Ventana sagital paramedial oblicua para el acceso de la rama medial del nervio raquídeo posterior guiado ecográficamente / Ultrasound guided parasagittal obliqua aproach for lumbar medial branch block

Objetivos: el método de abordaje ecográfico más utilizado para el bloqueo del ramo medial del nervio raquídeo posterior (RmNRp) requiere de la utilización de una técnica ecográfica biplanar con punción guiada en plano en ventana transversal, para situar la cánula perpendicular al RmNRp, limitando la realización de radiofrecuencia. La utilización de una ventana ecográfica parasagital oblicua permite el acceso al RmNRp permitiendo situar la cánula de forma paralela al nervio, logrando estímulos sensitivos y motores, y posibilitando la realización de radiofrecuencia térmica para segmentos lumbares por encima de L5.En el presente estudio valoramos la eficacia de este nuevo abordaje ecográfico mediante la comprobación fluoroscópica de la situación de la cánula y la comprobación de la obtención de estímulos sensitivos y motores. Material y métodos: se estudian 31 pacientes diagnosticados de síndrome facetario propuestos para la realización de bloqueos de RmNRp diagnósticos. Describimos cuatro ventanas ecográficas lumbares secuenciales necesarias para incluir los pacientes en el estudio. Una vez obtenidas, se localiza el punto objetivo utilizando una ventana parasagital oblicua para lograr la visualización de la cara externa de la apófisis articular superior y la parte más dorsal de la apófisis transversa. Se realiza punción guiada en plano hasta situar la punta en la unión entre apófisis articular superior y apófisis transversa. Una vez situada la cánula en el objetivo se procede a estímulo sensitivo 50 Hz y motor 2Hz para reposicionar la cánula en caso de no obtenerse estímulos. Una vez obtenido estímulo motor o sensitivo o ambos, se realiza una proyección fluoroscópica oblicua 30° y caudo-craneal para comprobar la localización de la punta de la aguja. Resultados: en el 16% de los pacientes no se pueden identificar las 4 ventanas ecográficas por lo que se aborta el procedimiento. En el 84% restante se consigue situar la aguja en el punto target en el 100% de los casos en el primer intento o con un sólo reposicionamiento de la aguja. Conclusión: la ventana ecográfica parasagital oblicua nos permite una aproximación tangencial al RmNRp lumbar con un alto índice de éxito para situar la cánula de radiofrecuencia de forma similar a cuando utilizamos fluoroscopia. La identificación de las cuatro ventanas ecográficas descritas en el estudio nos permite hacer un cribado de los pacientes tributarios a ecografía para el bloqueo de RmNRp (AU)

Objectives: The most used ultrasound guided medial branch block method requires the use of a biplane ultrasound technique. Using this technique the cannula is positioned not parallel to the medial branch by limiting their use to perform conventional radiofrequency. Using a sonographic parasagittal obliqua view allows placing the cannula parallel to the nerve, achieving sensory and motor stimuli and making possible radiofrequency above L5 lumbar segments. In the present study we determined the effectiveness of this new approach by using fluoroscopy and by obtention of sensory and motor stimuli. Material and methods: Thirty-one patients diagnosed with lumbar facet joint pain proposed for diagnostic medial branch blocks were studied. We describe four lumbar sequential sonographic views necessary to include patients in the study. Once obtained, the target point is located using a parasagittal oblique sonographic view to achieve the external face of the superior articular process and the more dorsal part of the transverse process. Puncture is performed guided in plane to place the tip at the junction between superior articular process and transverse process. Once the cannula located in the target proceeds to sensory stimulus 50 Hz and Motor 2 Hz to perform a cannula repositioning in case there were no stimuli. Once obtained either motor or sensory stimulus a caudal to craneal 30° oblique projection is performed by fluoroscopy to check the location of the needle tip. Results: In 16% of patients cannot identify the four ultrasound views so the procedure is aborted. In the remaining 84% is achieved by placing the needle into the target point at 100% of the cases on the first attempt or by once a repositioning of the needle. Conclusion: Ultrasound oblique parasagittal view allows us a tangential approach to the lumbar medial branch with a high rate of success to position the radiofrequency cannula similar to when using fluoroscopy. The sonographic identification of the four windows described in the study allows us to screening tributary patient for ultrasound medial branch blocks (AU)

Multilocus analysis of nucleotide variation in Drosophila madeirensis, an endemic species of the Laurisilva forest in Madeira.

Drosophila madeirensis is an endemic species of Madeira that inhabits the island Laurisilva forest. Nucleotide variation in D. madeirensis is analysed in six genomic regions and compared to that previously reported for the same regions in Drosophila subobscura, an abundant species in the Palearctic region that is closely related to D. madeirensis. The gene regions analysed are distributed along the O(3) inversion. The O(3) arrangement is monomorphic in D. madeirensis, and it was present in ancestral populations of D. subobscura but went extinct in this species after the origin of the derived O(ST) and O(3+4) arrangements. Levels of nucleotide polymorphism in D. madeirensis are similar to those present in the O(ST) and O(3+4) arrangements of D. subobscura, and the frequency spectrum is skewed towards rare variants. Purifying selection against deleterious nonsynonymous mutations is less effective in D. madeirensis. Although D. madeirensis and D. subobscura coexist at present in Madeira, no clear evidence of introgression was detected in the studied regions.

Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies.

BACKGROUND AND STUDY AIMS: Data on process quality and complications of colonoscopies are sparse, especially for the screening setting. We describe process quality in routine care, estimate the incidence of acute complications, and identify risk indicators for substandard care and complications. PATIENTS AND METHODS: We analyzed data from 236 087 compulsory health insurance (CHI) members who underwent colonoscopies in 2006. Data were documented prospectively in the Electronic Colonoscopy Documentation of the Bavarian Association of CHI Physicians, a registry of outpatient colonoscopies performed in practices throughout Bavaria, Germany. It covers demographic characteristics, indications, quality indicators, macroscopic and histological findings, diagnoses, and acute complications. RESULTS: Colon preparation resulted in clear bowels in 76.31 % of patients, liquid residues in 22.22 %, and dirty bowels in 1.47 %. In total, 92.85 % of the examinations were performed with patients under sedation/analgesia and 97.43 % of colonoscopies were complete. Photo documentation was present for 98.87 %. Male sex, middle age, screening, satisfactory bowel preparation, and sedation/analgesia were associated with completeness. A total of 735 patients (0.31 %) suffered complications, among them 520 bleedings (0.22 %), 69 perforations (0.03 %), and 152 cardiorespiratory complications (0.06 %). Male sex, higher age, nonscreening indication, biopsies, polypectomies, and absence of sedation/analgesia were indicative of a higher bleeding risk. Perforations were also related to biopsies and polypectomies. Higher age was the only discernible risk indicator for cardiorespiratory events. CONCLUSIONS: Outpatient colonoscopy is a safe procedure with a low risk of acute complications. Improving bowel preparation enhances completeness. Sedation/analgesia is conducive to both completeness and the lowering of the risk of acute complications.

[Cancer screening for women is less frequently visited in regions with lower household income--analysis of data from health insurances in Bavaria]. / Die Krebsfrüherkennungsuntersuchung für Frauen wird in Regionen mit niedrigerem Haushaltseinkommen seltener in Anspruch genommen--Analyse von Daten der Kassenärztlichen Vereinigung Bayerns.

AIM OF THE STUDY: Differences in health care in Germany have rarely been analysed. Recent research, however, indicates that subjects of the lower social class participate in cancer screening less frequently. METHODS: Participation in screening for cervical cancer among women older than 20 years has been analysed using billing information of the KVB (Kassenärztlichen Vereinigung Bayern) for the period from 2002-2005. Women were assigned to one of the 96 Bavarian districts based on their postal code. The following variables were used: Participation rate in cervical cancer screening; age; average household income; gynaecologists per 10,000 women. Multivariate analyses were based on age-stratified linear regressions. RESULTS: There are considerable regional differences in participation in screening for cancer among older women. Participation rates are lower in districts with lower average household income. The correlation between participation rates and average household income shows an almost linear dependence on the level of districts. This association could not be explained by the variable "gynaecologists per 10,000 women". CONCLUSION: In order to provide social equality in health care, regional differences in cancer screening participation should be targeted. This is especially important in districts with lower average household incomes.

Participation in cervical cancer screening by age and region--a cohort study with a 3 1/2 year follow-up on 2,223,135 women in Bavaria.

OBJECTIVE OF THE STUDY: Cervical cancer rates are higher in Germany than in comparable European countries. While other European countries have implemented invitation programs, Germany relied on annual free access only. Are sufficient screening participation rates achieved? METHODS: We analyzed data from 2,223,135 Bavarian women between 2002/3 and 2005/4 in a retrospective cohort, to evaluate screening participation, frequency, age dependencies and regional differences. RESULTS: The highest screening participation was amongst women between 20 and 29 (54.6% had at least one visit after one year, 84% within three years) and decreased progressively with increasing age. Participation was lowest for women above 70 in rural areas (in some regions less than 20% had at least one screening within three years). CONCLUSION: Poor participation rates in general are unlikely to account for the high cervical cancer rates in Germany. Low participation rates in elderly women, particularly those in rural regions might contribute to the well-known peak of cervical cancer in elderly women.

Changes in the recombinational environment affect divergence in the yellow gene of Drosophila.

