[Innovations in medical compression therapy]. / Innovationen der medizinischen Kompressionstherapie.

For the treatment of phlebological and lymphological diseases as well as constitutional edema diseases, a discussion of innovative concepts of medical compression therapy is essential. It is recommended that medical compression stockings should always be prescribed based on symptoms and with the lowest effective interface pressure to optimize the tolerability of compression therapy. Likewise, medical compression stockings with an integrated care formula, but also the application of additional skincare can improve the quality of life and compliance in patients with chronic venous insufficiency. Optimization of ulcer therapy can be achieved by using two-component compression stocking systems. These consist of an understocking and a firm outer compression stocking, which improve the venous and capillary hemodynamics with good wearing comfort and lead to the healing of venous ulcerations. Multicomponent compression bandages and short stretch bandages are proven in the decongestion phase of edema. Multicomponent bandages ensure a sustained interface pressure for at least 5 days and are ideal for outpatient treatment with less frequent dressing changes. For compression therapy in patients with arterial-venous leg ulcers (ABI [ankle brachial index] >0.5), specially developed "lite" versions of the multicomponent dressings can be used.

Therapy of aseptic nonunions with parathyroid hormone.

The absence of osseous consolidation of a fracture for 9 or more months with no potential to heal is defined as nonunion. Both for the patient and from a socioeconomic point of view, nonunions represent a major problem. Hypertrophic, vital nonunions are distinguished from atrophic avital ones. Risk factors for a delayed fracture healing are insufficient immobilisation, poor adaptation of the fracture surfaces or residual instability, interposition of soft tissue within the fracture gap, as well as circulation disturbances and infections. The incidence of nonunions after fractures of the long bones lies between 2.6 and 16% depending on the surgical technique used. In human and animal studies, a positive effect of parathyroid hormone (PTH) on fracture healing has been shown. PTH has a direct stimulatory effect on osteoblasts and osteoclasts. In addition, it appears to influence the effect of osseous growth factors. In this prospective study, 32 patients with nonunions were treated with teriparatide to investigate the effects of PTH on fracture healing. Definitive healing of the nonunions following PTH treatment could be observed in 95% of the cases.

[Amendments to the Drinking Water Ordinance: Legionellae in Hot Water Systems - Data from the Public Health Authority Frankfurt am Main, Germany]. / Änderungen der Trinkwasserverordnung: Legionellen in Großanlagen - Erfahrungen aus dem Gesundheitsamt Frankfurt am Main.

BACKGROUND: The first and second amendment to the Drinking Water Ordinance came in to force in the years 2011 and 2012 causing additional tasks and responsibilities for operators of commercial large-scale systems, usually hot water systems in large residential buildings, and for the local health authorities. This article describes the experiences of the health authority in Frankfurt/Main with these new regulations. Some of the revisions in the first amendment of the ordinance (TrinkwV 2001 (2011)) were omitted in the second revision (TrinkwV 2001 (2012)) such as the obligation to notify for large-scale systems. Furthermore, the intervals between the obligatory inspections were extended from 1 to 3 years and merely exceedances of the legal limits were to be notified in contrast to the previous obligation to notify all values. RESULTS: On the basis of the TrinkwV 2001 (2011) a large additional staff requirement had been estimated (13/21 positions). After the TrinkwV 2001 (2012) the tasks can be accomplished by less than 2 employees. While the notification obligation was still in force, the health authority received 4,461 notifications of large-scale systems, since then a further 477 have been notified. Of a total of 1,335 initial analyses, 794 (60%) exceeded the technical action value and in 113 properties with values exceeding 10,000/100 ml a usage restriction was necessary. CONCLUSIONS: Due to the suspension of the notification obligation to report any result of the analyses performed the assessment of the reports on large-scale systems has become difficult. An appropriate assessment of the implementation of the regulation is not possible, since the total number of large-scale systems is not known and a failure to report may result from a measured value below the technical action value as well as from a not inspected system. The large number of usage restrictions is an indication for the necessity to inspect and if required to treat and restore the system.

[Unrepaired fracture of the styloid process of the ulna: not a bad treatment result at distal radius fracture]. / Unbehandelter Abriss des Processus styloideus ulnae: Kein schlechteres Behandlungsergebnis bei distaler Radiusfraktur.

