Natural and hybrid immunity after SARS-CoV-2 infection in children and adolescents.

PURPOSE: In contrast to adults, immune protection against SARS-CoV-2 in children and adolescents with natural or hybrid immunity is still poorly understood. The aim of this study was to analyze different immune compartments in different age groups and whether humoral immune reactions correlate with a cellular immune response. METHODS: 72 children and adolescents with a preceding SARS-CoV-2 infection were recruited. 37 were vaccinated with an RNA vaccine (BNT162b2). Humoral immunity was analyzed 3-26 months (median 10 months) after infection by measuring Spike protein (S), nucleocapsid (NCP), and neutralizing antibodies (nAB). Cellular immunity was analyzed using a SARS-CoV-2-specific interferon-γ release assay (IGRA). RESULTS: All children and adolescents had S antibodies; titers were higher in those with hybrid immunity (14,900 BAU/ml vs. 2118 BAU/ml). NCP antibodies were detectable in > 90%. Neutralizing antibodies (nAB) were more frequently detected (90%) with higher titers (1914 RLU) in adolescents with hybrid immunity than in children with natural immunity (62.5%, 476 RLU). Children with natural immunity were less likely to have reactive IGRAs (43.8%) than adolescents with hybrid immunity (85%). The amount of interferon-γ released by T cells was comparable in natural and hybrid immunity. CONCLUSION: Spike antibodies are the most reliable markers to monitor an immune reaction against SARS-CoV-2. High antibody titers of spike antibodies and nAB correlated with cellular immunity, a phenomenon found only in adolescents with hybrid immunity. Hybrid immunity is associated with markedly higher antibody titers and a higher probability of a cellular immune response than a natural immunity.

Evaluation of a non-auditory neurocognitive test battery in hearing-impaired according to age.

PURPOSE: Due to the demographic shift, the number of older people suffering from hearing loss and from cognitive impairment increases. Both are closely related and hard to differentiate as most standard cognitive test batteries are auditory-based and hearing-impaired individuals perform worse also in non-auditory test batteries. Therefore, reference data for hearing-impaired are mandatory. METHODS: The computer-based battery ALAcog assesses multiple cognitive domains, such as attention, (delayed) memory, working memory, inhibition, processing speed, mental flexibility and verbal fluency. A data set of 201 bilaterally hearing-impaired subjects aged ≥ 50 (mean 66.6 (SD 9.07)) was analysed. The LMS method, estimated curves for the 10th, 25th, 50th, 75th and 90th percentile were calculated, and classified according to age, starting from the age of 50. RESULTS: Cognitive function shows a decline in all subtests as people age, except for verbal fluency, which remains almost stable over age. The greatest declines were seen in recall and delayed recall and in mental flexibility. Age and hearing ability did not correlate (p = 0.68). However, as people age, inter-subject variability of cognitive test results increases. This was especially the case for inhibition. Cognitive function was not correlated with hearing ability (each p ≥ 0.13). CONCLUSION: The present results make an approach to establish reference data for a comprehensive non-auditory test battery in a large sample of elderly hearing-impaired people which can be used as a simple tool to better contextualise cognitive performance beyond mean and median scores.

Pre-operative fluid bolus for improved haemodynamic stability during minor surgery: A prospectively randomized clinical trial.

BACKGROUND: Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction. METHODS: Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia. RESULTS: The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area. CONCLUSIONS: A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia.

Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft.

