[Practical Year - Surgery in the Reformed Curriculum MaReCuM (Mannheim)]. / PJ Chirurgie im Modellstudiengang MaReCuM (Mannheim).

Background: Since 2006 the practical year in the Mannheim Reformed Curriculum Medicine (MaReCuM) is divided into four quarters: the two required subjects (surgery and internal medicine), one elective and one of four offered fields in ambulatory medicine. Therefore students can more intensively focus on their preferences in the practical year. In the present article we describe the provided surgical training sites, the organisation of the practical year, the surgical training itself and the quality management. We provide answers to the following questions: does dividing the practical year into quarters have a (negative) influence on the grades of final exams; how interested, motivated and satisfied are students in the different (surgical) quarters of the practical year and in which quarter(s) can new generation staff be recruited? Methods: We used results of the final exams of three cohorts of the traditional Mannheim track and three cohorts of MaReCuM, as well as the results of the Mannheim Questionnaire of Satisfaction with Training Conditions in the Practical Year of Medical Education from the regular evaluation of three practical year cohorts within two years. Conclusions: Dividing the practical year into quarters is possible and can be organised together with the new "mandatory subject" ambulatory medicine. The introduction of quarters has no negative effects on the results of final exams. The assignment in the surgical field from students' perspectives with regard to motivation, interest, knowledge and satisfaction with training is comparable to surgical electives. Therefore recruitment of new staff is possible either in the surgical elective or in the surgical area of ambulatory medicine.

1-Year outcome of concomitant intracarpal lesions in patients with dislocated distal radial fractures: a systematic assessment of 78 distal radial fractures.

INTRODUCTION: Ligamentous lesions are concomitant to dislocated distal radius fractures in a high percentage. The purpose of this study was to evaluate the relevance of intracarpal lesions. METHODS: Seventy eight of an original cohort of 104 distal radius fractures (74%) were studied over a follow-up period of one year after surgery with complete data (X-rays, CT, MRI, follow-up X-rays and questionnaire). RESULTS: Most of our radius fractures (AO 23 type: A 39, B 9, C 30) present additional lesions: 97%. One-year evaluation showed an average Castaing score of 4.5 ± 2.5 points, means a "good" result of a scale of 0-27. Fifty five of seventy eight had an "excellent" or "good" result (<6 points). No patient had more than 12 points ("fair"). CONCLUSIONS: The dislocated distal radial fracture implies severe and complex injury to the whole wrist, mostly concerning intracarpal concomitant lesions (MRI). Surgical therapy of dislocated radius fractures followed by 6 weeks relief through thermoplastic splint seems to be sufficient to achieve good 1-year results. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance.

[Fractures of the neck of the femur in younger patients (15-50 years old). Outcome 4 years after surgery]. / Die Schenkelhalsfraktur bei jüngeren Patienten (15-50 Jahre). Klinisch-radiografisches Outcome 4 Jahre nach operativer Therapie.

INTRODUCTION: Traumatic fractures of the neck of the femur are rare injuries in younger patients between 15 and 50 years old. The short-term and long-term complications may cause substantial problems, in particular non-union and avascular necrosis (AVN) of the head of the femur. In the literature (and from some experts) the impression is occasionally given that there might be "proven" successful therapeutic procedures. METHODS: For this purpose we retrospectively analysed follow-up-data from our own patients in the years 2003-2007 and compared them with the literature. We identified 23 of a total of 376 patients with a femoral neck fracture as a cohort being younger than 50 years. 17 of those 23 patients were treated with an internal fixation. We were able to collect and analyse complete clinical and radiological data of 11 of these 17 patients 4.2 years after surgery. RESULTS: The mean interval between accident and surgery was 22 hours. Only one of the patients developed an AVN after internal fixation of the fracture and was implanted a total hip replacement 18 months postoperatively. There was no non-union of the femoral neck The clinical outcome after 4.2 years was very good. The mean Harris Hip Score was 95 points (of a max. of 100 pts.). CONCLUSIONS: The osteosynthesis of femoral neck fractures in younger patients showed good results and a low risk of AVN and non-union. Therefore the internal fixation of the femoral neck fracture should be preferred for the younger patients instead of a primary total hip replacement.

[Medical and sociodemographic aspects of domestic violence. Systematic evaluation of patient data from the emergency department of a maximum care hospital]. / Medizinische und soziodemographische Aspekte häuslicher Gewalt. Systematische Auswertung von Patientendaten einer Notaufnahme eines Krankenhauses der Maximalversorgung.

