Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study.

BACKGROUND: The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity. METHODS: Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients. RESULTS: Among the 214 patients included in the analysis, 121 (57%, 95% CI 50-63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08-1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14-1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81-0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge. CONCLUSIONS: More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis. Clinical Trial Registration NCT02349074 .

[Algorithm for securing an unexpected difficult airway : User analysis on a simulator]. / Algorithmus zur Sicherung des unerwartet schwierigen Atemwegs : Eine Anwenderanalyse am Simulator.

BACKGROUND: Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. OBJECTIVE: The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists. MATERIAL AND METHODS: After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists. RESULTS: Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a laryngeal mask in 22% and other instruments in 39%. Of the 50 participants 38 had already been institutionally trained in difficult airway management during the previous 2 years. For cricothyrotomy the participants needed a median time of 63 s and there was no difference between junior and senior anesthetists (p = 0.46). The cricothyrotomy was performed faster using a surgical approach than a transtracheal puncture approach using a Melker emergency cricothyrotomy set (52 s vs. 73 s, p = 0.014). CONCLUSION: The conformity to the algorithm of over 90% indicates a good training level of the participants concerning the difficult airway algorithm. In the observed sample flexible intubation endoscopy tended to be of high significance even in the unanticipated difficult airway. Cricothyrotomy was performed faster surgically than by the use of the transtracheal puncture approach, while no differences between junior and senior anesthetists were observed. For the successful management of an unexpected difficult airway, specific training of these special and rare events is crucial. A standardized provision of special airway instruments stored in a special trolley and frequent application of this trolley in the clinical routine is recommended.

[Cardiological functional diagnostics]. / Kardiologische Funktionsdiagnostik.

Cardiovascular diseases are common; therefore, adequate and guideline-based diagnostics and treatment are essential. In addition to an electrocardiogram (ECG) and (treadmill) exercise tests, echocardiography plays the pivotal role in functional cardiac testing. It is permanently available at the bedside and has a high diagnostic accuracy; however, examinations such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) as well as nuclear medical imaging, e.g. single proton emission CT (SPECT) and positron emission tomography (PET) are becoming more and more common in clinical practice. This is due to the wide range of additional information and the high diagnostic accuracy. In the following article, the individual possibilities of non-invasive cardiac functional testing are presented and their meaningful application will be discussed; however, studies on the meaningful application of non-invasive diagnostics are scarce.

Characterization of a hepatitis C virus-like particle vaccine produced in a human hepatocyte-derived cell line.

An effective immune response against hepatitis C virus (HCV) requires the early development of multi-specific class 1 CD8+ and class II CD4+ T-cells together with broad neutralizing antibody responses. We have produced mammalian-cell-derived HCV virus-like particles (VLPs) incorporating core, E1 and E2 of HCV genotype 1a to produce such immune responses. Here we describe the biochemical and morphological characterization of the HCV VLPs and study HCV core-specific T-cell responses to the particles. The E1 and E2 glycoproteins in HCV VLPs formed non-covalent heterodimers and together with core protein assembled into VLPs with a buoyant density of 1.22 to 1.28 g cm-3. The HCV VLPs could be immunoprecipited with anti-ApoE and anti-ApoC. On electron microscopy, the VLPs had a heterogeneous morphology and ranged in size from 40 to 80 nm. The HCV VLPs demonstrated dose-dependent binding to murine-derived dendritic cells and the entry of HCV VLPs into Huh7 cells was blocked by anti-CD81 antibody. Vaccination of BALB/c mice with HCV VLPs purified from iodixanol gradients resulted in the production of neutralizing antibody responses while vaccination of humanized MHC class I transgenic mice resulted in the prodution of HCV core-specific CD8+ T-cell responses. Furthermore, IgG purified from the sera of patients chronically infected with HCV genotypes 1a and 3a blocked the binding and entry of the HCV VLPs into Huh7 cells. These results show that our mammalian-cell-derived HCV VLPs induce humoral and HCV-specific CD8+ T-cell responses and will have important implications for the development of a preventative vaccine for HCV.

Differential Accumulation of Mercury and Selenium in Brown Trout Tissues of a High-Gradient Urbanized Stream in Colorado, USA.

