Cytology of the neovagina in transgender women and individuals with congenital or acquired absence of a natural vagina.

OBJECTIVE: The primary objective of this study was to describe the cytological findings of bowel and (penile) skin-lined neovaginas in patients with gender dysphoria (GD) and individuals with a congenital or acquired absence of a natural vagina. The secondary objective was to correlate the cytological findings with clinical characteristics such as oestrogen replacement therapy (ERT). METHODS: A retrospective review of an institutional pathology archive over a 15-year-period was performed to identify cytological samples of neovaginal vaults. The medical and surgical records of the patients identified (n=20) were evaluated. RESULTS: Well-preserved nucleated squamous cells were found in 70% (14/20) of patients. Neovaginal samples showing superficial, intermediate and parabasal cells plus Döderlein flora similar to normal cervical cytology were present in only 10% (2/20). Three samples (15%, 3/20) showed atypical squamous cells of undetermined significance (ASC-US) that were all negative for high-risk human papillomavirus (HR-HPV) types, whereas one case was positive for low-risk (LR) HPV. One patient (5%, 1/20) was diagnosed with an HR-HPV-positive high-grade squamous intraepithelial lesion (HSIL), and one patient (5%, 1/20) had an HR- and LR-HPV-positive low-grade squamous intraepithelial lesion (LSIL). The correlation between the presence of nucleated squamous cells and ERT was significant (P=.032). CONCLUSION: Cytological findings of the neovagina resemble normal cervical cytology with superficial, intermediate and parabasal cells as well as Döderlein bacilli in a minority of cases. Because precancerous lesions and invasive carcinoma may develop in the neovagina, patients with neovaginas should be subject to cancer screening programmes.

Color Doppler ultrasound-guided PTBD with and without metal stent implantation by endoscopic control: prospective success and early adverse event rates.

OBJECTIVE: There are just a few reports on Color Doppler Ultrasound-guided PTBD with and without metal stent implantation by endoscopic control. Ultrasound guidance facilitates percutaneous bile duct access and avoids severe adverse events. Internal biliary drainage rate in PTBD should be as high as possible as endoscopic ultrasound-guided cholangiodrainage (EUCD) offers internal drainage regularly. We report our prospective study analyzing success, internal drainage and adverse event rates. MATERIALS AND METHODS: Between June 2009 and November 2014 overall 63 PTBDs were performed prospectively in 37 patients (18 m, 19f; age on average: 72 years) with benign (9 %) and malignant (91 %) bile duct obstruction. Ultrasound was used in combination with fluoroscopic guidance. Whenever possible, primary or early secondary metal stent implantation via PTBD by endoscopic control was performed as a one step-procedure. RESULTS: 38 of 41 (93 %) initial PTBDs (in four patients PTBD was performed twice) were successful. 22 of 63 PTBDs were follow-up examinations with different interventions. In 34 of 38 successful (89 %) PTBDs, an internal drainage (or metal stent) was implanted. 12 metal stent implantations via PTBD were performed under endoscopic control. Just 2 (5 %) permanent external drainages were inserted. In 63 performed PTBDs 5 (7.9 %) early major adverse events (no severe intrahepatic bleeding) were documented and treated without any procedure related death. When metal stent implantation was performed via PTBD no adverse event was documented. CONCLUSION: Color Doppler guided PTBD is an effective and safe method for biliary drainage avoiding severe adverse events. Primary or early secondary metal stent implantation via PTBD reduces complication risks additionally. Endoscopic control of stent implantation via PTBD is helpful for optimal stent placement.

Septic shock in children in an urban area in Western Germany--outcome, risk factors for mortality and infection epidemiology.

