Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities.

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

[Fibroblast growth factor (FGF) endocrines and pulmonary fibrogenesis]. / Fibroblast growth factors (FGFs) endocrines et fibrogenèse pulmonaire.

As key actors in embryogenesis and organogenesis, fibroblast growth factors (FGFs) can assume a protective or an aggravative role in pulmonary fibrosis pathophysiology. Among the FGFs, endocrine FGFs (FGF19, FGF21 and FGF23), are characterized by low affinity to FGF receptors (FGFRs), enabling them to deploy endocrine activity in several organs. More specifically, their anti-fibrotic role has been reported in liver, kidney or myocardial fibrosis. Endocrine FGFs are of growing interest on account of their potential anti-fibrotic role in pulmonary fibrogenesis, as well. In this review, we aim to summarize current knowledge on the protective effects of endocrine FGFs in pulmonary fibrosis.

Depressive traits are associated with a reduced effect of choice on intentional binding.

A sense of agency (SoA) over wilful actions is thought to be dependent on the level of choice and the nature of the outcome. In a preregistered study, we manipulated choice and valence of outcome to assess the relationship between SoA across the depression and psychosis continuum. Participants (N = 151) completed a Libet Clock task, in which they had either a free or forced choice to press one of two buttons and received either a rewarding or punishing outcome. Participants also completed questionnaires on depressive and psychosis-like traits. Rewarding outcomes increased intentional binding. The evidence favoured no effect of choice on average, but this was influenced by inter-individual differences. Individuals reporting more depressive traits had less of a difference in intentional binding between free and forced choice conditions. We show that implicit SoA is sensitive to outcome valence and the effect of choice differs across the depression continuum.

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study.

BACKGROUND: Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques. OBJECTIVES: To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements. METHODS: A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20 mL ethanol 90%, 100 mg lignocaine and 5 mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported. RESULTS: Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups. CONCLUSION: Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

Neurólisis del plexo celiaco intraoperatoria directa frente a percutánea guiada por tomografía computarizada en el cáncer de páncreas no operable: estudio aleatorizado, controlado y de no inferioridad / Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study

Antecedentes: Se ha utilizado la neurólisis del plexo celiaco (NPC) para controlar el dolor producido por el cáncer de páncreas (CP) y, a nuestro entender, no existe ningún estudio que compare las técnicas de NPC intraoperatoria y NPC guiada por tomografía computarizada (TC). Objetivos: Comparar los efectos de NPC intraoperatoria y NPC guiada por TC en el CP no operable en cuanto a intensidad del dolor y necesidad de analgésicos. Métodos: Se incluyó a un total de 90 pacientes en este estudio prospectivo, aleatorizado, abierto, controlado y de no inferioridad, en el que se excluyó o perdió a 20 pacientes durante el seguimiento. Se asignó aleatoriamente a los pacientes en el grupo de NPC intraoperatoria o el grupo de NPC guiada por TC. En ambos grupos se inyectó una mezcla de 20ml de etanol al 90%, 100mg de lidocaína y 5mg de dexametasona en cada lado de la aorta. Se registraron la escala visual analógica (EVA) y el consumo oral diario de tramadol los días 7.°, 14.°, 30.°, 60.°, 120.° y 180.° tras la intervención. Se reportó la presencia de cualquier complicación relacionada con la intervención. Resultados: La puntuación EVA media fue similar en ambos grupos de NPC intraoperatoria y NPC guiada por TC desde el 7.° al 180.° posteriores la intervención. El consumo medio diario de analgésico (miligramos de tramadol por vía oral) fue comparable en ambos grupos tras la intervención en los días 7.°(50 frente a 50), 14.°(50 frente a 50), 3.0°(50 frente a 50), 60.°(50 frente a 50), 120.°(100 frente a 75) y 180.° (100 frente a 100). La incidencia de diarrea, vómitos, hipotensión y dolor de espalda fue similar en ambos grupos. Conclusión: La NPC intraoperatoria no es inferior a la NPC guiada por TC, ya que la asociación de ambas técnicas a la reducción de la gravedad del dolor y a las necesidades de analgésicos fue similar.(AU)

Background: Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques. Objectives: To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements. Methods: A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20ml ethanol 90%, 100mg lignocaine and 5mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported. Results: Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups. Conclusion: Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.(AU)

Use of PET-CT in diagnostic workup of periprosthetic infection of hip and knee joints: significance in detecting additional infectious focus.