Total mercury (THg) and selenium (Se) were analyzed by Inductively Coupled Plasma Mass Spectrometry in 11 internal and external tissues and stomach contents from 23 brown trout, Salmo trutta, of a 22.9-km reach of a high-gradient stream (upper Fountain Creek) in Colorado, USA, impacted by coal-fired power plants, shale deposits, and urbanization. Trout and water were sampled from four sites ranging from 2335 to 1818 m elevation. Lengths, weights, and ages of fish between pairs of the four sites were not significantly different. The dry weight (dw) to wet weight (ww) conversion factor for each tissue was calculated with egg-ovary highest at 0.379 and epaxial muscle fourth highest at 0.223. THg and Se in stomach contents indicated diet and not ambient water was the major source of Hg and Se bioaccumulated. Mean THg ww in kidney was 40.33 µg/kg, and epaxial muscle second highest at 36.76 µg/kg. None of the tissues exceeded the human critical threshold for Hg. However, all 23 trout had at least one tissue type that exceeded 0.02 mg/kg THg ww for birds, and four trout tissues exceeded 0.1 mg/kg THg ww for mammals, indicating that piscivorous mammals and birds should be monitored. Se concentrations in tissues varied depending on ww or dw listing. Mean Se dw in liver was higher than ovary at the uppermost site and the two lower sites. Liver tissue, in addition to egg-ovary, should be utilized as an indicator tissue for Se toxicity.

Combined arthroscopic tenodesis of the long head of biceps and rotator cuff repair in antero-superior cuff tears.

PURPOSE AND HYPOTHESIS: This study evaluates the functional and cosmetic results following fixation of the long head of the biceps (LHB) tendon at the antero-medial footprint anchor of a rotator cuff reconstruction, using the "lasso-loop" technique. METHODS: 39 patients with a mean age of 62 years with a rotator cuff tear and associated lesion of the LHB tendon were included in this study. Besides rotator cuff repair in an arthroscopic anchor technique, all patients received additional LHB tenodeses using the lasso-loop technique. Clinical follow-up consisted of the Constant score (CS), LHB score, DASH score, and WORC index. Relevant sub-items, such as elbow flexion strength and cosmesis, were compared to the contralateral arm. RESULTS: At an average follow-up of 22 months (11-39 months), the CS resulted in an average of 81 points. The biceps-specific LHB score showed a mean value of 89 points. The analysis of the DASH score showed an average of 16.9 points and the analysis of the WORC index showed an average result of 79.7 %. Distalization of the biceps muscle was objectively in three cases (7.7 %) (as observed by the examiner) and subjectively in one of those cases (as noted by the patient). There was a loss in elbow flexion strength compared to the contralateral side; however, this loss was not statistically significant and not associated with clinical apparent re-tear or insufficiency of the tenodesis. DISCUSSION: The arthroscopic lasso-loop tenodesis of the LHB tendon is a time and cost-efficient technique. No additional anchor is needed when included in the rotator cuff repair. Functional and cosmetical results as well as results from the biceps-specific LHB score were good to excellent. The loss in elbow flexion strength is most likely associated with concomitant rotator cuff lesion. CONCLUSION: The lasso-loop fixation technique of the LHB tendon using the antero-medial footprint anchor in rotator cuff tears is a reliable and cost-efficient procedure. LEVEL OF EVIDENCE: III.

[Intraoperative virtual implant planning for volar plate osteosynthesis of distal radius fractures]. / Intraoperative virtuelle Implantatplanung bei der volaren Plattenosteosynthese distaler Radiusfrakturen.

