[Novel surgical techniques for treatment of benign prostatic hyperplasia]. / Neue operative Techniken zur Therapie des benignen Prostatasyndroms.

In recent years new surgical techniques to treat benign prostatic hyperplasia have been introduced into urological practice and evaluated in clinical studies. Complications of standard procedures, e.g. transurethral resection of the prostate (TURP), can be avoided while maintaining equivalent clinical outcomes. The main goal is preservation of erectile and ejaculatory function. Furthermore, outpatient treatment associated with a rapid patient recovery would be desirable. This article presents the course of the interventions, the mechanisms of action and current clinical evidence for novel mechanical approaches of recanalization, water-based ablation as well as prostate artery embolization. Initial study results partially indicate that in the future practically all patients can be offered an individualized surgical technique, which provides optimal symptomatic and functional improvements with a minimized risk of complications.

European otorhinolaryngology training programs: results of a European survey about training satisfaction, work environment and conditions in six countries.

ORL-students and residents have an ongoing debate about the "best" programme in Europe. Aim of this study was to comparatively assess differences among programmes in training, satisfaction, quality of life (QoL) of residents and recent otorhinolaryngologist (ORL) specialists in France, Germany, Spain, Italy, Austria, and Belgium. A self-administered anonymous questionnaire, structured in ten sections including general information, provided guidance, working environment, training structure, teaching of medical students, publication work, QoL, and satisfaction with training, were emailed to residents and recent ORL specialists. 476 returned questionnaires from 6 countries revealed that daily work hours were the highest in France and Belgium with 11 and 10.4 h on average, respectively. QoL, work conditions, and salary were best in Germany followed by Austria in terms of possibility of part-time contracts, better respect for post-duty day off, and compensation for overtime. Satisfaction with training including support and guidance of seniors was lowest in Italy, but, on the other hand, the publication work and support had a more important place than in other countries. In Belgium, there was some gap between the quality of teaching and feedback from seniors as well as apprenticeship. The highest satisfaction with training was in France and Spain followed by Austria. The study results provide guidance before choosing an ORL training programme in Europe. Country-specific strengths could be included into future harmonization efforts to improve all programmes, facilitate professional exchange and, finally, establish standards-of-care carried out by well-trained doctors also looking after a satisfying work-life balance.

Integration of reward signalling and appetite regulating peptide systems in the control of food-cue responses.

Understanding the neurobiological substrates that encode learning about food-associated cues and how those signals are modulated is of great clinical importance especially in light of the worldwide obesity problem. Inappropriate or maladaptive responses to food-associated cues can promote over-consumption, leading to excessive energy intake and weight gain. Chronic exposure to foods rich in fat and sugar alters the reinforcing value of foods and weakens inhibitory neural control, triggering learned, but maladaptive, associations between environmental cues and food rewards. Thus, responses to food-associated cues can promote cravings and food-seeking by activating mesocorticolimbic dopamine neurocircuitry, and exert physiological effects including salivation. These responses may be analogous to the cravings experienced by abstaining drug addicts that can trigger relapse into drug self-administration. Preventing cue-triggered eating may therefore reduce the over-consumption seen in obesity and binge-eating disorder. In this review we discuss recent research examining how cues associated with palatable foods can promote reward-based feeding behaviours and the potential involvement of appetite-regulating peptides including leptin, ghrelin, orexin and melanin concentrating hormone. These peptide signals interface with mesolimbic dopaminergic regions including the ventral tegmental area to modulate reactivity to cues associated with palatable foods. Thus, a novel target for anti-obesity therapeutics is to reduce non-homeostatic, reward driven eating behaviour, which can be triggered by environmental cues associated with highly palatable, fat and sugar rich foods.

[Acute jaw-thoracic pain and syncope in a 41-year-old man]. / Akuter Kiefer-Thorax-Schmerz und Synkope bei einem 41-jährigen Patienten.

