Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis.

BACKGROUND: Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients. METHODS: We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients. RESULTS: The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients. CONCLUSION: We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.

Voice break in boys-temporal relations with other pubertal milestones and likely causal effects of BMI.

STUDY QUESTION: How is timing of voice break related to other male pubertal milestones as well as to BMI? SUMMARY ANSWER: We provide a comprehensive temporal analysis of male pubertal milestones, including reproductive hormone dynamics, confirm voice break as a late milestone of male puberty and report a likely causal relationship between higher BMI and earlier age at voice break in men. WHAT IS KNOWN ALREADY: Voice break represents a late pubertal milestone and recalled age at voice break is frequently used in epidemiological studies as a measure of puberty. In contrast, clinical studies use mainly testicular enlargement and/or genital tanner stage as the marker of pubertal onset. However, neither correlation of pubertal milestones nor reproductive hormone dynamics have been assessed in detail previously. Further, although BMI and puberty timing are known to be closely linked, cause and effect between these traits are not known. STUDY DESIGN, SIZE, DURATION: The study included a population-based mixed cross-sectional and longitudinal cohort (2006-2014, COPENHAGEN Puberty Study) of 730 healthy Danish boys. Data for 55 871 male research participants from the 23andMe study were obtained, including genome-wide single nucleotide polymorphism data and age at voice break. PARTICIPANTS/MATERIALS, SETTING, METHODS: We performed a detailed evaluation of pubertal milestones and reproductive hormone levels (study population 1). A Mendelian randomization (MR) approach was used to determine the likely causal link between BMI and timing of voice break (study population 2). MAIN RESULTS AND THE ROLE OF CHANCE: Voice break occurred at mean age 13.6 (95% CI: 13.5-13.8) years. At voice break, mean (95% CI) testosterone levels, LH levels and bi-testicular volume were 10.9 (10.0-11.7) nmol/L, 2.4 (2.2-2.5) IU/L and 24 (23-25) mL, respectively. Voice break correlated moderately strongly with timing of male pubertal milestones, including testicular enlargement, gonadarche, pubarche, sweat odor, axillary hair growth and testosterone above limit of detection (r2 range: 0.43-0.61). Timing of all milestones was negatively associated with age-specific BMI (all P ≤ 0.001). MR analyses inferred likely causal effects of higher BMI on earlier voice break in males (-0.35 years/approximate SD, P < 0.001). LIMITATIONS, REASONS FOR CAUTION: Participation rate of the population-based cohort was 25%. Further, boys that were followed longitudinally were examined approximately every 6 months limiting the time resolution of pubertal milestones. Using adult BMI as exposure instead of prepubertal BMI in the MR analysis and the known inaccuracies of the testosterone immunoassay at low testosterone levels may be further limitations. WIDER IMPLICATIONS OF THE FINDINGS: We provide valuable normative data on the temporal relation of male pubertal milestones. Further, the likely causal relationship between BMI and puberty timing highlights the importance of preventing obesity in childhood. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by Danish Agency for Science, Technology and Innovation (09-067 180); Danish Ministry of the Environment, CeHoS (MST-621-00 065); Capital Region of Denmark (R129-A3966); Ministry of Higher Education and Science (DFF-1331-00 113); Innovation Fund Denmark (InnovationsFonden, 14-2013-4); The International Center for Research and Research Training in Endocrine Disrupting Effects of Male Reproduction and Child Health. B.H., F.R.D., J.R.B.P. and K.K.O. are supported by the Medical Research Council (MC_UU_12015/2). The 23andMe study is supported by the National Human Genome Research Institute of the National Institutes of Health (R44HG006981). Members of the 23andMe Research Team are employees of 23andMe, Inc. and hold stock or stock options in 23andMe. TRIAL REGISTRATION NUMBER: NCT01411527.

[Apps in clinical use in orthopedics and trauma surgery : The status quo in Germany]. / Klinischer Einsatz mobiler Applikationen in der Orthopädie und Unfallchirurgie in Deutschland : Eine Bestandsaufnahme.

In the course of digitalization the smartphone is penetrating more and more areas of life giving the user mobile and almost ubiquitous access to the internet and other web applications. The advantages of mHealth are an integral part in some areas of patient care but in contrast to other disciplines, routine integration of mobile devices into orthopedics and trauma surgery is still in its infancy. A survey among German orthopedists and trauma surgeons revealed which kind of apps have become established in everyday clinical practice to date. Apps published by representative institutions such as the AO Foundation demonstrated the highest usage rates. In summary, the number of regularly used apps is low; however, the causes of this lack of acceptance have not yet been conclusively clarified. The authors of this study proclaim a significant increase in the use of mHealth and mobile devices in daily clinical practice in the future.

