Combining treatment for chronic hepatitis C with opioid agonist therapy is an effective microelimination strategy for people who inject drugs with high risk of non-adherence to direct-acting antiviral therapy.

Background & aims: Despite effective direct-acting antivirals (DAAs), hepatitis C virus (HCV) prevalence is high among people who inject drugs (PWIDs) and non-adherence to therapy remains a major obstacle towards HCV elimination in this subpopulation. To overcome this issue, we have combined ongoing opioid agonist therapy (OAT) with DAAs in a directly-observed therapy (DOT) setting. Method: From September 2014 until January 2021 PWIDs at high risk of non-adherence to DAA therapy, who were also on OAT, were included into this microelimination project. Individuals received their OAT and DAAs under supervision of healthcare workers as DOT in a pharmacy or low-threshold facility. Results: In total, 504 HCV RNA-positive PWIDs on OAT (387 men, 76.8%; median age: 38 years [IQR 33-45], HIV: 4.6%; hepatitis B: 1.4%) were included into this study. Two thirds reported ongoing intravenous drug use (IDU) and half of them had no permanent housing. Only 41 (8.1%) were lost to follow-up and two (0.4%) died of reasons unrelated to DAA toxicity. Overall, 90.7% of PWIDs achieved sustained virological response 12 weeks after treatment (SVR12) (95% CI: 88.1-93.2%). By excluding those lost to follow-up and hose who had died of causes unrelated to DAAs, the SVR12 rate was 99.1% (95% CI: 98.3-100.0%; modified intention-to-treat analysis). Four PWIDs (0.9%) experienced treatment failure. Over a median follow-up of 24 weeks (IQR 12-39), 27 reinfections (5.9%) were observed in individuals with the highest IDU rates (81.2%). Importantly, even though some were lost to follow-up, all completed their DAA treatment. By using DOT, adherence to DAAs was excellent with only a total of 86 missed doses (0.3% of 25,224 doses). Conclusions: In this difficult-to-treat population of PWIDs with high rates of IDU , coupling DAA treatment to OAT in a DOT setting resulted in high SVR12 rates equivalent to conventional treatment settings in non-PWID populations.

Female genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in Austria.

INTRODUCTION: Practical experience in the care of women with female genital mutilation/cutting (FGM/C) is uncommon in Austria. However, affected women require specialized gynecological and obstetric care. In our region, there is currently neither an official counseling center nor specially trained medical personnel to address the special needs of women after FGM/C. The aim of this study was to determine the potential need for obstetric care for women who have undergone FGM/C in our region. METHODS: We retrospectively reviewed women presenting for delivery at the LKH University Hospital Graz from 1.1.2010 until 31.12.2020 regarding the place of birth and/or the nationality of the mother to filter out women from a country with known FGM/C prevalence according to the UNICEF Global Database. Data on the documentation of FGM/C as well as demographic maternal data and peripartal parameters were gathered. Periods before and after the European refugee crisis in 2015 were compared. RESULTS: During the study period, a total of 35,628 deliveries took place at our hospital. 856 (2.4%) deliveries of 539 women were included due to nationality or birthplace in a country with known FGM/C prevalence. We found only 17/539 (3.2%) documented FGM/C cases. The estimated FGM/C prevalence among those patients was, however, 208/539 (38,6%). Women affected by FGM/C in our collective were most frequently from Nigeria, Egypt, Iraq, Ghana, and Somalia. No statistically significant increase in deliveries during the study period in the overall study cohort was observed, with the exception of deliveries of Somali women (p = 0.000). DISCUSSION: The discrepancy between documented and expected FGM/C rates (3,2% vs. 38,6%) in our collective suggests that most cases of FGM/C go undetected among women delivering in Austria. These data show the great need for special training for obstetricians and targeted contact points for affected women.