A 41-year-old physically active man with no significant past medical history presented with sudden thoracic pain. The patient was referred to the next tertiary care hospital. A CT scan showed an ectasia of the ascending aorta with irregularities of the aortic wall without dissection. Despite initial refusal, the patient was referred to a university hospital with experience in aortic surgery. A triphase ECG-synchronized cardiothoracic flash protocol performed on a 256 line CT scanner confirmed an aortic intramural hematoma and a covered aortic perforation. Shortly afterwards the patient collapsed and had to be resuscitated.

[Elastography as an additional tool in breast sonography. Technical principles and clinical applications]. / Elastographie als Zusatzmodalität der Mammasonographie. Technische Grundlagen und klinische Anwendungsmöglichkeiten.

In recent years the use of elastography in addition to sonography has become a routine clinical tool for the characterization of breast masses. Whereas free hand compression elastography results in qualitative imaging of tissue stiffness due to induced compression, shear wave elastography displays quantitative information of tissue displacement. Recent studies have investigated the use of elastography in addition to sonography and improvement of specificity in differentiating benign from malignant breast masses could be shown. Therefore, additional use of elastography could help to reduce the number of unnecessary biopsies in benign breast lesions especially in category IV lesions of the ultrasound breast imaging reporting data system (US-BI-RADS).

[Migration of a retained intra-abdominal foreign body into the colon]. / Migration eines intraoperativ belassenen Bauchtuches in das Kolon.

Even in the era of correct precautions and risk management culture adverse and preventable adverse events, such as intraoperatively residual foreign bodies remain a hot topic. Due to legal considerations and possible image loss many cases may remain unpublished leading to an underestimation of the real incidence in literature. The following casuistic is an example for a rarely documented and in this case a partial migration of a retained surgical sponge into the colon. The causes for the delayed foreign body detection, accounting for the relative good health even during chemoradiotherapy are analyzed in order to sharpen the awareness of such serious complications.

MRI-based breast volumetry-evaluation of three different software solutions.

As lipofilling of the female breast is becoming more popular in plastic surgery, the use of MRI to assess breast volume has been employed to control postoperative results. Therefore, we sought to evaluate the accuracy of magnetic resonance imaging (MRI)-based breast volumetry software tools by comparing the measurements of silicone implant augmented breasts with the actual implant volume specified by the manufacturer. MRI-based volume analysis was performed in eight bilaterally augmented patients (46 ± 9 years) with three different software programs (Brainlab© I plan 2.6 neuronavigation software; mass analysis, version 5.3, Medis©; and OsiriX© v.3.0.2. 32-bit). The implant volumes analysed by the BrainLab© software had a mean deviation of 2.2 ± 1.7% (r = 0.99) relative to the implanted prosthesis. OsiriX© software analysis resulted in a mean deviation of 2.8 ± 3.0% (r = 0.99) and the Medis© software had a mean deviation of 3.1 ± 3.0% (r = 0.99). Overall, the volumes of all analysed breast implants correlated very well with the real implant volumes. Processing time was 10 min per breast with each system and 30 s (OsiriX©) to 5 min (BrainLab© and Medis©) per silicone implant. MRI-based volumetry is a powerful tool to calculate both native breast and silicone implant volume in situ. All software solutions performed well and the measurements were close to the actual implant sizes. The use of MRI breast volumetry may be helpful in: (1) planning reconstructive and aesthetic surgery of asymmetric breasts, (2) calculating implant size in patients with missing documentation of a previously implanted device and (3) assessing post-operative results objectively.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes.

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: >/=126 mg/dL; 2-h value: >/=140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: greater than or equal to 126 mg/dL; 2-h value: greater than or equal to 140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Skeletal metastasis in tricholemmal carcinoma.