Cellulose degradation in Gastrophysa viridula (Coleoptera: Chrysomelidae): functional characterization of two CAZymes belonging to glycoside hydrolase family 45 reveals a novel enzymatic activity.

Cellulose is a major component of the primary and secondary cell walls in plants. Cellulose is considered to be the most abundant biopolymer on Earth and represents a large potential source of metabolic energy. Yet, cellulose degradation is rare and mostly restricted to cellulolytic microorganisms. Recently, various metazoans, including leaf beetles, have been found to encode their own cellulases, giving them the ability to degrade cellulose independently of cellulolytic symbionts. Here, we analyzed the cellulosic capacity of the leaf beetle Gastrophysa viridula, which typically feeds on Rumex plants. We identified three putative cellulases member of two glycoside hydrolase (GH) families, namely GH45 and GH9. Using heterologous expression and functional assays, we demonstrated that both GH45 proteins are active enzymes, in contrast to the GH9 protein. One GH45 protein acted on amorphous cellulose as an endo-ß-1,4-glucanase, whereas the other evolved to become an endo-ß-1,4-xyloglucanase. We successfully knocked down the expression of both GH45 genes using RNAi, but no changes in weight gain or mortality were observed compared to control insects. Our data indicated that the breakdown of these polysaccharides in G. viridula may facilitate access to plant cell content, which is rich in nitrogen and simple sugars.

Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma.

BACKGROUND: Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed. METHODS: This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group. RESULTS: Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury. CONCLUSION: Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

[Is the discharge letter still relevant? : Chances and risks of "Medical apps" in orthopedics and traumatology]. / Ist der Entlassungsbrief noch zeitgemäß? : Chancen und Risiken von "Medical Apps" in Orthopädie und Unfallchirurgie.

CURRENT SITUATION: The discharge letter currently represents the gold standard of the information and transfer document in the field of inpatient orthopedic and trauma patient care. In the age of digitization, the smartphone is penetrating more and more areas of life as an omnipresent internet access medium and is thus fundamentally influencing the awareness of our society. Whereas the use of applications on smartphones is already well established today, the range of medical apps is rudimentary. The potential of apps on smartphones as an innovative digital communication medium is undeniable, but the currently available medical apps in orthopedics and trauma surgery are available to a small patient clientele only. FORECAST: Currently, the use of medical apps is not an adequate alternative to the discharge letter. However, it is only a matter of time before the innovative potential of applications is used as a communication tool in outpatient and inpatient care. It is, therefore, essential to start creating the legal, ethical and medical framework and to establish a relevant regulatory body.

Mutations in CRLF1 cause familial achalasia.

We here report a family from Libya with three siblings suffering from early onset achalasia born to healthy parents. We analyzed roughly 5000 disease-associated genes by a next-generation sequencing (NGS) approach. In the analyzed sibling we identified two heterozygous variants in CRLF1 (cytokine receptor-like factor 1). Mutations in CRLF1 have been associated with autosomal recessive Crisponi or cold-induced sweating syndrome type 1 (CS/CISS1), which among other symptoms also manifests with early onset feeding difficulties. Segregation analysis revealed compound heterozygosity for all affected siblings, while the unaffected mother carried the c.713dupC (p.Pro239Alafs*91) and the unaffected father carried the c.178T>A (p.Cys60Ser) variant. The c.713dupC variant has already been reported in affected CS/CISS1 patients, the pathogenicity of the c.178T>A variant was unclear. As reported previously for pathogenic CRLF1 variants, cytokine receptor-like factor 1 protein secretion from cells transfected with the c.178T>A variant was severely impaired. From these results we conclude that one should consider a CRLF1-related disorder in early onset achalasia even if other CS/CISS1 related symptoms are missing.

Treatment with lenalidomide induces immunoactivating and counter-regulatory immunosuppressive changes in myeloma patients.