Anatomia do sistema reprodutor feminino de Alouatta belzebul (Linnaeus, 1766) / [Anatomy of the female reproductive system of the Alouatta belzebul (Linnaeus, 1766)]

O conhecimento da anatomia de qualquer animal silvestre é de fundamental importância para sua preservação e proteção. Neste contexto, o presente estudo objetivou descrever a morfologia do sistema reprodutor feminino de Alouatta belzebul. Foram utilizados seis espécimes de A. belzebul, fêmeas, adultas, e livres de lesões. Observou-se macroscopicamente que os ovários têm características morfológicas em formato ovoides, com superfície lisa, e, na análise histológica na região de córtex, evidenciou-se folículos ovarianos em diferentes estágios de desenvolvimento. As tubas uterinas anatomicamente são finas e curvilíneas, apresentando uma camada mucosa, uma muscular e outra serosa. O útero possui formato simples, com fundo globoso, com um miométrio altamente vascularizado, sendo organizado em feixes de fibras musculares lisas. A estrutura anatômica da vagina apresentou-se como um tubo muscular longo de paredes finas, onde, na região vestibular, o óstio externo da uretra é marcado por uma papila uretral bilobada e, na região de vulva, em sua porção caudal, contatou-se um clitóris bem desenvolvido. No que concerne à análise histológica da vagina, verificou-se, em região de mucosa vaginal, um extrato basal composto por epitélio estratificado pavimentoso não queratinizado atrófico. As descrições morfológicas fornecem, de forma inédita, informações importantes relativas à anatomia macroscópica e microscópica do sistema reprodutor feminino dessa espécie.(AU)

Knowledge of the anatomy of any wild animal is of fundamental importance for its preservation and protection. In this context the present study aimed to describe the morphology of the female reproductive system of A. belzebul. We used 6 specimens of A. belzebul, female, adult and free of lesions. It was macroscopically observed that the ovaries are ovoid with smooth surface and the histological analysis in cortical region showed ovarian follicles in different stages of development. The fallopian tubes are anatomically thin and curvilinear, with one mucous layer, one muscular and one serous layer. The uterus was presented in a simple format with a globular fundus, with a highly vascularized myometrium, being organized in bundles of smooth muscle fibers. The anatomical structure of the vagina presented itself as a long thin-walled muscular tube where in the vestibular region the external orifice of the urethra is marked by a bilobed urethral papilla and in the caudal portion in its caudal portion a well-developed clitoris. Regarding the histological analysis of the vagina, a basal extract composed of atrophic non-keratinized stratified squamous epithelium was found in the vaginal mucosa region. The morphological descriptions provide important information regarding the macroscopic and microscopic anatomy of the female reproductive system of this species in an unprecedented way.(AU)

Prophylactic salpingectomy for prevention of ovarian cancer at the time of elective laparoscopic cholecystectomy.

BACKGROUND: Most serous ovarian cancers are now understood to originate in the fallopian tubes. Removing the tubes (salpingectomy) likely reduces the risk of developing high-grade serous ovarian cancer. Numerous gynaecological societies now recommend prophylactic (or opportunistic) salpingectomy at the time of gynaecological surgery in appropriate women, and this is widely done. Salpingectomy at the time of non-gynaecological surgery has not been explored and may present an opportunity for primary prevention of ovarian cancer. METHODS: This study investigated whether prophylactic salpingectomy with the intention of reducing the risk of developing ovarian cancer would be accepted and could be accomplished at the time of elective laparoscopic cholecystectomy. Women aged at least 45 years scheduled for elective laparoscopic cholecystectomy were recruited. They were counselled and offered prophylactic bilateral salpingectomy at the time of cholecystectomy. Outcome measures were rate of accomplishment of salpingectomy, time and procedural steps needed for salpingectomy, and complications. RESULTS: A total of 105 patients were included in the study. The rate of acceptance of salpingectomy was approximately 60 per cent. Salpingectomy was performed in 98 of 105 laparoscopic cholecystectomies (93·3 per cent) and not accomplished because of poor visibility or adhesions in seven (6·7 per cent). Median additional operating time was 13 (range 4-45) min. There were no complications attributable to salpingectomy. One patient presented with ovarian cancer 28 months after prophylactic salpingectomy; histological re-evaluation of the tubes showed a previously undetected, focal serous tubal intraepithelial carcinoma. CONCLUSION: Prophylactic salpingectomy can be done during elective laparoscopic cholecystectomy.

