Ski- and snowboard related open peroneal nerve injury: A 20-year retrospective case series study.

INTRODUCTION: Traumatic peroneal nerve injury (PNI) caused by ski or snowboard edges is a severe but scarcely reported accident. METHODS: In a 20-year retrospective study, all skiers and snowboarders with this injury treated surgically at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Innsbruck, Austria, were included, covering a period from 1999/2000 to 2018/2019. RESULTS: In total, 34 patients were included in this study (30 males (88.2%) and 4 (11.8%) females). Of these 34 injured skiers or snowboarders, 33 (97.1%) were recreational athletes and Non-Austrian citizens, and 21 (61.8%) patients sustained accidental injuries without collision. All of the injuries under investigation, i.e., open lacerations, most often with complete transection, were the patients' main injuries. Surgery was performed with direct coaptation in 24 patients (70.6%), and with a suralis nerve graft in the other 10 patients (29.4%). CONCLUSION: Traumatic laceration of the peroneal nerve at the knee level by sharp ski or snowboard edges is a rare but severe injury. Causes for this injury may be multifactorial. Recommendations to reduce the risk of such an injury may follow general instructions and warnings to skiers and snowboarders regarding equipment, familiarity with the region, as well as appropriate skills and training.

Surgical rescue for persistent head and neck cancer after first-line treatment.

PURPOSE: Surgical rescue is a treatment option for persistent disease after first-line treatment treatment of head and neck cancer (HNC). METHODS: Patients with persistent HNC treated with rescue surgery between 2008 and 2016 were included. Patients who received a rescue neck dissection (ND only) and who received primary site surgery ± ND were analysed separately (primary site surgery ± ND). RESULTS: During the observation period, 35 patients received ND only and 17 primary site surgery ± ND. No perioperative mortality was observed. In nine patients with ND only and 12 patients with primary site surgery ± ND at least one complication was encountered. 41/52 (79%) patients had a complete response. Median overall survival of patients receiving rescue surgery was 56 months (95% CI 44-69 months). Median overall survival was best for patients with initial laryngeal and oropharyngeal cancer and worst for patients with hypopharyngeal cancer (p = 0.02). Functional deficits following rescue surgery were mainly observed in the domains speech, nutrition, and shoulder/arm mobility. The risk of functional impairment was higher for patients with rescue surgery at the primary tumor site (OR 2.5 ± 2; p = 0.07). CONCLUSION: Rescue surgery offers patients with resectable, persistent disease a realistic chance to achieve long-term survival. Especially patients with laryngeal and oropharyngeal cancer profited from rescue surgery. Rescue neck dissection is an effective and safe procedure. Patients with rescue surgery at the primary tumor site ± ND should expect complications and permanent functional impairment.

Differences between patients and medical professionals in the evaluation of aesthetic outcome following breast reconstruction with implants.

BACKGROUND AND AIM: Most studies on breast reconstruction evaluate different surgical techniques, types of implant or time of reconstruction. Moreover, evaluations are usually performed either by surgeons or by patients, but are rarely compared. We conducted a study on aesthetic outcome following breast reconstruction with implants comparing the evaluation by patients versus medical professionals. METHODS: Forty-seven patients, who had a breast reconstruction with implants between 2001 and 2010 (median follow-up 71 months), underwent a clinical examination, standardized photo documentation and filled out a questionnaire to evaluate their aesthetic result (rate 1 very good to 5 very poor). Photo documentation was independently evaluated by 18 medical professionals using the same evaluation instrument and the results were compared. Gender and patient aspects were taken into account. RESULTS: We found statistically significant differences between patients and medical professional ratings. The patient evaluation was better through all categories as compared to the evaluation by medical personnel. The degree of medical education or gender aspects did not significantly affect the professional ratings. Age at reconstruction, length of follow-up or primary versus secondary reconstruction did not seem to make a difference in the evaluations of the patients versus the medical professionals.. CONCLUSION: The differences between patient and expert opinion in rating of aesthetic results indicate that patient satisfaction is influenced by multiple factors and not only by good aesthetic outcome. Patient evaluation should therefore be carefully considered in treatment and outcome studies of breast reconstruction..

Structure-activity relationships of trans-substituted-propenoic acid derivatives on the nicotinic acid receptor HCA2 (GPR109A).

Nicotinic acid (niacin) has been used for decades as an antidyslipidemic drug in man. Its main target is the hydroxy-carboxylic acid receptor HCA2 (GPR109A), a G protein-coupled receptor. Other acids and esters such as methyl fumarate also interact with the receptor, which constituted the basis for the current study. We synthesized a novel series of substituted propenoic acids, such as fumaric acid esters, fumaric acid amides and cinnamic acid derivatives, and determined their affinities for the HCA2 receptor. We observed a rather restricted binding pocket on the receptor with trans-cinnamic acid being the largest planar ligand in our series with appreciable affinity for the receptor. Molecular modeling and analysis of the structure-activity relationships in the series suggest a planar trans-propenoic acid pharmacophore with a maximum length of 8 Å and out-of-plane orientation of the larger substituents.