BACKGROUND: Injuries due to domestic violence are a frequent occurrence in emergency departments. Although domestic violence has been well analyzed from the sociological point of view, medical data concerning patterns of injuries are rare. METHODS: Victims of domestic violence who presented at the emergency department of a maximum care hospital were included in the study. Sociodemographic data and patterns of injuries were documented. RESULTS: Of the patients who presented at the emergency room 1.4 % suffered injuries due to domestic violence and 70 % were women who had been predominantly attacked by the (ex) partner. The male victims were predominantly attacked by friends. In 88 % the head and neck were involved. Male patients were attacked with objects (as a kind of weapon) more frequently than women. A migration background was documented in 45 % of the female and 30 % of the male patients. CONCLUSION: Patterns can be easily recognized: the victims were predominantly female and were attacked by the (ex) partner. Injuries were localized to the upper part of the body. No excessive violence with life-threatening or fatal injuries was observed.

[Carpal lesions associated with dislocated fractures of the distal radius. A systematic screening of 104 fractures using preoperative CT and MRI]. / Karpale Begleitläsionen bei dislozierter distaler Radiusfraktur. Eine systematische Erfassung durch präoperative CT- und MRT-Untersuchung.

BACKGROUND: The functional outcome of surgically treated dislocated fractures of the distal radius is limited and does not correlate with radiographic results. Additional carpal lesions are assumed to be the cause. This study has evaluated which carpal lesions are associated with dislocated fractures of the distal radius. MATERIAL AND METHODS: A total of 104 consecutive patients with dislocated fractures of the distal radius were included in the study. The injured wrist was examined by radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine additional carpal lesions. RESULTS: Radiographically 51 of the 104 fractures presented as type A according to the AO classification, 10 as type B and 39 as type C. The CT scan detected that only 5 of the 51 type A fractures were exclusively metaphyseal fractures. All type A fractures were associated with ligamental lesions in MRI. CONCLUSIONS: The results of the study confirm the hypothesis that every dislocated fracture of the distal radius is a combined carpal trauma associated with additional osseous and/or ligamental lesions.

[What is the meaning of safety in hospitals?]. / Was bedeutet Sicherheit im Krankenhaus?

Patient safety in hospitals is difficult to define and is not measurable by operational safety parameters as in other fields. So-called adverse events (AE) are a collective of complications, failures, mistakes, errors and violations. Estimations of at least 9.2 % AEs in surgery with 0.1 % fatalities are given worldwide but there are no correlations between objective quantification of AEs and subjective or public perception of safety during the perioperative period. Patient safety during this period is mostly endangered by wound infections (safety 98 %) and nosocomial infections (safety 97 %). In spite of these facts, safety parameters for problems in anesthesia, blood transfusion, in retaining surgical instruments and so-called index events, such as patient and side identification errors are much higher. Patient safety is maintained in hospitals by objective means (surgical). Checklists have been proven to improve safety and critical incidence reporting, training and changing of attitudes could have further advantages but they are difficult to measure.

[Osseointegration of ceramic cement-free acetabular cups]. / Osteointegration zementfreier Hüftpfannen aus Keramik.

INTRODUCTION: A stable osseointegration of an alumina-matrix-composite-ceramic (AMC) could facilitate the use of a thin-walled monoblock acetabular cup for hip arthroplasty with large ball-heads providing advantages like reduced risk of dislocation. The aim of the pilot study was to examine the osseointegration of porous-coated alumina-matrix-composite-ceramic-monoblock cups after implantation in a sheep model. MATERIAL AND METHODS: The porous coated AMC-ceramic cups were taken out after a healing period of 8 and 52 weeks after unilateral implantation in 5 and 6 sheep, respectively. The osseointegration was analysed histomorphologically and histomorphometrically by representative serial sections after dying according to Masson-Goldner. The examination was stratified according the pole and the rim areas as a press-fit cup with an extended rim was used. Two animals had a hip dislocation after 8 weeks and these animals were excluded from the study and replaced. RESULTS: The cups were appraised as stable in the bony bed. Histologically, the rim area of the acetabular cup showed a higher osseointegration rate than the pole area. The rate of osseointegration in total was 3% after 8 weeks and 7% after 52 weeks. The rim area furnished 5.1% after 8 and 8.6% after 52 weeks. At the pole the osseointegration was 1,2% after 8 and 5.5% after 52 weeks. No significant differences were seen between both assessed time periods regarding the osseointegration rates. The bone showed an interlocking aspect with the pores of the coating as bony tissue was determined in the pores. CONCLUSION: The presented pilot study revealed a stable osseointegration of porous-coated AMC-ceramic monoblock cups one year after surgery in a weight-bearing animal model. Interlocking of bone and porous coating may provide a stable osseointegration in the presence of low osseointegration rates, whose enhancement seems to be preferable.