Tricholemmal carcinoma is an extremely rare cutaneous adnexal tumor, not exceeding 1-2 cm in diameter in some reported cases. The few reports describe only a greater histologic malignancy. Some cases of recurrences have been reported, and metastasis of the soft tissue was described once by Amaral et al in 1984. In the current patient with tricholemmal carcinoma of the right distal thigh, the primary tumor was unusually large. The first detected metastasis was localized in the right inguinal lymph nodes. Five years after diagnosis of tricholemmal carcinoma a metastasis of the left tibia and fibula were diagnosed. To our knowledge, an osseous metastasis in tricholemmal carcinoma has not been described. It is possible that a relationship between the extraordinary size and the osseous metastasis exists in the current patient.

[Proven and unproven hygiene measures in orthopedics]. / Sinnvolle und nicht sinnvolle Hygienemassnahmen in der Orthopädie.

Postoperative wound infections develop in approximately 2-5% of all patients after orthopedic surgery. After urinary tract infection and pneumonia, such wound infections (15%) are the third most frequent type of hospital-acquired infection. In this review we summarize all proven and unproven hygiene measures available in orthopedics, giving special attention to those implemented with the aim of preventing and controlling postoperative wound infections. Routine application only of hygiene procedures of proven efficacy will be an important contribution to economic and ecological quality assurance in hospital.

Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment.

Since the advent of operative ankle arthroscopy and magnetic resonance imaging (MRI) specific treatment of osteochondritis dissecans of the talus has progressed rapidly. Drilling is still the treatment of choice in early stages of osteochondritis dissecans of the talus. Rear-entry guides and preoperative planning with MRI have led to better results with this kind of treatment. Within 5 years, 42 patients (26 male and 16 female) underwent arthroscopic treatment of osteochondritis dissecans of the talus, 22 underwent percutaneous drilling, 13 cancellous bone grafting, 4 refixation, and 3 curettage. The average age of the patients was 28 years (range, 11 to 53 years). A clinical score system was used in a clinical and MRI follow-up of 19 of the patients with K-wire drilling. Up to 100 points are given in the categories pain, stability/insecurity, efficiency/pain-free walking distance, gait, differences in circumference, range of motion, and power. There was a history of trauma in 31 of the 42 patients. The majority of lesions (24 cases) were localized at the lateral talus, and these patients all had trauma. In 11 of the 18 lesions at the medial talus, there was no evidence of trauma. The 19 patients in the follow-up achieved an average of 87 points. K-wire drilling represents the chief component of early stages with intact or partially fractured cartilage surface, whereas arthroscopically controlled cancellous bone grafts after curettage are used in grade II stages only. Results of K-wire drilling are not worse than those of cancellous bone grafts; this is attributable to a generous perforation of the sclerosis. This has contributed to an improved preoperative diagnosis with MRI.

The operative treatment of full thickness cartilage defects in the knee joint with autologous chondrocyte transplantation.

OBJECTIVE: The high clinical and socio-economical impact of cartilage defects and chondral degeneration is well-known. After trauma or without a known etiology, often young patients suffer from pain and a loss of function leading into a decrease of physical activity and, more severe, into long term disability and unemployment. The clinical use of autologous chondrocyte transplantation was introduced in 1994 reporting the data of a pilot study. The objective of this study is to evaluate the efficacy of this method of surgery. METHODS: Autologous chondrocyte transplantation has been established in our department since 1995 for the treatment of large, full thickness cartilage defects which can be completely covered with hyaline-like cartilage without harming the subchondral bone plate. Our first patients (n=24) all showed Grade IV lesions and an average defect size of 6.27 cm2. All but 4 of the patients had at least 1 cartilage defect related operation on the knee. RESULTS: The patients and the clinicians rating indicated an increase of a modified Cincinnati Knee score from 3.6 point pre-operation to 6.9 points after 6 months and 8.1 points at 12 months on a scale from 1 (bad) to 10 (excellent). These results support the data of an international multicenter study with almost 2000 patients. The 5 year results described by the originate authors are good to excellent in 85%-95% with an adverse event rate of 5%. CONCLUSION: Autologous chondrocyte transplantation has to be considered a safe and effective method for the treatment of large full thickness cartilage defects. Alternative treatments are symptomatical: drilling, abrasion, lavage, chondroplasty, or osteotomies. The short term results are promising but a lot of patients have to be treated for osteoarthritis as a consequence of failure with total joint arthroplasty. Osteochondral transplantations have the disadvantage of limited harvesting sites and the impairment of the subchondral bone plate.

