A behavioral timing intervention upregulates striatal serotonergic markers and reduces impulsive action in adult male mice.

Many studies support the hypothesis that time-based interventions reduce impulsive behavior in rodents. However, few studies have directly assessed 1) how such interventions affect impulsive action rather than impulsive choice, 2) if intervention effects differ by sex, and 3) how time-based interventions affect neurochemistry in regions mediating decision-making and reward. Thus, we assessed how a fixed-interval (FI) intervention initiated during late adolescence and extending into adulthood affected dopaminergic and serotonergic analytes in the frontal cortex and striatum and subsequent impulsive action in adult male and female mice. Beginning on postnatal day (PND) 45, mice were either trained on a progressive series of FI schedules (FI 20, 40, & 60 s) or remained in the home cage. Following the intervention, increases in striatal serotonergic analytes were found in FI-exposed males and females (n = 8/sex/group) with few changes found in the frontal cortex. Impulsive action was assessed in the remaining mice (n = 10/sex/group) using a fixed-ratio waiting-for-reward (FR-wait) task in which completion of an FR-25 component initiated a "free" pellet component in which pellets were delivered at increasing intervals according to a fixed delay increment that varied across sessions. Responses reset the additive delay and initiated a new FR-25 component. FI-exposed males, but not females, showed fewer delay resets and no-wait resets relative to control mice. Importantly, FI-exposure did not affect discrimination reversal performance in either sex. These data suggest that time-based interventions may reduce impulsive action in addition to impulsive choice perhaps with increased male sensitivity. Additionally, time-based interventions appear to operate through striatal serotonergic augmentation.

[Reconstruction of the extensor apparatus with advanced structural defects in knee revision arthroplasty]. / Rekonstruktion des Streckapparates bei fortgeschrittenen Defekten in der Knierevisionsendoprothetik.

OBJECTIVE: Restoration of the extensor apparatus in the case of advanced tendon defects as part of revision total knee arthroplasty (TKA). Reconstruction and augmentation using vascularized gastrocnemius muscle and tendon. INDICATIONS: Advanced degeneration of the extensor apparatus (patella tendon; quadriceps tendon) with or without discontinuity, following revision arthroplasty. CONTRAINDICATIONS: Persistent infection or pending TKA revision. Damaged gastrocnemius or soleus muscle or Achilles tendon. SURGICAL TECHNIQUE: Extension of the surgical TKA-access medial-distally. Separation of the medial gastrocnemius muscle along the raphe and preparation of the distal tendon from the soleus portion. Transposition into the defect site, augmentation or reconstruction of the defect by double turn of the gastrocnemius tendon. The muscle belly serves to adequately cover the tendon as well as the ventral knee joint. Mesh coverage of the muscle. POSTOPERATIVE MANAGEMENT: Immobilization of the knee and ankle for 10 days until mesh graft healing. Stepwise increasing flection of the knee with 30°/60°/90° every 2 weeks. Total weight bearing with secured full extended knee, no weight bearing with flexed knee for 6 weeks. RESULTS: In 9 patients, 3 with complete rupture of the patellar tendon, 5 with destruction of the extensor apparatus, and 1 patient with rupture of the quadriceps tendon following TKA revision, good functional results were achieved with active extension of the knee joint and standing/gait stability 6 months after surgery.

[Minimally invasive lumbopelvic stabilization of sacral fracture and sacroiliac injury]. / Minimal-invasive lumbopelvine Stabilisierung bei Sakrumfraktur und Sprengung des Iliosakralgelenks.

OBJECTIVE: Rapid mobilization with full weight bearing by minimally invasive fixation of Os ilium to L5 in fractures of the sacrum and disruption of the sacroiliac joint (SIJ). INDICATIONS: Unstable injuries of the posterior pelvic ring in fractures of the sacrum and disruption of the SIJ. CONTRAINDICATIONS: Fracture of ilium and not injury related implants in the screw trajectory, neurological deficits regarding the fracture, decubitus in the area of surgical approach. SURGICAL TECHNIQUE: Minimally invasive screw placement in the pedicles of L5, access of ilium screw via the posterior superior iliac spine. Radiological display for the iliacal screw bearing trajectory in Os Ilium as a drop-shaped/triangle canal. Insert a Jamshidi needle orthograde in the beam path, change to guide wire and placement of iliacal screw after resection of the bone in the screw head area. Submuscular insertion of the longitudinal rods, in case of double-sided instrumentation similar procedure on the opposite side, reduction of the fracture and fixation of the rods to screws. POSTOPERATIVE MANAGEMENT: Postoperative mobilization with full weight bearing under physiotherapeutic guidance. RESULTS: Patients treated with lumbopelvic stabilization in our facility between 2012 and 2017 were identified via the hospital database and retrospectively evaluated. In 24 patients with median age of 60.1 years and a follow-up-time of 11.8 months, we found no implant displacement, infection and no wound healing problems. Full weight bearing was permitted in 21 of 24 cases, in 3 cases partial load bearing due to other injuries. Three patients reported moderate mechanical irritation of iliacal screws; 1 patient reported severe irritability with removal of the implants after bony healing of fracture 1 year postoperatively.