The complete coding region of the yellow (y) gene was sequenced in different Drosophila species. In the species of the melanogaster subgroup (D. melanogaster, D. simulans, D. mauritiana, D. yakuba, and D. erecta), this gene is located at the tip of the X chromosome in a region with a strong reduction in recombination rate. In contrast, in D. ananassae (included in the ananassae subgroup of the melanogaster group) and in the obscura group species (D. subobscura, D. madeirensis, D. guanche, and D. pseudoobscura), the y gene is located in regions with normal recombination rates. As predicted by the hitchhiking and background selection models, this change in the recombinational environment affected synonymous divergence in the y-gene-coding region. Estimates of the number of synonymous substitutions per site were much lower between the obscura group species and D. ananassae than between the species of the obscura group and the melanogaster subgroup. In fact, a highly significant increase in the rate of synonymous substitution was detected in all lineages leading to the species of the melanogaster subgroup relative to the D. ananassae lineage. This increase can be explained by a higher fixation rate of mutations from preferred to unpreferred codons (slightly deleterious mutations). The lower codon bias detected in all species of the melanogaster subgroup relative to D. ananassae (or to the obscura group species) would be consistent with this proposal. Therefore, at least in Drosophila, changes in the recombination rate in different lineages might cause deviations of the molecular-clock hypothesis and contribute to the overdispersion of the rate of synonymous substitution. In contrast, the change in the recombinational environment of the y gene has no detectable effect on the rate of amino acid replacement in the Yellow protein.

Nucleotide variation at the yellow gene region is not reduced in Drosophila subobscura: a study in relation to chromosomal polymorphism.

In contrast to Drosophila melanogaster and Drosophila simulans, the yellow (y) gene region of Drosophila subobscura is not located in a region with a strong reduction in recombination. In addition, this gene maps very close to the breakpoints of different inversions that segregate as polymorphic in natural populations of D. subobscura. Therefore, levels of variation at the y gene region in this species relative to those found in D. melanogaster and D. simulans may be affected not only by the change in the recombinational environment, but also by the presence of inversion polymorphism. To further investigate these aspects, an approximately 5.4-kb region of the A (=X) chromosome including the y gene was sequenced in 25 lines of D. subobscura and in the closely related species Drosophila madeirensis and Drosophila guanche. The D. subobscura lines studied differed in their A-chromosomal arrangements, A(st), A(2), and A(1). Unlike in D. melanogaster and D. simulans, levels of variation at the y gene region of D. subobscura are not reduced relative to those found at other genomic regions in the same species (rp49, Acp70A, and Acph-1). This result supports the effect of the change in the recombinational environment of a particular gene on the level of neutral variation. In addition, nucleotide variation is affected by chromosomal polymorphism. A strong genetic differentiation is detected between the A(1) arrangement and either A(st) or A(2), but not between A(st) and A(2). This result is consistent with the location of the y gene relative to the breakpoints of inversions A(1) and A(2). In addition, the pattern of nucleotide polymorphism in A(st)+A(2) and A(1) seems to point out that variation at the y gene region within these chromosomal classes is in the phase transient to equilibrium. The estimated ages of these arrangements assuming a star genealogy indicate that their origin cannot predate the D. madeirensis split. Therefore, the present results are consistent with a chromosomal phylogeny where Am(1), which is an arrangement present in D. madeirensis but absent in current populations of D. subobscura, would be the ancestral arrangement.

Divergence of the yellow gene between Drosophila melanogaster and D. subobscura: recombination rate, codon bias and synonymous substitutions.

The yellow (y) gene maps near the telomere of the X chromosome in Drosophila melanogaster but not in D. subobscura. Thus the strong reduction in the recombination rate associated with telomeric regions is not expected in D. subobscura. To study the divergence of a gene whose recombination rate differs between two species, the y gene of D. subobscura was sequenced. Sequence comparison between D. melanogaster and D. subobscura revealed several elements conserved in noncoding regions that may correspond to putative cis-acting regulatory sequences. Divergence in the y gene coding region between D. subobscura and D. melanogaster was compared with that found in other genes sequenced in both species. Both, yellow and scute exhibit an unusually high number of synonymous substitutions per site (ps). Also for these genes, the extent of codon bias differs between both species, being much higher in D. subobscura than in D. melanogaster. This pattern of divergence is consistent with the hitchhiking and background selection models that predict an increase in the fixation rate of slightly deleterious mutations and a decrease in the rate of fixation of slightly advantageous mutations in regions with low recombination rates such as in the y-sc gene region of D. melanogaster.

[The symptom hemobilia (author's transl)]. / Symptom Hämobilie. Fallbericht bei primär biliärer Zirrhose

A 46-year-old woman with a histologically, immunoserologically and biochemically confirmed chronic destructive non-suppurative cholangitis in the stage of incipient primary biliary cirrhosis developed an erosive, hemorrhagic cholangitis of obscure etiology with massive life-threatening bleeding from the biliary tracts. Hemobilia could be diagnosed endoscopically and confirmed by exploratory laparotomy. Postoperatively the biliary tracts were washed out with Tachostyptan, Ugurol and Trasylol through a T drain. The bleeding stopped within 48 hours and has not recurred since.