[Caution: aggressive! Dog bite injuries in clinical forensic medicine]. / Vorsicht: bissig! Hundebissverletzungen in der klinischen Rechtsmedizin.

Younger children in particular are at risk of becoming victims of dog attacks due to their small size. Such a biting incident can fulfil various criminal offences. In order to be able to satisfy possible legal claims, the injuries should be documented by forensic medicine and thus be legally binding. Therefore, close cooperation between the treating surgeons and forensic experts is recommended. A retrospective analysis of the cases of dog bite injuries in children and adults treated by clinical forensic medicine at the University Medical Center Rostock was carried out under various aspects. Adult casualties were predominantly injured on the lower extremities. The children examined were predominantly bitten on the head, neck and face region as well as the upper extremities. Injury severity ranged from skin redness to severe substance defects with loss of body structures. The biting dog was known in about half of the cases. In order to avoid dog bites in children, parents as well as children should be trained in dealing with dogs.

Comparison of environmental risk factors for esophageal atresia, anorectal malformations, and the combined phenotype in 263 German families.

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and anorectal malformations (ARM) represent the severe ends of the fore- and hindgut malformation spectra. Previous research suggests that environmental factors are implicated in their etiology. These risk factors might indicate the influence of specific etiological mechanisms on distinct developmental processes (e.g. fore- vs. hindgut malformation). The present study compared environmental factors in patients with isolated EA/TEF, isolated ARM, and the combined phenotype during the periconceptional period and the first trimester of pregnancy in order to investigate the hypothesis that fore- and hindgut malformations involve differing environmental factors. Patients with isolated EA/TEF (n = 98), isolated ARM (n = 123), and the combined phenotype (n = 42) were included. Families were recruited within the context of two German multicenter studies of the genetic and environmental causes of EA/TEF (great consortium) and ARM (CURE-Net). Exposures of interest were ascertained using an epidemiological questionnaire. Chi-square, Fisher's exact, and Mann-Whitney U-tests were used to assess differences between the three phenotypes. Newborns with isolated EA/TEF and the combined phenotype had significantly lower birth weights than newborns with isolated ARM (P = 0.001 and P < 0.0001, respectively). Mothers of isolated EA/TEF consumed more alcohol periconceptional (80%) than mothers of isolated ARM or the combined phenotype (each 67%). Parental smoking (P = 0.003) and artificial reproductive techniques (P = 0.03) were associated with isolated ARM. Unexpectedly, maternal periconceptional multivitamin supplementation was most frequent among patients with the most severe form of disorder, i.e. the combined phenotype (19%). Significant differences in birth weight were apparent between the three phenotype groups. This might be attributable to the limited ability of EA/TEF fetuses to swallow amniotic fluid, thus depriving them of its nutritive properties. Furthermore, the present data suggest that fore- and hindgut malformations involve differing environmental factors. Maternal periconceptional multivitamin supplementation was highest among patients with the combined phenotype. This latter finding is contrary to expectation, and warrants further analysis in large prospective epidemiological studies.

Practice of dilatation after surgical correction in anorectal malformations.

BACKGROUND: In order to prevent stricture of the neoanus after surgical correction, regular dilatation is recommended. There is a lack of knowledge about the performance of anal dilatation and the occurrence of pain. The aim of our investigation was to describe the practice of dilatation and to identify possible risk factors for painful procedures. METHODS: Congenital Uro-Rectal Malformations Network is a German interdisciplinary multicenter research network. With standard questionnaires, physicians interviewed 243 patients and/or their parents at home, additional 103 patients born since 2009 were assessed through their treating physicians. RESULTS: In total, 88 % of the patients received dilatations. Treatment lasted for 7 months in median (range 1-156 months), until the age of 13 months (range 1-171 months). In 69 % painful dilatation was reported; without a significant differences in age or gender. In 32 % bleeding was reported. In 30 % at least one dilatation was performed under general anesthesia. In 11 % some kind of analgesia was used. Type of fistula, dilatations lasting longer than 10 months and Hegar size above 15 were relevant factors for experience of pain. There were about 16 % postoperative strictures of the neoanus, without reported differences in dilatation procedures; but there was a relation to type of malformation. CONCLUSION: Considering the high number of painful treatments, predictors for painful dilatations should be further clarified through standardized documentation and prospective evaluation in order to improve follow-up.

Hydrocolonic sonography: a helpful diagnostic tool to implement effective bowel management.