Effective teaching modifies medical student attitudes toward pain symptoms.

INTRODUCTION: Recent studies have raised the question of whether last year medical students and first year residents show an adequate attitude toward their patient's pain as reflected by prescribed pain medication. Underuse of analgetics could be demonstrated in several studies even after a correct diagnosis of pain was made and has led to the term "oligoanalgesia." Our study was aimed at evaluating the potential of improving student attitudes toward pain by changing the curriculum during the last year of medical education. METHODS: The study was designed as a prospective, randomized controlled, blinded cohort study. A recent change by law (2002) in the official curriculum ("Approbationsordnung") made it possible to compare two groups of last year medical students who were trained in different curricula during a 1-year transitional period. One group received special training on various aspects of pain and analgesic therapy (new curriculum), while the other group followed the conventional curriculum (old curriculum) without further special training. Both students and examiners were blinded toward the study target. Measurement parameters were a clinical experiment with standardized patients (OSCE) and a key features test. RESULTS: The study shows a considerable improvement of attitude toward pain in those students undergoing the new curriculum. This group demonstrated better OSCE results and significant improvement in key features tasks, and also outperformed the old curriculum group in the choice of analgesia. DISCUSSION: Our results confirm the importance of humanistic attitudes in future doctors in addition to the traditional implementation of knowledge and skills. Changes in the medical curriculum can positively influence these attitudes.

[Osteointegration of an alumina matrix composite ceramic with a porous surface: mechanical and histological results of an animal experiment]. / Osteointegration einer Alumina-Matrix-Composite-Keramik mit poröser Oberfläche: Eine mechanische und histologische Untersuchung im Tierversuch.

INTRODUCTION: The aim of this study was to analyse mechanically and histologically the osteointegration of porous-surfaced ceramic implants made of an alumina matrix composite (AMC) by assessing maximum shear strength and histomorphometric bone ongrowth. METHODS: The surfaces of the cylindrically shaped AMC test implants were characterised by a porosity of 40% and a pore size of 150 to 300 microm. A total of 24 test cylinders was implanted bilaterally into the femurs of 6 female adult Goettinger minipigs. 12 weeks after surgery the animals were sacrificed. 12 test implants were used for a push-out test and 12 test implants were evaluated histologically. RESULTS: The mean maximum shear strength of the bone-implant interface was 7.6 +/- 2.0 MPa. Direct bone attachment was found in 7.4 +/- 3.4% of the histologically analysed surfaces. CONCLUSION: In summary, porous-surfaced AMC test implants demonstrated good mechanical stability in spite of a low percentage of bone ongrowth. This discrepancy could potentially be explained by bone ingrowth into the pores and subsequent interlocking mechanisms.

[Acute lymphoblastic leukemia presenting without peripheral blasts but with osteolysis and hypercalcemia in an adolescent. Atypical but not rare]. / Manifestation einer akuten lymphoblastischen Leukämie mit Osteolyse, Hyperkalzämie und unauffälligem Blutbild bei einer Jugendlichen. Untypisch aber nicht selten.

Joint pain is one of the major symptoms in early leukemia. We report on a 16-year-old girl who presented with groin pain and an osteolytic bone lesion. Acute lymphoblastic leukemia was diagnosed, but the laboratory workup and radiologic imaging revealed atypical results. Particularly in early precursor B-cell acute lymphoblastic leukemia, comparable initial symptoms and signs have been reported in adolescents; therefore, we recommend performing a bone marrow aspiration early on in cases of suspected osteolytic bone lesions.

[Introduction of a new intervertebral spacer for cervical fusion: results of a controlled animal study]. / Die zervikale, interkorporelle Fusion mit einem neuen, verschraubbaren Titanspacer. Eine kontrollierte, tierexperimentelle Studie.

