A Novel Rodent Orthotopic Forelimb Transplantation Model That Allows for Reliable Assessment of Functional Recovery Resulting From Nerve Regeneration.

Improved nerve regeneration and functional outcomes would greatly enhance the utility of vascularized composite allotransplantation (VCA) such as hand and upper extremity transplantation. However, research aimed at achieving this goal has been limited by the lack of a functional VCA animal model. We have developed a novel rat midhumeral forelimb transplant model that allows for the characterization of upper extremity functional recovery following transplantation. At the final end point of 12 weeks, we found that animals with forelimb transplantation including median, ulnar and radial nerve coaptation demonstrated significantly improved grip strength and forelimb function as compared to forelimb transplantation without nerve approximation (grip strength: 1.71N ± 0.57 vs. no appreciable recovery; IBB scale: 2.6 ± 0.7? vs. 0.8 ± 0.40; p = 0.0005), and similar recovery to nerve transection-and-repair only (grip strength: 1.71N ± 0.57 vs. 2.03 ± 0.42.6; IBB scale: 2.6 ± 0.7 vs. 2.8 ± 0.8; p = ns). Moreover, all forelimb transplant animals with nerve coaptation displayed robust axonal regeneration with myelination and reduced flexor muscle atrophy when compared to forelimb transplant animals without nerve coaptation. In conclusion, this is the first VCA small-animal model that allows for reliable and reproducible measurement of behavioral functional recovery in addition to histologic evaluation of nerve regeneration and graft reinnervation.

[Methohexital for treatment of intracranial hypertension]. / Methohexital zur Therapie des erhöhten intrakraniellen Drucks.

BACKGROUND: Barbiturate coma therapy is a useful method to control increased intracranial pressure (ICP) in patients with severe brain damage if standard measures have failed to lower ICP. Pentobarbital (not available in Germany) and thiopental (in Germany only approved for induction of anesthesia) have frequently been used in patients with intracranial hypertension and the effects and side-effects are well-described. However, little is known about the effect of methohexital (the only barbiturate in Germany approved for maintaining anesthesia) in lowering increased ICP. Therefore, the effect of methohexital on ICP was studied in patients where standard measures had failed to control intracranial hypertension. METHOD: A retrospective observational study was carried out with the inclusion criteria of patient age ≥18 years and methohexital therapy for 12 h or more with ICP monitoring in place. Methohexital was administered following a standardized algorithm to patients for whom standard measures, such as deep anesthesia, normoventilation, cerebral perfusion pressure (CPP) >65 mmHg, osmotherapy, neurosurgical evacuation of mass lesions, had failed to lower ICP. Methohexital was used if the ICP had risen above 20-25 mmHg for more the 20-30 min and otherwise manageable causes for the ICP increase had been ruled out. Methohexital was given continuously in addition to standard analgesia and sedation in doses of 2-4-6 mg/kg body weight (BW), depending on the ICP lowering effect. The records of the patient data management system from the years 2008/2009 were used to compare the ICP and CPP before and during methohexital administration. For statistical analyses Student's t-test was applied for measured values and the χ(2)-test was applied for percentage values whereby p<0.05 was defined as being statistically significant. RESULTS: During the study period 36 patients required methohexital therapy and 30 fulfilled the inclusion criteria. In 26 out of 30 patients the data were complete and these 26 patients were included in the data analyses. Of the patients 6 (23%) died due to elevated intracranial hypertension and 20 patients (77%) survived. In all patients methohexital lowered the ICP from 25.2 mmHg (standard deviation, SD ±4.3 mmHg) to 19.8 mmHg (SD ±12.5 mmHg) within the first 24 h, this result closely failed to reach a level of significance. In the 20 survivors methohexital lowered the ICP from 25.88 mmHg (SD ±4.8 mmHg) to 14.25 mmHg (SD ±6.9 mmHg) within the first 24 h, which is statistically highly significant. In non-survivors the ICP had risen from 24 mmHg (SD ±2.6 mmHg) to 32 mmHg (SD ±16.3 mmHg) within the first 24 h despite all efforts. Due to the CPP driven volume and vasopressor therapy no significant changes in the CPP during methohexital administration were observed. No significant changes in brain temperature (as possible cause for the decrease of the ICP) were observed. Non-survivors received significantly more methohexital due to increased ICP and required significantly more vasopressor therapy to maintain a sufficient CPP. CONCLUSIONS: Methohexital showed a clear trend for decreasing ICP in patients with intracranial hypertension refractory to standard therapeutic measures. In survivors the effect was highly significant. Patients not responding to methohexital therapy seemed to have an unfavorable outcome.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]. / EUROCRINE®: Nebennierenoperationen 2015 bis 2019 ­ überraschende erste Ergebnisse.