Complex mincer hand injury in a 4-year-old girl: successful revascularization.

We report on a four-year-old girl who suffered a complex mincer injury to the left hand, resulting in a partial amputation of her hand. To salvage the injured hand, revascularization was performed. The indication, advantages and outcome of the procedure are discussed.

Altered systemic serologic parameters in patients with silicone mammary implants.

BACKGROUND: The most common local complication in patients with silicone mammary implants (SMIs) is excessive peri-SMI connective tissue capsule formation and its subsequent contracture. However, considerable controversy remains as to whether these implants also cause systemic side effects. The present study was undertaken to identify possible alterations of serological markers in SMI patients that may herald systemic side effects. METHODS: We investigated several systemic serological parameters in 143 individuals, 93 of whom had received SMIs and 50 were controls. The patients were grouped according to the severity of capsular contracture (Baker scores I-IV) and the duration of SMI implants (less than 1 year, between 1 and 5 years, more than 5 years). We also included control groups (female blood donors, nurses with possible professional silicone exposure). Patients with breast cancer and subsequent SMI-reconstruction were excluded from the study since they are generally considered immunocompromised. The following parameters were determined: anti-neutrophil cytoplasmatic autoantibodies (cANCA), anti-nuclear autoantibodies (ANA), anti-cardiolipin antibodies (CL-Ab), rheumatoid factor (RF), complement components (C3, C4), circulating immune complexes (CIC), procollagen III (a marker of active fibrosis), anti-polymer antibodies (APA) and soluble intercellular adhesion molecule-1 (sICAM-1). RESULTS: The following parameters were increased in the sera of SMI patients: CIC, procollagen III, APA, sICAM-1. CONCLUSIONS: We found a set of parameters in serum that correlate with fibrosis development and the duration of the implants in otherwise healthy SMI carriers. Future studies will clarify whether these serological abnormalities will be useful in predicting clinical disease, and also further assess the sensitivity and specificity of these parameters. Our present recommendation as a result of this study is that SMI patients with persistent abnormal serological parameters should be monitored closely by a clinical team that includes rheumatologists.

[Closure of defects on the dorsum of the foot with free flaps. Functional and aesthetic aspects]. / Defektdeckung durch freie Lappenplastiken am Fussrücken. Funktionelle und ästhetische Aspekte.

BACKGROUND: Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow. PATIENTS AND METHODS: Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results. RESULTS: On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients. CONCLUSION: Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.

Spontaneous unilateral autoinflation of a saline-filled mammary implant.

We present the case of a woman with a massive volume increase in her right breast 12 years after breast augmentation with saline-filled silicone mammary implants (SMI). Tenderness of and pressure pain in the enlarged right breast were noted on physical examination. Intraoperatively, the right implant was seen to be markedly enlarged, altered in colour and filled with a brownish fluid as compared to the other side. No macroscopic damage, including to the valve of the enlarged SMI, was noticed. The liquid in the inflated SMI was subjected to biochemical analysis. Although neither cells nor nucleic acids were detected, 4 mg/ml protein was found in the liquid of the autoinflated SMI. On SDS-PAGE separation, these proteins resolved in a pattern similar to that of serum proteins. This observation was corroborated by Western blots for several serum proteins. Surprisingly, proteins in the SMI liquid were significantly more glycosylated and oxidised than were serum proteins; this finding indicates a process of protein ageing. We hypothesise that the reason for this in vivo expansion was a defective valve and not colloid osmotic swelling, as previously suggested.

[Possible nerve injuries in ankle dislocations. Trimalleolar fracture including the proximal fibula]. / Mögliche Nervenverletzungen bei Sprunggelenkluxationsverletzungen. Trimalleoläre Fraktur mit Beteiligung der proximalen Fibula.

We present a patient with an exceptional fracture type--a Maisonneuve fracture associated with a lateral ankle fracture--and the therapy of this injury. The Maisonneuve fracture consists of a proximal fibular fracture which is associated with failure of the deltoid ligament or medial malleolus and diastasis of the distal tibiofibular syndesmosis. Diverse nerves of the lower leg can be affected by severe trauma as well as by fracture-associated complications or an operation. Fracture fragments, an excessive distension caused by the trauma, or a fracture-associated hematoma can cause injury to the deep peroneal nerve or the branches of the superficial peroneal nerve at the level of the ankle. We want to point out the possibility of nerve lesions of the lower leg associated with this complex fracture. Additionally the operative access to the ankle in this context is discussed.

An appraisal of INTERNIST-I.

INTERNIST-I was an expert system designed in the early 1970's to diagnose multiple diseases in internal medicine by modelling the behaviour of clinicians. Its form and operation are described, and evaluations of the system are surveyed. The major result of the project was its knowledge base which has been used in successor systems for medical education and clinical use. We also survey the effects of the project through these systems, and conclude that the most successful of them in the near future is likely to be Quick Medical Reference (QMR) when used as an "electronic textbook" of medicine.