AIM: This study investigated the fusion properties of a new intervertebral spacer that is directly fixed to the adjacent vertebrae by screws. The new spacer was compared with an identical spacer without direct fixation but with an additional plate and with an autologous bone graft. METHODS: A single-level, cervical fusion was performed on 18 mature Merino sheep. Three treatment groups of six sheep each were used. Group A used an autogenous bone graft and an additional anterior plate. Group B used a titanium solid spacer with a titanium plasma-sprayed (TPS) surface and an additional anterior plate. Group C used a similar spacer as group B that was directly fixed with the adjacent vertebrae with 4 screws. The standing period was 12 weeks. The substrates were evaluated radiographically and histologically. RESULTS: Dislocation of the spacer or the bone graft occurred in one of the 6 cases in each group A and B, while 5 of the 6 spacers were dislocated in group C. Successful fusion was found in 4 of the 6 cases in groups A and C and in 5 of the 6 cases in group B. The histomorphometry revealed a direct bone apposition at the interface of the bone graft (group A) at 11.6% of the surface. The surfaces of the spacers were osseointegrated in 1.1% in group B and 1.0% in group C. DISCUSSION: As the dislocation rate shows, the fixation of the new spacer (group C) seems to be less stable than the fixation of the bone graft or the spacer with the additional plate. Although the intervertebral fusion is comparable for all groups, the extent of the osseointegration is much higher for the bone graft than for the spacers. In conclusion, the bone graft may offer a much better long-term stability than do the spacers.

[Improvement of osseointegration of bio-inert ceramics by modification of the surface--results of an animal experiment]. / Verbesserung der knöchernen Integration bioinerter Keramiken durch Modifikation der Oberfläche--Ergebnisse eines Tierversuchs.

The aim of this experimental study was to screen different surface structures of alumina and zirconia ceramic implants for their osteointegration properties. Alumina and zirconia ceramic test implants having different surface structures (smooth, macro-structured, corundum-blasted, porous) were implanted in the femora of mini-pigs, and left in situ for 12 weeks. After removal, the implants were evaluated macroradiographically and histologically. The smooth and macro-structured ceramic surfaces showed virtually no bony ingrowth, neither in the cortical nor the cancellous bone areas. In contrast, a rough surface finish or a porous surface structure allowed extensive bony ingrowth. The osteointegration rates varied between 20.5% and 41.7% (cancellous bone), and between 26.0% and 52.8% (cortical bone). With regard to the development of ceramic implants for clinical use, for example in the field of total hip replacement, these data provide a basis for further, more comprehensive studies.

Interphase fluorescence in situ hybridization assay for the detection of 3q21 rearrangements in myeloid malignancies.

In myeloid malignancies, chromosome rearrangements involving band 3q21 are associated with a particularly poor prognosis of the disease. Their sensitive and unequivocal detection is therefore of great clinical importance. In this report, we describe the establishment of an interphase fluorescence in situ hybridization (FISH) assay that complements classical cytogenetic analysis in the diagnosis of such aberrations. PACs that map centromeric and telomeric of known 3q21 breakpoints were labeled with different fluorescent dyes, and the separation of the normally colocalizing signals was used as an indicator of the presence of a 3q21 rearrangement. Two cell lines and 10 primary samples from myeloid leukemia and myelodysplastic syndrome (MDS) patients with 3q21 rearrangements were investigated using the newly established method. The rate of false positivity was determined in 27 control samples from patients with various types of myeloid malignancies. In addition to providing a sensitive and rapid test for the detection of 3q21 aberrations, the interphase FISH assay yields preliminary information about the localization of individual breakpoints. Six of the 10 breakpoints in the patient samples map to an only recently described breakpoint cluster region (BCR) 60 kb centromeric of the originally reported 3q21 BCR. These findings may contribute to the understanding of the molecular basis of the clinical features associated with 3q21 rearrangements.

Mid-term results of the cementless CLS stem. A 7- to 11-year follow-up study.

Between 1986 and 1990, 335 primary total hip arthroplasty (THA) were performed using the cementless CLS stem. The mean age at surgery was 55.3 years. The retrospective study was performed at an average follow-up time of 8.9 years. A total of 232 patients (69.3%) underwent clinical and radiological examination, 33 patients (9.9%) were interviewed by telephone, and 9 stems (2.7%) had been replaced meanwhile. The mean Harris hip score was 91.7 points, and the mean Merle D'Aubigne score was 16.8 points. One stem had subsided during the first postoperative year. Ectopic ossifications classified as Brooker III were noted in 5.7%, with no Brooker IV being seen. Radiolucent lines were found in 43.5%, and 11% showed enlargement with time. Focal osteolyses were present in 36%, of which 24% progressed with time. At the latest follow-up, we did not find any stem loosening clinically or radiologically.

[Long-term results with the cement-free Spotorno CLS shaft]. / Langzeitergebnisse mit dem zementfreien CLS-Schaft von Spotorno.