BACKGROUND: There are well-defined criteria for the treatment of distal radius fractures but the impact of an unrepaired fracture of the styloid process of the ulnar on recovery after operative treatment is uncertain. This study evaluated radiological and functional results after different operative treatment procedures of distal radius fractures in patients with an untreated fracture of the styloid process of the ulna and those without such a fracture. METHODS: Out of 480 patients with operatively treated distal radius fractures 238 were examined at least 1 year after injury. The fracture of the styloid process of the ulna was not repaired. Three groups (patients without a fracture of the styloid process of the ulna, patients with a tip fracture and those with a basal fracture) were evaluated by multivariate analysis (MANOVA) in order to detect influences of the fracture of the styloid process of the ulna on the radiological and functional results. RESULTS: Neither the existence nor the location of the fracture of the styloid process of the ulna had a significant effect on the radiological and functional results (p(function)=0,849, p(radiology)=0,330, p(scores)=0,426, MANOVA). CONCLUSIONS: The repair of a fracture of the styloid process of the ulna is not necessary if reduction and fixation of the distal radius fracture is anatomical and stable.

The size and internal structure of a heterochromatic block determine its ability to induce position effect variegation in Drosophila melanogaster.

In the In(1LR)pn2a rearrangement, the 1A-2E euchromatic segment is transposed to the vicinity of X heterochromatin (Xh), resulting in position effect variegation (PEV) of the genes in the 2BE region. Practically the whole X-linked heterochromatin is situated adjacent to variegated euchromatic genes. Secondary rearrangements showing weakening or reversion of PEV were obtained by irradiation of the In(1LR)pn2a. These rearrangements demonstrate a positive correlation between the strength of PEV of the wapl locus and the sizes of the adjacent heterochromatic blocks carrying the centromere. The smallest PEV-inducing fragment consists of a block corresponding to approximately 10% of Xh and containing the entire XR, the centromere, and a very proximal portion of XL heterochromatin. Heterochromatic blocks retaining the entire XR near the 2E region, but lacking the centromere, show no PEV. Reversion of PEV was also observed as a result of an internal rearrangement of the Xh blocks where the centromere is moved away from the eu-heterochromatin boundary but the amount of X heterochromatin remaining adjacent to 2E is unchanged. We propose a primary role of the X pericentromeric region in PEV induction and an enhancing effect of the other blocks, positively correlated with their size.

Isochromosome Xq in Klinefelter syndrome: report of 7 new cases.

In this collaborative study we report on 2 prenatally and 5 postnatally diagnosed cases with a 47,X,i(Xq),Y chromosomal constitution. Excepting tall stature, the 5 adult patients showed all typical manifestations of Klinefelter syndrome. Taken together with previously reported cases, these data suggest that Klinefelter syndrome with isochromosome Xq has a favorable prognosis with normal mental development, and with normal-to-short stature. The prevalence of this Klinefelter variant is calculated to be between 0.3-0.9% in males with X chromosome polysomies.

5-HT1B receptor knockout, but not 5-HT1A receptor knockout mice, show reduced startle reactivity and footshock-induced sensitization, as measured with the acoustic startle response.

To investigate whether the hyperreactivity to mild environmental and novel stimuli in 5-HT1B receptor knockout (1BKO) mice, as suggested by measures of exploratory, aggressive, and impulsive behaviors, can be extended to phasic stimuli, 1BKO and wildtype mice were tested in acoustic startle reactivity and plasticity paradigms, including habituation, prepulse inhibition, and footshock-induced sensitization of the startle response. Furthermore, we compared 5-HT1A receptor knockout (1AKO) and 1BKO mice to further test the suggested opposite behavioral profiles in these two genotypes. Results show that startle reactivity and footshock-induced sensitization was reduced in 1BKO mice, with no changes in habituation or PPI. In contrast, 1AKO mice did not differ from WT mice in any of the measures. These results indicate that an absence of 5-HT1B receptors, but not of 5-HT1A receptors, affects the modulation of startle reactivity and footshock-induced sensitization, without influencing startle plasticity. Moreover, this study suggests that 1AKO mice display a distinct, but not opposite behavioral profile from 1BKO mice. Furthermore, it is concluded that the hyperreactivity in 1BKO mice cannot be generalized to all stimuli, including the startling stimuli used in this study, but is probably restricted to mild environmental stimuli only.