BACKGROUND: Only sparse data exist about children with septic shock in Europe. The present study aimed to evaluate demographics, treatment, outcome and risk factors for mortality in Western Germany. PATIENTS: Children with septic shock aged 2 months to 17 years. METHODS: In a multi-center retrospective study of 20 children's hospitals data were obtained and analyzed by chart review. Risk factors for mortality were identified and assessed by multivariate regression analysis. RESULTS: Overall mortality in 83 cases with septic shock was 25% (21 patients). Significant risk factors were high PRISM III score, low pH, low arterial systolic blood pressure, presence of disseminated intravascular coagulation and extent of multi-organ failure, but not lactate (p=0.05) and base excess (p=0.065). Mortality in hospitals which treated 10 or more patients (category 1) was 17% and increased to 22% in hospitals which treated 3-6 patients (category 2). In hospitals with only 1 or 2 patients (category 3) mortality rate was 61% (p<0.01 when compared to category 1 or 2). A stepwise increase was also seen in the severely sick patients according to PRISM III (>19): category 1: 23%, category 2: 40%, category 3: 62.5% (p<0.05 for comparison of category 1 and 3). Multivariate analysis of significant risk factors revealed low number of treated patients as the only individual risk factor for mortality. CONCLUSION: Mortality from pediatric septic shock in an urban area in Western Germany is high. Disease severity and treatment in a department with few cases were associated with increased mortality.

Reverse genetic screening reveals poor correlation between morpholino-induced and mutant phenotypes in zebrafish.

The widespread availability of programmable site-specific nucleases now enables targeted gene disruption in the zebrafish. In this study, we applied site-specific nucleases to generate zebrafish lines bearing individual mutations in more than 20 genes. We found that mutations in only a small proportion of genes caused defects in embryogenesis. Moreover, mutants for ten different genes failed to recapitulate published Morpholino-induced phenotypes (morphants). The absence of phenotypes in mutant embryos was not likely due to maternal effects or failure to eliminate gene function. Consistently, a comparison of published morphant defects with the Sanger Zebrafish Mutation Project revealed that approximately 80% of morphant phenotypes were not observed in mutant embryos, similar to our mutant collection. Based on these results, we suggest that mutant phenotypes become the standard metric to define gene function in zebrafish, after which Morpholinos that recapitulate respective phenotypes could be reliably applied for ancillary analyses.

[Imaging modalities and therapy options in patients with acute flank pain]. / Bildgebungsmodalitäten und Therapieoptionen bei Patienten mit akutem Flankenschmerz.

The objective of this article is the description of imaging techniques for the evaluation of patients with acute flank pain and suspicion of urolithiasis and the impact of these techniques in the therapy management of patients with calculi.

Prevalence, extent and severity of severe periodontal destruction in an urban Aboriginal and Torres Strait Islander population.

BACKGROUND: The aim of this study was to document the three main indicators of severe periodontal destruction and to evaluate factors associated with those indicators in an urban Indigenous population in Australia. METHODS: A cross-sectional survey of a convenience sample of Aboriginal adults from an Australian urban area was undertaken. Socio-demographic data and smoking status were collected by interview and health status by a medical record audit. Clinical attachment loss (CAL) was used to determine prevalence, extent and severity of severe periodontitis. Factors with significant association with periodontal indicators at bivariate level were further included in multivariable analysis controlling for age and gender. RESULTS: A total of 251 Aboriginal adults participated in the study. The proportion with severe periodontitis was 11.9% (95% CI: 7.6-16.3), extent: 5.0% (95% CI: 3.3-6.7) and severity: 5.3 mm (95% CI: 5.0-5.6). These estimates are significantly higher than that of other Australians. Current smokers had significantly higher prevalence rate (PR) of severe periodontitis: PR = 2.8 (95% CI: 1.3-6.0). People with diabetes and current smokers had significantly higher extent of sites with CAL 6+ mm: 1.9 (1.1-3.3) and 2.1 (1.2-3.6) respectively. Having diabetes was associated with significantly higher severity score (ß: 0.96 (SE: 0.47)). CONCLUSIONS: A high proportion of this urban Aboriginal population had severe periodontal disease related to smoking and diabetes.

Gamma nail in the treatment of closed trochanteric fractures. Results and indications of 121 cases.

