[Treatment costs for anterior cruciate ligament reconstruction: procedure related cost analysis in an university hospital]. / Behandlungskosten in der Kreuzbandchirurgie: Therapiebezogene Kostenträgerrechnung an einem Universitätsklinikum.

BACKGROUND: Complex procedures in knee surgery, such as anterior cruciate ligament (ACL) reconstruction with the double bundle technique are not specially recognized within the German diagnosis-related groups (G-DRG) system. Hence, the goal of the present study was to perform a cost unit calculation and evaluate how ACL reconstruction in single versus double bundle techniques is remunerated. PATIENTS AND METHODS: In 30 patients ACL reconstruction was performed with the single bundle technique (group A) and in 21 an anatomic double bundle reconstruction (group B) was performed. All costs including those for human resources, implants and materials, as well as general costs for administration and facilities were calculated. RESULTS: All cases entered one DRG category, the I30Z "complex procedures at the knee joint". Thus, the revenue in 2008 was 2,996.65 euro per case and in 2009 3,120.35 euro per case. Calculating all costs, the profit contributions in 2008 and 2009 were 592,42 euro and 716,12 euro, respectively for group A. However, in group B the profit contributions were 314,68 euro and 438,38 euro, respectively. CONCLUSION: Performing the double bundle technique for ACL reconstruction in a university hospital setting, significant cost reductions are needed to achieve the revenue generated by the single bundle technique. Additional changes of the relative weighting in the DRG are also necessary.

Rare structural variants found in attention-deficit hyperactivity disorder are preferentially associated with neurodevelopmental genes.

Attention-deficit/hyperactivity disorder (ADHD) is a common and highly heritable disorder, but specific genetic factors underlying risk remain elusive. To assess the role of structural variation in ADHD, we identified 222 inherited copy number variations (CNVs) within 335 ADHD patients and their parents that were not detected in 2026 unrelated healthy individuals. Although no excess CNVs, either deletions or duplications, were found in the ADHD cohort relative to controls, the inherited rare CNV-associated gene set was significantly enriched for genes reported as candidates in studies of autism, schizophrenia and Tourette syndrome, including A2BP1, AUTS2, CNTNAP2 and IMMP2L. The ADHD CNV gene set was also significantly enriched for genes known to be important for psychological and neurological functions, including learning, behavior, synaptic transmission and central nervous system development. Four independent deletions were located within the protein tyrosine phosphatase gene, PTPRD, recently implicated as a candidate gene for restless legs syndrome, which frequently presents with ADHD. A deletion within the glutamate receptor gene, GRM5, was found in an affected parent and all three affected offspring whose ADHD phenotypes closely resembled those of the GRM5 null mouse. Together, these results suggest that rare inherited structural variations play an important role in ADHD development and indicate a set of putative candidate genes for further study in the etiology of ADHD.

[Diagnostic approaches to acute knee injury in childhood and adolescence. Yesterday and today]. / Diagnostisches Vorgehen beim Kniegelenktrauma im Kindes- und Jugendalter. Gestern und heute.

INTRODUCTION: Clinical examination of acute knee injury in childhood is often difficult and therefore magnetic resonance imaging (MRI) serves as an additional diagnostic tool. The aim of the present study was to evaluate on the one hand the indications for diagnostic arthroscopy and on the other hand the indications for MRI. METHODS: Of the children treated between 1990 and 1999, 87 (group 1) underwent arthroscopy after clinical examination. Between 2000 and 2006 (group 2) 83 patients were examined using MRI after clinical examination and 53 were subsequently submitted to arthroscopy. RESULTS: In group 1 the clinical diagnosis was verified by arthroscopy in 79%. In group 2 the clinical and arthroscopic diagnoses were consistent in 60% of the patients. The MRI diagnosis was correctly recognized for patella dislocation in all cases, for ligament injuries in 83% and for meniscus injuries in 56%. Due to the application of MRI before arthroscopy the fraction of diagnostic arthroscopies could be reduced from 22% to 13%. CONCLUSION: The number of diagnostic arthroscopies in childhood can be reduced by application of MRI.

[Phlegmon of the palm of the hand as initial manifestation of the Lemierre syndrome]. / Hohlhandphlegmone als Erstmanifestation des Lemierre-Syndroms.