INTRODUCTION: MPFL reconstruction is widely and successfully used for treating patella instability, either as a standalone procedure or in combination. Although different techniques allow for MPFL reconstruction, the use of a free tendon graft is one of the most commonly used. The phenomenon of tunnel widening or tunnel enlargement is well described in ACL reconstruction, but so far only little effort has been put into evaluating this phenomenon after MPFL reconstruction. MATERIALS AND METHODS: Patients who received an MPFL reconstruction with a free gracilis tendon graft were identified by review of patient files. Additional clinical examination and magnetic resonance imaging were performed to assess tunnel enlargement and clinical outcome. RESULTS: Fifty-one knees of 49 patients (34 female, 17 male) with a mean follow-up of 3.0 ± 1.4 years were included in this study. Mean age at the time of surgery was 22.6 ± 8.5 years. Mean Tegner score decreased from preoperative 5.3 ± 2.0 to 4.0 ± 1.4 postoperative. Postoperative IKDC and Kujala scores were 74 ± 16 and 80 ± 15, respectively. Twenty-three patients showed a tunnel enlargement at follow-up examination. Of these 23 patients, 20 showed a tunnel that was positioned too proximal, whereas only 13 of the 28 patients showing no enlargement had a tunnel that was positioned too proximal (p = 0.0033). Interestingly, patients showing a tunnel enlargement at follow-up examination also showed significantly better Kujala (84 ± 12 vs. 75 ± 16; p = 0.03) and IKDC scores (80 ± 7 vs. 70 ± 19; p = 0.02) when compared to the non-enlarged group. CONCLUSION: Tunnel enlargement after MPFL reconstruction with a free gracilis tendon graft seems to be connected to mechanical overload due to a proximal malposition of the femoral tunnel. Interestingly, this did not influence clinical outcome as patients with tunnel enlargement showed better Kujala and IKDC scores.

Effects of standardized acoustic stimulation in premature infants: a randomized controlled trial.

OBJECTIVE: The objective of this study was to investigate the effects of recorded lullabies and taped maternal voice in premature infants. STUDY DESIGN: Sixty-two preterm infants in a stable condition with 30<37 weeks of gestation and <10 days of postnatal age were randomly assigned to hear (A) recorded lullabies or (B) taped maternal voice for 30 min each evening during 14 consecutive days or (C) receive no standardized acoustic stimulation (control group). Heart rate and respiratory rate were recorded daily before, during and after the intervention (A and B) or a comparable period with no intervention (C), whereas activity was measured on days 1, 7 and 14 of the intervention using accelerometers. RESULTS: Both interventions led to a significant decrease in heart rate and respiratory rate during and after the stimulation when compared with the control group. The changes were more pronounced in infants with higher gestational ages (P=0.001). Lower activity was measured during the intervention when compared with the control group (P<0.01). CONCLUSIONS: Standardized acoustic stimulation with recorded lullabies and taped maternal voice led to a decrease in heart rate and respiratory rate, and was associated with lower activity. Whether this indicates a reduced stress reaction needs to be investigated in further studies.

A pocket-sized hand held ultrasound system for intraoperative transthoracic echocardiography by anaesthesiologists: A feasibility study.

BACKGROUND: The intraoperative application of focused transthoracic echocardiography (TTE) is often considered to be restricted. Echocardiography with pocket-sized hand held ultrasound systems has been shown to be feasible in various settings. OBJECTIVE: The aim of this study was to investigate the feasibility of the intraoperative application of pocket-sized echocardiography and the comparison of its imaging quality and diagnostic reliability and variability with a standard ultrasound system. METHODS: After written informed consent, TTE was performed on 40 anaesthetised general, vascular, visceral, thoracic surgical and orthopaedic patients according to the FATE protocol: first, with a pocket-sized and second, with a high-end ultrasound system randomly by two anaesthetists. Imaging quality of four basic and three additional FATE views was rated on an established scale from 1 (impossible) to 5 (perfect). Successful TTE was defined, if one basic FATE views would be rated as grade 4 or 5 or alternatively two views as grade 3. Pathologic findings by both ultrasound devices were documented and imaging quality and pathologic findings were compared. RESULTS: All 40 patients presented acceptable imaging quality, resulting in a success rate of 1.0 (97.5%-CI 0.91-1, p= 0.015). The individual imaging ratings of each view were significantly lower with the pocket-sized system, but still showed acceptable imaging quality. With the high-end device more pathologic findings were detected (107 vs. 87), but none of the relevant or severe pathologies were overseen with the hand-held device. CONCLUSION: The application of a pocket-sized echocardiography device for focused intraoperative TTE is feasible and can appropriate be used for the initial evaluation of relevant pathologies in the operating theatre.

The relationship between initial closed reduction and the surgical reconstruction of the radiocarpal joint line in distal radial fractures.