BACKGROUND: Since 2015 operations performed in the field of endocrine surgery have been entered into the European registry EUROCRINE®. The aim of this analysis was a description of the current healthcare situation for adrenal surgery in a homogeneous healthcare environment corresponding to the German-speaking countries-or to the presence of the working group on surgical endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)-and to assess the adherence to current international treatment guidelines. METHODS: An analysis of the preoperative diagnostics, the applied operative techniques and the underlying histological entities was carried out for all operations on adrenal glands in Germany, Switzerland and Austria, which were registered in EUROCRINE® from 2015 to 2019. RESULTS: In the total of 21 participating hospitals from the German-speaking EUROCRINE® countries, 658 operations on adrenal glands were performed. In 90% of cases unilateral adrenalectomy was performed, in 3% bilateral adrenalectomy and in 7% other resection procedures. In 41% the main histological diagnosis was an adrenocortical adenoma. In 15% malignant entities were detected on final histology, including 6% adrenocortical carcinoma (ACC) and 8% metastases to the adrenal glands. 23% of the operations were performed for pheochromocytoma. This entity was primarily resected using minimally invasive approaches (82%), whereas minimally invasive techniques were applied in 28% for ACC and in 66% for metastases to the adrenal glands. CONCLUSION: Surprisingly, following adrenocortical adenoma and pheochromocytoma, the third most common histological entity was metastasis of different extra-adrenal primary tumors to the adrenal gland. Of the operations for ACC 28% were scheduled for minimally invasive techniques, but conversion to open surgery was necessary in 20%. The analysis revealed discrepancies between treatment reality and international guideline recommendations that raise questions, which will be addressed by an updated version of the EUROCRINE® module for the documentation of adrenal surgery.

[Medicolegal aspects in emergency medical care : Analysis of the frequency of advance health care directives and the influence on decision making in emergency medicine]. / Medizinrechtliche Aspekte bei der notärztlichen Versorgung : Analyse zur Häufigkeit von Patientenverfügungen und deren Einfluss auf notärztliche Entscheidungsprozesse.

BACKGROUND: Medical decisions in an emergency medical services (EMS) situation are always extremely time- critical and sensitive, potentially leading to medicolegal consequences. Advance health care directives (AHCDs) are crucial components in the patients' participative decision making. When a patient refuses resuscitation, and/or other life-extending treatments, emergency physicians face possible ethical, medical, and medicolegal conflicts. METHODS: As part of the RIMANO II Study [Risk Management Präklinische (prehospital) Notfallmedizin (emergency medicine)], all 18 "emergency physician bases" of the Berlin Fire Department were polled regarding the influence of AHCDs in regard to emergency medical decision making. The assessment was based on anonymous questionnaires. Furthermore, emergency medical suggestions for improvement of AHCDs were gathered. Descriptive statistics and qualitative methods were used for evaluation. RESULTS: A total of 112 responses from emergency physicians could be incorporated into the study. Anesthesiologists represented the largest group (n = 55, 49 %), followed by internists (n = 40, 36 %). The median length of experience in EMS was 7 years [interquartile range (IQR) 4-14 years]. Patients' "do not resuscitate" orders were obeyed in 78/112 cases (70 %, 95 % CI 69-78 %). In 49/112 cases (44 %, 95 % CI 34-53 %), the request to not be hospitalized was granted. The length of EMS experience, type of medical specialty, the number of EMS cases and ways in which AHCDs were handled were all contributing factors to the various emergency medical interventions. CONCLUSION: AHCDs appear to have an influence in the emergency medical decision process. However, it is presently unclear as to what a standardized and universally comprehensible AHCD should look like, in order to provide a framework that is both acceptable and necessary in a prehospital emergency medicine environment, ensuring medicolegal certainty for the parties involved.

