High Femoral Antetorsion Is a Major Risk Factor for Anterior Knee Pain whereas Trochlea Dysplasia Predisposes for Patella Dislocation.

PURPOSE OF THE STUDY Patellofemoral stability and congruency are influenced by different parameters. Their contribution to anterior knee pain and instability is not fully understood. We investigated, if isolated femoral antetorsion of more than 25° leads to patellofemoral instability. MATERIAL AND METHODS We analyzed 90 knees in patients with patellofemoral complaints and correlated clinical and radiological characteristics. Patients presenting at our center between January 2018 and December 2020 because of patellofemoral pain or instability were included, provided that there was no previous surgical intervention done. RESULTS The severity of trochlea dysplasia classified using the Oswestry-Bristol classification significantly correlated with events of patellofemoral dislocations. (χ=8.152, p=0.043, φ=0.288). All males with a history of patella dislocation had at least a mild trochlea dysplasia. The majority of females complaining about patellofemoral symptoms in general had a dysplastic trochlea. Patella alta is more frequently found in patients with trochlea dysplasia than in patients with a normal femoral trochlea anatomy. DISCUSSION The majority of unstable patellofemoral joints showed a dysplastic trochlea. A high femoral antetorsion was found to be an additional minor factor contributing to instability. Isolated high femoral antetorsion without trochlea dysplasia rather leads to anterior knee pain without patella dislocation. Furthermore, no direct significant correlation between patella alta and patellofemoral instability was found. Patella alta can therefore rather be seen as a result of a dysplastic trochlea than a primary major risk factor for patellofemoral instability. CONCLUSIONS Trochlea dysplasia is the major risk factor for patellofemoral instability. Patella alta can rather be seen as a result of a dysplastic trochlea than as a primary risk factor for patella instability or pain. Isolated high femoral antetorsion often leads to patellofemoral pain syndrome but not to patella dislocations. Key words: MPFL, patella instability, patellofemoral instability.

Anaplastic thyroid carcinoma: changing trends of treatment strategies and associated overall survival.

PURPOSE: The prognosis of anaplastic thyroid cancer (ATC) is poor. Despite various attempts to modify common treatment modalities, including surgery, external beam radiation (EBRT) and chemotherapy (CTX), no standardized treatment is yet established. This study aimed to analyze the changing trends of treatment concepts and associated overall survival (OS) over the last two decades. METHODS: A retrospective analysis was conducted on 42 patients with histologically confirmed ATC. The outcome measures included the evaluation of clinical characteristics and treatments performed with regard to OS. RESULTS: Median OS for all tumor stages was 6 (range 1 week-79) months, 6.5 months for stage IVA/B and 4 months for stage IVC carcinoma patients. Twenty-one patients with stage IVA/B carcinomas underwent curative treatment, including thyroidectomy with lymphadenectomy (TTX plus LAD, n = 11) or multimodal treatment with TTX plus LAD and EBRT plus/minus CTX (n = 10). The median OS of patients with stage IVA/B carcinomas was significantly prolonged after multimodal treatment than after surgery alone (25 vs. 3 months, p = 0.04). Fifteen of 18 patients with stage IVC carcinomas received palliative, 3 patients multimodal treatment. The median OS of stage IVC patients after trimodal therapy was not significantly longer than after debulking procedures (6 vs. 7 months, p = 0.25). In the time period 1999-2009, only 4 (21%) patients received multimodal treatment compared to 9 (39%) in the period from 2009 to 2019, but this did not result in a significantly prolonged survival in the latter period (8.5 vs. 15 months, p = 0.61). CONCLUSION: Concurrent radio- and/or chemotherapy in combination with surgery seems to result in improved survival in stage IVA/B ATC, whereas this is not the case in patients with stage IVC tumors. Novel treatment regimens are urgently needed to improve the dismal prognosis of ATC.

A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms.

PURPOSE: The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms. METHODS: Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed. RESULTS: In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure. CONCLUSION: The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.

[Surgical treatment of parathyroid carcinoma : Does the initial en bloc resection improve the prognosis?] / Chirurgie des Nebenschilddrüsenkarzinoms : Verbessert die initiale En-bloc-Resektion die Prognose?

