[Chances and Potential of a Modern Surgical Skills Lab as Substantial Practical Part of the Study of Human Medicine - "The Magdeburg Model"]. / Chancen und Potenziale eines modernen chirurgisch geprägten SkillsLabs im Rahmen des Humanmedizinstudiums ­ das Magdeburger Modell.

Introduction: Surgical education of medical students within "skills labs" have not been standardised throughout Germany as yet; there is a substantial impact of available aspects such as personal and space at the various medical schools. Aim: The aim of this contribution is to illustrate the concept of a surgical skills lab in detail, including curricular teaching and integrated facultative courses at the Medical School, University of Magdeburg ("The Magdeburg Model") in the context of a new and reconstructed area for the skills lab at the Magdeburg's apprenticeship center for medical basic abilities (MAMBA). Method: We present an overview on the spectrum of curricular and facultative teaching activities within the surgical part of the skills lab. Student evaluation of this teaching concept is implemented using the programme "EvaSys" and evaluation forms adapted to the single courses. Results: By establishing MAMBA, the options for a practice-related surgical education have been substantially improved. Student evaluations of former courses presented within the skills lab and the chance of moving the skills lab into a more generous and reconstructed area led to a reorganisation of seminars and courses. New additional facultative courses held by student tutors have been introduced and have shown to be of great effect, in particular, because of their interdisciplinary character. Conclusion: Practice-related surgical education within a skills lab may have the potential to effectively prepare medical students for their professional life. In addition, it allows one to present and teach the most important basic skills in surgery, which need to be pursued by every student. An enthusiastic engagement of the Office for Student Affairs can be considered the crucial and indispensable link between clinical work and curricular as well as facultative teaching with regard to organisation and student evaluation. The practice-related teaching parts and contents at the surgical section of a skills lab should be integrated into the National Competence-based Catalogue of Teaching Aims in Medicine ("NKLM").

[Plastic-surgical treatment options in necrotising fasciitis]. / Plastisch-chirurgische Therapieoptionen bei der nekrotisierenden Fasziitis.

Necrotising fasciitis (NF) is considered a rare and possibly life-threatening infection of the subcutaneous tissue and of the fascia. A specific characteristic is the rapid progress of the disease associated with considerable local pain. Since laboratory parameters as well as imaging are only unspecific, diagnosis is set up clinically. Even in the case of a serious suspicion, an immediate and radical debridement has to be initiated, accompanied by intensive care and adequate antibiotic treatment. Only after stabilisation of the general physical condition and local - sometimes extensive - wound debridement, can coverage and reconstruction of soft tissue defects be appropriately performed by the measures and procedures of plastic surgery.

[Therapeutic options for pressure ulcers]. / Therapieoptionen bei Dekubitalulzera.

The aim of this overview is based on remarks on the pathogenesis of and therapy for pressure ulcers and selected but representative cases to demonstrate current options of plastic coverage. As a consequence of the demographic developments, in particular, with regard to the increasing proportion of older patients as well as the advances in modern medicine, the number of multimorbid, geriatric and bedridden patients and of those with prolonged sickbed periods has been steadily growing. Therefore, partly severe manifestations of pressure ulcers at various exposed body regions can be observed in spite of the best preventive intention of care. While in the early stages rather conservative treatment is adequate, surgical intervention might become important and indispensable for a sufficient treatment in advanced stages. To facilitate basic care and to appropriately treat the infectious focus, the methods and procedures of plastic surgery can become relevant. Although there are several options and approaches existing to sanitise and cover defects of pressure ulcers, which are described within the article based on representative cases, preventive measures can still be considered the best approach.

[What do general, abdominal and vascular surgeons need to know on plastic surgery - aspects of plastic surgery in the field of general, abdominal and vascular surgery]. / Was der Allgemein-, Viszeral- & Gefäßchirurg über plastische Chirurgie wissen sollte - plastisch-chirurgische Aspekte in der Allgemein- & Viszeralchirurgie.

There is overlap between general, abdominal and vascular surgery on one hand and plastic surgery on the other hand, e.g., in hernia surgery, in particular, recurrent hernia, reconstruction of the abdominal wall or defect closure after abdominal or vascular surgery. Bariatric operations involve both special fields too. Plastic surgeons sometimes use skin and muscle compartments of the abdominal wall for reconstruction at other regions of the body. This article aims to i) give an overview about functional, anatomic and clinical aspects as well as the potential of surgical interventions in plastic surgery. General/abdominal/vascular surgeons can benefit from this in their surgical planning and competent execution of their own surgical interventions with limited morbidity/lethality and an optimal, in particular, functional as well as aesthetic outcome, ii) support the interdisciplinary work of general/abdominal/vascular and plastic surgery, and iii) provide a better understanding of plastic surgery and its profile of surgical interventions and options.