Diagnostic procedures after completion of oral immunisation against classical swine fever in wild boar.

The purpose of this paper is to define diagnostic procedures for wild boar after the completion of oral immunisation against classical swine fever (CSF). Epidemiological analysis of CSF in wild boar in Germany demonstrated that it is vital to carry out virological investigations on all animals found dead, sick or involved in traffic accidents. In principle, this should ensure an effective and prompt diagnosis of CSF. In addition, a defined number of wild boar, especially young animals < or = 6 months old, should also be tested for CSF virus to guarantee a high confidence level in the virological monitoring. Which animals should be examined serologically depends on the age class investigated, the season in which vaccination was stopped and the period of time since completion of vaccination. Therefore, different serological procedures have been defined for different situations during the first three years after completion of oral immunisation.

Reduction in slippage with 11-cm Lap-Band and change of gastric banding technique.

BACKGROUND: Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band, and the long-term results of the re-operated patients. METHODS: Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band, and the PFT11 group (n=177) received the new 11-cm Lap-Band. Follow-up rate was 99%. RESULTS: Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion. CONCLUSION: Since the introduction of the PFT and the 11-cm Lap-Band, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

[Twelve years of laparoscopic cholecystectomy]. / Zwölf Jahre laparoskopische Cholezystektomie Ergebnisse einer prospektiven Studie von 4498 an einer Klinik durchgeführten Cholezystektomien.

UNLABELLED: We studied developments in indication, operation time, conversion rate, morbidity, and mortality from the beginning of laparoscopic cholecystectomy. Between 1990 and 2002 we prospectively evaluated 4498 patients undergoing cholecystectomy (CE), of whom 79% were treated laparoscopically (lap). In 6.6%, the procedure had to be converted from laparoscopic to open cholecystectomy (con), and 14% were performed open from the beginning (open). During the above time period, the rate of open CE decreased steadily (49% in 1990 to 7.2% in 2002). The average operation time of lap CE remained constant with an average of 74 min (range 20-330). The conversion rate decreased in spite of broader indication for lap CE in even more complicated gallstone diseases, from an initial 9.4% to 2.5%. Among intraoperative complications in lap and con, bile duct lesions remained constant with 5/3856 (0.1%), bleeding which led to conversion decreased from 1.9% to 0.3%, and the rate of gall bladder perforation increased from 12% to 20.5%. Thirty-day morbidity was 2% in lap CE, 5% in con, and 11.5% in open. The mortality was 0% in lap, 0.7% in con, and 1% in open. CONCLUSION: Since the introduction of laparoscopic cholecystectomy the indication for this minimal-invasive operation steadily increased, the conversion-rate decreased and the complication-rate could be held low. Even with fast laparoscopic experience 7% of all cholecystectomies are technically difficult and remain to be carried out primarily in an open technique. The laparoscopic cholecystectomy has become the gold standard in the therapy of gallstone disease.

A new form of Filgrastim with sustained duration in vivo and enhanced ability to mobilize PBPC in both mice and humans.