[Treatment-process analysis of orthopaedic trauma surgery patients at an outpatient setting in a university hospital]. / Prozessanalyse der ambulanten Behandlung unfallchirurgischer Patienten an einer universitären Poliklinik.

BACKGROUND: The cost pressure in a competitive environment forces hospitals and physicians to optimize clinical processes. In order to secure competitive advantages, a continuous evaluation of relevant processes is necessary. OBJECTIVE: Administrative and medical processes in a university outpatient department for orthopedics and traumatology were evaluated using the lean method in order to reduce patient waiting times. MATERIAL AND METHODS: Over a period of 2 weeks all patients who were treated in the department for orthopedic and trauma surgery on an outpatient basis were included in the assessment of the process. Personnel in the policlinic were prepared and trained to record times for appointments made by telephone, arrival time at the hospital, first contact, administrative procedure, first contact with the doctor, length of stay in the radiology and anesthesiology departments and completion of treatment. In addition, potential inefficiencies were identified through patient flow analysis and personal interviews with personnel in the administration and outpatient departments as well as residents and senior physicians. RESULTS: A total of 126 patients were enrolled in the study. The average length of stay of patients in the outpatient clinic was 144 min (range 30-371 min). A necessary imaging examination increased the length of stay by an average of 53 min and a necessary premedication by an average of 78 min compared to patients with no further consultations. CONCLUSION: By analyzing the pathways and times of patients, various reasons for waiting times in the university outpatient clinic could be shown. This study shows that a structured application of lean management and a dedicated analysis create added value for patients by reducing waiting times.

[Challenges of discharge management in geriatric traumatology : Example of an integrated orthogeriatric service]. / Herausforderungen des Entlassmanagements in der Alterstraumatologie : Beispiel einer integrierten traumatologisch-geriatrischen Komplexbehandlung.

BACKGROUND: Geriatric patients are currently responsible for almost one third of all emergency hospital admissions. An increase of 50% is expected in the next decade. This age redistribution poses new challenges for inpatient care and discharge management. The requirements of an orthopedic trauma surgery clinic in the care of this patient group can be clarified with the help of this first collaboratively created geriatric orthopedic trauma surgery complex treatment unit of a university hospital. OBJECTIVE: What influence do age and delirium have on discharge management, length of inpatient stay and discharge destination in a geriatric cohort? MATERIAL AND METHODS: All patients who received inpatient treatment as part of the orthopedic trauma surgery geriatric complex treatment (GKB) between May 2017 and December 2019 were evaluated. An analysis of the demographics, length of inpatient stay, discharge destinations and evaluation of the Barthel index collected on admission and discharge, the mini-mental state examination (MMSE) and the geriatric depression scale (GDS) were carried out. RESULTS: Out of 312 patients, 110 men and 193 women with a median age of 81 years, 77 patients (24.6%) showed delirium when enrolled in the GKB and 39 (12.5%) dementia. Older patients presented more often with delirium than younger people (p = 0.013), especially those aged 70-79 years (p = 0.037). Dementia patients suffered more frequently from postoperative delirium (p < 0.01). The mean hospital stay was 17.79 days (±4.6 days). The GKB was regularly completed in 60.7% of all cases and 39.3% patients dropped out early. Patients with delirium were discharged significantly less often into their own home but into short-term care or nursing homes (p = 0.038). A general correlation between delirium development and the discharge destination was noticeable (p = 0.004). CONCLUSION: Patients with dementia are more likely to develop delirium postoperatively, which leads to an increase in the length of inpatient stay, an increase in treatment costs and more work for the discharge management team. In addition, the discharge to the patients' home is impaired by delirium, which means that the growing need for places in short-term care and nursing homes also creates socioeconomic burdens.

[Process optimization in the operating room area]. / Prozessoptimierung im operativen Bereich.