[Clinical manifestation of extravasation caused by infusion and its therapeutic management]. / Klinische Manifestationen infusionsbedingter Extravasate und ihr therapeutisches Management.

INTRODUCTION: Extravasal application of chemo-therapeutic agents may cause necrosis of surrounding tissue. Often tendons, nerves and muscles are destroyed. In some cases a surgical excision with an additional coverage is indicated. PATIENTS AND METHODS: In the last ten years we have treated 44  patients with necrosis after extravasation. The defects were mostly localised at the hand or distal forearm, but the cubital fossa and the thorax were affected, too. Excision of the infiltrated tissue was performed and the defect covered with local or free flaps, split skin graft or primary closure. RESULTS: In nearly all cases a stable coverage was achieved. An amputation of the hand was never necessary. Patients with immunosuppression or comorbidity sometimes had wound-healing difficulties that in some cases necessitated further operations. Serious complications were in one case a flap necrosis and another patient died 2  days after the operation because of his nephrotic syndrome. CONCLUSION: Chemotherapy extravasation is an important oncological complication that may cause permanent functional disability of the anatomic region. A variety of free and local flaps with tolerable donor site morbidity can be used for -coverage. We prefer a two-step procedure with radical resection of the area and conditioning of the wound with vacuum therapy or temporary wound coverage and in the next step the definitive wound closure. Conservative treatment is -often followed by a high rate of complications. Early radical debridement and coverage with an adequate flap offers a cure with good functional results.

[The plastic coverage of soft-tissue defects after endoprosthesis on the lower limb]. / Die plastische Versorgung von Weichteildefekten nach Endoprothetik an der unteren Extremität.

BACKGROUND: The implantation of endoprostheses is an established procedure in orthopaedic and trauma surgery. However, the techniques are often associated with a high risk of post-interventional infections and wound healing disorders that can result in loss of the prosthesis or the limb--most likely based on an insufficient debridement and poor soft-tissue coverage. The purpose of this study was to evaluate the efficacy of the coverage methods in our patient population. PATIENTS: In the past 10 years 38 patients with exposed knee prostheses and 14 patients following an ankle endoprosthesis were included in this retrospective study over the period from 2001 to 2011. Soft-tissue reconstructions around the knee were mostly performed by unilateral or bilateral gastrocnemius flaps combined with split-skin grafts. One defect was covered with a free flap. 57% of the soft-tissue defects around the ankle are often problematic and were closed by a pedicled peroneus brevis muscle flap and 35% by a free flap (3 with a latissimus dorsi muscle flap, 2 with a free lateral upper arm flap and one with an anterolateral tight flap). RESULTS: In our patient population we achieved stable soft-tissue coverage in most of the cases using the above-mentioned flaps. Due to multiple preexisting comorbidities, it was observed that the course was frequently prolonged and wound healing difficulties occurred. These, however, could be controlled by conservative means or small secondary procedures. CONCLUSION: A radical debridement and an early appropriate defect coverage of the exposed prosthesis is crucial in the reconstruction process. Through a close interdisciplinary collaboration a stable soft-tissue covering can be achieved. Consequently it is possible to avoid a loss of the endoprosthesis, marked functional deficits or even amputations.

Treatment of intraarticular middle phalanx fractures using the Ligamentotaxor®.