Lenalidomide activates the immune system, but the exact immunomodulatory mechanisms of lenalidomide in vivo are poorly defined. In an observational study we assessed the impact of lenalidomide on different populations of immune cells in multiple myeloma patients. Lenalidomide therapy was associated with increased amounts of a CD8(+) T cell subset, phenotypically staged between classical central memory T cells (TCM) and effector memory T cells (TEM), consequently termed TCM/TEM. The moderate expression of perforin/granzyme and phenotypical profile of these cells identifies them as not yet terminally differentiated, which makes them promising candidates for the anti-tumour response. In addition, lenalidomide-treated patients showed higher abundance of CD14(+) myeloid cells co-expressing CD15. This population was able to inhibit both CD4(+) and CD8(+) T cell proliferation in vitro and could thus be defined as a so far undescribed novel myeloid-derived suppressor cell (MDSC) subtype. We observed a striking correlation between levels of TCM/TEM, mature regulatory T cells (T(regs)) and CD14(+) CD15(+) MDSCs. In summary, lenalidomide induces both activating and inhibitory components of the immune system, indicating the existence of potential counter-regulatory mechanisms. These findings provide new insights into the immunomodulatory action of lenalidomide.

Results of surveillance for infections with Shiga toxin-producing Escherichia coli (STEC) of serotype O104:H4 after the large outbreak in Germany, July to December 2011.

After the massive outbreak of infections with Shiga toxin-producing Escherichia coli (STEC) of serotype O104:H4 in Germany in the summer of 2011, post-outbreak surveillance for further infections with this type of STEC was maintained until the end of 2011. This surveillance was based on national mandatory reporting of STEC infections and the associated complication of haemolytic uraemic syndrome (HUS), as well as on data obtained from a questionnaire. Between the outbreak's end (5 July) and 31 December 2011, a total of 33 post-outbreak cases were recorded. Post-outbreak cases occurred with diminishing frequency towards the year's end and resembled the outbreak cases in many respects, however the proportion of HUS among all post-outbreak cases was smaller than during the outbreak. Two thirds of the post-outbreak cases were likely infected by contact with known outbreak cases. Both laboratory and nosocomial spread was noted in this period. No post-outbreak case recalled sprout consumption as a potential source of infection. The scarcity of information conveyed by the nonculture tests routinely used in Germany to diagnose STEC made linkage of post-outbreak cases to the outbreak difficult. Though post-outbreak surveillance demonstrated the outbreak strain's potential for lengthy chains of transmission aided by prolonged shedding, our results and continued routine surveillance until the end of 2013 do not support the notion, that the outbreak strain has been able to establish itself in the German environment.

[Coping with multiple sclerosis in partnerships: a systematic review of the literature]. / Bewältigung der Multiplen Sklerose in der Partnerschaft : Eine systematische Literaturübersicht.

BACKGROUND: As with other chronic diseases, multiple sclerosis (MS) is not only experienced by the persons suffering from the disease but also their partners. OBJECTIVE AND METHOD: To explore the current level of knowledge on dealing with MS in relationships and to obtain indications of factors that have a positive impact on the way of coping with the disease, studies on this topic were sought in the databases of Cinahl, Medline and PsycINFO using the following keywords: multiple sclerosis, spouses, couples, married couple, dyadic system, dyadic systems and dyads. The results were interpreted in the context of "Developmental-contextual model of couples coping with chronic illness across the adult life span". RESULTS: Systematic allocation of the study results found in this way created a comprehensive image of the coping process. The results clearly showed that both partners experience difficult feelings such as uncertainty, fear, depression and distress. Coping in a relationship with the often continuously changing situations and the associated stress is done best by couples who consistently exchange their mutual perceptions, inform one another of the mental and physical strains in open discussions and synchronise their ideas regarding the generation of the meaning and satisfaction with life. CONCLUSION: Targeted support for dyadic coping can lead to stress reduction and higher relationship satisfaction of couples living with MS.

Comparison of the level of physical activity after the COVID-19 pandemic in Poland, Slovakia and the Czech Republic.

BACKGROUND: The COVID-19 pandemic was associated with limited physical activity (PA) of most of the world's population. This cross-sectional prospective study aimed to assess the levels of PA of university students in Poland, Czech Republic and Slovakia after COVID-19 using the International Physical Activity Questionnaire Short Form (IPAQ-SF). METHODS: A total of 2635 students completed questionnaires regarding their PA levels using the IPAQ-SF between September and December 2022. RESULTS: PA measured by metabolic equivalent of task (MET) scores, varied between the three countries: Slovakia median MET-minutes/week score 4459.9; Czech Republic 3838.8 Poland 3567.1. The results of the post hoc analysis revealed there were significant differences in MET-minutes/week values between the Czech Republic and Poland (p < 0.035) as well as between the Czech Republic and Slovakia (p < 0.037). The analysis of energetic expenditure during walking revealed that students from the Czech Republic and Slovakia had higher median MET-min/weeks values (Czech 2284.1; Slovak 2467.1) compared to their Polish (1536.1) peers (p < 0.001). Polish cohort presented with significantly higher body mass index (BMI) (p < 0.001) than Czech and Slovak groups (BMI Czech: 22.3; Slovak 22.8; Polish 23.8). CONCLUSIONS: Significant differences in PA levels between the Czech Republic, Poland, and Slovakia university students were identified. Slovakia showed the highest median PA measured as a MET score, and Poland showed the lowest. Compared to available pre-COVID studies it seems the total level of PA in the observed cohorts has not returned to the pre-COVID levels and students remain less active.