INTRODUCTION: The diagnosis and management of periprosthetic knee and hip infections as well as the identification and management of possible additional infectious foci is of great importance for successful therapy. This study analyses the importance of 18F deoxyglucose PET-CT (PET-CT) in the identification of additional infectious focus and subsequent impact on management of periprosthetic infection (PPI). MATERIAL AND METHODS: A retrospective analysis of the clinical data and findings in the period from January 2008 to December 2018 was carried out. One hundred and four patients with in-hospital treatment due to PPI of a hip or knee joint were identified and included in this study. All patients underwent a standardized clinical examination and further surgical and antibiotic therapy. The reevaluation of performed PET-CTs was specifically carried out with regard to the local PPI or detection of secondary foci. RESULTS: PET-CT successfully verified the PPI in 84.2% of the patients. A total of 78 possible additional foci were detected in PET-CT in 56 (53.8%) of the examined patients. Predilection sites for possible secondary foci were joints (42.3%), pulmonary (15.4%), ear-nose-throat (15.4%), spine (11.5%), and the musculocutaneous tissues (11.5%). Fifty-four positive PET-CT findings were confirmed clinically with need of additional adequate treatment. CONCLUSION: PET-CT is a valuable diagnostic tool to confirm periprosthetic joint infection. At the same time, the whole-body PET/CT may detect additional foci of infection with impact on subsequent treatment strategy. PET was of special value in detecting infections at distant locations far from the primary infected joint in significant number. These distant infection locations can be potential cause of a re-infection. This clearly reflects the need of their diagnosis.

Optogenetic stimulation of striatal patches modifies habit formation and inhibits dopamine release.

Habits are inflexible behaviors that develop after extensive repetition, and overreliance on habits is a hallmark of many pathological states. The striatum is involved in the transition from flexible to inflexible responding, and interspersed throughout the striatum are patches, or striosomes, which make up ~15% of the volume of the striatum relative to the surrounding matrix compartment. Previous studies have suggested that patches are necessary for normal habit formation, but it remains unknown exactly how patches contribute to habit formation and expression. Here, using optogenetics, we stimulated striatal patches in Sepw1-NP67 mice during variable interval training (VI60), which is used to establish habitual responding. We found that activation of patches at reward retrieval resulted in elevated responding during VI60 training by modifying the pattern of head entry and pressing. Further, this optogenetic manipulation reduced subsequent responding following reinforcer devaluation, suggesting modified habit formation. However, patch stimulation did not generally increase extinction rates during a subsequent extinction probe, but did result in a small 'extinction burst', further suggesting goal-directed behavior. On the other hand, this manipulation had no effect in omission trials, where mice had to withhold responses to obtain rewards. Finally, we utilized fast-scan cyclic voltammetry to investigate how patch activation modifies evoked striatal dopamine release and found that optogenetic activation of patch projections to the substantia nigra pars compacta (SNc) is sufficient to suppress dopamine release in the dorsal striatum. Overall, this work provides novel insight into the role of the patch compartment in habit formation, and provides a potential mechanism for how patches modify habitual behavior by exerting control over dopamine signaling.

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study. / Neurólisis del plexo celiaco intraoperatoria directa frente a percutánea guiada por tomografía computarizada en el cáncer de páncreas no operable: estudio aleatorizado, controlado y de no inferioridad.

BACKGROUND: Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques. OBJECTIVES: To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements. METHODS: A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20ml ethanol 90%, 100mg lignocaine and 5mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported. RESULTS: Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups. CONCLUSION: Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. MATERIALS AND METHODS: We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. RESULTS: Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36-62 years; range, 17-95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. CONCLUSIONS: Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

Middle Meningeal Artery Embolization Using Combined Particle Embolization and n-BCA with the Dextrose 5% in Water Push Technique for Chronic Subdural Hematomas: A Prospective Safety and Feasibility Study.