[Transposition of the extensor indicis tendon in reconstruction of thumb extension after rupture of the extensor pollicis longus tendon]. / Die Transposition der Sehne des Extensor indicis zur Wiederherstellung der Daumenstreckung nach Ruptur der Sehne des Extensor pollicis longus.

During a period of 13 years we performed 56 extensor indicis proprius (EIP) transpositions for reconstruction of the ruptured or severed extensor pollicis longus tendon. The open injuries (n = 9) involved failed primary repair or untreated tendon injuries. The subcutaneous ruptures occurred after distal radius fractures (n = 17) or other closed injuries of the wrist (n = 10), without trauma in 14 patients and in 6 patients by rheumatoid synovialitis or collagenosis. 35 patients returned for follow-up examination 8 months to 10.5 years after operation. According to the evaluation scheme suggested by Geldmacher et al. we report 13 excellent, 19 good and 3 satisfactory results. Although several authors prefer EPL reconstruction with an intercalated tendon graft, we recommend the EIP transposition as a simple procedure with predictable satisfactory results.

[Replantation at lower leg level]. / Replantation auf Unterschenkelhöhe.

INTRODUCTION: Replantation in reconstructive surgery is an established procedure due to microsurgical techniques. It can be routinely performed in unilateral lower leg amputation. In some cases of bilateral amputation, in which orthotopic replantation is not possible due to the complex trauma, heterotopic replantation is a therapeutic option. This avoids prosthetic fitting. METHODS: We report five cases of orthotopic and two of heterotopic lower limb replantations. Functional outcome concerning sensibility, mobility, pain, and aesthetic result were assessed clinically and using a questionnaire. RESULTS: Functional outcome and patient satisfaction were good. The psychological situation of the patients as well as mobility and stability of the replanted limbs were satisfying. Heterotopically replanted patients found the replanted legs superior to the prostheses. CONCLUSIONS: We conclude that, in lower leg amputation, attempts should be made to replant the extremity. In bilateral lower leg amputations, at least one limb should be reconstructed, even if "only" a heterotopic replantation can be performed.

[Reliability and responsiveness of the German version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH)]. / Reliabilität und Veränderungssensitivität der deutschen Version des Fragebogens Arm, Schulter und Hand (DASH).

BACKGROUND: Whilst there are some studies which have focussed on the validity and also others partially on the reliability of the German version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), studies regarding test-retest reliability and responsiveness do not exist. The purpose of this study was to analyse these two meaningful properties of the officially approved German version of the DASH. METHODS: Of 101 consecutive patients with distal radius fractures, 72 were followed prospectively at three time intervals. To evaluate the reliability, internal consistency (Cronbach's alpha) and correlation between the DASH points from the 12- and 13-week examinations (Spearman's correlation coefficient and intra-class coefficient) were calculated. Responsiveness was assessed using the parameters change score, standardised effect size and standardised response mean. These values were compared with the same values obtained from the traditional measures of grip strength and range of motion. RESULTS: Internal consistency and test-retest reliability of the DASH were excellent (Cronbach's alpha >0.95, Spearman's correlation coefficient r=0.912, ICC=0.945). Responsiveness of the DASH was moderate (change score=8.93, SRM=0.55, SES=0.41). Responsiveness of the ROM deficit and grip strength were larger than that for data from the DASH. CONCLUSION: The German DASH is a reliable and responsive measure. It can detect changes in disabilities over time in patients with distal radius fractures. Traditional impairment measures reflect important functional aspects and should be included in clinical outcome evaluation.

[Value of a combined ossification prophylaxis with indomethacin and radiotherapy for acetabular fractures]. / Wertigkeit einer kombinierten Ossifikationsprophylaxe mit Indometacin und Bestrahlung bei Azetabulumfrakturen.