BACKGROUND: Digital planning of implants is in most cases conducted prior to surgery. The virtual implant planning system (VIPS) is an application developed for mobile C-arms, which assists the virtual planning of screws close to the joint line during surgery for treatment of distal radius fractures with volar plate osteosynthesis. The aim of this prospective randomized study was to acquire initial clinical experiences and to compare the VIPS method with the conventional technique. METHOD: The study included 10 patients for primary testing and 30 patients with distal radius fractures of types A3, C1 and C2, divided in 2 groups. In the VIPS group, after placement of the plate and fracture reduction, a virtual 3D model of the plate was matched with the image of the plate from the fluoroscopic acquisition. Next, the length and position of the screws close to the joint line were planned on the virtual plate. The control group was treated with the same implant in the conventional way. Data were collected regarding screw replacement, fluoroscopy and operating room (OR) times. RESULTS: The VIPS group included six A3, one C1 and eight C2 fractures, while the control group consisted of six A3 and nine C2 fractures. Three screws were replaced in the VIPS group and two in the control group (p = 0.24). The mean intraoperative fluoroscopy time of the VIPS group amounted to 2.58 ± 1.38 min, whereas it was 2.12 ± 0.73 min in the control group (p = 0.26). The mean OR time in the VIPS group was 53.3 ± 34.5 minutes and 42.3 ± 8.8 min (p = 0.23) in the control group. CONCLUSION: The VIPS enables a precise positioning of screws close to joint line in the treatment of distal radius fractures; however, for routine use, further development of the system is necessary.

A Bayesian changepoint analysis of ChIP-Seq data of Lamin B.

The spatial organisation of the chromosomes in the nucleus is influenced by chromatin regions binding to the nucleic lamina, i.e., the inner part of the nucleic envelope. To investigate the architecture of chromosomes in the interphase nucleus, it is thus of high interest to detect such chromatin segments. This goal can be achieved by considering the fibrous protein Lamin B as a surrogate, since regions of high abundance of Lamin B can indicate chromatin segments attached to the nucleic lamina. We analyse ChIP-Seq (Chromatin-Immunoprecipitation Sequencing) data from an experiment that is designed to record Lamin B abundance. We introduce a Bayesian segmentation procedure in which a Markov Chain Monte Carlo (MCMC) algorithm is used for inference about the desired segmentation. The procedure is based on a Bayesian hierarchical model. Inference allows the distinction between regions of high versus low levels of Lamin B, and therefore, gives an insight into the binding of the chromatin to the nucleic envelope. An implementation of this approach is available in the statistical software environment R. This article is part of a special issue entitled: Computational proteomics in the post-identification era. Guest Editors: Martin Eisenacher and Christian Stephan.

Endogenous rhythmic growth in oak trees is regulated by internal clocks rather than resource availability.

Common oak trees display endogenous rhythmic growth with alternating shoot and root flushes. To explore the mechanisms involved, microcuttings of the Quercus robur L. clone DF159 were used for (13)C/(15)N labelling in combination with RNA sequencing (RNASeq) transcript profiling of shoots and roots. The effect of plant internal resource availability on the rhythmic growth of the cuttings was tested through inoculation with the ectomycorrhizal fungus Piloderma croceum. Shoot and root flushes were related to parallel shifts in above- and below-ground C and, to a lesser extent, N allocation. Increased plant internal resource availability by P. croceum inoculation with enhanced plant growth affected neither the rhythmic growth nor the associated resource allocation patterns. Two shifts in transcript abundance were identified during root and shoot growth cessation, and most concerned genes were down-regulated. Inoculation with P. croceum suppressed these transcript shifts in roots, but not in shoots. To identify core processes governing the rhythmic growth, functions [Gene Ontology (GO) terms] of the genes differentially expressed during the growth cessation in both leaves and roots of non-inoculated plants and leaves of P. croceum-inoculated plants were examined. Besides genes related to resource acquisition and cell development, which might reflect rather than trigger rhythmic growth, genes involved in signalling and/or regulated by the circadian clock were identified. The results indicate that rhythmic growth involves dramatic oscillations in plant metabolism and gene regulation between below- and above-ground parts. Ectomycorrhizal symbiosis may play a previously unsuspected role in smoothing these oscillations without modifying the rhythmic growth pattern.

[Assessment of systolic function in patients with poor echogenicity: echocardiographic methods]. / Abschätzung der linksventrikulären systolischen Funktion bei Patienten mit schlechter Bildqualität : Echokardiographische Methoden.

The visual echocardiographic evaluation of left ventricular (LV) systolic function can be cumbersome, especially in patients with poor image quality. This review describes several alternative echocardiographic methods to determine LV systolic function: endocardial border delineation by contrast agents, mitral annular plane systolic excursion, mitral annular velocity derived from tissue Doppler, myocardial performance index, mitral regurgitation derived LV dP/dtMax and estimation of cardiac output by Doppler echocardiography. The review introduces the respective methods along with the presentation of suitable measurements, clinical implications and methodological limitations.

