Accuracy of core needle biopsy for histologic diagnosis of soft tissue sarcoma.

The biopsy technique of choice in soft tissue sarcoma (STS) diagnosis is controversial. We examined the diagnostic accuracy of percutaneous core needle biopsy (CNB) and compared it to open incisional biopsy. A retrospective study included 91 incisional biopsies and 102 CNBs. A pair-match investigation was conducted on 19 patient pairs, comparing sensitivity, specificity, and diagnostic accuracy. Furthermore, we investigated the role of molecular pathology in sarcoma diagnostics. In 81/91 (89%) patients with incisional biopsy, the entity was confirmed by definitive pathology, whereas this was the case in 89/102 (87%) CNB patients (p = 0.52). Grading remained unchanged in 46/55 (84%) of incisional and 54/62 (87%) of CNBs (p = 0.61). The pair matched analysis showed that the correct entity was determined in 96% of incisional and 97.6% of core needle biopsies. The time between the initial consultation and the interdisciplinary tumor board's treatment recommendation was shorter in core needle biopsies (8.37 vs. 15.63 days; p < 0.002). Incisional biopsies led to two wound infections and one hematoma, whereas wound infection occurred in one patient after CNB. CNB leads to faster diagnosis while reaching the same histological accuracy and is less burdensome for patients. Still, surgeons need to remain aware of the possibility of biopsy failure.

Cryptic introgressions contribute to transgressive segregation for early blight resistance in tomato.

KEY MESSAGE: We identified cryptic early blight resistance introgressions in tomato breeding lines and demonstrated efficient genotypic selection for resistance in the context of a tomato breeding program. Early blight is a widespread and problematic disease affecting tomatoes (Solanum lycopersicum). Caused by the fungal pathogen Alternaria linariae (syn. A. tomatophila), symptoms include lesions on tomato stems, fruit, and foliage, often resulting in yield losses. Breeding tomatoes with genetic resistance would enhance production sustainability. Using cross-market breeding populations, we identified several quantitative trait loci (QTL) associated with early blight resistance. Early blight resistance putatively derived from 'Campbell 1943' was confirmed in modern fresh market tomato breeding lines. This resistance offered substantial protection against early blight stem lesions (collar rot) and moderate protection from defoliation. A distinctive and potentially novel form of early blight foliar resistance was discovered in a processing tomato breeding line and is probably derived from S. pimpinellifolium via 'Hawaii 7998'. Additional field trials validated the three most promising large-effect QTL, EB-1.2, EB-5, and EB-9. Resistance effects for EB-5 and EB-9 were consistent across breeding populations and environments, while EB-1.2's effect was population specific. Using genome-wide marker-assisted backcrossing, we developed fresh market tomato lines that were near-isogenic for early blight QTL. Resistance in these lines was largely mediated by just two QTL, EB-5 and EB-9, that together captured 49.0 and 68.7% of the defoliation and stem lesion variance, respectively. Our work showcases the value of mining cryptic introgressions in tomato lines, and across market classes, for use as additional sources of disease resistance.

[Safety culture in orthopedics and trauma surgery : Course concept: interpersonal competence by the German Society for Orthopaedics and Trauma (DGOU) and Lufthansa Aviation Training]. / Sicherheitskultur in Orthopädie und Unfallchirurgie : Kurskonzept: Interpersonal Competence by Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) and Lufthansa Aviation Training.

Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3­column model.

[Interpersonal competence in orthopedics and traumatology : Why technical and procedural skills alone are not sufficient]. / Interpersonelle Kompetenz in Orthopädie und Unfallchirurgie : Warum technische und prozedurale Fähigkeiten alleine nicht ausreichen.

Patient safety has increasingly gained significance as criterion which clinics and doctors will be measured against in terms of ethics and finances. The "human factor" moved into focus regarding the question of how to reduce treatment errors in clinical daily routine. Nevertheless, systematic mediation of interpersonal competences only plays a minor role in the catalogue of requirements for medical specialization and professional training. This is the case not only in orthopedics and traumatology, but in other medical fields as well. At the insistence of DGOU and in cooperation with Lufthansa Flight Training, a training model was initiated, comparable to training models used in aviation. In aviation, apart from the training of procedural and technical abilities, regular soft skills training has become standard in the training of all Lufthansa staff. Several studies confirm that by improving communication, interaction, and teamwork skills not only a reduction of intolerable incidents is observed, but also a positive economic effect. Interpersonal competences should be firmly anchored in orthopedics and traumatology and thus be implemented as third post in specialist training.

[Representatives of orthopaedic and trauma surgery residents in Germany]. / Assistentensprecher in Orthopädie und Unfallchirurgie in Deutschland.