[The influence of oral niacin doses during different dietary protein levels on indexes of rumen fermentation, blood parameters and fattening performance of young bulls]. / Untersuchungen zum Einfluss oraler Niacingaben bei unterschiedlicher Proteinversorgung auf Kennzahlen der Pansenfermentation, Blutinhaltsstoffe und die Mastleistung von Jungbullen.

The influence of added niacin (0, 0.5 or 1 g per animal per day) and different crude protein contents (9.2 to 12.0% of DM) or the supply of various N-sources (urea, rape seed meal, soya bean meal, fish meal) were investigated on rumen fermentation, blood parameters, feed intake, weight gain and dry matter (DM) intake per weight gain in three individual feeding experiments with 156 growing bulls weighing between 175 and 300 kg per animal. Niacin supplementation did not significantly influence (P > 0.05) investigated parameters of rumen fermentation and blood. Ruminal propionate concentration increased insignificantly (from 18.9 to 19.5 moles per 100 moles on the average), inorganic P of blood serum somewhat decreased (from 2.98 to 2.82 mmol per 1) when niacin was added (P > 0.05). Protein level did not significantly influence rumen fermentation and blood parameters except an increased urea concentration in the blood of cattle fed with diets richer in protein. The DM intake of control bulls and niacin supplemented animals amounted to 6.35 and 6.46 kg per animal per day on average. Influence of niacin on DM intake varied in dependence on protein source. The daily weight gain increased from 1003 (control) to 1040 g per animal per day (+ niacin, P > 0.05). Niacin increased weight gain of bulls of urea (+ 43 g) and rape seed or soya bean meal added rations (+ 60 g per animal per day), but did not influence the weight gain in fish meal added rations. Increased weight gain resulted from ruminal and metabolic effects (about 2/3) as well as enhanced feed intake of bulls (about 1/3). Feed efficiency mostly improved.

[Investigations concerning the use of the rumen fermentation regulator monensin in feeding fattening bulls]. / Untersuchungen zum Einsatz des Pansenfermoregulators "Monensin" in der Mastbullenfütterung.

In two digestion experiments with wethers and seven feeding experiments with 198 fattening bulls with rations rich in (greater than 55% of the dry matter intake from roughage), the influence of the antibiotic monensin on the digestibility of the ration, on rumen-physiologic characteristic values and on fattening and slaughtering results was investigated. The digestibility of the organic matter and the crude nutrients was not significantly influenced by the use of monensin (20 mg/kg dry matter). The administration of 200 mg monensin per fattening bull and day resulted in an increase of the molar concentration of propionate in the rumen fluid by 9.7 mol%, the concentration of acetate and butyrate decreased by 7.3 resp. 2.8 mol %. On an average of the seven experiments the intake of dry matter was diminished by 5.1% through the use of monensin, the live weight increase remained almost unaffected (3.0% additional increase), feed and energy requirement per kg live weight were improved by 7.9%. The fattening results do not always correspond in the various experiments. The results of the dressing of the carcass, the composition of the carcass and the quality of the meat remained unaffected by the administration of monensin.

Tracer and freeze-etching analysis of intra-cellular membrane-junctions in Paramecium with a note on a new heme-nonapeptide tracer.

In paramecia the membranes of alveoli and trichocysts are permanently connected to the cell membrane by membrane-junctions, which consist of membrane-intercalated particles in a regular geometrical arrangement. Trichocysts contain secretory material discharged by exocytosis. In unfixed or fixed cells these two compartments were impermeable to the following tracers: To "microperoxidases", i.e. a cytochrome c-derived heme-nonapeptide and a heme-undecapeptide (WM approximately 1650, 1900) applied in vivo, as well as to lanthanum and cytochrome c used during (La) or after (cytochrome c) fixation. The heme-nonapeptide was prepared by TPCK trypsin digestion of cytochrome c and subsequent purification by Sephadex gel chromatography--a simple and inexpensive new procedure resulting in preparations of high yield and purity. Tracers entered alveoli only when the plasmalemma and the alveolar membranes ruptured upon glutardialdehyde fixation. In no case were transmembraneous channels detectable in regions containing membrane-intercalated particles; this holds true for all tracers used and for freeze-fracture replicas obtained by tantalum-tungsten evaporation. With regard to attachment sites over trichocysts our results do not support the assumptions by others according to which exocytosis would be driven by an osmotic shift via transmembraneous channels (which would be analogous to inter-cellular coupling phenomena mediated by gap-junctions), unless such channels would be assumed to operate as carriers rather than via diffusion. Tracers did not penetrate trichocysts before exocytosis occurred. The functional role of membrane-intercalated particles on trichocyst attachments remains unclear. Despite some resemblance with gap-junctions all types of intra-cellular membrane-junctions investigated are functionally "tight" at the level of "resolution" obtained with tantalumtungsten-shadowing and with the tracers used.