INTRODUCTION: Whilst initial closed reduction followed by definitive open fixation is widely applied in the treatment of distal radial fractures, the effect of the closed reduction on the reconstruction of the articular surface remains unclear. Our research questions were: METHODS: Palmar tilt and radiocarpal inclination of 425 patients were measured at admission, following initial closed reduction and after surgical reconstruction. RESULTS: Closed reduction increased palmar tilt by 12.1° and radial inclination by 2.7°. Open surgical reduction further corrected palmar tilt by 17.88° and radial inclination by 3.5°. Whilst there was no association between postoperative palmar tilt and initially achieved closed reduction, a significant association between radial inclination following closed reduction and surgical fixation was found. CONCLUSION: Our retrospective study challenges the existence of a relationship between the initial closed reduction and the reconstruction of the anatomic joint line in surgically treated distal radial fractures.

Which factors influence MRI-pathology concordance of tumour size measurements in breast cancer?

OBJECTIVES: To assess MRI-pathology concordance and factors influencing tumour size measurement in breast cancer. MATERIALS AND METHODS: MRI tumour size (greatest diameter in anatomical planes (MRI-In-Plane) and greatest diameter along main tumour axis (MRI-MPR)) of 115 consecutive breast lesions (59 invasive lobular carcinoma, 46 invasive ductal carcinoma, and 10 ductal carcinoma in situ) was retrospectively compared to size measured at histopathology (pT size (Path-TNM) and greatest tumour diameter as relevant for excision (Path-Diameter; reference standard)). Histopathological tumour types, preoperative palpability, surgical management, additional high-risk lesions, and BI-RADS lesion type (mass versus non-mass enhancements) were assessed as possible influencing factors. RESULTS: Systematic errors were most pronounced between MRI-MPR and Path-TNM (7.1 mm, limits of agreement (LoA) [-21.7; 35.9]), and were lowest between MRI-In-Plane and Path-Diameter (0.2 mm, LoA [-19.7; 20.1]). Concordance rate of MRI-In-Plane with Path-Diameter was 86% (97/113), overestimation 9% (10/113) and underestimation 5% (6/113); BI-RADS mass lesions were overestimated in 7% (6/81) versus 41% (13/32) for non-mass enhancements. On multivariate analysis only BI-RADS lesion type significantly influenced MRI-pathology concordance (p < 0.001). 2/59 (3%) ILC did not enhance. CONCLUSION: Concordance rate varies according to the execution of MRI and histopathological measurements. Beyond this only non-mass enhancement significantly predicted discordance. KEY POINTS: • Execution and scope of MRI and histopathological size measurements influence concordance rate. • Non-mass like enhancement predicts discordance. • Additional high-risk lesions in proximity of tumour do not cause measurement discordance. • Low percentage of ILC do not enhance at all.

Focused intraoperative transthoracic echocardiography by anesthesiologists: a feasibility study.

BACKGROUND: Focused transthoracic echocardiography (TTE) is frequently used perioperatively for hemodynamic monitoring and diagnosis of cardiovascular instability, but less commonly intraoperatively. METHODS: To evaluate the feasibility of intraoperative TTE, we enrolled 222 anesthetised patients from August to November 2012 into a prospective observational study. 162 patients underwent TTE examination according to the Focused Assessed Transthoracic Echocardiography (FATE) protocol after positioning and draping for surgery. Sixty additional hemodynamically unstable subjects were examined during anesthesia and surgery. The imaging quality of four FATE views was rated on a scale from 1 (impossible) to 5 (perfect). TTE was assessed as applicable, if at least two of the four basic FATE views were graded 4 or 5, or three views were assessed as grade 3. RESULTS: Imaging quality was unacceptable in 20 patients, resulting in a feasibility rate of 91% (97.5%-CI 0.86-1, P=0.01). TTE was feasible in hemodynamically unstable subjects (91.7%; 97.5%-CI 0.82-1.0), in orthopedic and trauma patients (>95% respectively, [97.5%-CI 0.83-1]) and in abdominal surgery (78%). CONCLUSION: TTE can be applied in the operating theatre during surgery, although its use during abdominal surgery is somewhat limited.

Comorbid psychiatric disorders in female adolescents with first-onset anorexia nervosa.