[Heart involvement in Friedreich's ataxia]. / Herzbeteiligung bei Friedreich-Ataxie.

Friedreich's ataxia is a rare hereditary disease and although the gene defect has already been identified as a deficiency of the mitochondrial protein frataxin, the pathophysiology is still unknown. Although a multisystem disorder organ involvement is predominantly neurological. Besides the characteristic features of spinocerebellar ataxia the heart is frequently also affected. Cardiac involvement typically manifests as hypertrophic cardiomyopathy, which can progress to heart failure and death. So far most research has focused on the neurological aspects and cardiac involvement in Friedreich's ataxia has not been systematically investigated. Thus, a better understanding of the progression of the cardiomyopathy, cardiac complications and long-term cardiac outcome is warranted. Although no specific treatment is available general cardiac therapeutic options for cardiomyopathy should be considered. The current review focuses on clinical and diagnostic features of cardiomyopathy and discusses potential therapeutic developments for Friedreich's ataxia.

Tears of the rotator cuff. Causes--diagnosis--treatment.

Rotator cuff ruptures are the most common degenerative tendon injury and occur mainly in older patients as multifactorial disorders manifesting the main symptoms of pain and restricted range of motion. Thorough clinical examination of the shoulder includes testing the function of the rotator cuff and leads to a tentative clinical diagnosis that is the prerequisite for diagnostic imaging procedures. Sonography of the shoulder gives rapid access to a very good sensitive overview of the rotator cuff. Conventional radiological imaging permits differential diagnosis since a reduced acromiohumeral interval is understood as a direct sign of rotator cuff rupture. The gold standard in imaging diagnostics is MRI because it not only delivers images of rotator cuff defects, but also permits interpretation of degenerative changes in the musculature. Significant pain relief can be achieved by conservative therapy such as analgesia, manual therapy and physiotherapeutic exercises and leads to improvements in the active range of motion. Persistent pain or progressive pain during conservative therapy are indications for surgical intervention. Arthroscopy-assisted treatment is tissue friendlier than open surgery and is today considered the standard for surgical treatment of rotator cuff rupture because of higher patient acceptance. Recent studies report that surgical rotator cuff repair leads to significant improvement in function, pain relief, and greater patient satisfaction. The principles of postoperative care after surgical rotator cuff repair are immobilization and gradual loading with passive and active exercises.

Long-term outcome of enzyme-replacement therapy in advanced Fabry disease: evidence for disease progression towards serious complications.

OBJECTIVE: The long-term effects of enzyme-replacement therapy (ERT) in Fabry disease are unknown. Thus, the aim of this study was to determine whether ERT in patients with advanced Fabry disease affects progression towards 'hard' clinical end-points in comparison with the natural course of the disease. METHODS: A total of 40 patients with genetically proven Fabry disease (mean age 40 ± 9 years; n = 9 women) were treated prospectively with ERT for 6 years. In addition, 40 subjects from the Fabry Registry, matched for age, sex, chronic kidney disease stage and previous transient ischaemic attack (TIA), served as a comparison group. The main outcome was a composite of stroke, end-stage renal disease (ESRD) and death. Secondary outcomes included changes in myocardial left ventricular (LV) wall thickness and replacement fibrosis, change in glomerular filtration rate (GFR), new TIA and change in neuropathic pain. RESULTS: During a median follow-up of 6.0 years (bottom and top quartiles: 5.1, 7.2), 15 events occurred in 13 patients (n = 7 deaths, n = 4 cases of ESRD and n = 4 strokes). Sudden death occurred (n = 6) only in patients with documented ventricular tachycardia and myocardial replacement fibrosis. The annual progression of myocardial LV fibrosis in the entire cohort was 0.6 ± 0.7%. As a result, posterior end-diastolic wall thinning was observed (baseline, 13.2 ± 2.0 mm; follow-up, 11.4 ± 2.1 mm; P < 0.01). GFR decreased by 2.3 ± 4.6 mL min(-1) per year. Three patients experienced a TIA. The major clinical symptom was neuropathic pain (n = 37), and this symptom improved in 25 patients. The event rate was not different between the ERT group and the untreated (natural history) group of the Fabry Registry. CONCLUSION: Despite ERT, clinically meaningful events including sudden cardiac death continue to develop in patients with advanced Fabry disease.