Postoperative ossifications of the shoulder. Incidence and clinical impact.

Periarticular ossifications of the shoulder after surgery have been described since the beginning of the century. Risk factors and the clinical impact of heterotopic bone formation have been discussed controversially. After open surgery on the shoulder, 131 patients (rotator cuff repair n = 106, acromioplasty n = 25) were included in a retrospective study if pre- and postoperative X-rays were available. The age of the 90 men and 41 women averaged 51 years (range 29-67 years). The minimum follow-up was 2 years. Also, 108 patients were interviewed by questionnaire to estimate the subjective outcome of the procedure (5 patients were reported dead). A clinical examination was carried out on 86 patients using the Constant score for evaluation of the objective outcome. Heterotopic ossifications were found in 35 cases (26.7%), 28 of them after rotator cuff reconstruction and 7 after acromioplasty. A good to excellent result was reported by 89% (n = 65) of the patients without and by 80% (n = 28) of the patients with ossifications. The Constant score averaged 69 points and 74 points (n = 60), respectively. A significant difference between the two collectives could not be calculated. As significant risk factors for the formation of heterotopic bone, the existence of osteoarthritis and the duration and complexity of the procedure could be cited. The appearance of periarticular ossifications after surgery of the shoulder seems to be of minor clinical impact. Severe cases with major functional deficits should and can be prevented by a fast and atraumatic operation technique.

Conservative management of pyogenic osteomyelitis of the occipitocervical junction.

STUDY DESIGN: A report of three cases of pyogenic osteomyelitis of the occipitocervical junction. OBJECTIVE: To describe the conservative management of pyogenic osteomyelitis of the occipitocervical junction. SUMMARY OF BACKGROUND DATA: The therapeutic approach to inflammation of the upper cervical spine is controversial. METHODS: Pyogenic osteomyelitis of the occipitocervical junction is rare. In the orthopedic literature, only a few case reports with variable treatment methods are available. Three patients with pyogenic osteomyelitis of the occipitocervical junction were treated nonoperatively. Intravenous antibiotic therapy was begun after direct cultures or blood cultures were obtained. Early mobilization was accomplished by application of a halo vest. RESULTS: Two patients recovered by spontaneous fusion of the occipitocervical junction. Instability developed in the spine of one patient, but she refused further treatment. CONCLUSIONS: Diagnosis of osteomyelitis of the upper cervical spine is difficult. In cases with absence of neurologic symptoms or spinal abscess formation, treatment can be nonoperative.

["Lumbar intervertebral disk-induced sciatica" diagnostic error in extensive extra- and intrapelvic lipoma]. / Fehldiagnose "bandscheibenbedingte Lumboischialgie" bei ausgedehntem extra- und intrapelvinem Lipom.

PURPOSE: The aim of this study is to demonstrate the importance of the differential diagnosis of sciatica. Radiculopathy in the lower extremity of an adult usually originates from a herniated nucleus pulposus. In this paper an extraspinal cause of sciatica due to a pelvic tumor is reported, which is initially often not recognized. METHODS AND RESULTS: A 67-year old woman suffered from sciatica. After one year of unsuccessful conservative treatment and beginning weakness of hip flexion a computed tomography of the pelvis revealed a giant lipoma with compression of the lumbosacral plexus. CONCLUSIONS: The results of this case illustrate the problem of over-rating CT-findings of the lumbar intervertebral disks in patients with sciatica. Extraspinal tumorous causes of radiculopathy are rare, but should be considered if the therapeutical measures are resistant to treatment. Computed tomography and magnetic resonance imaging are most useful in confirming a retroperitoneal tumor causing lumbosacral radiculopathy.