BACKGROUND AND PURPOSE: Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization. MATERIALS AND METHODS: We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume. RESULTS: A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post-middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume). CONCLUSIONS: Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.

[Informed consent for surgery: clearly regulated by the patient rights law-significant uncertainty among medical students : Legal analysis and inventory of over 2500 medical students in Berlin as part of the Progress Test Medicine]. / Chirurgische Aufklärung: Klar geregelt durch das Patientenrechtegesetz ­ deutliche Unsicherheit bei Medizinstudierenden : Rechtsanalyse und Bestandsaufnahme bei über 2500 Berliner Medizinstudierenden im Rahmen des Progress Test Medizin.

BACKGROUND: Obtaining informed consent is a challenging task and is part of the educational objectives in the German NKLM. Teaching formats are inconsistent and time-consuming, with little emphasis on legal aspects, although they have moved into the focus of attention since the implementation of patient rights laws and play an important role in legal proceedings. OBJECTIVES: The aim of this study was the evaluation of medical students' knowledge about the legal aspects of obtaining informed consent. A legal analysis was performed, and the patient rights laws were reviewed with reference to implications for undergraduate medical education. MATERIALS AND METHODS: After the analysis of laws and jurisdiction, multiple-choice questions regarding the legal aspects of obtaining informed consent were created and placed in the Progress Test Medicine (PTM). A statistical analysis of the results of Berlin medical students was performed descriptively. RESULTS: The answers of 2625 (winter semester 2018/19) and 2409 (summer semester 2019) medical students in Berlin were analyzed. The rate of students who answered the questions about the procedures requiring informed consent and adequate time for consideration increased over time but did not reach comparable values to all PTM questions. Questions about required content were answered correctly by 30 to 60% of the students, regardless of their level of training; we did not see an increase along with the time of study. CONCLUSION: In our study, we were able to show that medical students of all educational levels show tentativeness when it comes to the legal aspects of obtaining informed consent. Yet, the legal framework offers room for new teaching formats like "Co-Action", introduced in this paper for the first time, where students acquire informed consent while being supervised by the medical doctor in charge.

[Lung imaging in severe asthma]. / Imagerie de l'asthme sévère.

INTRODUCTION: Asthma is a common disease whose diagnosis does not typically rely on the results of imaging. However, chest CT has gained a key place over the last decade to support the management of patients with difficult to treat and severe asthma. STATE OF THE ART: Bronchial wall thickening and mild dilatation or narrowing of bronchial lumen are frequently observed on chest CT in people with asthma. Bronchial wall thickening is correlated to the degree of obstruction and to bronchial wall remodeling and inflammation. Diverse conditions which can mimic asthma should be recognized on CT, including endobronchial tumours, interstitial pneumonias, bronchiectasis and bronchiolitis. Ground-glass opacities and consolidation may be related to transient eosinophilic infiltrates, infection or an associated disease (vasculitis, chronic eosinophilic pneumonia). Hyperdense mucous plugging is highly specific for allergic bronchopulmonary aspergillosis. PERSPECTIVES: Airway morphometry, air trapping and quantitative analysis of ventilatory defects, with CT or MRI, can help to identify different morphological subgroups of patients with different functional or inflammatory characteristics. These imaging tools could emerge as new biomarkers for the evaluation of treatment response. CONCLUSION: Chest CT is indicated in people with severe asthma to search for additional or alternative diagnoses. Quantitative imaging may contribute to phenotyping this patient group.

Does the Time of Starting Progesterone Luteal Support Affect Embryo Transfer in Long Agonist Protocol Downregulated ICSI Cycles? A Randomized Controlled Trial.