Interferometry with Bose-Einstein condensates in microgravity.

Atom interferometers covering macroscopic domains of space-time are a spectacular manifestation of the wave nature of matter. Because of their unique coherence properties, Bose-Einstein condensates are ideal sources for an atom interferometer in extended free fall. In this Letter we report on the realization of an asymmetric Mach-Zehnder interferometer operated with a Bose-Einstein condensate in microgravity. The resulting interference pattern is similar to the one in the far field of a double slit and shows a linear scaling with the time the wave packets expand. We employ delta-kick cooling in order to enhance the signal and extend our atom interferometer. Our experiments demonstrate the high potential of interferometers operated with quantum gases for probing the fundamental concepts of quantum mechanics and general relativity.

[Echocardiography in diabetic cardiomyopathy]. / Echokardiographie bei diabetischer Kardiomyopathie.

The term diabetic cardiomyopathy was initially introduced in the 1980s when evidence was found that diabetes leads to a distinct cardiomyopathy, independent of coronary artery disease or hypertension. The detection of diabetic cardiomyopathy using echocardiography is challenging because no pathognomonic signs exist; however, it is the merit especially of the newer echocardiographic techniques, such as deformation imaging, that it is now possible to describe the morphology and function of diabetic hearts. Unfortunately, no long-term echocardiography studies are available describing disease progression in detail. Therefore, staging and differential diagnosis of diabetic cardiomyopathy remains challenging. This review tries to fill this gap by presenting a possible echocardiographic staging algorithm. Early stages of diabetic cardiomyopathy are marked by a deterioration of longitudinal systolic function and a compensative elevated radial function. Diastolic dysfunction is another early sign. When the disease progresses the functional deterioration is accompanied by morphological changes, such as left ventricular concentric hypertrophy and fibrosis. End stage disease is characterized by reduced ejection fraction and ventricular dilatation. Very late stage can mimic dilative cardiomyopathy.

[Assessment of diastolic heart failure. Current role of echocardiography]. / Beurteilung der diastolischen Herzinsuffizienz. Aktueller Stellenwert der Echokardiographie.

Diastolic heart failure, also known as heart failure with preserved left ventricular ejection fraction (HF-pEF), is responsible for approximately 50 % of all heart failure cases. According to current guidelines the diagnosis HF-pEF requires three criteria: (1) signs or symptoms of heart failure, (2) presence of a normal left ventricular ejection fraction and (3) evidence of diastolic dysfunction. Echocardiography is the diagnostic modality of choice, especially after ruling out other causes of dyspnea, such as pulmonary diseases, heart rhythm disturbances and volume overload. Important echocardiographic parameters for the assessment of diastolic function are atrial dimensions, myocardial mass, mitral inflow pattern, pulmonary vein flow, propagation velocity of mitral inflow and the tissue Doppler of the mitral annulus. Nevertheless, a complete echocardiographic examination should be performed in every patient with heart failure. In general, diastolic dysfunction is frequently associated with increased atrial diameter and left ventricular hypertrophy. In advanced stages pulmonary hypertension can be present. A robust method for evaluation of systolic function in patients with diastolic dysfunction is crucial. The mitral inflow pattern provides various parameters to describe diastolic function (E/A ratio, deceleration time, isovolumetric relaxation time). In case of difficulties to separate a normal from a pseudonormal mitral inflow pattern the Valsalva maneuver can be used. Another valuable parameter for this differentiation is the duration of the backward flow in the pulmonary veins in contrast to forward flow over the mitral valve. Tachycardia or atrial fibrillation is a major problem for grading of diastolic function; however, in patients with atrial fibrillation E/e' is a well-established parameter. In summary, this review provides a detailed overview and discussion of the established and newer echocardiography techniques for the evaluation of diastolic function and provides an algorithm for the assessment of diastolic dysfunction in everyday routine.