OBJECTIVE: Patients with anorexia nervosa (AN) exhibit high rates of psychiatric comorbidity. To disentangle the effects of duration of illness on comorbid psychiatric symptoms, we investigated the rates of comorbid psychiatric disorders, suicidality and self-harm behaviour in adolescent patients with a first onset of AN. METHODS: In adolescent females (n = 148) with a first onset of AN, body mass index, psychiatric comorbidity (according to DSM-IV), depressive symptoms, suicidality and self-injurious behaviour were assessed. RESULTS: Seventy patients (47.3%) met the criteria for at least one comorbid psychiatric disorder. The binge-purging subtype was associated with increased rates of psychiatric comorbidity, suicidality and self-injurious behaviour. The severity of eating disorder-specific psychopathology influenced current psychiatric comorbidity and suicidal ideation. CONCLUSION: Prevalence rates of comorbid psychiatric disorders and suicidal ideation are considerably lower among adolescents with AN compared with adults. An early and careful assessment, along with adequate treatment of the eating disorder, might prevent the development of severe psychiatric comorbidities.

[Characteristics in treatment of the hip in patients with Down syndrome]. / Besonderheiten in der Behandlung des Hüftgelenks bei Kindern mit dem Down-Syndrom.

BACKGROUND: The treatment of hip instability in patients with Down syndrome is challenging. We have performed different pelvic osteotomies and corrections at the proximal femur for this indication. This retrospective study was conducted to evaluate the clinical and radiological outcome of each intervention. MATERIAL AND METHODS: All in all, 166 patients with Down syndrome were treated at our orthopaedic department in the observation period. Problems related to the hip joint were diagnosed in 63 of those patients. Only patients who underwent surgery were included in this study. The charts and X-rays of these 31 patients were evaluated with respect to the following parameters: incidence of the hip problem, concomitant diseases, temporal progress, kind of operation method and date, duration of stay in the hospital, after-care, follow-on surgery related to complications, AC angle, CE angle, ACM angle, CCD angle, index of migration according to Reimers, classification of Bauer and Kerschbauer and general morphology of the femoral head. The group was compared with an age-matched group of 21 patients with hip dysplasia. Those patients underwent the same sort of operation in the same year. RESULTS: In the Morbus Down group, we performed surgery for preservation of the hip in 49 cases. This included 13 osteotomies according to Chiari, 11 triple osteotomies according to Tönnis, 10 corrections by femoral varus derotation osteotomy, 8 pelvic osteotomies according to Pemberton, 5 pelvic osteotomies according to Salter and 2 open reductions of the hip. With respect to the moment of surgery, we detected three peaks of age. There was no difference in course of disease and quantity of complications between the groups. Satisfactory results concerning clinical and radiological outcome were achieved predominantly by complete redirectional acetabular osteotomies. Half of the patients who were solely treated by femoral varus derotation osteotomy needed follow-on surgery in the form of pelvic osteotomy. Comparison of preoperative and postoperative range of motion of the hip joint between groups detected capsular insufficiency, increased ligamentous laxity and muscular hypotonia in patients with Down syndrome. Comparison of pelvic radiographs demonstrated significant improvement concerning measured angles in both groups. Preoperative values with respect to AC angle and CE angle were demonstrated to be lower in the hip dysplasia group (p < 0.01); whereas values for ACM angle were comparable between groups. CONCLUSION: Hypermobility and secondary dislocation of the hip joint is a common problem in patients with Down syndrome, which often requires surgical intervention at an early stage. According to our data and clinical results we suggest a complete redirectional acetabular osteotomy in combination with capsular plication for treatment of this challenging condition.

Definition of DLPFC and M1 according to anatomical landmarks for navigated brain stimulation: inter-rater reliability, accuracy, and influence of gender and age.

The optimization of the targeting of a defined cortical region is a challenge in the current practice of transcranial magnetic stimulation (TMS). The dorsolateral prefrontal cortex (DLPFC) and the primary motor cortex (M1) are among the most usual TMS targets, particularly in its "therapeutic" application. This study describes a practical algorithm to determine the anatomical location of the DLPFC and M1 using a three-dimensional (3D) brain reconstruction provided by a TMS-dedicated navigation system from individual magnetic resonance imaging (MRI) data. The coordinates of the right and left DLPFC and M1 were determined in 50 normal brains (100 hemispheres) by five different investigators using a standardized procedure. Inter-rater reliability was good, with 95% limits of agreement ranging between 7 and 16 mm for the different coordinates. As expressed in the Talairach space and compared with anatomical or imaging data from the literature, the coordinates of the DLPFC defined by our algorithm corresponded to the junction between BA9 and BA46, while M1 coordinates corresponded to the posterior border of hand representation. Finally, we found an influence of gender and possibly of age on some coordinates on both rostrocaudal and dorsoventral axes. Our algorithm only requires a short training and can be used to provide a reliable targeting of DLPFC and M1 between various TMS investigators. This method, based on an image-guided navigation system using individual MRI data, should be helpful to a variety of TMS studies, especially to standardize the procedure of stimulation in multicenter "therapeutic" studies.