The aim of this study was to compare the effects of starting progesterone (P4) luteal support (LS) on day of egg retrieval (ER) or day of embryo transfer (ET) on the ratio of difficult ET and cycle outcome. This was a RCT ( ClinicalTrials.gov Identifier: NCT03040830) carried out at Mansoura Integrated Fertility Center (MIFC), Mansoura, Egypt, from November 2015 to January 2017. A total of 171 eligible long agonist ICSI cases were randomly allocated on day of ER into group A (86) starting LS as daily IM 100 mg P4 on day of ER and group B (85) starting P4-LS on day of ET. Difficult ET was defined as blood on ET catheter and/or sounding or dilating the cervix. Primary outcome was the overall ratio of difficult ET and ratios on day 3 and 5 ET. Secondary outcome was the ongoing pregnancy rate (OPR) and implantation rate (IR). The results are presented as % for groups A and B respectively: overall difficult ET (44.1, 24.7) (p = 0.009); day 3 difficult ET (23.2, 24.4) (p = 0.45); day 5 difficult ET (62.7, 25.6) (p = 0.001); overall OPR (38.3, 44.7) (p = 0.43); day 3 ET OPR (41.8, 33.3) (p = 0.51); day 5 ET OPR (34.8, 57.5) (p = 0.048); overall IR (20.0, 22.5) (p = 0.62); day 3 ET IR (17.8, 13.4) (p = 0.44); day 5 ET IR (22, 34.1) (p = 0.09). In conclusion, starting P4 luteal support on egg retrieval day is associated with significantly higher ratio of difficult embryo transfer and lower ongoing pregnancy rate and tendency to lower IR in day 5 ET, so starting P4-LS on day of ET is recommended.

[Diagnostic difficulties of chronic pulmonary berylliosis in France]. / Difficultés diagnostiques de la bérylliose pulmonaire chronique en France.

INTRODUCTION: The epidemiology of chronic beryllium disease (CBD) in France is poorly understood. The aim of this study was to determine the number of prevalent cases of CBD in France between 2010 and 2014. METHODS: We conducted a national survey using a specific questionnaire distributed by the professional pathology services. RESULTS: In total, 33 CBD cases were reported in France, with a diagnosis established between 1982 and 2014. 85% (28/33) of CBD cases resulted from professional exposure and mostly concerned foundry workers (39%). A definite diagnosis defined by the association of an abnormal beryllium lymphocyte proliferation test and of a granulomatous inflammatory response in the lung, was obtained in 29/33 cases (88%). The other cases were probable CBD, defined by a granulomatous lung disease with a beryllium exposure, but without evidence of beryllium sensitisation. The diagnosis of granulomatous disease was confirmed a mean of 4 years after the end of exposure. The median delay between diagnosis of a granulomatous disease and diagnosis of CBD was 2 years (range 0-38 years). A genetic predisposition was found in 14 of 17 tested patients (82%). CONCLUSION: In this study, we report 33 cases of CBD followed in France between 2010 and 2014. The poor understanding of CBD and the exposure leading to it, the late development after the end of exposure, the complexity of the diagnosis and the similarities with sarcoidosis may explain the small number of cases reported.

A prospective follow-up study on the role of clinical pharmacists in sustainably optimized pain measurement and pain therapy consequences.

Appropriate analgesic therapy requires adequate pain measurement. A few studies have already demonstrated benefits of clinical pharmacists supporting physicians' prescribing. Nevertheless, there are still open questions about pharmaceutical interventions at the nursing level in order to optimise pain therapy sustainably. We performed a prospective controlled follow-up intervention study to analyse the sustainability of improved pain measurement performance (PMP) and its therapeutic consequences. Half a year after a successful guidance implementation in two study units (control and intervention unit), pharmacists performed an individual coaching for nurses only in the intervention unit. We consecutively monitored patient-nurse contacts and evaluated PMP with a 7-point scale (from 0: no pain measurement to 6: optimal pain measurement) in three 4-week periods (t1 : before guidance implementation, t2 : directly after guidance implementation, t3 : half a year after guidance implementation) on both units. Therapeutic consequences of PMP were evaluated in a post-hoc patient chart review. In the t1 period, we found a median PMP of 0 in both units which rose to 6 (control unit) vs. 5 (intervention unit) in t2 period due to guidance implementation in both units. In the t3 period, we found a decrease of PMP to 0 in controls vs. to 4 in the intervention unit (p<0.001). We also found, that improved PMP did not lead to a more individualised analgesic prescribing and administration of more on-demand analgesics. A coaching concept of clinical pharmacists improved the sustainability of nurses' PMP after a successful guidance implementation. Our results illustrate the potential of including clinical pharmacist in interprofessional pain therapy teams.