Randomized controlled trial of behavioral treatment for comorbid obesity and depression in women: the Be Active Trial.

OBJECTIVE: Depression is associated with increased risk for obesity and worse weight loss treatment outcomes. The purpose of the present study was to test the hypothesis that delivering evidence-based behavior therapy for depression before a lifestyle weight loss intervention improves both weight loss and depression. DESIGN: In a randomized controlled trial, obese women with major depressive disorder (N=161, mean age=45.9 (s.d.: 10.8) years) were randomized to brief behavior therapy for depression treatment followed by a lifestyle intervention (BA) or a lifestyle intervention only (LI). Follow-up occurred at 6 and 12 months. Main outcome measures included weight loss and depression symptoms. RESULTS: Intention-to-treat analyses revealed both conditions lost significant weight, but no differences between conditions in weight change at 6 months (BA=-3.0%, s.e.=-0.65%; LI=-3.7%, s.e.=0.63%; P=0.48) or 12 months (BA=-2.6%, s.e.=0.77%; LI=-3.1%, s.e.=0.74%; P=0.72). However, the BA condition evidenced significantly greater improvement in Beck Depression Inventory-II scores relative to the LI condition at both 6 months (BA mean change=-12.5, s.d.=0.85; LI mean change=-9.2, s.d.=0.80, P=0.005) and 12 months (BA mean change=-12.6, s.d.=0.97; LI mean change=-9.9, s.d.=0.93; P=0.045). Participants who experienced depression remission by 6 months (61.2%) lost greater weight (mean=-4.31%; s.e.=0.052) than those who did not (39.7%; mean=-2.47%, s.e.=0.53; P=.001). CONCLUSION: Adding behavior therapy to a lifestyle intervention results in greater depression remission but does not improve weight loss within 1 year. Improvement in depression is associated with greater weight loss.

[Femoral neck fractures]. / Schenkelhalsfrakturen.

Femoral neck fractures (FNF) are the most frequent fractures in the older population and are also of high socioeconomic importance due to the high risk of mortality. The diagnostics are based on the clinical examination and imaging procedures. The classification systems used in the routine clinical practice are oriented towards the prognosis and are therefore a valuable aid in making decisions for the selection of the treatment procedure. Early surgery is decisive for the success of treatment. Older patients (> 60 years) with arthritically damaged hips and a high degree of fracture dislocation benefit from prompt hip replacement (bipolar systems, total hip arthroplasty, dual mobility systems). In contrast, joint-preserving surgery by osteosynthesis is indicated in younger patients with a low degree of dislocation. This article summarizes the clinically relevant aspects of FNF and gives an overview of current treatment strategies with inclusion of the scientific literature.

[Intensive care management of acute diseases of the aorta]. / Intensivmedizinisches Management akuter Aortenerkrankungen.

Acute aortic diseases represent a group of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as a range of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, a number of severe complications need to be anticipated by critical care physicians. Additionally, a notable symptom is severe and refractory hypertension, especially in the acute phase. This article provides a summary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.

Unloader bracing in osteoarthritis of the knee - Is there a direct effect on the damaged cartilage?

