[What went wrong? Analysis of Medical Malpractice Arbitration Proceedings Conducted by a German Arbitration Board after Breast Reductions]. / Was geht schief? Schlichtungsverfahren nach Mammareduktionen - eine Analyse der Eingriffe mit Behandlungsfehler und Haftungsanspruch der Norddeutschen Schlichtungsstelle.

INTRODUCTION: The Arbitration Board for Medical Liability Issues of the Medical Association of North Germany ("Norddeutsche Schlichtungsstelle") is responsible for 10 federal states in Germany (Berlin, Brandenburg, Bremen, Hamburg, Mecklenburg-Western Pomerania, Lower Saxony, Saarland, Saxony-Anhalt, Schleswig-Holstein and Thuringia) and is the largest arbitration board in Germany. The data available from the Norddeutsche Schlichtungsstelle provides an insight into sources of malpractice during the treatment of reduction mammoplasty. MATERIAL UND METHODS: We analysed patient request, expert opinions prepared by independent physicians on behalf of the Norddeutsche Schlichtungsstelle and the final verdicts of 88 arbitration proceedings after breast reduction mammoplasties performed between 2000 and 2007. This data allows for each case to be addressed from different viewpoints. Furthermore we analysed the statistical data entered into the Medical Error Reporting System by the arbitration board. RESULTS: Among the 88 patient requests after reduction mammoplasty, the arbitration board found a causal relationship between damage caused to a patient's health and medical malpractice in 37 cases. Therefore, 42% of requests resulted in a liability case. This is a higher rate than that of general arbitration proceedings, where only in 24% of all cases a causal relationship is confirmed by the Norddeutsche Schlichtungsstelle. Most patients were operated on by gynaecologists. In 92% of liability cases, mistakes happened during the planning and the performance of the surgical procedure, mainly during planning (65%) and surgical incisions (41%). The patients mainly complained about scars (78%), asymmetry (68%) and skin necrosis of the areola (24%). Financial disadvantage was mentioned less often (46%) than psychological stress (70%). DISCUSSION: The higher rate of liability claims may be due to the fact the surgical procedures changing the shape of breasts are more complex than generally expected. Not only the surgery itself, but also the adequate planning and aftercare are of predominant importance for patient satisfaction. All these factors lead to the relatively high rate of medical malpractice in plastic aesthetic breast surgery. Also the communication factor should not be underestimated.

Purification and characterisation of the phosphoglycerate kinase isoenzymes of Trypanosoma brucei expressed in Escherichia coli.

The Trypanosoma brucei phosphoglycerate kinase (PGK) glycosomal and cytosolic isoenzymes have been overexpressed in Escherichia coli and purified to near-homogeneity. Both enzymes were similar to the corresponding natural proteins with respect to their physicochemical and kinetic properties. In addition, a mutant of the glycosomal PGK lacking the 20 amino acid long C-terminal extension was overexpressed and purified. Various properties of this truncated glycosomal PGK were examined and it was found that in some aspects the protein behaved quite differently when compared with its natural counterpart. This was notably the case for the apparent Km for 3-phosphoglyceric acid, its sensitivity to inhibitors and its response to salts and guanidine HCl. However, its Vmax was found to be similar to that of the natural glycosomal PGK. These results suggest that the changes in the C-terminus caused a conformational change effecting the 3-phosphoglyceric acid binding site located at the N-terminal domain of the protein.

[Viability and Particle Size of Fat Grafts Obtained with WAL and PAL Techniques]. / Vitalität und Partikelgröße bei der autologen Fetttransplantation mit der WAL und der PAL Technik.

BACKGROUND: Water jet-assisted liposuction (WAL) and power-assisted liposuction (PAL) are used for autologous fat grafting. This study analyses the viability and particle sizes of fat grafts obtained by these techniques. PATIENTS, MATERIAL AND METHODS: The WAL and PAL techniques were applied in 9 female patients in identical body regions. In order to analyse cell viability, fat grafts were tested via the WST-8 assay and DNA quantification immediately after liposuction. Furthermore, in order to determine particle size, an optically evaluable water-fat emulsion was analysed by macroscopic inspection and light microscopy. RESULTS: The WST-8 assay showed significantly lower extinction values (OD) for use of the WAL technique - corresponding to a lower metabolical activity - compared to PAL liposuction: WAL 1.85±0.56 OD, PAL 2.25±0.57 OD. The quotient of extinction values and cell DNA concentration determined by DNA quantification also indicated statistically significant differences between both systems of liposuction in favour of using power-assisted systems: WAL 0.061±0.023 OD/µg, PAL 0.083±0.029 OD/µg. On the other hand, microscopic and macroscopic analyses showed significantly greater diameters (d) for fat grafts obtained with the PAL technique than by WAL liposuction: dmakroWAL=0.8 mm and dmakroPAL=1.1 mm or, respectively, dmikroWAL 0.89 mm and dmikroPAL=0.93 mm. CONCLUSION: Power-assisted liposuction obtains fat grafts with a higher metabolical activity than water jet-assisted liposuction. A falsification of extinction values within the WST-8 assay due to diversity of the number of cells was eliminated by additionally implemented DNA quantification. According to the current scientific debate, the particle size of obtained fat grafts is also considered as an important criterion for the success of autologous fat grafting. For clinical use, one should favour techniques which provide the smallest and most viable fat grafts as possible. In our opinion, the significantly lower size of WAL particles compared to the higher viability of PAL grafts indicates a necessity of analysing viability as well as particle size in order to evaluate liposuction systems. Data solely about in vitro viability of fat grafts fail to offer a recommendation for the use of a specific technique.