BACKGROUND: Heterotopic ossification is a complication in patients with surgically treated acetabular fractures. The incidence is related to the surgical approach (extended iliofemoral, posterior or a combined approach). The objective of this study was to evaluate the incidence of heterotopic ossification in patients with acetabular fractures who received a combined prophylaxis with both a single dose of radiation and indomethacin compared to those who received only a prophylaxis with radiation or indomethacin. PATIENTS AND METHODS: A total of 24 patients with a combined prophylaxis after surgery were examined retrospectively 24 months after trauma. A systematic literature review was performed and our own results were compared with different methods for prophylaxis of heterotopic ossification from the literature. RESULTS: Only one patient developed a heterotopic ossification. In accordance with the literature, combined prophylaxis showed the least incidence of ossification compared to the other methods. Differences in incidence frequencies were significant between the different prophylaxis methods. CONCLUSION: A combined prophylaxis for heterotopic ossification in surgically treated acetabular fractures seems to be a better alternative than a prophylaxis with radiation or indomethacin alone.

Prolonged moderate-intensity exercise without and with L-carnitine supplementation in patients with MCAD deficiency.

Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is probably the most common inborn error of fatty acid oxidation (FAO). Routine L-carnitine supplementation in the treatment of MCADD is controversial. To establish the effects of L-carnitine supplementation during prolonged moderate-intensity exercise in MCADD, five patients and three control subjects were studied during 2 hours of moderate-intensity exercise after a 12-hour fast. Patients were studied twice, once with and once without L-carnitine supplementation (50 mg/kg per day). Blood samples were collected before, during and after exercise, and analysed for routine parameters, acylcarnitines and carnitine biosynthesis intermediates. Urine was collected before and after exercise, and analysed for acylcarnitines. All patients were able to complete the exercise test without any apparent clinical or biochemical adverse effects, even without L-carnitine supplementation. A significant rise in plasma free fatty acids and octanoylcarnitine levels during exercise was seen in all patients, indicating a substantial increase in FAO during exercise. Octanoylcarnitine levels in plasma were significantly higher in patients with L-carnitine supplementation, suggesting increased clearance of accumulating acylcarnitines. A statistically significant increase of plasma and urinary free carnitine levels, as well as of plasma gamma-butyrobetaine was seen in MCADD patients without L-carnitine supplementation. These data suggest an increase in carnitine biosynthesis. In conclusion, although L-carnitine supplementation may promote clearance of accumulating acylcarnitines during moderate-intensity exercise, no apparent beneficial effect of this supplementation on clinical and biochemical parameters was observed in MCADD patients. Our results suggest that MCADD patients are able to increase carnitine biosynthesis during exercise to compensate for carnitine losses.

[Differential treatment of diaphyseal humerus fractures]. / Differenzierte Behandlung der Humerusdiaphysenfrakturen.

The evaluation of 174 humeral shaft fractures treated operatively in our institution and a literature review are used to illustrate the indications for operative treatment. For some indications, the authors prefer Hackethal's bundle nails. A simple operative technique and a small approach incision far distant from the fracture site, which prevents the fracture hematoma, and the very low complication rate are the advantages of this method, making it an alternative to plating and even to bracing. Operative treatment is clearly indicated for compound fractures grades II and III. As the humerus--unlike the tibia--has a good soft tissue envelope, plating can be carried out without the danger of insufficient soft tissue coverage. Complete radial palsy is also an indication for primary operative nerve revision, followed by stable osteosynthesis, preferably with plate. In our series primary radial palsies were observed in 47 (27%) of cases; on revision we found 5 cases of nerve division and 2 of impingement between fragments. Further absolute indications are the rare injuries to the brachial artery, bilateral fractures, and combination with a forearm fracture ("floating elbow"). Closed fractures without concomitant injuries can generally be managed conservatively. We have treated 84 of these fractures with Hackethal's nails. The only serious complications were one non-union (1.2%) and one deep infection (1.2%).

[Pseudarthrosis of an occult fracture in zone III of the sacrum]. / Pseudarthrose nach okkulter Längsfraktur in Zone III des Sakrums.