ANTECEDENTES: La mayoría de carcinomas serosos de ovario se originan en las trompas de Falopio. La exéresis de las trompas (salpingectomía) probablemente reduce el riesgo de desarrollar un carcinoma seroso ovárico de alto grado. Numerosas sociedades ginecológicas recomiendan efectuar una salpingectomía profiláctica (u oportunista) en el momento de una cirugía ginecológica en determinadas mujeres, y esta conducta está ampliamente difundida. Sin embargo, no se ha analizado la realización de la salpingectomía durante cirugías no ginecológicas como forma de prevención primaria del carcinoma ovárico. MÉTODOS: Determinar si la salpingectomía profiláctica con intención de reducir el riesgo de desarrollar cáncer de ovario sería aceptada y podría llevarse a cabo durante una colecistectomía laparoscópica electiva. Se reclutaron mujeres ≥ 45 años de edad programadas para colecistectomía laparoscópica electiva. A todas ellas se les aconsejó y ofreció la realización de una salpingectomía bilateral profiláctica en el momento de su colecistectomía. Las variables analizadas fueron la tasa de realización de la salpingectomía, la duración y las etapas quirúrgicos para efectuar este procedimiento, y las complicaciones. RESULTADOS: La aceptación de la salpingectomía fue aproximadamente del 60%. La salpingectomía se realizó en 98 de 105 colecistectomías laparoscópicas (93%) y no se pudo realizar en 7 pacientes (7%) por escasa visibilidad o adherencias. La mediana del tiempo quirúrgico adicional fue de 13 (rango 4-45) minutos. No hubo complicaciones atribuibles a la salpingectomía. Una paciente presentó cáncer de ovario 28 meses después de la salpingectomía profiláctica; la reevaluación histológica de las trompas mostró un carcinoma intraepitelial seroso focal tubárico (serous tubal intraepithelial carcinoma, STIC) no detectado previamente. CONCLUSIÓN: La salpingectomía profiláctica se puede realizar durante la colecistectomía laparoscópica electiva.

[Quality assurance in specialized palliative home care (QUAPS): a questionnaire's feasibility]. / Qualitätssicherung in der spezialisierten ambulanten Palliativversorgung (QUAPS) ­ Praktikabilität eines Fragebogens.

BACKGROUND: Structure and process parameters are not sufficient for adequate quality assurance in specialized palliative home care (SAPV). Asking the patients and their relatives for their assessment is crucial. A focus group in Jena, Germany, developed the quality assurance in specialized palliative home care (QUAPS) questionnaire for this assessment of outcome parameters, which was tested in two studies. OBJECTIVES: The aim of the study was to evaluate the feasibility of a questionnaire for patients, relatives and SAPV teams. MATERIAL AND METHODS: The questionnaire collects outcome parameters on a Likert scale as well as the distress of respondents using the numeric rating scale (NRS). In the pilot study, QUAPS I was tested in three SAPV teams. The survey was simplified in the follow-up study, QUAPS II, where 17 teams were included. Both studies were conducted with an ex-post-facto design. RESULTS: In QUAPS I, complete datasets could be obtained for 43 out of 308 surveyed cases. In QUAPS II, 169 complete datasets resulted from 371 surveyed cases. The SAPV staff assessed the QUAPS II survey as being organizationally feasible. The questionnaire shows good internal consistency and high approval for the surveyed aspects of SAPV care. Ceiling effects occurred. More than 70% of respondents reported a distress score >5. CONCLUSIONS: The simplified survey in QUAPS II resulted in a higher rate of complete datasets. The detected ceiling effects restrict the conclusions of the survey. Biases like social desirability cannot be ruled out. In the future, a combination of different questionnaires (e. g. integrated palliative outcome score [IPOS] and QUAPS) should be explored.

Directly observed therapy of chronic hepatitis C with ledipasvir/sofosbuvir in people who inject drugs at risk of nonadherence to direct-acting antivirals.

An important subgroup of people who inject drugs (PWID) receiving opioid agonist therapy (OAT) cannot be treated in the setting of a hepatology centre and would not regularly ingest their medication when handed to them for self-administration. Our hypothesis was that chronic hepatitis C in these patients could be ideally managed if modern, interferon-free regimens were administered together with OAT under direct observation of a physician or nurse at a low-threshold facility. In this open-label, noninterventional, proof-of-concept study (ClinicalTrials.gov number, NCT02638233), 40 PWID at risk of nonadherence to direct-acting antivirals (DAA) and previously untreated chronic hepatitis C virus genotype 1 infection without cirrhosis were treated with ledipasvir/sofosbuvir for 8 weeks. Patients received antiviral treatment together with OAT under direct observation of a physician or nurse at a low-threshold facility. By following the concept of directly observed therapy, excellent adherence to antiviral therapy was achieved as follows: only 0.16% (95% CI: 0.03-0.47) of scheduled dates for ingestion of the antiviral therapy in combination with OAT were missed by the 40 patients. The rate of sustained virological response 12 weeks after end of therapy was 100% (95% CI: 91.2-100.0). Between week 12 and week 24 of follow-up reinfections were recorded in 2 of 40 patients (5%). Directly observed therapy of chronic hepatitis C is highly effective in PWID at risk of nonadherence to DAA. By this new concept, a group of difficult-to-treat patients can be cured, who could not have been treated in settings of studies published so far.