Molecular analysis of the cytosolic and glycosomal glyceraldehyde-3-phosphate dehydrogenase in Leishmania mexicana.

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) activity was detected in two cell compartments of Leishmania mexicana promastigotes. These activities could be attributed to two different isoenzymes, one residing in glycosomes, the other in the cytosol. We have cloned and sequenced the genes for both isoenzymes. The glycosomal enzyme is encoded by two tandemly linked genes of identical sequence and contains features frequently found in glycosomal enzymes: the presence of peptide insertions, a small carboxy-terminal extension with a potential glycosomal targeting signal (-SKM) and an excess of positively charged residues (net charge +7). Only one open reading frame was detected for the cytosolic enzyme. The amino acid sequences of the two proteins are only 55% identical. We discuss some evolutionary aspects of the observed organization of the GAPDH genes in the Trypanosomatidae and the role of the two isoenzymes in the metabolism of these organisms. The possibility to develop GAPDH-specific inhibitors that will be effective against the enzyme of various parasitic members of this family is explored.

Communication in plastic surgery by means of e-mail: experiences and recommendations for clinical use.

The Internet is a global network of computers with a broad variety of services and options. Electronic mail (email) is the most frequently used service. For a plastic surgeon, this mode is the fastest and the most cost-effective way of transferring data of any kind. The critical aim of this study was to assess the transfer of confidential data by means of e-mail and to present general conditions for the use of e-mail. Therefore, experiences with this means of communication are described to point to the possibilities, but also to indicate problems and weak points of this medium. Some rules should be obeyed for the transfer of confidential patient data by means of e-mail to satisfy the demand for data-security standards. Also, medicolegal aspects must be considered. These recommendations or rules and aspects will be discussed to offer a guideline to plastic surgeons for their e-mail applications.

[E-mail in plastic surgery--a useful addition to current communication possibilities?]. / E-mail in der Plastischen Chirurgie--Eine sinnvolle Ergänzung bestehender Kommunikationsmöglichkeiten?

The internet is a global network of computers with a broad variety of services and options. It offers completely new ways of communication and investigation. At present, this new medium seems to be the final technical revolution in communication. It presents new dimensions which were utopia so far. Electronic mail (e-mail) is the most frequently used service within the internet. For a plastic surgeon it seems to be the fastest and the most cost-effective way of transferring data of any kind. The aim of this paper is to critically assess the transfer of confidential data via e-mail as well as to present general conditions for the use of e-mails. Therefore, our own experiences made with this technology are described to point to the possibilities, but also to indicate problems and weaknesses of this medium. Some rules should be obeyed for the transfer of confidential patient data via e-mail in order to satisfy the demand for data-security standards. Also medicolegal aspects must be considered. These recommendations or rules and aspects will be discussed to offer a guideline to plastic surgeons for their e-mail applications.

[Autologous fat injection for treatment of carpometacarpal joint osteoarthritis of the thumb - a promising alternative]. / Eigenfettinjektion in das Sattelgelenk zur Behandlung der Rhizarthrose - eine viel versprechende Therapieoption.

Classical surgical options for osteoarthritis of the thumb carpometacarpal joint irreversibly des-troy the normal anatomy of the wrist. Although overall satisfaction rates with these procedures are high, time to achieve normal hand function and ability to work may take 12-16 weeks. Therefore a non-ablative less invasive surgical option would be interesting. We injected adipose tissue into the thumb carpometacarpal joint in a pilot study. Average preoperative pain according to a VAS was 7.4 in action and 3.8 during rest. It was reduced considerably to 2.2 in action and 0 during rest after 1 month and to 2.4 and 0.8, respectively, 3 months after surgery. The reduction of pain in action was statistically significant 1 month after injection (p=0.042). Average grip strength was 78% and pinch grip strength was 74% in comparison to the healthy side preop-eratively, 89% and 80% one month postoperatively and 93% and 89%, respectively, 3 months postoperatively. An average DASH score of 58 preoperative was reduced to 36 after 1 month and 33 after 3 months. The amelioration of hand function was statistically significant (p=0.042 and p=0.043). There were no side effects and all patients were satisfied. These preliminary results are promising. Adipose tissue injection seems to be an alternative to consider, especially as it does not exclude classical surgical options in cases of failure.