Comparison of metabolic profiles of acutely ill and short-term weight recovered patients with anorexia nervosa reveals alterations of 33 out of 163 metabolites.

Starvation represents an extreme physiological state and entails numerous endocrine and metabolic adaptations. The large-scale application of metabolomics to patients with acute anorexia nervosa (AN) should lead to the identification of state markers characteristic of starvation in general and of the starvation specifically associated with this eating disorder. Novel metabolomics technology has not yet been applied to this disorder. Using a targeted metabolomics approach, we analysed 163 metabolite concentrations in 29 patients with AN in the acute stage of starvation (T0) and after short-term weight recovery (T1). Of the 163 metabolites of the respective kit, 112 metabolites were quantified within restrictive quality control limits. We hypothesized that concentrations are different in patients in the acute stage of starvation (T0) and after weight gain (T1). Furthermore, we compared all 112 metabolite concentrations of patients at the two time points (T0, T1) with those of 16 age and gender matched healthy controls. Thirty-three of the metabolite serum levels were found significantly different between T0 and T1. At the acute stage of starvation (T0) serum concentrations of 90 metabolites differed significantly from those of healthy controls. Concentrations of controls mostly differed even more strongly from those of AN patients after short-term weight recovery than at the acute stage of starvation. We conclude that AN entails profound and longer lasting alterations of a large number of serum metabolites. Further studies are warranted to distinguish between state and trait related alterations and to establish diagnostic sensitivity and specificity of the thus altered metabolites.

Breast microcalcifications as type descriptors to stratify risk of malignancy: a systematic review and meta-analysis of 10665 cases with special focus on round/punctate microcalcifications.

PURPOSE: To use a systematic review and meta-analysis to determine the predictive value of five suspicious type descriptors of microcalcifications, with special focus on round/punctate microcalcifications because of controversy. MATERIALS AND METHODS: We performed a literature search using three databases and one search engine. We screened citations for malignancy rates of type descriptors. We regarded malignancy rates below 2% (BI-RADS 3) and above 95% (BI-RADS 5) as clinically significant threshold values for suspicion (BI-RADS 4). RESULTS: Forty studies from 14 countries with a total of 10,665 microcalcification lesions were included. The pooled malignancy rates were: coarse heterogeneous, 13% (95% confidence interval (95%-CI): 7 - 20%); amorphous or indistinct, 27% (95%-CI: 21-33%); pleomorphic, 50% (95%-CI: 43-58%); linear, 78% (95%-CI: 68 - 86%). The pooled malignancy rate of all round/punctate microcalcifications was 9% (95%-CI: 6-13%), for the subgroup follow-up it was 0,5% (95%-CI: 0.08-2.57%), and with histological verification it was 14% (95%-CI: 11-19%). Woman selection and consideration of additional suspicious image findings were reasons for between-study heterogeneity. Addition of ACR distribution descriptors diversified risk stratification, but did not alter BI-RADS assessment category. CONCLUSION: All suspicious type descriptors including round/punctate microcalcifications as well as combinations of type with suspicious distribution descriptors fell into BI-RADS assessment category 4. Exclusion of suspicious adjunct factors can direct clustered, round/punctate microcalcifications to a lower BI-RADS assessment category.

[Measurement on printed paper strips or on the ultrasound device with computer assistance - which technique is more accurate in paediatric hip ultrasound?]. / Ausmessung auf Papier oder computergestützt am Ultraschallgerät - Welches Verfahren ist genauer in der Sonografie der Säuglingshüfte?