BACKGROUND: The operating room (OR) accounts for the highest fraction of hospital costs and also has the largest proportion of revenue. Classical goals of optimizing OR efficiency are to increase the quality of treatment and economic success. As the reduction of qualified personnel as the largest cost factor was favored for many years, nowadays a shortage of nursing personnel is threatening the surgery departments in many German hospitals. OBJECTIVE: Which improvements are possible while the OR already suffers from restrictions? What are critical resources, what are the critical burdens and how can they be optimized? MATERIAL AND METHODS: An analysis of the OR organization of an orthopedic and traumatology department with reduced OR capacity due to a shortage of OR and anesthesia nursing personnel was performed. This was followed by the evaluation of possible alterations with the corresponding advantages and disadvantages. After selection and implementation, the qualitative and quantitative differences were examined before and after the alterations. RESULTS: Multifaceted problem areas could be identified. The establishment of a fast track OR with concentration of additional resources on many fast points in an OR instead of on a few complex cases was selected and implemented. The installation of a holding area for patients waiting for surgery eliminated transportation delays almost entirely. Alterations in the OR planning and capacity distribution reduced nocturnal operating times. Despite reduction of the OR capacity both the number of operations performed and the incision to suture times could be increased. CONCLUSION: Optimization of the processes in the OR is possible and necessary, despite the lack of personnel. Even only a few structural changes can eliminate bottlenecks, resulting in qualitative and quantitative improvements.

[Medical service providers as bottleneck in orthopedics and trauma surgery : Problems and solution strategies in interdisciplinary collaboration]. / Medizinische Dienstleister als Nadelöhr in Orthopädie und Unfallchirurgie : Probleme und Lösungsstrategien in der interdisziplinären Zusammenarbeit.

BACKGROUND: Due to limited financial and human resources, efficient planning of patient flows, operation preparations and perioperative diagnostics are of great importance. In the present study potential problems and solution strategies in the interdisciplinary collaboration between orthopedic surgeons, trauma surgeons and colleagues in anesthesiology and radiology departments are presented. MATERIAL AND METHODS: After implementation of a process management system, the data were collated and the number of patients, the utilization of external departments in the consultation, waiting times and patient adherence to appointments were analyzed. Patient satisfaction was determined using a questionnaire. In addition, the current literature was searched regarding the topic of process optimization and interdisciplinary cooperation. RESULTS: The waiting time for an appointment in the outpatient clinic consultation in orthopedics and trauma at the University Hospital Bonn was between 9.15 and 11.23 days. Of the patients 10-20% from the consultation presented in the premedication outpatient department. Radiological imaging was performed in 22-28% of the cases. Patient satisfaction was recorded using a questionnaire gathering information on medical treatment, organization and infrastructure as well as treatment success. The importance of an efficient and digitally organized cooperation is generally promoted in the literature; however, there is insufficient data on the subject of process organization and economic interdisciplinary cooperation. CONCLUSION: By implementing a process management, deficiencies in the workflow and interdisciplinary collaboration can be identified and optimized in a structured manner. This also improves patient and employee satisfaction and the quality of treatment.

[Ulnar-sided wrist pain in sports: TFCC lesions and fractures of the hook of the hamate bone as uncommon diagnosis]. / Ulnarer Handgelenkschmerz beim Schlagsport: TFCC-Läsionen und Frakturen des Hamulus ossis hamati als seltene Diagnosen.

Injuries to the hand and wrist are common sports injuries. The diagnosis and therapy of wrist injuries are becoming more important, especially in increasingly more popular ball-hitting sports, such as golf, tennis and baseball. Ulnar-sided wrist pain is initially often misdiagnosed and treated as tenosynovitis or tendinitis but tears of the triangular fibrocartilage complex (TFCC) and fractures of the hook of hamate bone, which can also occur in these sports are seldomly diagnosed. The aim of this study was to conduct a systematic review of the literature focussing on TFCC lesions and fractures of the hook of the hamate bone in racquet sports, baseball and golf. A systematic review of the literature was performed in PubMed on the occurrence of TFCC lesions and fractures of the hook of the hamate bone. All studies and case reports were included. Because of the rarity of these injuries there were no exclusion criteria concerning the number of cases. Injuries associated with ball-hitting sports, such as TFCC lesions and fractures of hook of the hamate bone are still underrepresented in the current literature on sports injuries. The diagnosis and treatment of these injuries are often delayed and can severely handicap the performance and career of affected professional as well as amateur athletes.

Real-time dosimetry reduces radiation exposure of orthopaedic surgeons.

BACKGROUND: Cancer prevalence of orthopaedic surgeons is elevated and chronic exposure to occupational ionizing radiation is seen as one reason. HYPOTHESIS: Use of a new dosimeter enabling radiation dose monitoring in real-time may reduce radiation exposure of orthopaedic surgeons. MATERIALS AND METHODS: Over a period of four months, the surgeon and the C-arm operator were equipped with a novel dosimeter called DoseAware(®) (DA) while using the C-arm fluoroscope intraoperatively. Data of 68 patients DA were retrospectively compared using matched-pair analysis with 68 controls without DA. Both groups were assessed regarding fluoroscopic time (FT) and radiation dose (RD). Seven types of operative procedures were performed: internal fixation of subcapital humerus fractures, midshaft clavicular fractures, distal radius fractures, pertrochanteric femoral fractures, ankle fractures, traumatic vertebral fractures and osteoporotic vertebral fractures. RESULTS: Concerning the FT, use of DoseAware(®) led to a significant reduction for all evaluated operation types except for internal fixation of distal radius fractures (P=0.0511). Regarding the RD, use of DoseAware(®) led to a significant reduction for all evaluated operation types except trochanteric femoral fractures with a PFNA(®) (P=0.0841). CONCLUSION: DoseAware(®) allowing real-time radiation dose monitoring reduces radiation exposure of the orthopaedic surgeon and instantly demonstrates the effects of dose-reduction techniques. LEVEL OF EVIDENCE: Level III retrospective case control study.