[Comments on the topic of attesting to health status at arrest during medical emergency care]. / Anmerkungen zur Problematik der Attestierung einer Haftfähigkeit während des ärztlichen Bereitschaftsdienstes.

A common problem for Emergency Room doctors on call is whether or not an arrested patient is sufficiently healthy to allow his transfer to jail. When there are signs of injury, or doubts about the patient's condition, the police must bring the patient in for medical examination to get a certification of the patient's health condition. He must be examined according to the information about his health and pre-existing conditions. Additional treatment should be undertaken, depending on patient's condition. The diagnoses must be written and summarized accurately and concisely. Additional documentation, such as photographic evidence must also be saved in the medical records. Should there be symptoms of a serious but difficult to diagnose condition, like traumatic head injury, the patient should always be admitted to the hospital. The medical certification or permission for imprisonment can not be enforced when the medical condition of the patient changes.

Molecular cloning and analysis of two tandemly linked genes for pyruvate kinase of Trypanosoma brucei.

In Trypanosoma brucei (stock 427) genes encoding the glycolytic enzyme pyruvate kinase are present on two homologous chromosomes. We have cloned and characterized one of the alleles. Two large, tandemly arranged open reading frames were found, each coding for a pyruvate kinase polypeptide of 498 amino acids. The gene sequences differ at 15 positions, resulting in five amino acid substitutions. The calculated molecular masses of the polypeptides are 54,378 Da and 54,363 Da. These values are somewhat smaller than those reported for the subunit molecular mass of the purified protein, which is 57-59 kDa. However, in vitro translation of the DNA region corresponding to the open reading frame, and translation of the RNA in a wheat-germ lysate, yielded a product that comigrated exactly with the native polypeptide in SDS/PAGE. The overall identity between the sequences of the trypanosomal enzyme and the enzymes from other sources is 41-51%. The conserved residues are not equally distributed over the polypeptide. The primary structure of domains A and, to a lesser extent, B, which constitute the active site, are rather well conserved. In contrast, the sequence of domain C, which supposedly is involved in the regulation of the enzyme activity, is much more variable. The cytosolically located pyruvate kinase of T. brucei lacks the specific features found in the majority of the glycolytic enzymes of this organism that are sequestered in a microbody-like organelle, the glycosome. It has neither a relatively high subunit molecular mass, due to unique insertions or terminal extensions, nor a high excess of positively charged amino acids. The polypeptide is shorter than that of most other pyruvate kinases and the calculated net charge is only +3.

The cytosolic and glycosomal isoenzymes of glyceraldehyde-3-phosphate dehydrogenase in Trypanosoma brucei have a distant evolutionary relationship.

Trypanosoma brucei contains two isoenzymes for glyceraldehyde-3-phosphate dehydrogenase: one enzyme resides in a microbody-like organelle, the glycosome; the other is found in the cytosol. Previously we have reported the characterization of the gene for the glycosomal enzyme [Michels, P. A. M., Poliszczak, A., Osinga, K. A., Misset, O., Van Beeumen, J., Wierenga, R. K., Borst, P. & Opperdoes, F. R. (1986) EMBO J. 5, 1049-1056]. Here we describe the cloning and analysis of the gene that codes for the cytosolic isoenzyme. The gene encodes a polypeptide of 330 amino acids, with a calculated molecular mass of 35440 Da. The two isoenzymes are only 55% identical. The cytosolic glyceraldehyde-3-phosphate dehydrogenase differs from the glycosomal enzyme in the following respects: (a) its subunit molecular mass is 3.4 kDa smaller due to the absence of insertions and a small C-terminal extension which are unique to the glycosomal protein; (b) the cytosolic enzyme has a lower pI (7.9, as compared to 9.3 for the glycosomal isoenzyme), which is due to a reduction in the excess of positively charged amino acids (the calculated net charges of the polypeptides are +2 and +11, respectively). We have compared the amino acid sequences of the two T. brucei glyceraldehyde-3-phosphate dehydrogenases, with 24 available sequences of the corresponding enzyme of other organisms from various phylogenetic groups. On the basis of this comparison an evolutionary tree was constructed. This analysis strongly supports the theory that T. brucei diverged early in evolution from the main eukaryotic branch of the phylogenetic tree. Further, two separate branches for the lineages leading to Trypanosoma are inferred from the amino acid sequences, suggesting that the genes for the two glyceraldehyde-3-phosphate dehydrogenases of the trypanosome are distantly related and must have been acquired independently by the trypanosomal ancestor. The branching determined with the glycosomal enzyme precedes that found with the cytosolic enzyme. The available data do not allow us to decide which of the two genes originally belonged to the trypanosome lineage and which entered the cell later by horizontal gene transfer.