Fecal incontinence is a serious problem that may lead to social segregation and psychological problems. Patients with anorectal malformations frequently suffer from fecal incontinence even with an excellent anatomic repair. In these patients, an effective management program with enemas can improve their quality of life. We want to present our experience with hydrocolonic sonography as a diagnostic tool to predict the type and volume of enema needed to initiate an effective bowel management. Patients who presented with soiling regardless of the type of anomaly were included in the study. Thirty patients aged 4-18 were evaluated. The diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, and stool protocol. Twenty patients suffered from true fecal incontinence and were included in a bowel management program. These patients received oral polyethyleneglycol to evacuate stool impaction. Bowel management was initiated with the help of hydrosonography to evaluate bowel motility. The volume of the enema was determined according to the amount of fluid that was needed to fill the colon to the cecum. Twenty patients were investigated with the help of hydrocolonic sonography. Eighteen patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at reevaluation. Two patients did not follow the therapeutic regime and, therefore, did not show an improved condition concerning soiling in the long run. Hydrocolonic sonography is a helpful diagnostic tool to assess colonic volume and motility to predict the type and volume of enema needed for an effective bowel management.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformations. Part 2: evaluation of psychosocial need.

PURPOSE: Only a few patients with anorectal malformations (ARM) have satisfactory bowel functions. Studies of ARM have reported psychosocial problems in up to 73% of patients. The aim of the current study was to document the psychosocial needs of patients with ARM. METHODS: Between June 2004 and September 2005, 44 patients with ARM were treated; the sample included 30 patients (23 males and 7 females) aged 4-17. To focus on potential psychosocial strain, a comprehensive grading system with a sophisticated perspective of continence, associated malformations, number of surgical interventions and postoperative complications was introduced. For psychosocial screening, the following instruments were used: German "Basis-Dokumentation" (BADO), Impact on Family Scale (IFS), the Strengths and Difficulties Questionnaire (SDQ). All families assessed their own psychosocial needs. An extensive psychosocial programme was provided. RESULTS: Twenty-three patients were suffering severe burden according to the comprehensive grading system. Nearly half of the families reported increased financial stress, and one-third reported emotional or hyperactivity problems of the child. More than 70% confirmed psychosocial need. CONCLUSIONS: Paediatric surgeons should promote psychosocial support for all patients who suffer severe forms of ARM or its numerous associated malformations as well as for patients undergoing numerous surgical interventions or having many postoperative complications.

[Injury prevention as the physician's challenge]. / Prävention von Verletzungen als ärztliche Aufgabe.

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

Stereotactic brain biopsy in AIDS.

In the hope of finding a treatable condition, the need for rapid diagnosis in HIV-seropositive patients with brain lesions is apparent. In order to evaluate the efficacy of stereotactic brain biopsy in AIDS patients, we retrospectively studied 25 HIV-infected patients undergoing stereotactic biopsy. Brain lesions were identified with gadolinium-enhanced MRI and/or contrast CT. Brain biopsy was performed using the system of Riechert. From 8 up to 15 small tissue samples from one or two targets were obtained in every patient. The biopsy material was examined cytologically, histologically (including electron microscopy), immunohistochemically and, in part, by animal test and polymerase chain reaction (PCR). A definite diagnosis was achieved in 92%. Diagnosis included primary central nervous system lymphoma (PCNSL) (10), toxoplasmosis (10), progressive multifocal leukoencephalopathy (2) and one case of co-existing toxoplasmosis and cytomegalovirus infection. Two biopsies were non-diagnostic. All PCNSLs showed polymorphic B-cell populations of high malignancy; accurate classification according to the Kiel classification was not possible. In 3 lymphomas Epstein-Barr nuclear antigen (EBNA) 2-mRNA could be detected by PCR and confirmed immunohistochemically by EBNA 2 expression. In 6 cases autopsy confirmed the biopsy diagnosis. Conventional histology was not sufficiently decisive for toxoplasmosis and progressive multifocal leukoencephalopathy, so that immunohistochemistry and animal tests became very important for a final diagnosis. With the help of different morphological and molecular biological techniques stereotactic brain biopsy appears to be an effective method in the diagnosis of HIV-associated brain lesions. In view of the marked radio- and chemosensitivity of PCNSLs it is mandatory to establish an early and accurate histological diagnosis for adequate treatment.

[The central nervous system of infants born to HIV-positive mothers-- neuropathology, immunohistochemistry in in situ hybridization]. / Das Zentralnervensystem von Kindern HIV-positiver Mütter--Neuropathologie, Immunhistochemie und in-situ-Hybridisierung.

The central nervous system (CNS) of 12 fetuses from human-immunodefiency-virus-seropositive mothers was investigated. Postconceptional ages ranged between 15 and 21 weeks. 3 preterm infants born to HIV positive mothers whose survival ranged from 6 hours to 6 months were included in the study. In all cases, the development of the CNS was macroscopically normal. The microscopic examination showed many ectopic neurons indicating disturbances of normal neuronal migration. As a regular finding there was a significant increase in microglia in all areas of the CNS but no microglial nodules were found. In all cases haematogenous monocytes were scattered in the perivascular space of the cerebral parenchyma as well as in the chorioid pexus. The virus-antigen p24 could neither be detected immunohistochemically in the paraffin sections nor in the frozen material of the brain or by in-situ-hybridization. In contrast, in five of the cases investigated the placenta showed macrophages, socalled Hofbauer cells with p24-associated antigen.