BACKGROUND: Unloading knee braces represent a conservative treatment option for non-pharmalogical management of unicompartmental osteoarthritis of the knee. Though there is consensus on the clinical effectiveness of unloading, the effect mechanism of bracing remains part of a debate. Our study was designed to assess the effect of unloader bracing on damaged cartilage via MRI cartilage mappings. METHODS: Fourteen patients (7 female, 7 male, mean age 43.1 ± 9.4 years) with unicompartmental cartilage wear in knees with varus or valgus malalignment were enrolled. Clinical scores, radiographs and MR-graphic properties (T2/T2* mapping, T1 Delayed Gadolinium Enhanced MRI of the cartilage (dGEMRIC) mapping, high-resolution PDw sequences) of knee cartilage were recorded before and three months after brace use. RESULTS: Bracing the knees for a mean of 14.4 ± 2.0 weeks (range 11 to 18 weeks) resulted in significant pain reduction (VAS changed from 5.9 ± 2.0 to 2.0 ± 1.3, p < 0.001) and improvement in knee function (KOOS increased from 42.1 ± 22.7 to 64.8 ± 18.7, p < 0.001). In the affected cartilage regions T2 relaxation times significantly decreased from 56.1 ± 11.4 ms to 46.5 ± 11.2 ms (p < 0.05). No changes in T1-dGEMRIC and T2* relaxation times, thickness or the extent of the damaged cartilage area could be detected. CONCLUSIONS: Our results suggest, that unloader bracing improves the biochemical properties of the damaged cartilage by increasing collagen and proteoglycan concentration as well as decreasing the cartilage edema.

Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era.

Objective: Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes. Materials and methods: A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward. Results: A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666). Conclusion: Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.

Bioactivation of scaffolds in osteonecrosis.

Avascular osteonecrosis (AVN) due to local ischemia leads to an inhomogeneous osseous defect, which can be treated by resection and with bone substitute materials in a joint-preserving treatment. Due to the underlying risk profile of AVN, the mostly subchondral localization and the size of the local bone defect, bone regeneration is impaired. Therefore, bioactivation of the applied bone substitute materials prior to application is highly desirable. Apart from the use of growth factors and other soluble substances, the autologous application of location-typical cells and tissue is a useful alternative to support the bone healing properties of scaffolds. This article presents various methods to activate scaffolds for bone stimulation and discusses these techniques with respect to recent data from the literature.

[Post-traumatic necrosis of the humeral head-Endoprosthesis or joint preservation]. / Posttraumatische Humeruskopfnekrose ­ Endoprothese oder Gelenkerhalt.

BACKGROUND: Humerus fractures play a major role in daily clinical routine, and subsequent osteonecrosis is common after osteosyntheses. OBJECTIVES: The current paper highlights the incidence and cause of osteonecrosis after proximal humerus fractures, with respect to presentation of anatomy and risk factors. METHODS: Display of the literature and therapy options for humerus fracture and subsequent necrosis. RESULTS: Humerus fractures are the seventh most frequent fractures in humans. The complication rate is 40%, and the described rate of necrosis is up to 34%. Accordingly, the surgical revision rate is at 19% according to recent literature. CONCLUSION: The treatment of humerus head fracture must consider numerous variables. The individual type of fracture and the current individual situation of the patient must be included in the process of choosing the right treatment. Modern implants with screw locking features should be used, and for certain circumstances the direct implantation of a prosthesis should be considered. Thereby the expectations of the patient with respect to the postoperative activity level play a major role.

[Is there an association between the reduced school years in grammar schools and headache and other health complaints in adolescent students?]. / Besteht ein Zusammenhang zwischen der verkürzten Gymnasialzeit und Kopfschmerzen und gesundheitlichen Belastungen bei Schülern im Jugendalter?

BACKGROUND: The reduction of school years in grammar schools from 9 to 8 years (G9 vs. G8) is supposed to exhibit increased impairments of health of the latter group of students. Aim of the present study was to investigate whether G8-students are exposed to more stress and report more headaches and other health complaints than G9-students. PARTICIPANTS: 1 260 formers of grammar schools in Munich (10 (th) vs. 11 (th) form). METHODS: In a survey, the frequency of headache and other health complaints, experience of chronic stress and health-related quality of life were assessed with a questionnaire and compared between the two groups of different grammar-school durations (G8 vs. G9). RESULTS: 83.1% of all formers reported to suffer from headache at least once per month. Further frequently reported health complaints were back pain (47.7%), excessive need for sleep (45.6%) and pain in neck or shoulder (45.0%). 20.4% of the formers reported high exposure to stress. The greatest reductions in quality of life were found with respect to school-related and physical wellbeing. As the only significant differences, formers of G8 reported fewer daily leisure time and that available leisure time was not sufficient for recreation. CONCLUSIONS: The high prevalence of pain, health complaints and stress indicates high demands to all grammar scholars. High demands due to the reduction of school years in grammar school, however, are not reflected in increased health impairments in these formers, but rather in limited leisure time activities.

Long-term management of the liver transplant patient: recommendations for the primary care doctor.

No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.