The Gamma Nail is the latest advance in the treatment of trochanteric fractures based on intramedullary nailing principles during closed procedures. Its design is based on Küntscher's Y-nail and locking intramedullary (IM) nails. This paper reports the results from the first-ever series of 121 patients operated between 1988 and 1990. They were followed until bone union was achieved. The mean patient age was 75 years. Most patients were in poor general health and had unstable fractures. Anatomical preoperative reduction was achieved in 72% of cases. Fixation was good in 66% of cases and acceptable in 27% of cases. Intra-operative complications consisted of nine fractures without consequences. Of the treated patients, 83.4% resumed weight-bearing during the first week. There was one case of deep infection that resolved with treatment. The mortality rate was 12.3% at three months. We noted 7 alunions in varus, 3 in valgus, 2 in external rotation and 1 in internal rotation. There were no cases of non-union. In six cases, the screw had cut out of the femoral head. The drawbacks associated with surgical treatment methods for trochanteric fractures also apply to the Gamma nail. Nevertheless, one of its primary advantages is the possibility of using a closed procedure. When compared to Ender nailing, knee pain is absent and weight-bearing can be achieved in all patients, no matter the fracture type.

[IgG4-related systemic disease with autoimmune pancreatitis and lung involvement primarily presenting as pancreatic cancer with pulmonary metastases]. / IgG4-assoziierte Autoimmunpankreatitis und Lungenerkrankung mit der primären, klinischen Präsentation eines pulmonal metastasierten Pankreaskarzinoms.

BACKGROUND: After the first case publication using the term "autoimmune pancreatitis" in 1995 and the successful treatment with steroids we now can distinguish between two clinical und histopathological forms of autoimmune pancreatitis. Type 1 autoimmune pancreatitis (AIP) is usually part of an IgG4-related systemic disease. AIP Typ 2 is an IgG4-independent pancreatic disease. For both entities pancreas cancer is the most important differential diagnosis. CASE REPORT: We report the case of an 82-year-old male patient who primarily presented with obstructive jaundice. Computed tomography (CT) revealed the typical image of a small cancer of the head of the pancreas with pulmonary metastases. After endoscopic drainage of the bile duct a CT-guided biopsy of a pulmonary nodule was performed in which cancer was ruled out. Next the patient was treated with steroids because of "tumour-associated cachexia". In the follow-up the mass in the head of the pancreas like the lung nodules had surprisingly disappeared. In the complete work-up the immune histochemical staining of the lung biopsy revealed subsequently a typical IgG4-associated inflammation. After termination of the therapy the disease relapsed as sclerosing cholangitis. CONCLUSION: The IgG4-related systemic disease with AIP can present as cancer of the pancreas with lung metastases. Extrapancreatic IgG4-positive histopathology and response to therapy with steroids can help to diagnose the disease in complex clinical presentations.

[Imaging techniques and their impact in treatment management of patients with acute flank pain]. / Die bildgebenden Verfahren und ihre Rolle beim Behandlungsmanagement von Patienten mit akutem Flankenschmerz.

The purpose of this overview is to provide a general summary of the imaging techniques applied at the Vienna Hospital for the investigation of acute flank pain and the diagnosis of stone disease and the evaluation of their efficacy and impact on therapy management. The number of publications on the issue of "intravenous urography (IVU) vs computed tomography (CT)" is abundant; in recent years, advocates of CT make up the majority. In the Department of Urology at the Vienna Hospital, conventional techniques such as ultrasound and IVU besides UHCT still play an important role. This overview presents the advantages and disadvantages of the various imaging techniques for diagnosis of stone disease and evaluates their significance regarding therapy management of patients with acute flank pain.

Preparing strategic information management plans for hospitals: a practical guideline SIM plans for hospitals: a guideline.