This retrospective study reviews 298 sequential cementless CLS Spotorno stems, which achieved their primary fixation and bony in- or ongrowth predominantly in the metaphyseal region. The minimum follow-up was 10 years and the average follow-up 11.7 years (range 10-14). The mean age at surgery was 55.2 years (range 32.2-68.9). Of the patients, 76.2% (227 stems) were followed up: 172 patients (57.7%) underwent clinical and radiological examination and 52 patients (55 stems, 18.5%) were interviewed by telephone. Of 298 stems, 13 (4.4%) had been replaced in the mean time, only 6 stems (2.0%) because of an aseptic loosening. The evaluation included both clinical (Merle d'Aubigne and Harris hip score) and radiographic parameters (plain X-rays). The mean Merle d'Aubigne score was 16.7 points, and the mean Harris hip score was 94.3 points. Radiolucent lines were detected in 33.7%; 5.8% showed enlargement within the last 3 years. Focal osteolyses were present in 30.8% of patients; 2.9% had progressed within the last 3 years. At follow-up, one patient presented with new clinical and radiological evidence of aseptic stem loosening. The current study showed an aseptic loosening of the CLS stem in 2.3%, a good osseointegration and good functional score results in more than 90%. The primary fixation and bony in- or ongrowth predominantly in the metaphyseal region seems to achieve good clinical results. Wear is the main reason for the osteolytic changes. Frequent clinical and radiological follow-up is important to detect bone reactions and loosening of the stem.

[A new standard method for experimental for measuring cement coat strength in endoprosthesis implantation]. / Eine neue Standardmethode zur experimentellen Vermessung der Zementmantelstärke in der Endoprothetik.

The distribution of bone cement around an endoprosthesis influences its stability over the long term. We have developed a new method for the experimental measurement of the cement mantle thickness of an endoprosthesis. The use of this computer-aided procedure is described in a hip prosthesis. Transverse sections of a human femur containing a cemented stem were prepared, recorded with a CCD camera and the images fed into a computer. The image-processing software differentiated the metal and bone cement on the basis of the different colours. Radial lines were drawn from the calculated centre of gravity of the stem, and the cement thickness was measured automatically along these lines. In our experiment, the accuracy of the method was 0.2 mm. This method of measuring the thickness of the cement mantle is accurate, rapid and practical.

Detection of leukocytes in contact with the vessel wall from in vivo microscope recordings using a neural network.

Leukocytes play an important role in the host defense as they may travel from the blood stream into the tissue in reacting to inflammatory stimuli. The leukocyte-vessel wall interactions are studied in post capillary vessels by intravital video microscopy during in vivo animal experiments. Sequences of video images are obtained and digitized with a frame grabber. A method for automatic detection and characterization of leukocytes in the video images is developed. Individual leukocytes are detected using a neural network that is trained with synthetic leukocyte images generated using a novel stochastic model. This model makes it feasible to generate images of leukocytes with different shapes and sizes under various lighting conditions. Experiments indicate that neural networks trained with the synthetic leukocyte images perform better than networks trained with images of manually detected leukocytes. The best performing neural network trained with synthetic leukocyte images resulted in an 18% larger area under the ROC curve than the best performing neural network trained with manually detected leukocytes.

[Osseontegration of trial implants of carbon fiber reinforced plastics]. / Knöchernes Einwachsverhalten von Probekörpern aus kohlefaserverstärktem Kunststoff.

PROBLEM: To what extent are carbon fibre-reinforced plastics (CFRP) suitable as an osseous integration surface for implants? METHOD: CFRP test implants having a plexus-structured, rhombus-structured, and plexus-structured, hydroxyapatite surface were implanted in the femura of mini-plgs. Exposure time lasted 12 weeks. The implants were subjected to a macroradiological, a histological-histomorphometrical, and a fluorescence-microscopical evaluation. RESULTS: One half of the uncoated, plexus-structured implants were not osteointegrated, the other half displayed an osteointegration rate of 11.8% in the spongy area and 29.8% in the cortex layer. The HA-coated test implants showed an osteointegration of 29.5% in the spongiosa and 56.8% in the cortex layer. The rhombus-structured test implants had an osteointegration of 29.2% (spongiosa) and 46.2% (cortex layer). CONCLUSION: Compared to the osteointegration of metallic, especially titanium surfaces the CFRP surfaces tested by us fared worse, especially the uncoated, plexus-structured surfaces. For this reason we view very critically the use of carbon-fibre reinforced plastics together with the surfaces tested by us as osteointegrating surfaces.