AIM: Two different measurement techniques of ultrasonograms of the infant hip were evaluated with respect to reproducibility of the Graf classification and variation of α- and ß-angles. MATERIAL AND METHODS: In a cross-sectional, blinded study, the hips of 207 consecutive newborn babies (101 male; 106 female) were sonographically screened at an average of 2.64 days after birth. Each hip was measured twice by three investigators with different levels of experience - a paediatric orthopaedic surgeon, a senior surgeon and a trained medical student. A mobile ultrasound system (SONOLINE G60S®, Siemens, Erlangen, Germany), equipped with a 7.5 MHz linear transducer, was used. Both hip joints were measured twice by all three investigators. The measurement was performed 6-8 weeks later in a blinded manner. The sonograms were initially printed out on high-quality paper strips and measured by pencil, ruler and goniometer. Finally, each investigator evaluated the same sonograms computer-assisted, using the trackball and dashboard of the ultrasound system. RESULTS: Concerning intraobserver reliability, we observed a significant reduction of variation both for α- and ß-angles in favour of the classic measurement on printed strips (p < 0.05). The interobserver calculation also detected a trend for higher angle variation when the angles were measured electronically. The reproducibility of Graf classification was not influenced by the kind of measurement technique. The outcome was not affected by investigator's level of experience (p > 0.05). CONCLUSIONS: This study demonstrated considerable advantages for the classic measurement of paediatric hip ultrasonograms with pencil and goniometer on printed paper strips compared to computer-aided measurement concerning variation of α- and ß-angles.

[Current Diagnostics and Treatment of FAI in Germany]. / Aktueller Stand der Behandlung des FAI in Deutschland.

AIM: Femoroacetabular impingement (FAI) is a recently proposed mechanical concept for the development of osteoarthritis of the hip. Aim of this nationwide survey is the description of the current status of diagnostics and therapy of FAI in Germany. MATERIAL AND METHODS: All orthopedic and traumatological hospitals listed in the "list of German hospitals 2006" were invited via e-mail to take part in this anonymous survey. RESULTS: The questionnaire was answered by 682 departments (50.5 %). 98 (14.3 %) of these departments treated FAI in 2007. CONCLUSION: In Germany, diagnostics and treatment of FAI were performed inconsistently in a small number of specialized hospitals.

Screening for anorexia nervosa via measurement of serum leptin levels.

Due to their sub-normally low fat mass, leptin levels in patients with acute anorexia nervosa (AN) are well below reference levels for age and sex-matched controls. This hypoleptinemia entails endocrinological and behavioral characteristics observed in AN patients during starvation. We aimed to study the appropriateness of hypoleptinemia as a diagnostic marker for AN by assessing sensitivity, specificity and likelihood ratios for different referral serum leptin levels for predicting anorexia nervosa and healthy leanness. For prediction, we additionally generated a score based on a multivariate logistic model including body mass index (BMI; kg/m²) and leptin level. For this purpose, we measured leptin levels in 74 female patients with acute AN upon admission for inpatient or outpatient treatment. Adolescent and adult patients were recruited according to DSM-IV criteria from two multi-center studies. Additionally, leptin levels were measured in 65 female healthy, lean students. Mean serum leptin level was significantly decreased in patients with AN compared to underweight controls (0.87 ± 0.90 vs. 6.43 ± 3.55 µg/L, p < 0.001). Leptin predicted AN independently of BMI; we confirmed a cutoff value in the range of 2 µg/L as having both high specificity and sensitivity. Hypoleptinemia represents a state marker of acute AN and is useful for a laboratory-based diagnostic screening.

[Anterior shoulder instability--the current situation]. / Vordere Schulterinstabilität--Aktueller Stand.

AIM: The aim of the study was to survey the current state of the conservative and operative treatment of anterior shoulder instability and its rehabilitation in German hospitals. METHODS: A previously evaluated online questionnaire was sent out to all German hospitals with orthopaedic or trauma surgery departments. The Federal Statistical Office's hospital list was the basis for the selection of hospitals. The questions referred to the year 2007. The survey, including 3 reminders, was conducted over 3 months. The questionnaire consisted of 6 response categories: always (100%), almost always (99-81%), predominantly (80-51%), rarely (50-21%), almost never (20-1%) and never (0%). RESULTS: The response rate was 41% and 67% of these had carried out shoulder stabilisations. In total, 99.2% of the 67% were evaluable. The proportion of shoulder surgery was 8.4% of the total number of operations. Shoulder stabilisations represented 10.6% of these operations. A specialised shoulder department existed in 22.9%. Conservative treatment was carried out with an immobilisation of the arm "predominantly", "almost always" and "always" for internal rotation in 70.8% and in 23.4% for external rotation. The shoulders were "predominantly", "almost always" and "always" stabilised in an arthroscopic technique in 68.2% and in an open one in 31.8% of the clinics. With 92.9%, the Bankart repair was the most common operation. Shoulder instability was principally treated with the arthroscopic technique, regardless of the care level and department and is considered the best surgical technique. Physiotherapy was prescribed "always" and "almost always" in 99.3%. The rate of reluxation after conservative treatment was estimated at 35.5%, after operative open anterior shoulder stabilisation at 9.1% and after arthroscopic shoulder stabilization at 10.6%. Nevertheless, 49.4% of respondents expected the best results after arthroscopic treatment. Participants, who mainly applied the arthroscopic technique, expected a lower rate of reluxation in comparison to other techniques (p<0.001). CONCLUSION: The operative shoulder stabilisation is most frequently carried out as arthroscopic Bankart repair. A standardised, subsequent treatment is well established.