OBJECTIVES: Systematic information management in hospitals demands for a strategic information management plan (SIM plan). As preparing a SIM plan is a considerable challenge we provide a practical guideline that is directly applicable when a SIM plan is going to be prepared. METHODS: The guideline recommends a detailed structure of a SIM plan and gives advice about its content and the preparation process. It may be used as template, which can be adapted to the individual demands of any hospital. RESULTS: The guideline was used in several hospitals preparing a SIM plan. Experiences showed that the SIM plans could be prepared very efficiently and timely using the guideline, that the proposed SIM plan structure suited well, that the guideline offers enough flexibility to meet the requirements of the individual hospitals and that the specific recommendations of the guideline were very helpful. CONCLUSIONS: Nevertheless, we must strive for a more comprehensive theory of strategic information management planning which -- in the sense of enterprise architecture planning -- represents the intrinsic correlations of the different parts of a SIM plan to a greater extent.

Mathematical modeling of regulatory mechanisms in yeast colony development.

In the present study, yeast colony development serves as a model system to study growth of fungal populations with negligible nutrient and signal transport within the mycelium. Mathematical simulations address the question whether colony development is governed by diffusional limitation of nutrients. A hybrid one-dimensional cellular automaton model was developed that describes growth of discrete cells based upon microscopic interaction rules in a continuous field of nutrient and messenger. The model is scaled for the geometry of the experimental setup, cell size, growth- and substrate uptake rates. Therefore, calculated cell density profiles and nutrient distributions can be compared to experimental results and the model assumptions can be verified. In the physiologically relevant parameter range, simulations show an exponentially declining cell density along the median axis of the colonies in case of a diffusion limited growth scenario. These results are in good agreement with cell density profiles obtained in cultivations of the yeast Candida boidinii with glucose as the limiting carbon source but stand in contrast to the constant cell density profile estimated for Yarrowia lipolytica grown under the same conditions. While from the comparison of experimental results and simulations a diffusion limited growth mechanism is proposed for glucose limited C. boidinii colonies, this hypothesis is rejected for the growth of Y. lipolytica. As an alternative, a quorum sensing model was developed that can explain the evolution of constant cell density profiles based on the effect of a not further characterized unstable or volatile messenger.

Osteoprotegerin and receptor activator of nuclear factor-kappaB ligand (RANKL) in the serum of healthy adults.

AIMS: Osteoprotegerin and the receptor activator of the nuclear factor-kappaB ligand (RANKL) are decisive factors for maintaining the balance between bone formation and bone resorption. As new, sensitive ELISAs have been developed recently, reference serum ranges should be established to use these analytes for possible diagnostic purposes. METHODS: Measurements were performed in serum samples of 142 healthy adults (82 women, 60 men) between 20 and 70 years of age (mean age: 46 years) using ELISA kits from Immundiagnostik, Bensheim, Germany. RESULTS: Serum concentrations of osteoprotegerin were age and gender independent and showed a Gaussian distribution, while RANKL concentrations were also age independent but differed between males and females, with a non-Gaussian distribution. For osteoprotegerin a gender-independent upper 97.5 percentile limit of 3.6 pmol/L was calculated while the corresponding limits for RANKL and the ratio of RANKL to osteoprotegerin amounted to 3.29 pmol/L and 2.78 in women and 1.66 pmol/L and 2.18 in men, respectively. CONCLUSIONS: Both osteoprotegerin and RANKL were quantifiable in serum of healthy adults, which means that these compounds can be used as potential diagnostic tools.

European quadricentric evaluation of a breast MR biopsy and localization device: technical improvements based on phase-I evaluation.

Our purpose was to report about technical success, problems and solutions, as experienced in a first multicentre study on MR-guided localisation or vacuum biopsy of breast lesions. The study was carried out at four European sites using a dedicated prototype breast biopsy device. Experiences with 49 scheduled localisation procedures and 188 vacuum biopsies are reported. Apart from 35 dropped indications, one localisation procedure and 9 vacuum biopsies were not possible (3 times space problems due to obesity, 2 times too strong compression, 3 times impaired access from medially, 2 times impaired access due to a metal bar). Problems due to too strong compression were recognised by repeat MR without compression. During the procedure problems leading to an uncertain result occurred in eight vacuum biopsies, two related to the procedure: one limited access, and one strong post-biopsy enhancement. Improvements after phase-I study concerned removal of the metal bar, development of an improved medial access, of a profile imitating the biopsy gun, optimisation of compression plates and improved software support. The partners agreed that the improvements answered all important technical problems.