Intravascular (post-hysterectomy) leiomyoma (IVL) as late tumor thrombus within the inferior vena cava (IVC)-A rare case primarily imposing as IVC thrombus originating from left renal vein after former left nephrectomy status.

INTRODUCTION: Intravascular leiomyoma is a rare type of myoma. It was firstly described by Birch-Hirschfeld in 1896, however, its intracardiac subtype was firstly reported by Durck in 1907. Most patients are asymptomatic. The tumor invades mostly the tributaries of the inferior vena cava (IVC) with upward extension that may approach the intracardiac space. AIM: By means of a scientific case report, a patient with the very rare diagnosis of an endocaval leiomyoma thrombus post-hysterectomy is described based on the clinical experiences obtained in the specific case management and selective references from the literature. CASE PRESENTATION: A 48-years old female was diagnosed with intravascular tumor growth within the IVC with intracardiac extension using chest and abdominal CT scan, ECG and echocardiography which was approached by an interdisciplinary (vascular and cardiothoracic) surgical intervention (278 min) including heart-lung machine (99 min) with favorable postoperative result (R0 resection status with mid-term outcome, no recurrent tumor growth). Histopathological investigation diagnosed leiomyoma origin already from ovarian vein most likely in context to the former hysterectomy (3 years ago). DISCUSSION AND CONCLUSION: Intravascular leiomyoma is a benign tumor with invasive tendency, which can be considered a diagnostic and therapeutic challenge. It should be thoroughly investigated to be planned for a radical surgical removal. By possible adherence to the intraabdominal or -thoracic organs, an interdisciplinary and eventually step-wise surgical approach (combining vascular, abdominal, thoracic and heart surgery as well as gynecology and urology), which can be demanding, is recommended to be seriously considered to i) reliably achieve R0 resection status and, thus, ii) provide best outcome, quality of life and prognosis.

[Challenges of primary hip arthroplasty with high hip dislocation]. / Herausforderungen der primären Hüftendoprothetik bei hoher Hüftluxation.

BACKGROUND: Endoprosthetic care of high hip dislocation is a surgical challenge. The hip anatomy is greatly altered in these patients, including a rather flat and small acetabulum with impaired bone quality and a relevant chance of a bony defect of the acetabular roof. Additionally, the front coverage and in some cases even the dorsal coverage of the hip are missing. The proximal femur is characterized with an increased antetorsion, a coxa valga position and an enlarged greater trochanter. The medullary cavity is narrowed, the offset is reduced, and the absolut leg length can be enlarged. Further anatomic variations can have been caused by previous surgeries. AIM OF THE TREATMENT: The goal of the endoprosthetic care is the re-creation of a hip with an anatomic center of rotation, an anatomic offset and equal leg length. TREATMENT: This can be achieved by a medial shift of the acetabular cup. An acetabular osteotomy including central cancellous bone graft or a bony graft to reinforce the acetabular roof might be necessary. In cases in which an anatomic acetabular cup placement is not possible, a more cranial placement can be done. Further strategies that are essential in several cases are shortening or re-orientation osteotomies of the femur, reaming of the medullary cavity and correct implant selection. Additionally, thorough soft tissue management is of main importance. Generally, the surgery should be well prepared preoperatively.

[Hypersensitivity pneumonitis and abscess reaction to nontuberculous mycobacteria acquired form jacuzzi aerosol]. / Pneumopathie d'hypersensibilité à mycobactéries atypiques se compliquant d'un abcès à Mycobacterium intracellulare.