BACKGROUND: We evaluated the outcome of intraarticular middle phalanx fractures after dynamic treatment with the Ligamentotaxor® system. MATERIALS AND METHODS: Ten consecutive patients (seven male, three female; mean age 52 years) with intraarticular middle phalanx fractures were treated with the Ligamentotaxor® between 2009 and 2011. Proximal interphalangeal joint mobility, grip strength and 'Disabilities of the Arm, Shoulder and Hand' (DASH) score were evaluated in a 15-month follow-up. The reconstitution of the intraarticular space was measured immediately after trauma, at 6 weeks and at 15 months by radiograph control. The severity of the trauma was classified according to AO. RESULTS: We found B1 30 %, C1 (Seno I + II) 50 % and C3 (Seno III-V) 20 %. In 60 % of the cases, fractures were localized on the middle base of the fifth digit, in 20 % on the third digit and in 20 % on the index finger. The dynamic treatment lasted 7 weeks; patients were exposed to full workload after 9 weeks. The mean flexion mobility after 15 months reached 73° (range 60-100°), and the extension deficit was 13° (range 0-20°) on average. Grip strength attained 71.3 % (range 60-87 %) of the contralateral side. Initial x-ray after trauma compared to the x-ray after 15 months showed an intraarticular space reconstitution average of 0.5 mm (range 0.1-0.9 mm) anterior-posterior and 0.6 mm (range 0.1-1 mm) lateral. Patients evaluated their outcome with an average of 14.6 points (range 3.3-26.7) using the DASH score. CONCLUSION: Good results can be obtained with the Ligamentotaxor®. We recommend it for the dynamic treatment of intraarticular middle phalanx finger fractures. Larger series and long-term results are needed.

[Treatment of fingertip amputation with semiocclusive dressing]. / Behandlung von Fingerkuppenamputationen mittels Semiokklusivverband.

BACKGROUND: Finger injuries are particularly challenging with respect to function and aesthetics. Flap surgery of the hand is technically demanding and can cause large defects if incorrectly performed. METHOD: Semiocclusive dressing, as described by Mennen and Wiese in 1993 is a simple and well-established method for treating fingertip amputations and soft tissue defects. The method is based on the principle of a moist chamber and is a good conservative option for treating these defects with respect to both function and aesthetics.

An isolated hand tumour as primary manifestation of sarcoidosis.

BACKGROUND: Sarcoidosis is a systemic disorder with unknown etiology, characterized by non-caseating granulomas in numerous organs and tissues. In 90% of patients lung and lymph nodes are involved. The incidence of sarcoidal granulomas in the upper extremities is low. Here we present the case of a primary hand manifestation of sarcoidosis without clinical systemic involvement. OBJECTIVES: A young woman presented with a painful swelling in her right hand. There were no signs of inflammation. Normal perfusion, mobility and sensibility were found. Magnetic resonance imaging (MRI) revealed a tumour infiltrating the muscles and flexor tendons of the third digit around the metacarpal bone and with pathological signal enhancement after administration of contrast medium. RESULTS: Intraoperatively, nodular masses and fat tissue were seen. Histological examination after radical tumour resection showed sarcoidal granulomas. Postoperative staging diagnostics with computed tomography (CT) demonstrated multiple thoracic lymph node swellings in the mediastinum and bilateral hill. Follow-up after one year we saw normal scars in the palmar hand. There was no sign of local recurrence. The pulmological care is still going on. CONCLUSIONS: Sarcoidosis is a rare, often asymptomatic disease. Patients present with dyspnoe and cough caused by the inflammation of the lung. The first clinical manifestation of sarcoidosis as a tumor in the palmar hand is unusual. Extrapulmonary systemic or progressive sarcoidosis is regarded as an indication for therapy with glucocorticosteroids. This case demonstrates that surgical excision enabled complete local cure without necessity of systemic and/or local treatment with steroids.

Long-term memory of visually cued fear conditioning: roles of the neuronal nitric oxide synthase gene and cyclic AMP response element-binding protein.

Nitric oxide (NO) produced by neuronal nitric oxide synthase (nNOS) has a role in late-phase long-term potentiation (LTP) and long-term memory (LTM) formation. Our recent studies implicated NO signaling in contextual and auditory cued fear conditioning. The present study investigated the role of NO signaling in visually cued fear conditioning. First, visually cued fear conditioning was investigated in wild-type (WT) and nNOS knockout (KO) mice. Second, the effects of pharmacological modulators of NO signaling on the acquisition of visually cued fear conditioning were investigated. Third, plasma levels of corticosterone were measured to determine a relationship between physiological and behavioral responses to fear conditioning. Fourth, levels of extracellular signal-related kinase (ERK1/2) and cyclic AMP response element binding protein (CREB) phosphorylation, downstream of NO signaling, were determined in the amygdala as potential correlates of fear learning. Mice underwent single or multiple (4) spaced trainings that consisted of a visual cue (blinking light) paired with footshock. WT mice acquired cued and contextual LTM following single and multiple trainings. nNOS KO mice acquired neither cued nor contextual LTM following a single training; however, multiple trainings improved contextual but not cued LTM. The selective nNOS inhibitor S-methyl-thiocitrulline (SMTC) impaired cued and contextual LTM in WT mice. The NO donor molsidomine recovered contextual LTM but had no effect on cued LTM in nNOS KO mice. Re-exposure to the visual cue 24 h posttraining elicited freezing response and a marked increase in plasma corticosterone levels in WT but not nNOS KO mice. The expression of CREB phosphorylation (Ser-133) was significantly higher in naive nNOS KO mice than in WT counterparts, and pharmacological modulators of NO had significant effects on levels of CREB phosphorylation and expression. These findings suggest that visual cue-dependent LTM is impaired in nNOS KO mice, and aberrant modulation of CREB in the absence of the nNOS gene may hinder cued and contextual LTM formation.