CD44: survival and metastasis in chondrosarcoma.

OBJECTIVE: Recent studies have shown abnormal expression of CD44s and some of its isoforms in many human malignancies, but little is known about the presence of CD44 in chondrosarcoma. In this study the expression of CD44s and two variant isoforms was evaluated. It was assumed that abnormalities in these receptor proteins may be associated with clinical outcome of the patients. METHOD: Thirty paraffin-embedded chondrosarcoma samples were immunostained with monoclonal antibodies for CD44s, CD44v5 and CD44v6. Two independent examiners who were unaware of the clinical status of the patients evaluated the immunohistochemical results. The percentage of CD44-positive cells was scored semiquantitatively. A rate of higher than 10% was considered as overexpression. RESULTS: Among the 30 patients (median age 50 years) there were 22 conventional chondrosarcomas, two dedifferentiated chondrosarcomas, two extraskeletal chondrosarcomas, and one periostal, mesenchymal, clear cell and myxoid chondrosarcoma each. In the immunochemistry staining overexpression (>10% of cells) of CD44s was shown in 56.7% (17 of 30), of CD44v5 in 43.3% (13 of 30) and of CD44v6 in 6.7% (two of 30) of the tumors. Four grade III chondrosarcomas (80%) and 10 (71.4%) grade II chondrosarcomas showed overexpression for CD44s, whereas CD44s was overexpressed in only three (27.3%) grade I chondrosarcomas. Cox regression suggests overexpression of CD44s to be an additional prognostic marker for chondroid bone tumors independent of grading and other covariates. CONCLUSIONS: Overexpression of CD44s correlated significantly with metastatic potential and with poorer survival in patients with chondrosarcoma. CD44s might be an independent additional marker, but small sample size remains to be considered.

Low-frequency rTMS of the vertex in the prophylactic treatment of migraine.

High-frequency repetitive transcranial magnetic stimulation (rTMS) increases and low-frequency rTMS decreases neural excitability. Clinically, rTMS shows beneficial effects in the treatment of neurological and psychiatric disorders. Furthermore, chronic and neuropathic pain has been shown to respond to rTMS treatment. A small pilot study revealed prophylactic effects of high-frequency rTMS in migraine. As there is evidence of neuronal hyperexcitability in migraine, we conducted a placebo-controlled, blinded study to evaluate the therapeutic effects of low-frequency rTMS in migraine. The primary end-point was defined as a reduction of migraine attacks compared with placebo, secondary outcomes were a reduction in the total number of days with headache, hours with headache, pain intensity and a decrease of analgesic intake for migraine. Twenty-seven migraineurs completed the study and were treated with rTMS on five consecutive days. For the verum group, two trains of 500 pulses with a frequency of 1 Hz were applied over vertex with a round coil. For the treatment of the placebo group, a figure-of-eight sham coil was used. A significant decrease of migraine attacks could be observed in the verum group. However, when comparing these effects with placebo, no significance was evident. The same was true concerning secondary outcome measures with regard to days with migraine and total hours with migraine. No effects were evident for pain intensity and use of analgesics. The rTMS treatment was tolerated well. rTMS stimulation over vertex with 1 Hz was not effective in migraine prophylaxis when compared with placebo. The positive effects regarding migraine attacks, days and total hours with migraine in the verum group are encouraging and indicate that further research on this topic is warranted.