MR-Guided vacuum biopsy of 206 contrast-enhancing breast lesions.

PURPOSE: To determine the accuracy and clinical use of MR-guided vacuum biopsy (VB) of enhancing breast lesions. MATERIAL AND METHODS: 254 lesions were referred to MR-guided vacuum-assisted breast biopsy. In 43 (16 %) patients the indication was dropped because the lesions could not be identified at the time VB was scheduled. This was due to hormonal influences (n = 37), to too strong compression (n = 3) or to misinterpretation of the initial diagnostic MRI (n = 3). In 5 cases (2 %) VB was not performed due to obesity (n = 2); problems of access (n = 2) or a defect of the MR-unit (n = 1). VB was performed on altogether 206 lesions. In 4 cases (2 %) VB was unsuccessful. This was immediately realized on the post-interventional images. Thus a false negative diagnosis was avoided. Verification included excision of the cavity in cases with proven malignancy or atypical ductal hyperplasia (ADH) and (for benign lesions) retrospective correlation of VB-histology with pre-and postinterventional MRI and subsequent follow-up. RESULTS: 51/202 successful biopsies proved malignancy. In 7 cases ADH and in 144 cases a benign lesion was diagnosed. One DCIS was underestimated as ADH. All other benign or malignant diagnoses proved to be correct. CONCLUSION: MR-guided VB allows reliable histological work-up of contrast-enhancing small lesions which are not visible by any other modality.

Micro flow modules with combined fluid flow channel and optical detection waveguide--hyper Rayleigh scattering as a case study.

Micro flow modules with optical detection have been fabricated in a way which enables optical waveguiding inside and a defined interaction length along the fluid channel. Because of the usually lower refractive index of the solution compared with that of the substrate, so-called "leaky" optical wave-guiding must be employed. The combination of the fluid flow channel function with that of the optical waveguide has advantages for all miniaturized optical detection cells. It has been shown for hyper Rayleigh scattering (HRS) that improvement of the analytical principle is inherent in the miniaturization. The detection limit can be enhanced by at least a factor of 20. The applied HRS measurement procedure also enables simultaneous detection of two photon absorption (TPA) fluorescence. The severe boundary conditions of capillary electrophoresis were used as micro flow module design constraints to enable the transfer of the approach to other types of analysis.

New isoelectric buffers for capillary electrophoresis: N-carboxymethylated polyethyleneimine as a macromolecular isoelectric buffer.

Isoelectric buffers are attractive for electrophoresis because of their low conductivity, and their compatibility with indirect photometric detection in capillary electrophoresis (CE) where they do not interfere with the detection by exhibiting competitive displacement of the UV-absorbing probe ion. N-carboxymethylated polyethyleneimine (CMPEI) was prepared by introducing a half molar equivalent of carboxylate groups onto a polyethyleneimine backbone. Its isoelectric point determined by conductometric titration and from the pH of its dilute aqueous solution is approx. 6.8, which allows isoelectric buffering at a lower pH compared to histidine (pI7.7). Although the isoelectric point is somewhat diffuse, as expected for a polymeric compound, it exhibits a buffering capacity at a pI point of about twice that of histidine. Studies of electroosmotic flow (EOF) profile at various pH values in fused silica capillaries showed that CMPEI adsorbs onto the fused silica wall and reverses the EOF at pH < 6.5. CMPEI was applied as a buffer in an electrolyte containing 0.5 mM of the anionic dye tartrazine used as the probe for indirect detection of anions. The separation system exhibited a stable baseline, no system peaks, separation efficiencies of up to 195,000 theoretical plates, and detection limits down to 0.2 microM or 2 amol of injected analyte.

Fixation of odontoid fractures by an anterior screw.

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D'Alonzo type-II fractures and 52 with type III. Roy-Camille's classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.