[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]. / S2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz ­ Revision 2017.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

An experimental study on the influence of trace impurities on ionization of atmospheric noble gas dielectric barrier discharges.

While the influence of trace impurities in noble gas discharges is well established in theoretical work, experimental approaches are difficult. Particularly the effects of trace concentrations of N2 on He discharges are complicated to investigate due to the fact that for He 5.0 the purity of He is only 99.999%. This corresponds to a residual concentration of 10 ppm, thereof 3 ppm of N2, in He. Matters are made difficult by the fact that He DBD plasmajets are normally operated under an ambient atmosphere, which has a high abundance of N2. This work tackles these problems from two sides. The first approach is to operate a DBD plasmajet under a quasi-controlled He atmosphere, therefore diminishing the effect of atmospheric N2 and making a defined contamination with N2 possible. The second approach is using Ar as the operating gas and introducing propane (C3H8) as a suitable substitute impurity like N2 in He. As will be shown both discharges in either He or Ar, with their respective impurity show the same qualitative behaviour.

[Effect of wrist arthroscopy with intraarticular hyaluronan substitution therapy: a randomised, controlled, prospective, non-blinded, single-centre, comparative trial]. / Auswirkungen einer intraartikulären Substitutionstherapie mit Hyaluronsäure im Rahmen handgelenksarthroskopischer Operationen. Eine randomisierte, kontrollierte, prospektive, unverblindete, monozentrische Vergleichsstudie.

PURPOSE: The present study investigates the effect of an intra- and postoperative intraarticular hyaluronan injection (HS) in patients undergoing wrist arthroscopy. PATIENTS AND METHODS: A total of 140 adults were included and prospectively randomised to one of 2 treatment groups. All patients presented wrist pain resistant to non-operative therapy. 69 patients were assigned to therapeutic wrist arthroscopy without additional treatment (A-group), another 70 patients were assigned to wrist arthroscopy and additional intraarticular instillation of a 1% HS solution (HS-group). The HS administration (2 mL of 1% HS solution each) was performed directly at the end of arthroscopic procedure and a second time 3 weeks after surgery. For outcome assessment, Mayo wrist score (modified according to Krimmer, MMWS), DASH questionnaire, absolute grip strength, VAS pain (visual analogue scale) and clinical global impression (CGI) of patients and investigators were used. The follow-up was 6 months. Furthermore, the correlation between severity of pathological findings and level of postoperative benefit was investigated. RESULTS: In both groups, pain decreased and the function of the wrist joint improved. While pa-tients with additional HS injection had significantly better values in MMWS than patients without additional HS injection, no significant differences could be observed for DASH score, absolute grip strength and pain intensity. 12 and 24 weeks after surgery, therapeutic success was rated better in HS-group than in A-group. The highest clinical benefit was obtained for patients in the HS-group with marginal to moderate pathological findings. CONCLUSION: The benefit of therapeutic wrist arthroscopy can be significantly improved by a 2-time intraarticular substitution of hyaluronan.

What is the best fixation target? The effect of target shape on stability of fixational eye movements.

People can direct their gaze at a visual target for extended periods of time. Yet, even during fixation the eyes make small, involuntary movements (e.g. tremor, drift, and microsaccades). This can be a problem during experiments that require stable fixation. The shape of a fixation target can be easily manipulated in the context of many experimental paradigms. Thus, from a purely methodological point of view, it would be good to know if there was a particular shape of a fixation target that minimizes involuntary eye movements during fixation, because this shape could then be used in experiments that require stable fixation. Based on this methodological motivation, the current experiments tested if the shape of a fixation target can be used to reduce eye movements during fixation. In two separate experiments subjects directed their gaze at a fixation target for 17s on each trial. The shape of the fixation target varied from trial to trial and was drawn from a set of seven shapes, the use of which has been frequently reported in the literature. To determine stability of fixation we computed spatial dispersion and microsaccade rate. We found that only a target shape which looks like a combination of bulls eye and cross hair resulted in combined low dispersion and microsaccade rate. We recommend the combination of bulls eye and cross hair as fixation target shape for experiments that require stable fixation.