Inhibition of Vaccinia virus entry by a broad spectrum antiviral peptide.

Concerns about the possible use of Variola virus, the causative agent of smallpox, as a weapon for bioterrorism have led to renewed efforts to identify new antivirals against orthopoxviruses. We identified a peptide, EB, which inhibited infection by Vaccinia virus with an EC(50) of 15 microM. A control peptide, EBX, identical in composition to EB but differing in sequence, was inactive (EC50>200 microM), indicating sequence specificity. The inhibition was reversed upon removal of the peptide, and EB treatment had no effect on the physical integrity of virus particles as determined by electron microscopy. Viral adsorption was unaffected by the presence of EB, and the addition of EB post-entry had no effect on viral titers or on early gene expression. The addition of EB post-adsorption resulted in the inhibition of beta-galactosidase expression from an early viral promoter with an EC(50) of 45 microM. A significant reduction in virus entry was detected in the presence of the peptide when the number of viral cores released into the cytoplasm was quantified. Electron microscopy indicated that 88% of the virions remained on the surface of cells in the presence of EB, compared to 37% in the control (p<0.001). EB also blocked fusion-from-within, suggesting that virus infection is inhibited at the fusion step. Analysis of EB derivatives suggested that peptide length may be important for the activity of EB. The EB peptide is, to our knowledge, the first known small molecule inhibitor of Vaccinia virus entry.

[Soft-tissue defects following olecranon bursitis. Treatment options for closure]. / Weichteildefekte nach komplizierter Bursitis olecrani : Therapieoptionen zur Defektdeckung am Ellenbogen.

Olecranon bursitis has a high prevalence and is commonly treated conservatively. However, in case of bacterial infection and open injuries with chronic courses, surgery is indicated. Despite high surgical standards, soft-tissue defects cannot always be avoided in primary surgery for infectious olecranon bursitis. For complicated courses with persisting defects, standardized closing procedures are available. For maintaining adequate elbow function and avoiding long disease progression, definite closure of the defect should be achieved. Various treatment options exist: VAC therapy and local, island, distant, and free flaps. Between 1996 and 2007, 12 Patients with complicated olecranon bursitis were treated in our institution. Of them, 11 received surgery. In complicated courses of olecranon bursitis with soft-tissue defects, fistulas, or recurrent wound healing disorders, there are several procedures for plastic covering of the elbow.

High Mobility Group Box 1-Protein expression in canine haematopoietic cells and influence on canine peripheral blood mononuclear cell proliferative activity.

High Mobility Group Box 1-Protein (HMGB1) is a nuclear chromosomal protein occurring ubiquitary in mammalian tissues. HMGB1 demonstrates cytokine function and induces inflammation when actively released by haematopoietic cells or passively released during cell necrosis. This study aimed at the determination of HMGB1 expression in different cell types and at the evaluation of the role of HMGB1 in PBMC proliferation. Therefore we investigated the HMGB1 mRNA expression level in different canine haematopoietic cell types and the influence of exogenous rhHMGB1 on canine PBMC proliferation. Differentiated haematopoietic blood cells showed lower relative HMGB1 expression levels compared to CD34+ haematopoietic stem cells. Relative HMGB1 expression seemed also to decrease during differentiation of CD34+ stem cells into dendritic cells. Furthermore, peripheral blood CD14+ monocytes and granulocytes showed a lower relative HMGB1 expression in comparison to CD3+ T-lymphocytes. When exogenous rhHMGB1 at low concentrations was added to single PBMC cultures an increase of proliferation was obvious. However, in higher concentrations HMGB1 lost its stimulative effect. In conclusion, HMGB1 is broadly expressed in canine haematopoietic cells with highest levels in haematopoietic stem cells. HMGB1 induced directly PBMC proliferation.