[Low flow/low gradient aortic valve stenosis : clinical and diagnostic management]. / "Low-Flow/Low-Gradient"-Aortenklappenstenose : Klinisches und diagnostisches Spektrum.

Low gradient aortic stenoses (AS) represent a special challenge for physicians with respect to an exact diagnosis and optimal therapy. The difficulty lies in the estimation of the severity of AS which is decisive for subsequent treatment and the prognosis. Low flow and low gradient can be due to systolic or diastolic dysfunction by high-grade as well as by medium-grade AS and be of non-valvular origin. The latter group is to be interpreted as pseudoaortic stenosis as long as the low flow can successfully be raised by interventional means. However, only patients in the first group can be expected to profit from valve replacement and for patients in the second group the accompanying diseases must be the focus of therapeutic treatment. Therefore, according to recent European surveys up to 30% of patients with severe AS are undertreated due to false estimation of the severity of stenosis and perioperative risk stratification. Furthermore, follow-up investigations have shown that patients with low flow/low gradient stenosis and borderline-normal ejection fraction (EF) are in an advanced stage of the disease because they have often developed a severe reduction in longitudinal myocardial function and in addition have pronounced myocardial replacement fibrosis due to cardiac remodelling despite a preserved EF. Therefore, aortic valve area, mean pressure gradient and EF alone cannot be taken into consideration for the management of patients with severe AS but a comprehensive assessment of the hemodynamics, such as stroke volume, special functional parameters as well as individual clinical appearance is essential for precise diagnostic and therapeutic decision making.

Arthroscopic refixation of a combined fracture of the greater and lesser tuberosity of the proximal humerus.

UNLABELLED: Combined fractures of the greater and the lesser tuberosity are very rare injuries. This is a case report on arthroscopic treatment using suture anchors and one distal fixation screw. Clinical and radiographic follow-up showed recovery of active motion and consolidation of the fragments in anatomic positions. LEVEL OF EVIDENCE: V.

Using high-resolution radar images to determine vegetation cover for soil erosion assessments.

Healthy soils are crucial for human well-being. Because soils are threatened worldwide, politicians recognize the need for soil protection. For example, the European Commission has launched the Thematic Strategy for Soil Protection, which requests the European member states to identify high risk areas for soil degradation. Most states use the Universal Soil Loss Equation (USLE) to assess soil erosion risk at the national scale. The USLE includes different factors, one of them is the vegetation cover and management factor (C factor). Modern satellite-based radar sensors now provide highly accurate vegetation cover data, enabling opportunities to improve the accuracy of the C factor. The presented study proves the suitability for C factor determination based on a multi-temporal classification of high-resolution radar images. Further USLE factors were derived from existing data sources (meteorological data, soil maps, digital elevation model) to conduct an USLE-based soil erosion assessment. The resulting map illustrates a qualitative assessment for soil erosion risk within a plot of about 7*12 km in an agricultural region in Poland that is very susceptible to soil erosion processes. A high erosion risk of more than 10 tonnes per ha and year was assessed to occur on 13.6% (646 ha) of the agricultural areas within the investigated plot. Further 7.8% (372 ha) of agricultural land is threaten by a medium risk of 5-10 tonnes per ha and year. Such a spatial information about areas of high or medium soil erosion risk are crucial for the development of strategies for the protection of soils.

Denervation of the thumb carpometacarpal joint for symptomatic osteoarthritis in 46 patients.

We investigated the effect of an extended denervation procedure in the thumb carpometacarpal (CMC) joint in patients suffering from CMC osteoarthritis. Between 2006 and 2018, 46 patients underwent the procedure in our clinic and were included in this retrospective study. Pain, strength, range of motion, DASH score, complications and overall satisfaction were determined. Assessment showed a significant decrease in pain and excellent physical function at a median 5 years' follow-up. Twelve patients needed secondary surgery due to persistent pain. Overall, 28 of the 46 patients were satisfied with the results of the denervation. Even though the results of CMC denervation are poorer than with simple trapeziectomy, considerable pain relief can be achieved in selected young, physically active patients by exclusively soft-tissue surgery, conserving the biomechanical properties of the joint. In case of failure of the procedure, all other options remain available.