BACKGROUND: Radical en bloc resection of the tumor with ipsilateral hemithyroidectomy and central lymphadenectomy (PTX+HTX) is currently the generally recommended treatment strategy for parathyroid carcinoma (PC) in Germany; however, it remains unclear whether the en bloc resection leads to a prognostic benefit compared to parathyroidectomy (PTX) alone, especially considering disease-free and overall survival. OBJECTIVE: This study analyzed the survival of patients with PC after PTX+HTX compared to patients with PTX. METHODS: Patients with PC were identified from a prospective database and retrospectively analyzed regarding clinicopathological features, surgical treatment, disease-free interval and overall survival. RESULTS: Out of 1705 patients who were operated on because of primary hyperparathyroidism (pHPT), 18 (1.1%) had histologically confirmed PC. In nine patients PTX+HTX was initially performed and the other nine patients received only PTX. After PTX, all of the nine patients developed a recurrence after a median of 18 months (range 7-84 months), while only one patient had a recurrence after PTX+HTX. After PTX a median three (range 2-18) reoperations were indicated for relapse but after PTX+HTX only one patient had to undergo two relapse surgeries (p < 0.001). The recurrence-free survival after PTX+HTX was significantly longer than after PTX (143 vs. 18 months, p = 0.01), while the overall survival of both groups after a median follow-up of 107.5 months did not significantly differ. DISCUSSION: If there is any clinical suspicion of PC, an en bloc resection should be performed to prolong recurrence-free survival and avoid reoperations.

[Alternative approaches in thyroid surgery]. / Alternativzugänge in der Schilddrüsenchirurgie.

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

Bacterial survival and distribution during buffy coat platelet production.

BACKGROUND AND OBJECTIVES: At Canadian Blood Services, buffy coat (BC) platelet concentrates (BC-PCs) show a generally lower bacterial contamination rate than apheresis PCs. This study investigated whether the PC production method contributes to this observation. MATERIALS AND METHODS: Whole blood (WB) inoculated with eight bacterial strains was processed using the BC method. Bacteria were enumerated throughout BC-PC production and subsequent PC storage. Endotoxin production and bacterial adhesion to PC bags were evaluated during PC storage. PC quality was monitored by CD62P expression (flow cytometry) and changes in dynamic light scattering (ThromboLUX® ). RESULTS: During overnight WB hold, Staphylococcus epidermidis titres remained unchanged, commercial Escherichia coli and Klebsiella pneumoniae were eliminated and the remaining organisms proliferated to high concentrations. Through BC-PC production, bacteria segregated preferentially towards the cellular fractions compared to plasma (P < 0·05). During PC storage, most bacteria adhered to the PC bags and Gram negatives produced clinically significant endotoxin levels. Changes in CD62P expression or ThromboLUX scoring did not consistently reflect bacterial contamination in BC-PCs. CONCLUSION: WB hold during BC-PC production does not have a broad-spectrum bactericidal effect, and therefore, other factors contribute to low rates of contamination in BC-PCs.

[Big surprise in the lesser pelvis]. / Große Überraschung im kleinen Becken.

A 17-year-old young man presented at our clinic with asymptomatic microhematuria. Ultrasonography and computer tomography found an intraperitoneal lesion of unknown dignity located on top of the bladder. Surgical exploration and histological examination confirmed the diagnosis of a secondary pelvic spleen, a lien bipartitus.

Geographically predominant genotypes of Aspergillus terreus species complex in Austria: s microsatellite typing study.

Aspergillus terreus species complex is recognized as a frequent agent of invasive aspergillosis in Tyrol. The reason for this specific epidemiological situation is unclear. Aspergillus terreus strains isolated from environmental and clinical sources were genotyped using a novel panel of short tandem repeats and were evaluated for virulence. Three major endemic genotypes collected from the Inn region and its side valleys were found to cause the majority of invasive A. terreus infections. All of these genotypes were of the same mating type, which suggests that a mating barrier is present between these geographically well-adapted strains which is found to persist for at least 11 years. The three major genotypes were prevalent in both human infections and the environment. No major differences in virulence were observed using Galleria mellonella as model. Our data suggest a specific environmental exposure being responsible for the high incidence of A. terreus infections in Innsbruck, the Inn valley and side valleys (Tyrol, Austria).