[Results of extensor indicis transfer for reconstruction of the extensor pollicis longus tendon]. / Ergebnisse der Extensor indicis-Plastik zur Rekonstruktion der Extensor pollicis longus-Sehne.

Rupture of the extensor pollicis longus tendon is a frequent complication after distal radius fractures or other traumatic and non-traumatic events. Typical is the loss of the function of extension in the thumb. The extensor indicis transfer is a simple and effective technique for reconstruction of the extension with a low donor-site morbidity. We report on 38 patients with extensor indicis transfer. Postoperatively the patients received a dynamic motion splint for 4 weeks. For evaluation we have done pre- and postoperative ultrasound scans of the thumb, evaluated the DASH score and carried out a clinical examination.

[Therapeutic options for aggressive fibromatosis]. / Therapieoptionen bei der aggressiven fibromatose.

INTRODUCTION: Aggressive fibromatosis, e.g., desmoid tumour, is a rare neoplasm of the connective tissue with local infiltrative growth. Because of the high recurrence rates and destruction of the surrounding tissue, these tumours are classified as semi-malignant. However, desmoid tumors tend not to metastasise. Arising from deep musculoaponeurotic structures, a monoclonal proliferation of fibroblasts occurs. Radical surgical treatment with tumour excision accompanied by radiotherapy is the current standard therapy that can be supplemented by pharmacological treatment in a few cases. PATIENTS AND METHOD: We report on 9 patients (5 males and 4 females) with surgical therapy for aggressive fibromatosis. The neoplasm was located on the extremities in 7 cases (4 x upper extremity, 3 x lower extremity), one tumour was situated in the chin and one in the rectus abdominis muscle. All patients were treated with radical tumour resection. Postoperatively, adjuvant radiotherapy was performed depending on the resection level of each patient. RESULTS: In 6 cases complete tumour resection (R0) was achieved. Following surgery, regular follow-ups with a physical examination and MR images were performed. In 3 cases a total tumour resection was impossible (R1 resection). The aggressive fibromatosis had infiltrated the pelvis in 2 cases implying a hemipelvectomy for R0 resection which was not practicable. Furthermore, diffuse locoregional infiltration of the chin region occurred in one case. In these cases, an adjuvant radiotherapy with 25 x 2 Gy was started postoperatively after the accomplished wound healing. Treatment with chemotherapeutic agents was not necessary. DISCUSSION: Aggressive fibromatosis is a semimalignant neoplasm of the connective tissue with an extremely high recurrence rate. Macroscopically, indistinct solid lesions are found with the destruction of muscles and other surrounding structures. Therapy of choice is the radical surgical resection. Radiotherapy is indicated for patients with non-resectable tumours. Pharmacological treatment should be considered for patients with unsuccessful local therapy.

Pharmacokinetics of oral mycophenolate mofetil in combination with CsA in dogs after nonmyeloablative allogeneic hematopoietic stem cell transplantation.

Mycophenolate mofetil (MMF) has been used successfully in solid organ transplantation (SOT) and more recently in nonmyeloablative hematopoietic stem cell transplantation (HSCT) for prophylaxis of graft rejection and acute graft-versus-host disease. However, the pharmacokinetics of MMF seem to differ when applied in HSCT compared to SOT. Here, we analyzed pharmacokinetics of mycophenolic acid (MPA), the active metabolite of MMF, in a nonmyeloablative canine HSCT model. Dogs received nonmyeloablative TBI for conditioning followed by leukocyte antigen-identical littermate HSCT and immunosuppression containing cyclosporin A (CsA) and different doses of MMF. Pharmacokinetics were performed on days 2, 14 and 27. Dose escalation of MMF from 10 to 30 mg/kg tended to increase area under the curve (AUC) and the apparent oral clearance by 45 and 110%, respectively. Doses applied had no linear association with MPA concentration or blood trough level. No significant drug accumulation occurred over time. Using a twice daily MMF regimen, we conclude that an AUC of 30-60 mug/ml h as recommended for SOT cannot be reached in HSCT. Toxicities did not permit single doses higher than 30 mg/kg. Thus, if larger AUCs are desired in order to assure sufficient immunosuppression in HSCT, MMF might have to be administered at least three times daily.