Lemierre's syndrome is a rare disease in young otherwise healthy people showing septic embolism in the lungs and peripheral vessels. We report the case of a 19-year-old male patient who presented initially with a phlegmon of the right palm and beginning septic shock. During the clinical course a subcutaneous abscess of the left shoulder, multiple lesions of the lungs and a pericardial abscess were identified and Lemierre's syndrome was diagnosed. In this case, positron emission tomography (PET) was revealed to be an appropriate instrument to determine the extent of the disease in a one step procedure.

[Comparable results after arthroscopic replacement of the anterior cruciate ligament : Clinical and functional results after single bundle and double bundle reconstruction]. / Vergleichbare Ergebnisse nach arthroskopischem Ersatz des vorderen Kreuzbandes : Klinische und funktionelle Ergebnisse nach Einzelbündel- und Doppelbündelrekonstruktion.

INTRODUCTION: Rupture of the anterior cruciate ligament (ACL) has been surgically reconstructed mainly arthroscopically for many years. The long-propagated single bundle replacement was followed by recommendations for the anatomical double-bundle reconstruction. The aim of this study is the evaluation of clinical follow-up results in terms of function and stability after performing an ACL reconstruction with both the single bundle (SB) and the double bundle (DB) technique. METHODOLOGY: Eighty patients receiving ACL reconstruction were included (41 SB / 39 DB). The follow-up period was 17.4 months. To assess knee joint stability, anteroposterior translation and rotation translation were determined. In addition, arthrometric measurement and the implementation of standardized scores were performed. Data were statistically evaluated using the Pearson χ2 test and Fisher's exact test (p = 0.05). RESULTS: While the Lachman test in the SB group showed a significant (p = 0.032) greater stability of the knee joints, a higher stability of the knee joints in the DB group was documented by the anterior drawer test and the stability measurement with the rolimeter. In the DB group a significantly higher number of patients with local sensitivity deficits (p = 0.045) and paresthesia as well as a significantly higher active and passive flexion deficit were noted compared to the SB group (p = 0.09 / p = 0.038, respectively). CONCLUSION: Based on the results of this study it is currently not possible to give any recommendations regarding any operating procedure after a follow-up period of at least 12 months. However, there is evidence of a higher complication rate in the DB group. Clinically, these results should be considered in the evaluation of the indications.

[Pigmented villonodular synovitis]. / Seltene Schleimhauterkrankung zerstört die Gelenke. Frühzeitige Diagnose erspart Gelenkersatz.

Pigmented villonodular synovitis (PVNS) is a rare, strongly proliferative disease of the lining of thejoint, synovial bursa and tendon (synovial) sheath. If left untreated, it leads to severe destruction of the joint resulting in an early need for endoprosthetic replacement. The clinical signs are unspecific. Using the diagnostic gold standard MRI, the complete extent of PVNS can usually be determined non-invasively. Once histological confirmation has been obtained, radical tumor resection, synovectomy, possibly curettage, and postoperative irradiation must be applied.

Persistence and reactivation of human adenoviruses in the gastrointestinal tract.

Reactivation of persistent human adenoviruses (HAdVs) is associated with high morbidity and mortality in paediatric haematopoietic stem cell transplant (HSCT) recipients. Although invasive HAdV infections mainly arise from the gastrointestinal (GI) tract, the specific sites of HAdV persistence are not well characterised. We prospectively screened biopsies from 143 non-HSCT paediatric patients undergoing GI endoscopy and monitored serial stool specimens from 148 paediatric HSCT recipients for the presence of HAdV by real-time PCR. Persistence of HAdV in the GI tract was identified in 31% of children, with the highest prevalence in the terminal ileum. In situ hybridisation and immunohistochemistry identified HAdV persistence in lymphoid cells of the lamina propria, whereas biopsies from five transplant recipients revealed high numbers of replicating HAdV in intestinal epithelial cells. The prevalence of HAdV species, the frequencies of persistence in the GI tract and reactivations post transplant indicated a correlation of intestinal HAdV shedding pre-transplant with high risk of invasive infection. HAdV persistence in the GI tract is a likely origin of infectious complications in immunocompromised children. Intestinal lymphocytes represent a reservoir for HAdV persistence and reactivation, whereas the intestinal epithelium is the main site of viral proliferation preceding dissemination. The findings have important implications for assessing the risk of life-threatening invasive HAdV infections.