[Transaxillary robot-assisted thyroidectomy: First experiences with a new operation technique]. / Transaxilläre roboterassistierte Schilddrüsenresektion : Erste Erfahrungen mit einer neuen Operationsmethode.

BACKGROUND: The main advantage of transaxillary robotic-assisted thyroid surgery (TRAT) is the avoidance of a scar on the neck. As TRAT is still rarely performed in Germany, there are not yet any German reports on acceptance, operation times and complications. METHODS: In a pilot study all patients with an indication for hemithyroidectomy without preoperative evidence of malignancies or previous neck surgery and a lobe size < 30 ml, a body mass index (BMI) < 30 and age > 18 years were offered transaxillary robotic-assisted hemithyroidectomy (TRAHT) after a detailed explanation of this operation. The acceptance of this new technique, the operation time, complications and patient satisfaction were prospectively recorded and analyzed. RESULTS: Between January 2013 and October 2014 a total of 65 patients were offered the option of a TRAHT and 21 (32%) patients opted for this surgical technique. None of these 21 operations had to be converted and there were no intraoperative complications. The median operation time was 190 min (range 106-300 min) with a significant learning curve (first 5 TRAHT 219 min and last 5 TRAHT 163 min), 10 (48%) patients had a postoperative slight transient skin dysesthesia in the area of the access route, 4 (19%) patients had a transient recurrent laryngeal nerve palsy and 2 patients (9%) had a transient upper brachial plexus palsy. After the first 21 TRAHT operations, 2 Dunhill operations for Grave's disease were also performed via a single axillary incision. The operation times were 320 min and 260 min without complications and 21 out of the 23 patients (91%) were highly satisfied with the cosmetic result and would choose TRAT again. CONCLUSION: The TRAT procedure still has low acceptance by German patients but patient satisfaction after surgery is high due to the cosmetic result. The extended operation time, new complications (e.g. transient plexus palsy) and a potentially increased rate of transient recurrent laryngeal nerve palsy must be critically considered.

Mucormycosis--from the pathogens to the disease.

Mucormycosis is an emerging fungal infection worldwide, with devastating disease symptoms and diverse clinical manifestations. The most important underlying risk factors are immunosuppression, poorly controlled diabetes, iron overload and major trauma. The aetiological agents involved in the disease have been re-classified due to changes in taxonomy and nomenclature, which also led to appropriately naming the disease 'mucormycosis'. This article shortly explains the new nomenclature, clinical manifestations and risk factors and focuses on putative virulence traits associated with mucormycosis, mainly in the group of diabetic ketoacidotic patients.

Modeling and treating internalizing psychopathology in a clinical trial: a latent variable structural equation modeling approach.

BACKGROUND: Clinical trials are typically designed to test the effect of a specific treatment on a single diagnostic entity. However, because common internalizing disorders are highly correlated ('co-morbid'), we sought to establish a practical and parsimonious method to characterize and quantify changes in a broad spectrum of internalizing psychopathology targeted for treatment in a clinical trial contrasting two transdiagnostic psychosocial interventions. METHOD: Alcohol dependence treatment patients who had any of several common internalizing disorders were randomized to a six-session cognitive-behavioral therapy (CBT) experimental treatment condition or a progressive muscle relaxation training (PMRT) comparison treatment condition. Internalizing psychopathology was characterized at baseline and 4 months following treatment in terms of the latent structure of six distinct internalizing symptom domain surveys. RESULTS: Exploratory structural equation modeling (ESEM) identified a two-factor solution at both baseline and the 4-month follow-up: Distress (measures of depression, trait anxiety and worry) and Fear (measures of panic anxiety, social anxiety and agoraphobia). Although confirmatory factor analysis (CFA) demonstrated measurement invariance between the time-points, structural models showed that the latent means of Fear and Distress decreased substantially from baseline to follow-up for both groups, with a small but statistically significant advantage for the CBT group in terms of Distress (but not Fear) reduction. CONCLUSIONS: The approach demonstrated in this study provides a practical solution to modeling co-morbidity in a clinical trial and is consistent with converging evidence pointing to the dimensional structure of internalizing psychopathology.