Rapid-onset central motor plasticity in multiple sclerosis.

OBJECTIVE: To study rapid-onset central motor plasticity, and its relationship to motor impairment and CNS injury in patients with multiple sclerosis (MS). METHODS: In this cross-sectional observational study, motor plasticity was examined neurophysiologically and behaviorally in 22 patients with moderately severe (median Expanded Disability Status Scale score 2.5 [0-6]) stable MS and matched healthy controls. First, plasticity was assessed using paired associative stimulation (PAS), a protocol modeling long-term synaptic potentiation in human cortex. PAS combines repetitive electric nerve stimulation with transcranial magnetic stimulation (TMS) of the contralateral motor cortex. Second, motor learning was tested by a force production task. Motor impairment was assessed by functional tests. CNS injury was evaluated by obtaining normalized N-acetyl-aspartate (NAA/Cr) spectra using magnetic resonance spectroscopy and by the corticomuscular latency (CML) to the abductor pollicis brevis muscle as tested by TMS. RESULTS: Patients with MS performed worse than controls in functional motor tests, CMLs were prolonged, and NAA/Cr was decreased. PAS-induced enhancement of corticospinal excitability and training-induced increments of motor performance were comparable between patients with MS and controls. Neither PAS-induced plasticity nor motor learning performance correlated with motor impairment or measures of CNS injury. Patients with high CNS injury and good motor performance did not differ significantly from those with high CNS injury and poor motor performance with respect to PAS-induced plasticity and motor learning success. CONCLUSIONS: Despite motor impairment and CNS injury in patients with multiple sclerosis (MS), rapid-onset motor plasticity is comparable to that in healthy subjects. Compensation of MS-related CNS injury is unlikely to be constrained by insufficient rapid-onset neuroplasticity.

[Palliative care in respiratory medicine]. / Palliativmedizin in der Pneumologie.

Palliative care should be part of respiratory medicine for two reasons: first, many respiratory diseases--besides thoracic tumours--need palliative care in the late stages of the disease. Second, dyspnoea is a common symptom in advanced, primary extrapulmonary diseases and the knowledge of respiratory specialists can be beneficial in the treatment of this symptom. In this paper we describe frequent symptoms of advanced pulmonary diseases and their treatment. Moreover, we focus on the structure of palliative care in Germany.

[Eosinophilic gastritis after helicobacter pylori eradication]. / Eosinophile Gastritis nach Helicobacter-pylori-Eradikation.

The development of eosinophilic gastritis immediately after Helicobacter pylori eradication has not previously been described: A 62-year-old woman developed eosinophilic gastritis immediately after a triple therapy for Helicobacter pylori eradication, consisting of pantoprazole, amoxicillin and clarithromycin. She suffered from burning epigastric pain and loss of appetite. Blood eosinophilia, gastritis and eosinophilic infiltration of the gastric corpus wall were detected. The treatment with low-dose prednisolone led to remission of the blood eosinophilia, complaints, gastritis and eosinophilic infiltration. The remission persisted after the prednisolone treatment had been finished. Eosinophilic gastritis can be diagnosed only by pathohistological examination. This need for biopsy should be stressed, because the usual gastritis treatment with proton pump inhibitors fails in cases of eosinophilic gastritis. Helicobacter pylori does not seem to play a significant role in the aetiopathology of this disorder. In our case, we suggest that the eradication drug therapy actually caused the disease.

Smooth pursuit eye movements to isoluminant targets.