Reversal of hypoxemia by inhaled nitric oxide in children with severe hepatopulmonary syndrome, type 1, during and after liver transplantation.

BACKGROUND: The hepatopulmonary syndrome with profound hypoxemia is a rare but severe complication for children with liver cirrhosis. It can be reversed by liver transplantation (LT), which is now regarded as a good indication. However, previous reports have described cases of transient or fatal deteriorations of intrapulmonary shunting after pediatric liver transplantation with dramatically worsening hypoxemia. METHODS AND RESULTS: A similar case during and after LT in a 4-year-old girl with severe hepatopulmonary syndrome is described with prompt reversal of hypoxemia by inhaled nitric oxide, which was discontinued definitely until day 14 after LT. CONCLUSIONS: During or after LT, worsening hypoxemia may be improved by using inhaled nitric oxide in pediatric patients undergoing liver transplantation for liver cirrhosis and hepatopulmonary syndrome. The mechanisms are unclear, but may involve mismatching lung ventilation-perfusion. However, additional clinical reports are necessary before accepting these results.

Results of breast conserving therapy for early breast cancer and the role of mammographic follow-up.

PURPOSE: The following article is a review of 23 years of breast-conserving therapy in our hospital. This study was performed to assess and improve the follow-up care of women with early breast cancer and to evaluate whether or not biannual mammogram is useful. METHODS AND MATERIALS: Between 1972 and December 1995, 3072 women with pathological size pT1 and pT2 breast cancer were treated with conservative surgery and radiation therapy. Eighty-five patients developed a recurrence in the treated breast as the first site of failure, 12 of which had positive axillary nodes. In the following patient study, those with an noninvasive recurrence were excluded. A retrospective assessment of the entire mammographic course was made, starting with the mammogram at the time of original diagnosis to the mammogram of the recurrence. RESULTS: In our study group the probability for local failure ranged from 1 to 2% per year. At 5 and 10 years the actuarial rates were 5 and 10%. The median time to recurrence was 41 months (range 8-161). Twenty-six (31%) recurrences were detected by mammography alone, 10 (12%) by clinical examination only, and 35 (41%) by both methods. For the patients with an ipsilateral recurrence, the overall actuarial 5- and 10-year survival after treatment was 87 and 70%, respectively. The 5-year actuarial rate of survival from salvage mastectomy was 61%. CONCLUSION: Considering the high percentage of recurrences detectable by mammography and the possibility of detection within a short-term interval, we think biannual mammographic follow-up is appropriate for the first years following breast-conserving therapy.

[Duplex sonographic studies on the pathogenesis of splenic hemodynamics in liver cirrhosis]. / Duplexsonographische Untersuchungen zur Pathogenese der lienalen Hämodynamik bei Leberzirrhose.

AIM OF STUDY: The haemodynamic role of the spleen in portal hypertension remains unclear. Duplex sonography was undertaken prospectively to discover the relationship of splenomegaly and splenic vein flow to type and severity of liver cirrhosis and portal vein flow, as well as to the degree of oesophageal varices. PATIENTS AND METHODS: 89 patients (54 men, 35 women; mean age 52 [26-81] years), diagnosed in the second half of 1993 as having liver cirrhosis were consecutively included in the study. In 40 patients the cirrhosis was in stage A (according to Child-Pugh classification), in 31 in stage B and in 18 in stage C. RESULTS: Portal vein flow fell significantly with increasing degree of cirrhosis (stage A: 8.29 cm/s; stage B 7.03 cm/s; stage C 5.26 cm/s; P < 0.05). Splenic vein flow differed significantly only between stages B and C (stage A: 9.22 cm/s; stage B: 9.46 cm/s; stage C: 7.87 cm/s; B vs C, P < 0.05). There was no correlation between portal vein flow, splenic vein flow, degree of splenomegaly and extent of oesophageal varices. CONCLUSION: The results may be explained by the presence of collateral circulations and by the differing pathophysiological part played by the spleen in liver cirrhosis of different aetiologies.