NKX2.5 mutations in patients with tetralogy of fallot.

BACKGROUND: Recent reports have implicated mutations in the transcription factor NKX2.5 as a cause of tetralogy of Fallot (TOF). To estimate the frequency of NKX2.5 mutations in TOF patients and to further investigate the genotype-phenotype correlation of NKX2.5 mutations, we genotyped 114 TOF patients. METHODS AND RESULTS: Patients were recruited prospectively (November 1992 through June 1999) and tested for a 22q11 deletion; those with 22q11 deletion or recognized chromosomal alteration were excluded from the present study. Patients were screened for NKX2.5 alterations by conformation-sensitive gel electrophoresis and sequencing of fragments with aberrant mobility. Four heterozygous mutations were identified in 6 unrelated patients with cases of TOF, including 3 with pulmonary atresia and 5 with right aortic arch; none had ECG evidence of PR interval prolongation. Three of 4 mutations (Glu21Gln, Arg216Cys, and Ala219Val) altered highly conserved amino acids, of which 2 mapped in the conserved NK2 domain. The fourth mutation (Arg25Cys) was identified in 3 unrelated probands in the present study and has been previously reported. No homeodomain mutations were identified. CONCLUSIONS: NKX2.5 mutations are the first gene defects identified in nonsyndromic TOF patients. NKX2.5 mutation is present in >/=4% of TOF patients. Mutations identified in the present study mapped outside of the homeodomain, were not associated with atrioventricular conduction disturbances, and were not fully penetrant, in contrast to mutations previously reported that impair homeodomain function.

Antiretroviral therapy in sporadic adult amyotrophic lateral sclerosis.

Clinical and experimental findings in idiopathic amyothrophic lateral sclerosis (ALS) would be compatible with a retroviral involvement. In 35 adult patients with non-familial ALS we observed elevated circulating immune complexes, a decrease in IgG3 isotype and enzyme-linked sorbent assay (ELISA) serum antibodies against human spuma retrovirus (HSRV), confirmed by specific human foamy virus immunoblots. All 35 were negative for IgM or relevant IgG anti-ganglioside antibodies. We treated 12 HIV-negative, immune-complex-positive ALS patients with 500 mg d-1 zidovudine p.o. over 2-10 months and found reductions of serum creatine kinase and circulating immune complexes from two days to two weeks after the beginning of medication.

Limited reliability of E-cadherin as a specific marker for in vitro-generated Langerhans cells.

Langerhans cells (LC) are a unique population of dendritic cells (DC) found in the epidermis where they can be identified by the expression of CD1a, E-cadherin and cytoplasmic Birbeck granules (BG) as their hallmark. Over the past years many techniques have been described to generate LC in vitro from either monocytes or CD34(+) hematopoietic cell progenitors. Antibodies against Lag and Langerin (two epitopes associated with BG) and E-cadherin (a Ca(2+)-dependent homophilic adhesion molecule) have been used to detect in vitro-generated LC. In this study we investigated whether the expression of E-cadherin on in vitro-generated CD1a(+) from either CD34(+) cells or monocytes is able to discriminate LC from other DC. Our results demonstrate that E-cadherin alone is not a reliable marker to specifically identify in vitro-generated LC.

Cultural diversity in Florida nursing programs: a survey of deans and directors.

To determine how nursing programs in the state of Florida promote and integrate cultural diversity, a survey of deans and directors was conducted. Of 90 deans and directors surveyed, 46 (51%) responded. The ethnic composition of students and faculty in the respondents' programs was examined in comparison with that of the Florida population. Hispanics, Blacks, and Asians were found to be underrepresented in nursing faculty as compared with their proportion in the state population. The majority of deans and directors ranked the goal of promoting cultural diversity of moderate importance. The two most critical issues perceived by the respondents were the lack of cultural knowledge, sensitivity, and awareness, and the academic problems and educational deficits of minority students. In 50% of the programs surveyed, culture content was integrated throughout the curriculum. Other programs either integrated culture content in specific classes or offered a course in transcultural nursing. Although numerous approaches are currently being employed to recruit ethnically diverse faculty and students, the data suggest that more extensive and innovative efforts are needed to overcome existing barriers. As nursing faces the challenge of caring for a multicultural society in the 21st century, nursing leaders and organizations must collaborate to resolve the issues and problems revealed in this survey.