At slow speeds, chromatic isoluminant stimuli are perceived to move much slower than comparable luminance stimuli. We investigated whether smooth pursuit eye movements to isoluminant stimuli show an analogous slowing. Beside pursuit speed and latency, we studied speed judgments to the same stimuli during fixation and pursuit. Stimuli were either large sine wave gratings or small Gaussians blobs moving horizontally at speeds between 1 and 11 degrees /s. Targets were defined by luminance contrast or color. Confirming prior studies, we found that speed judgments of isoluminant stimuli during fixation showed a substantial slowing when compared with luminance stimuli. A similarly strong and significant effect of isoluminance was found for pursuit initiation: compared with luminance targets of matched contrasts, latencies of pursuit initiation were delayed by 50 ms at all speeds and eye accelerations were reduced for isoluminant targets. A small difference was found between steady-state eye velocities of luminance and isoluminant targets. For comparison, we measured latencies of saccades to luminance and isoluminant stimuli under similar conditions, but the effect of isoluminance was only found for pursuit. Parallel psychophysical experiments revealed that different from speed judgments of moving isoluminant stimuli made during fixation, judgments during pursuit are veridical for the same stimuli at all speeds. Therefore information about target speed seems to be available for pursuit eye movements and speed judgments during pursuit but is degraded for perceptual speed judgments during fixation and for pursuit initiation.

[Uveitis intermedia in Whipple's disease]. / Uveitis intermedia bei Morbus Whipple.

We report a case of a 45-year-old man who complained of progressive vision loss in his right eye. Visual acuity was 20/300 in the right eye and 20/25 in the left eye. Bilateral uveitis intermedia R>L was diagnosed and treated with systemic and local steroids. An internal checkup was also done, and duodenal biopsy identified Whipple's disease. Despite specific antibiotic therapy, the patient's follow-up examination showed increased inflammatory activity R>L and bilateral cataracta complicata. Cataract surgery and pars plana vitrectomy with removal of epiretinal membranes were done. Histologic analysis of the vitreous and epiretinal membranes showed periodic acid-Schiff-positive macrophages, pathognomonic for Whipple's disease. Whipple's disease is a rare but severe disease with multiple manifestations and should be considered a differential diagnosis in uveitis.

Assessment of patient safety research from an organizational ergonomics and structural perspective.

The aim of this study is to review patient safety improvement initiatives within a conceptual framework that builds upon principles of organizational ergonomics and emphasizes structural factors that influence patient safety. The literature review included 131 English language published studies of patient safety improvement strategies extracted using Medline, Ovid Healthstar, PubMed and CINAHL searches. Keywords for the search included: 'patient safety'; 'medical errors'; 'adverse event'; 'iatrogenic'; and truncated options for 'improve'. The multilevel, hierarchical framework offered in this paper integrates quality management principles and organizational ergonomics theory and organizes patient safety initiatives according to sociotechnical system elements within three structural levels: health policies and associated health care organizations; health care delivery organizations; and health care microsystems. Utilizing the conceptual framework, this review of patient safety improvement initiatives highlights the need for consideration of the impact of all improvement proposals on each structural component within health care systems. The review also supports the need for patient safety research to evolve from exploratory, 1-D reporting to multi-level, integrated research.

Fatal recurrent subarachnoid hemorrhage after complete endovascular aneurysm occlusion.

Endovascular treatment of aneurysms has become an alternative to the neurosurgical approach. Here, we describe a patient presenting with a subarachnoid hemorrhage (SAH) due to a basilar tip aneurysm, which was completely occluded with coils. Fourteen days later the patient died due to massive recurrent SAH. Histologic evaluation showed aneurysm rerupture with coil dislocation in the subarachnoid space. This is a rare histologically documented case of fatal recurrent hemorrhage early after coil embolization of cerebral aneurysms.

Congenital oesophageal atresia discordant for tracheo-oesophageal fistula occurring in a set of dizygotic twins.

The authors present a set of female diamnionic and dichorionic twins with different blood types and congenital oesophageal atresia (EA) in both. Surgical management was successful. It can be assumed that EA with tracheo-oesophageal fistula in twin B occurred during an early embryological stage whereas the isolated EA in twin A was the result of a later event. To our knowledge, this is the first published set of dizygotic twins with different types of EA.

[Sacrococcygeal extraspinal myxopapillary ependymoma]. / Sacrococcygeales extraspinales myxopapilläres Ependymom--Fallbericht.

A 9-year-old boy was admitted with a circumscript subcutaneous tumor of the sacral region. Serum alpha-fetoprotein was not elevated. The lesion was excised en bloc including the top of the coccygis. Histology revealed a myxopapillary ependymoma without bony involvement. Metastases were excluded. Extraspinal myxopapillary ependymoma is a rare tumor of the sacrococcygeal region with a potential risk to develop metastases and for local relapse. Long-term follow-up is recommended.