Granulocyte colony-stimulating factor (G-CSF) has proven effective in the prophylaxis of chemotherapy-induced neutropenia and as a mobilizer of peripheral blood progenitor cells. The longevity of G-CSF action is limited by its removal from the body by two mechanisms. The first is thought to be mediated via receptors (receptor mediated clearance [RMC]) predominantly on neutrophils, the second process is likely the result of renal clearance. With the intention of developing a novel form of Filgrastim (r-met HuG-CSF) with a sustained duration of action in vivo, a new derivative named SD/01 has been made by association of Filgrastim with poly(ethylene glycol). The desired properties of this new agent would include a prolonged duration of action sufficient to cover a complete single course of chemotherapy. SD/01 is shown here to sustain significantly elevated neutrophil counts in hematopoietically normal mice for 5 days. In neutropenic mice effects were noted for at least 9 days, accompanying a significant reduction in the duration of chemotherapy induced neutropenia. Normal human volunteers showed higher than baseline ANC for around 9 to 10 days after a single injection of SD/01. Data from these normal volunteers also indicate that mobilization of CD34+ cells and progenitors may occur in a more timely manner and to around the same absolute numbers as with repeated daily injections of unmodified Filgrastim. These data indicate that SD/01 represents an efficacious novel form of Filgrastim with actions sustained for between one and two weeks from a single injection.

A Genetic Mouse Model of Parkinson's Disease Shows Involuntary Movements and Increased Postsynaptic Sensitivity to Apomorphine.

Alpha-synuclein (SNCA) protein aggregation plays a causal role in Parkinson's disease (PD). The SNCA protein modulates neurotransmission via the SNAP receptor (SNARE) complex assembly and presynaptic vesicle trafficking. The striatal presynaptic dopamine deficit is alleviated by treatment with levodopa (L-DOPA), but postsynaptic plastic changes induced by this treatment lead to a development of involuntary movements (dyskinesia). While this process is currently modeled in rodents harboring neurotoxin-induced lesions of the nigrostriatal pathway, we have here explored the postsynaptic supersensitivity of dopamine receptor-mediated signaling in a genetic mouse model of early PD. To this end, we used mice with prion promoter-driven overexpression of A53T-SNCA in the nigrostriatal and corticostriatal projections. At a symptomatic age (18 months), mice were challenged with apomorphine (5 mg/kg s.c.) and examined using both behavioral and molecular assays. After the administration of apomorphine, A53T-transgenic mice showed more severe stereotypic and dystonic movements in comparison with wild-type controls. Molecular markers of extracellular signal-regulated kinase 1 and 2 (ERK1/2) phosphorylation and dephosphorylation, and Fos messenger RNA (mRNA), were examined in striatal tissue at 30 and 100 min after apomorphine injection. At 30 min, wild-type and transgenic mice showed a similar induction of phosphorylated ERK1/2, Dusp1, and Dusp6 mRNA (two MAPK phosphatases). At the same time point, Fos mRNA was induced more strongly in mutant mice than in wild-type controls. At 100 min after apomorphine treatment, the induction of both Fos, Dusp1, and Dusp6 mRNA was significantly larger in mutant mice than wild-type controls. At this time point, apomorphine caused a reduction in phospho-ERK1/2 levels specifically in the transgenic mice. Our results document for the first time a disturbance of ERK1/2 signaling regulation associated with apomorphine-induced involuntary movements in a genetic mouse model of synucleinopathy. This mouse model will be useful to identify novel therapeutic targets that can counteract abnormal dopamine-dependent striatal plasticity during both prodromal and manifest stages of PD.

Cbfa1 does not regulate RANKL gene activity in stromal/osteoblastic cells.