[Revolution is a sensitive undertaking]. / Revolution ist ein heikles Unterfangen.

A psychological condition of exhaustion, accompanied by panic, triggered by a conversion symptom understood as the "emergency braking" of a drive towards a greater enjoyment of life because of a conflict of conscience arose which was held at bay. The symptom fades away, the drive is not given up in its entirety but is projected onto the loved one. The patient allows her conscience to take over once more in that she takes on the role of the conscience for her loved one. The price is possible satisfaction.

Activated thrombin-activatable fibrinolysis inhibitor (TAFIa) levels are decreased in patients with trauma-induced coagulopathy.

INTRODUCTION: The thrombin-activatable fibrinolysis inhibitor (TAFI) is a potent inhibitor of fibrinolysis. However, the time course of TAFI and its activated form (TAFIa) following trauma, in particular in patients suffering trauma-induced coagulopathy, has been poorly examined. METHODS: A total of 26 severely injured trauma patients were prospectively enrolled. TAFI and TAFIa levels were measured upon arrival and through hospital days one to 10. Trauma-induced coagulopathy was defined as elevated international normalized ratio (INR), and/or prolonged activated partial thromboplastin time (aPTT) and/or thrombocytopenia within one day of admission. RESULTS: TAFIa and TAFI levels showed the largest decrease on days one and two, respectively, with a progressive increase thereafter. Overall, 11 patients developed coagulopathy. No statistically significant differences were found for TAFI levels between the two groups. For TAFIa, however, coagulopathic patients experienced significantly lower levels on admission and on days six to eight (all p<0.05). Statistically significant correlations were found between TAFIa level on admission and the amount of packed red blood cells (p=0.011; Spearman's correlation coefficient=-0.5) and fresh frozen plasma (p=0.044; Spearman's correlation coefficient=-0.405) transfused within the initial 24hours. CONCLUSION: Depletion of TAFIa may contribute to the development of trauma-induced coagulopathy.

Molecular species of phosphatidylethanolamine from continuous cultures of Saccharomyces pastorianus syn. carlsbergensis strains.

Saccharomyces pastorianus syn. carlsbergensis strain 34/70 is well known to be the most used strain for lager beer production. The difference between this strain and very closely related strain 34/78 is the latter's greater flocculating character. This single physiological trait can cause technical difficulties in beer production. The aim of this study was to determine whether lipid analysis by a combination of thin layer chromatography (TLC) with electrospray ionization mass spectrometry (ESI-MS) could be used as a strain-typing technique in order to distinguish S. pastorianus syn. carlsbergensis strain 34/70 from strain 34/78. Both strains (34/70 and 34/78) were harvested after continuous culture under standard conditions. Polar lipids were then extracted from lyophilized cultures and analysed by TLC in order to separate phospholipid families. Phosphatidylethanolamine (PE) was extracted and investigated using ESI-MS, to gain further information on individual molecular species. Using TLC analysis, lipids were separated corresponding to standards for PE, phosphatidylcholine (PC), phosphatidylglycerol (PG), cardiolipin (CL), phosphatidylserine (PS), phosphatidylinositol (PI), phosphatidic acid (PA) and sphingomyelin (SM). ESI-MS of the PE band, separated by TLC, showed that electrospray mass spectra were highly reproducible for repeat cultures. Novel findings were that both brewing strains displayed major phospholipid peaks with m/z 714, PE (34 : 2) m/z 742, PE (36 : 2) and m/z 758, PE (37 : 1). However, strain 34/78 had additional peaks of m/z 700, PE (33 : 2) and m/z 728, PE (35 : 2). Strain 34/70 had an extra peak with m/z 686 PE (32 : 2). We conclude that combined TLC/ESI-MS can distinguish between S. pastorianus syn. carlsbergensis 34/70 and 34/78 and may be a useful typing technique for differentiation of closely related yeast strains. This novel approach may aid quality assurance and could be suitable for yeast collections and larger industrial companies.