INTRODUCTION: Mycobacterium avium complex can be responsible for a number of different radio-clinical presentations, ranging from invasive infections to hypersensitivity pneumonitis due to repeated inhalation of antigens. The diagnosis of hypersensitivity pneumonitis is clinical, radiological, biological and microbiological. CASE REPORT: A 61-year-old male developed a hypersensitivity pneumonitis reaction to non-tuberculous mycobacteria, following the repeated use of his own spa, which later evolved into chronic respiratory failure. The diagnosis was made via an environmental analysis. Immunosuppressive treatment comprising corticosteroids and methotrexate led to moderate improvement, but may also have been responsible for the development of a M. intracellulare abscess. Despite 12 months of well-conducted antibiotic treatment, the evolution was unfavourable, with a relapse of a M. intracellulare infection three months after the end of treatment, followed by the patient's death. CONCLUSION: Hypersensitivity pneumonitis reaction to non-tuberculous mycobacteria should be considered in patients who have their own spa. In the absence of microbiological identification, environmental analysis may guide the diagnosis. A fatal evolution of PHS is infrequent but prognosis may depend on the degree of associated fibrosis.

Detection of APAF1 mutation in Holstein cows and mummified foetuses in Japanese dairy herds.

Some of the highest genetic merit sires have been shown to harbour recessive mutations affecting fertility, which may spread rapidly in the population through AI. These disorders may result in abortion and decline in pregnancy per insemination in cows. This study was carried out on 240 Holstein-Friesian cows and 15 mummified foetuses. Blood and tissue samples were collected from the cows and mummified foetuses, respectively, for DNA extraction. Allele-specific PCR was designed for the detection of the cows and foetuses carrying the nonsense mutation (C/T) in apoptosis peptide activating factor 1 gene (APAF1). The mutant allele frequency of the APAF1 in carrier cows and mummified foetuses was calculated. Milk samples were taken from the carrier and non-carrier cows for progesterone assay. The allele-specific PCR reaction efficiently distinguished the C/T mutation in APAF1. Of 240 cows, seven cows (2.9%) were diagnosed to carry one copy of the mutant allele of APAF1. However, the carrier frequency was 33.3% in mummified foetuses (five of 15). The mutant allele frequency was 0.02 and 0.17 in the cows and mummified foetuses, respectively. Concentrations of progesterone did not differ between cows with APAF1 mutation and non-carrier cows during 45 days post-insemination. This study provided allele-specific PCR for the detection of APAF1 mutation in cows. Moreover, it reports the carrier and mutant allele frequencies of APAF1 in dairy cows and mummified foetuses in Japan.

Thermomechanical method for cement extraction in revision arthroplasty.

BACKGROUND: In joint revision surgery, bone cement extraction remains a major challenge which even today has not seen a satisfactory solution yet. We studied in an experimental setting the impact of heat sources on the mechanical properties and microstructure of bone cement and determined the glass transition temperature (T G) of bone cement. As a result, it would be possible to establish a thermomechanical method which makes use of the structural and material-specific property changes inherent in bone cement at elevated temperatures. METHODS: Prepared samples of polymerized bone cement were thermoanalyzed with a Netzsch STA 409 C thermal analyzer. Samples weighing approx. 55 mg were heated to 390 °C at a rate of 5 K/min. Both simultaneous differential thermal analysis and thermogravimetry were employed. The thermomechanically induced changes in the microstructure of the material were analyzed with a computed tomography scanner specifically developed for materials testing (3D-µXCT). RESULTS: The bone cement changed from a firm elastic state over entropy-plastic (air atmosphere 60-155 °C) to a plastic viscosity state (air atmosphere >155 °C). Between 290 and 390 °C, the molten mass disintegrated (decomposition temperature). CONCLUSION: Our study was able to determine the glass transition temperature (T G) of bone cement which was about 60 and 65 °C under air and nitrogen, respectively. Heating the dry bone cement up to at least 65 °C would be more than halve the strength needed to detach it. Bone cement extraction would then be easy and swift.