Fractures in the midline of the sacrum are rare, a pseudarthrosis has not been described previously. We report about a 53-year-old woman with a midline fracture of the sacrum which has not been recognized, although there were indirect fracture signs on the native x-rays and a CT was performed. The surgical treatment with sacral compression bars was successful and pseudarthrosis healing resulted but the patient continued to have mild low back pain. The case reported here confirms that low back pain may caused by pathologic changes of the posterior part of the pelvis. The unusual fracture location could be caused by a bifid spinous process.

[Cytogenetic paternity test in father-daughter incest (case report) (author's transl)]. / Zytogenetischer Paternitätsnachweis bei Vater-Tochter-Inzest.

Cytogenetic test for paternity proved superior to serological tests in a case in which possible father-daughter incest was to be proven or disproven. Of seven fetal chromosomal markers three were derived from the putative father, two from the mother and two paternal markers were present in both fetus and mother as a consequence of the incest. The fetus was homozygous for a paternal marker on chromosome 22.

[Extremely high alpha-fetoprotein levels in a puncture specimen with few cells following amniocentesis and interpretation by sonography]. / Extrem hoher Alpha-Fetoproteinspiegel in einem zellarmen Punktat nach Amniozentese und Klärung durch Sonographie.

We report on a prenatal diagnosis with high alpha-fetoprotein level and a positive acetylcholinesterase activity in a presumptive amniotic fluid. Ultrasonographic examinations revealed a hydropic fetus with a nuchal cystic hygroma. Chromosome analysis of the aborted foetus ascertained the suspected Turner syndrome. The highly elevated alpha-fetoprotein concentration and the positive acetylcholinesterase activity as well as the absence of the cells in the fluid make it clear, that the punctate originated from a cystic hygroma. Other cases from the literature are discussed.

Ring chromosome 15 in a male adult with radial defects. Evaluation of the phenotype.

A case of a 37-year-old male patient with r(15) is reported. At birth he was small and light for dates. His main features are: short stature, head circumference in the lower normal range, mid-facial hypoplasia, radial defects, and mental retardation. Evaluation of the phenotype led us to conclude that a wide spectrum of malformations is possible. There is apparently no strong correlation between karyotype and phenotype.

[Intramedullary stabilisation of metastatic fractures of long bones]. / Intramedulläre Stabilisierung metastatisch bedingter Frakturen langer Röhrenknochen.

UNLABELLED: Surgical treatment of metastatic fractures of long bones is mostly a palliative one. Intramedullary stabilisation without resection of metastases follows the aim of the palliative therapy concept. PATIENTS AND METHODS: From 01.01.1995 to 30.08.2001 36 manifest and 4 impending long bone fractures were registered in 22 female and 16 male patients, with a mean age of 63 years. In addition, one revision was necessary due to persisting instability after humeral intramedullary bundle nailing. Pathological fractures were found in the humerus (n=11), femoral neck (n=6), per- and subtrochanteric region (n=12), femoral shaft (n=10) and tibia (n=2). Most of them were malignancies of the kidneys (n=13), bronchi (n=7) and breast (n=6). One patient with a solitary metastasis in the humerus received curative treatment by resection, open reduction and internal fixation. All other cases underwent palliative stabilisation. Metastatic lesions of the femoral neck were treated by resection and prosthetic replacement. The remaining fractures were stabilized intramedullarily without resection of metastases or use of bone cement. In 9 cases, a locking nail was implanted in the humerus, and one patient received humeral bundle nailing. In the lower extremities, we used a classic-nail or gamma-nail in 15 and a locking nail in 8 cases. Two moribund patients did not undergo surgery. RESULTS: No intraoperative complications occurred. 63 % of the patients with stabilisation of the leg were able to walk at the time of discharge. The mean survival time (Kaplan-Meier) of patients after palliative operation amounted to 161.5 days (95 % CI 92.7; 230.3). We found 6 postoperative complications: temporary palsy of the radial nerve (n=1), soft tissue infection (n=1), dislocation of the nail (n=2), loosening of the distal locking screw (n=1), proceeding osteolysis with high fracture risk (n=1). CONCLUSION: Intramedullary stabilisation without resection of metastases using locking nails meets the requirements of palliative therapy. This procedure is less invasive and allows early weight bearing.