaussian distribution. For osteoprotegerin a gender-independent upper 97.5 percentile limit of 3.6 pmol/L was calculated while the corresponding limits for RANKL and the ratio of RANKL to osteoprotegerin amounted to 3.29 pmol/L and 2.78 in women and 1.66 pmol/L and 2.18 in men, respectively. CONCLUSIONS: Both osteoprotegerin and RANKL were quantifiable in serum of healthy adults, which means that these compounds can be used as potential diagnostic tools.

Closed locked intramedullary nailing. Its application to comminuted fractures of the femur.

For many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescoping of the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to dynamic locking when weight-bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indications for intramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fractures complicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-two patients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that were complicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a mean time of 4.5 months for the severely comminuted fractures and seven months for the fractures that had a loss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normal motion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three after a second locked nailing and one after a third) and one had a septic non-union that eventually healed after removal of the nail and screws, débridement, and immobilization with an external fixator. Based on this experience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and early mobilization of the patient is possible.

Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur.

Thirty-seven fractures of the distal part of the femur in thirty-five patients were treated with interlocking intramedullary nailing. All fractures were nailed by a closed technique after any intercondylar extension of the fracture had been managed by reduction and stabilization with percutaneous lag-screws. Patients who had an isolated condylar fracture or a severely comminuted intercondylar fracture were treated with other types of implants. There were thirty extra-articular (type-A) fractures and seven intra-articular (type-C1 and type-C2) fractures. Postoperatively, early mobilization exercises and weight-bearing were begun. At an average duration of follow-up of 20.5 months (range, fifteen to twenty-six months), all thirty-seven fractures had healed. There were no malunions of either the supracondylar or the intercondylar fractures. Complications were infrequent and included chronic irritation from the distal screws in three patients and delayed union in one; the latter healed with two centimeters of shortening after bone-grafting. There were no infections. The functional results were assessed with the modified knee-rating system of The Hospital for Special Surgery. Thirteen knees (35 per cent) had an excellent result; twenty-two (59 per cent), a good result; and two (5 per cent), a fair result. The results correlated with the age of the patient and the presence of an intra-articular fracture. We concluded that closed interlocking intramedullary nailing is an excellent technique for both supracondylar and simple intercondylar fractures in which closed reduction and percutaneous fixation of the articular fracture is possible.

MR-Guided vacuum biopsy of 206 contrast-enhancing breast lesions.

PURPOSE: To determine the accuracy and clinical use of MR-guided vacuum biopsy (VB) of enhancing breast lesions. MATERIAL AND METHODS: 254 lesions were referred to MR-guided vacuum-assisted breast biopsy. In 43 (16 %) patients the indication was dropped because the lesions could not be identified at the time VB was scheduled. This was due to hormonal influences (n = 37), to too strong compression (n = 3) or to misinterpretation of the initial diagnostic MRI (n = 3). In 5 cases (2 %) VB was not performed due to obesity (n = 2); problems of access (n = 2) or a defect of the MR-unit (n = 1). VB was performed on altogether 206 lesions. In 4 cases (2 %) VB was unsuccessful. This was immediately realized on the post-interventional images. Thus a false negative diagnosis was avoided. Verification included excision of the cavity in cases with proven malignancy or atypical ductal hyperplasia (ADH) and (for benign lesions) retrospective correlation of VB-histology with pre-and postinterventional MRI and subsequent follow-up. RESULTS: 51/202 successful biopsies proved malignancy. In 7 cases ADH and in 144 cases a benign lesion was diagnosed. One DCIS was underestimated as ADH. All other benign or malignant diagnoses proved to be correct. CONCLUSION: MR-guided VB allows reliable histological work-up of contrast-enhancing small lesions which are not visible by any other modality.

Fixation of odontoid fractures by an anterior screw.

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D'Alonzo type-II fractures and 52 with type III. Roy-Camille's classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.

Open adult femoral shaft fracture treated by early intramedullary nailing.

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed.

Effects of psychological stress on cold pressor test results.

The authors evaluated the incidence of a psychological stressor in the modification of blood pressure induced by the cold pressor test in normotensive and medicated hypertensive subjects. The study was carried out in two stages: In the first, 28 (14 normotensive and 14 hypertensive) subjects were administered a cold pressor test. Fifteen days later, 14 subjects repeated the same experiment. The remaining 14 subjects (7 hypertensive and 7 normotensive) also repeated the cold pressor test, with the difference that, to add a stressful psychological situation, the physician "abandoned" them at the beginning. The addition of the psychological stress significantly increased only systolic blood pressure in both the hypertensive and the normotensive subjects. Furthermore, the hypertensive subjects did not recover their basal blood pressure values following the cold pressor test when the psychologically stressful situation had been added. These results show the importance of considering psychological aspects when applying physical pressor tests.