[Elastic titanium nails for minimally invasive intramedullary splinting of metacarpal fractures]. / Elastischer Titannagel zur minimalinvasiven Osteosynthese von Mittelhandfrakturen.

AIM: The goal in treatment of metacarpal fractures is to restore the normal function of the hand. Although a majority of these fractures can be treated non-operatively, surgery is recommended for displaced fractures and in case of a patient wish for primary stability for practise. A poor clinical outcome is described for metacarpal shortening of more than 5 millimeters and for rotational deformity. Whereas plate osteosynthesis may lead to soft tissue irritation involving tendon adhesions and scar formation, we have used the elastic stable intramedullary nailing [ESIN] technique using titanium elastic nails (TEN) for intramedullary splinting of short metacarpal shaft and neck fractures. METHOD: Within 5 years, ESIN was performed in 95 patients. The operative technique was evaluated retrospectively concerning its functional results and complications. RESULTS: Sixty-three patients were analysed after an average follow-up of 14.0 ± 5.2 weeks. The mean DASH-Score was 2.3 ± 3.9 points. We saw one implant out-of-position and three cases of skin irritation affording TEN shortening. Two superficial wound infections were treated conservatively. Pseudarthrosis and nail breakage were not observed. After TEN removal 9 ± 2.4 weeks post implantationem no refracture occurred. CONCLUSION: Minimally invasive intramedullary stabilisation of short metacarpal shaft and neck fractures with a TEN is a safe surgical technique and achieves primary stability for practise. It reliably leads to fracture healing and produces excellent functional results.

A CT-free, intra-operative planning and navigation system for minimally invasive anterior spinal surgery - an accuracy study.

OBJECTIVE: A comprehensive study was performed to evaluate the accuracy of a newly developed CT-free, intra-operative planning and navigation system for anterior spine surgery. MATERIALS AND METHODS: Instruments and an image intensifier were tracked using the SurgiGATE navigation system. A laboratory study was performed on 27 plastic vertebrae. Fiducial markers were implanted in the vertebrae for accuracy evaluation purposes, and a dynamic reference base was placed on the vertebrae to establish a patient coordinate system (P-COS). Two fluoroscopic images were used for intra-operative planning. The graft bed plan was recorded in P-COS, followed by surgical formation of the graft bed, which was visualized. To evaluate the accuracy, the vertebrae were scanned with CT, and the markers were used to calculate an accurate paired-point registered transformation between the CT coordinate system and P-COS. RESULTS: Using the new SPO module, accurate planning and navigation of a resection of the vertebral body is possible using two fluoroscopic images. The overall mean error between the planned resection volume and the actual resection was 0.98 mm. In addition, the module can serve as an educational tool for training spine surgeons. CONCLUSIONS: The new fluoroscopy-based system can be used safely for accurate performance of anterior resection during spondylodesis. New methods for safe and accurate registration during anterior spine surgery need to be developed.

Early detection of metastasis by alterations in the cellular immune system in the murine liver and blood.

We investigated the reaction of the cellular immune system of liver and blood in the C57BL/6 mouse to a metastasizing Lewis lung carcinoma. The cellular immune system of the liver consists of mature and immature macrophages, B-cells, T-cells including their subpopulations, and natural killer cells, and their percentage frequencies differ significantly from those in the corresponding mononuclear blood cell (MBC) compartment. This suggests that the hepatic immune cells represent a system with autonomous function showing a typical homing of its members. Imminent metastasis to the liver is signalled by impressive alterations in the percentage frequencies of nonparenchymal liver cells (NPLC). There are a dramatic loss of mature macrophages, an increase in immature macrophages, a reduction of T-helper cells leading to a low CD4/CD8 ratio, and an increase in natural killer cells. In the blood, the corresponding precursor cells show comparable changes with a delay of at least 2 days. Early metastasis is accompanied by a significant increase in mononuclear NPLC producing tumour necrosis factor alpha. The alterations in percentage frequencies of the NPLC during tumour metastasis differ markedly from the changes in these cells in the liver during endotoxinaemia.