The rates of osteoblast and osteoclast formation are tightly balanced, possibly due to the requirement of mesenchymal osteoblast progenitors for osteoclastogenesis. Osteoblast differentiation requires the transcription factor Cbfa1, whereas osteoclastogenesis results from the interaction between receptor activator of NF kappa B ligand (RANKL), expressed on stromal/osteoblastic cells, and RANK, a surface receptor on hematopoietic precursors. A striking decrease in the number of osteoclasts in Cbfa1-deficient mice suggested that Cbfa1 might be involved in RANKL expression. To investigate this possibility and to elucidate the mechanisms regulating RANKL expression, we isolated the 5'-flanking region of the murine RANKL gene and found that it contains two potential binding sites for Cbfa1 (OSE2-like sites). Cbfa1 bound to either of these sites in gel shift assays and stimulated the activity of a chimeric promoter consisting of multimerized RANKL OSE2-like sites inserted upstream from a minimal thymidine kinase (tk) promoter in transient transfections. However, Cbfa1 cotransfection did not stimulate murine RANKL promoter-luciferase constructs. Further analysis revealed that removal of these sites from the RANKL promoter by either site-directed mutagenesis or 5'-deletion did not alter the basal activity of promoter-reporter constructs. Conditional expression of Cbfa1 in a stromal/osteoblastic cell line stimulated osteocalcin mRNA by fivefold, but had no significant effect on RANKL mRNA levels. Conversely, conditional expression of a dominant-negative form of Cbfa1 in the same cell line inhibited osteocalcin mRNA by threefold, but had no effect on RANKL mRNA. Although these results cannot rule out a novel function for Cbfa1 in RANKL expression, they demonstrate that Cbfa1 does not regulate RANKL gene activity in the same manner as known targets of this transcription factor, such as osteocalcin.

Veno-occlusive disease, nodular regenerative hyperplasia and hepatocellular carcinoma after azathioprine treatment in a patient with ulcerative colitis.

We report the case of a 66-year-old male with ulcerative colitis diagnosed in 1987, who had been treated with azathioprine (AZA) for the past two years (average dose about 1.6 mg/kg/day). In May 1999 he presented with painless jaundice, fatigue and recent weight loss. Cholestatic enzymes were elevated, alpha-fetoprotein was normal and hepatitis B/C serology negative. After diagnosis of veno-occlusive disease (VOD) and hepatocellular carcinoma (HCC) via biopsy, tumour resection was performed. The histology was typical for a well-differentiated HCC with trabecular and pseudoglandular structures. Neighbouring liver tissue was atrophic, with nodular regenerative hyperplasia (NRH), peliosis-like sinusoidal ectasias and intra-sinusoidal accumulation of blood, associated with peri-sinusoidal fibrosis. Although none of the well-established risk factors for HCC such as cirrhosis, hepatitis B/C, metabolic liver disease or toxins were present, this patient developed HCC. This and previous reports suggest that NRH and/or VOD associated with AZA represent a risk factor for HCC. AZA should therefore not only be stopped in patients with NRH/VOD but patients should also be screened for HCC.

Cystathionine gamma-lyase activity in the cephamycin C producer Streptomyces lactamdurans.

Extracts of the cephamycin C producer S. lactamdurans were found to possess cystathionine gamma-lyase activity (E.C. 4.4.1.1). This represents the first demonstration of this enzyme of the reverse transsulfuration pathway in a prokaryotic organism. A likely involvement of reverse transsulfuration in antibiotic synthesis is indicated by the fact that propargylglycine, a mechanism-based inhibitor of the gamma-lyase, is a strong inhibitor of cephamycin C production.

Can continuous intraoperative facial electromyography predict facial nerve function following cerebellopontine angle surgery?