Factors influencing age at diagnosis of primary ciliary dyskinesia in European children.

Primary ciliary dyskinesia (PCD) is a hereditary disorder of mucociliary clearance causing chronic upper and lower airways disease. We determined the number of patients with diagnosed PCD across Europe, described age at diagnosis and determined risk factors for late diagnosis. Centres treating children with PCD in Europe answered questionnaires and provided anonymous patient lists. In total, 223 centres from 26 countries reported 1,009 patients aged < 20 yrs. Reported cases per million children (for 5-14 yr olds) were highest in Cyprus (111), Switzerland (47) and Denmark (46). Overall, 57% were males and 48% had situs inversus. Median age at diagnosis was 5.3 yrs, lower in children with situs inversus (3.5 versus 5.8 yrs; p < 0.001) and in children treated in large centres (4.1 versus 4.8 yrs; p = 0.002). Adjusted age at diagnosis was 5.0 yrs in Western Europe, 4.8 yrs in the British Isles, 5.5 yrs in Northern Europe, 6.8 yrs in Eastern Europe and 6.5 yrs in Southern Europe (p < 0.001). This strongly correlated with general government expenditures on health (p < 0.001). This European survey suggests that PCD in children is under-diagnosed and diagnosed late, particularly in countries with low health expenditures. Prospective studies should assess the impact this delay might have on patient prognosis and on health economic costs across Europe.

Severe Graves' ophthalmopathy may be a risk factor for the development of postthyroidectomy hypocalcaemia.

PURPOSE: The aim of this study was to compare the rate of hypocalcaemia after thyroid resection in patients with versus patients without Graves' Ophthalmopathy (GO). PATIENTS AND METHODS: 153 patients following thyroid surgery for Grave's disease were studied. Patients were divided into three groups according to the severity of GO at the time of surgery using the NOSPECS classification. Subgroup I comprised of 70 patients without GO, subgroup II comprised of 63 patients with moderate GO and 20 patients with severe GO were assigned to Subgroup III. Association between severe ophthalmopathy and postoperative hypocalcaemia after thyroidectomy was investigated. RESULTS: 12/70 patients complained transient and 3/70 permanent hypocalcemia within subgroup I. 14/63 patients developed transient and 4/63 patients permanent hypocalcaemia within subgroup II. There were 7/20 patients with transient and 5/20 cases with permanent hypocalcaemia in the patient group with severe GO (subgroup III). The incidence of permanent postthyroidectomy hypocalcaemia was significantly higher in the subgroup III with severe GO when compared to the subgroup I without GO (p=0.004). CONCLUSION: Although postthyroidectomy hypocalcemia seems to be a multifactorial phenomenon, this study implicates unknown role of severe GO at time of surgery in the development of hypocalcaemia after thyroid surgery for Graves' disease. Therefore, patients with GO should be considered for surgery at high volume centres specialised in thyroid and parathyroid surgery.

Open diverticulectomy in a patient with a giant symptomatic retro-pancreatic duodenal diverticulum. A case report.

Although often incidentally found, diverticular disease of the small bowel and duodenum may generate complications and impose surgical treatment. Diagnosis of small bowel diverticulosis is difficult because the clinical picture is usually ambiguous. We report a case of diverticulosis of the whole intestine including a giant symptomatic retro-pancreatic duodenal diverticulum in a 74-year-old patient who presented with recurrent episodes of abdominal pain, weight loss and intestinal obstruction. The diagnosis was made by MRI enteroclysis and endoscopy. Open diverticulectomy with choledochostomy and insertion of a T-tube was performed and resulted in a rapid improvement of the symptoms.

Cardiac rupture in embolic myocardial infarction after implantation of a valved aortic conduit.

We report a case of an apical myocardial infarction complicated by left ventricular wall rupture due to coronary artery embolism four years after surgery of an acute type A dissection of an aortic aneurysm with implantation of a valved aortic conduit.