Intraoperative cranial nerve monitoring has significantly improved the preservation of facial nerve function following surgery in the cerebellopontine angle (CPA). Facial electromyography (EMG) was performed in 60 patients during CPA surgery. Pairs of needle electrodes were placed subdermally in the orbicularis oris and orbicularis oculi muscles. The duration of facial EMG activity was noted. Facial EMG potentials occurring in response to mechanical or metabolic irritation of the corresponding nerve were made audible by a loudspeaker. Immediate (4-7 days after tumor excision) and late (6 months after surgery) facial nerve function was assessed on a modified House-Brackmann scale. Late facial nerve function was good (House-Brackmann 1-2) in 29 of 60 patients, fair (House-Brackmann 3-4) in 14, and poor (House-Brackmann 5-6) in 17. Postmanipulation facial EMG activity exceeding 5 minutes in 15 patients was associated with poor late function in five, fair function in six, and good function in four cases. Postmanipulation facial EMG activity of 2-5 minutes in 30 patients was associated with good late facial nerve function in 20, fair in eight, and poor in two. The loss of facial EMG activity observed in 10 patients was always followed by poor function. Facial nerve function was preserved postoperatively in all five patients in whom facial EMG activity lasted less than 2 minutes. Facial EMG is a sensitive method for identifying the facial nerve during surgery in the CPA. EMG bursts are a very reliable indicator of intraoperative facial nerve manipulation, but the duration of these bursts do not necessarily correlate with short- or long-term facial nerve function despite the fact that burst duration reflects the severity of mechanical aggression to the facial nerve.

[Oral immunization against classical swine fever (CSF) in the Federal State of Brandenburg from 1995 to 1997]. / Orale Immunisierung gegen die klassische Schweinepest (KSP) beim Schwarzwild im Land Brandenburg von 1995 bis 1997.

The first findings of classical swine fever in wild boar occurred in the rural district Ostprignitz-Ruppin of Brandenburg in March 1995. Up to this time the area was considered to be free of swine fever in domestic and wild boars. The swine fever cases were marked particularly by the occurence of dead games and clinically decreased individuals as well as by the involvement of young wild boars. (< 10 kg carcass weight). In Brandenburg, the eradication programme of classical swine fever was based on oral immunization with an attenuated type C vaccine (so called Dessauer wild boar lure) carried out within the frame of a field trial since 1995. The success of oral immunization was examined by the development of swine fever positive-findings within the swine fever endangered district and by the seroconversion in the entire vaccination area. Due to the oral immunization the classical swine fever prevalence decreased from 4.65% in March 1995 to 0.58% in December 1997. After the third immunization the seroconversion reached on average rates between 30% and 35%. The seroconversion increased with carcass weight and with number of subsequent immunization. During the investigation period the rate of seroconversion in wild boars up to 17 kg carcass weight was 13.2%, in wild boars from 18 to 28 kg carcass weight 23.1%, sub-adult wild boars from 29 to 56 kg carcass weight 33.2%, and the adult wild boars above 57 kg carcass weight 41.5%.

[Neurosurgical therapy of Parkinson disease. Deep brain stimulation]. / Neurochirurgische Therapie der Parkinson-Krankheit. Deep-Brain-Stimulation.

The introduction of continuous high frequency stimulation (deep brain stimulation) into functional neurosurgery has opened up new avenues in the treatment of Parkinson's disease. This new technique expands the therapeutic possibilities available to those patients in whom, over the years, the effectiveness of drug treatment has deteriorated, or severe side effects developed. In the individual case, the decision as to whether to operate is taken on the basis of interdisciplinary cooperation between the care-providing neurologist and the neurosurgeon specialized in this particular field.

[Enrolment of intensive care patients in clinical studies. Ethical, legal and organizational problems from an interdisciplinary point of view]. / Der Einschluss von Intensivpatienten in klinische Studien. Ethische, rechtliche und organisatorische Probleme aus interdisziplinärer Sicht.

Nowadays, most patients in hospital die in the intensive care unit from sepsis and multiple organ failure. Clinical research in this critically ill and vulnerable patient population bears a lot of ethical and legal problems; however, it remains a must in order to develop evidence-based diagnostic and therapeutic strategies for life-threatening diseases with special respect to limited health care resources. With regard to the Declaration of Helsinki, good clinical practice guidelines (GCP) from the European Medicines Agency (EMA) and the German medical drug law (AMG) this article discusses ethical and legal aspects of patient inclusion for clinical trials as well as incentives for appropriate patient recruitment from an interdisciplinary point of view.