Surface versus confinement induced morphology transition in triblock copolymer films: a grazing incidence small angle neutron scattering investigation.

The internal nanostructure resulting from microphase separation in triblock copolymer films of polyparamethylstyrene-block-polystyrene-block-polyparamethylstyrene, P(pMS-b-Sd8-b-pMS), has been investigated with grazing incidence small angle neutron scattering (GISANS). X-ray reflectivity, grazing incidence small-angle X-ray scattering (GISAXS), optical microscopy and atomic force microscopy (AFM) complement the investigation. The influence of two limiting interfaces present in confinement is compared to the presence of only one surface. GISANS allows for the detection of structures in the very limited sample volume of confined films as well as for a depth sensitivity to probe the near free surface part of bulk films. With respect to the surface a perpendicular oriented lamella is observed. In contrast to the shrinkage of the characteristic lamellar spacing in confinement at the free surface, a slight increase is determined.

[TSE surveillance in small ruminants and pigs: a pilot study]. / Uberwachung von TSE bei kleinen Wiederkäuern und Schweinen: Eine Pilotstudie.

Switzerland is controlling Transmissible Spongiform Encephalopathies (TSE) in cattle (BSE) and small ruminants (scrapie). Since BSE is potentially transmissible to sheep, goats or pigs through feeding of contaminated meat and bone meal, implementation of an active surveillance programme for TSE in these species is discussed. The aim of this pilot study was to obtain preliminary data on the prevalence ofTSE and other neurological disorders in these populations. For that purpose, a total of 398 perished and 825 slaughtered adult small ruminants and pigs was examined for the presence of neuropathological changes. None of these animals revealed positive for TSE. However, the investigations demonstrated that perished sheep and goats exhibited a higher prevalence of relevant neuropathological changes when compared with slaughtered animals. From these results, it is concluded that perished small ruminants are probably a risk population for TSE and should be considered as target populations for an active surveillance programme.

Thin casein films as prepared by spin-coating: influence of film thickness and of pH.

Casein films were successfully prepared with the spin-coating technique of aqueous casein solutions on base-treated glass surfaces. The film structure is investigated in real space with optical microscopy and atomic force microscopy and for the first time in reciprocal space with grazing incidence small-angle X-ray scattering (GISAXS). The size of the substructures detected in the film increases with pH from 170 nm (pH 5.1) up to 490 nm (pH 9.4). Dynamic light scattering experiments reveal that the average diameters of casein micelles in solution exhibit the same quantitative increase. This result suggests that the substructures detected in the bulklike films with GISAXS reflect intact casein micelles. However, with thin homogeneous casein films, the micelle size diminishes with decreasing film thickness. This indicates that the moderate pressures introduced by spin-coating force the micelles to rearrange into a more compact structure.

[Swiss scrapie surveillance. I. Clinical aspects of neurological diseases in sheep and goats]. / Scrapie-Uberwachung in der Schweiz. I. Klinische Aspekte von neurologischen Erkrankungen bei Schaf und Ziege.

Small ruminants infected with scrapie show a large range of often unspecific clinical symptoms. The most-often described signs, locomotion, sensibility and behavioural disorders and emaciation, rarely occur together, and cases have been described in which only one of those signs was detectable.Thus, formulating a well-circumscribed definition of a clinical suspect case is difficult. Most animals with CNS-effecting diseases such as listeriosis, polioencephalomacia, cerebrospinal nematidiasis and enterotoxemia will, in a thorough neurological examination, show at least some scrapie-like symptoms. Among the 22 neurological field cases examined in this study, a goat with cerebral gliomatosis and hair lice showed the closest similarity to clinical scrapie. The unilateral deficiency of the cerebral nerves has potential as an clinical exclusion criterion for scrapie. However, the laboratory confirmation--or exclusion--of scrapie remains important. It thus needs to be realized that a consistent and thorough examination of neurologically diseased small ruminants (including fallen stock) is the backbone of a good surveillance system for these diseases. This should be a motivation for submitting adult sheep and goats for neuropathological examination.