In most German hospitals there are resident representatives to stand in for the rights and interests of residents. The precise number of representatives in orthopaedic and trauma surgery is unknown, as well as the field of duty and the rights of this position.The Junges Forum O&U presents survey data, which were collected from members of the German Society for Trauma Surgery (DGU), the German Society for Orthopaedics and Orthpaedic Surgery (DGOOC) and the German Society for Orthopaedics and Trauma (DGOU). All had an age below 40 years. The Survey was carried out in a period between 27th of January 2015 and 26th of March 2015.These data allowed the Junges Forum O&U to analyse the duties and numbers of representatives for residents in orthopaedic and trauma surgery in Germany. Questionnaires from 316 representatives were fully analysed. Of these, 92 % work at university hospitals. The conditions of election and the duties are not defined. The activity as representative was mainly fulfilled in spare time. The major aspect was conflict resolution between colleagues.The Junge Forum O&U presents the recommendation for election, field of duty and meetings on a regular basis with the other residents or even the first-line management.

[The Summer School of the German Society for Orthopaedics and Traumatology - A Success Story]. / Die Summer School der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie ­ eine Erfolgsgeschichte.

Background: It has been known for several years that orthopaedic and trauma clinics suffer from a shortage of young people, due to the substantial loss in attractiveness. The Youth Forum OU has been addressing this problem for many years, by initiating many projects such as the Summer School to counteract this trend. The purpose of this research is to evaluate the success of Summer Schools since 2009. Methods: The Youth Forum OU performed a survey in December 2014 to answer the research question on the basis of an internet-based poll of the student participants in all Summer Schools between 2009 and 2014. Following data cleansing, 121 students and former students were included in the survey. Results: Seventy-two completed questionnaires were collected and included in the evaluation. The survey included 40 % of Summer School participants, with a mean age of 27.3 years (SD ± 2.95); 50 % were female. Participation in the Summer School helped 50 % of the respondents to decide to start advanced study in orthopaedics and/or traumatology (OU). One third of these Summer School participants had already finished a university degree; 100 % are now residents in orthopaedics and/or traumatology. Regardless of prior plans, 87.2 % of participants are now residents in OU. Thirty-three are still students: 78.8 % have already decided to work in OU. The survey also served to identify the factors positively and negatively associated with OU. Unfavourable factors included the reputation of OU, and the difficulty of reconciling family and work. Favourable factors included surgical work and personal experience during university studies. Discussion: The aim of this study was to evaluate whether the efforts of the Youth Forum OU, the German Society for Orthopaedics and Traumatology (DGOU) and the local hospitals lead to increased interest in OU. The answer to this question is positive. This is particularly true for those students who did not plan to become an orthopaedic or trauma surgeon before participating in a Summer School. In conclusion, the efforts to recruit residents for OU by using Summer Schools were successful. Moreover, this research offers approaches to counteract the loss of attractiveness of OU.

[Long-term survival after severe trauma]. / Langzeitüberleben nach schwerem Trauma.

Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.

[P.A.R.T.Y. An initiative for more risk awareness among young road users]. / P.A.R.T.Y. Eine Initiative für mehr Risikobewusstsein bei Jugendlichen.

BACKGROUND AND OBJECTIVES: Accident prevention strategies aim to inform young people about risk-taking behavior and the consequences of trauma. The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program is an accident prevention program that focuses on the prevention of road traffic accidents among young road users. Initial results of the program were evaluated to find out if the implementation of this prevention program is feasible in Germany. MATERIAL AND METHODS: During a 1-day interactive course young road users were introduced to the work carried out in an accident trauma unit and were informed about injury mechanisms and about the consequences of trauma. A systematic evaluation was made by all participants. The results were analyzed to find out whether it is possible to implement the program and the impressions gained by the participants of the program in order to be able to make further adjustments. RESULTS: A total of 219 young road users participated in the P.A.R.T.Y. program between 2011 and 2013. All participants reviewed the structure of the program with the help of school grades. Of the participants 59 % (n = 129) rated the program as "very good" and 41 % gave the rating of "good". Overall, 70 % of all participants advocated that all people of the same age should participate in the program. The structure was described as being well-balanced with respect to the theoretical and practical stations. CONCLUSION: The P.A.R.T.Y. program is a standardized and well-established concept that can also contribute to accident prevention in Germany. It provides the possibility to implement an accident awareness program throughout Germany. Initial results show that the program can be implemented in German hospitals and that the program appeals to the target group of young road users.

Patterns of early resuscitation associated with mortality after penetrating injuries.

BACKGROUND: Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma. METHODS: Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more). RESULTS: A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15.7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24.4 per cent). Predicted mortality rates according to RISC-II were 20.4 and 20.5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0.121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres. CONCLUSION: Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

[Bilateral carotid artery dissection in a kite surfer by strangulation with the kite lines]. / Bilaterale Karotisdissektion eines Kitesurfers durch Strangulation mit Kiteleinen.

While a kite surfer was preparing the kite it was caught by a gust of wind, which blew it 10 m into the air and the cords became entangled around the neck of the kite surfer causing strangulation. After admittance to hospital, the diagnostics revealed multiple injuries including a bilateral dissection of the internal carotid arteries, cerebral edema and multiple fractures. As kitesurfing is gaining popularity severe injuries are becoming more frequent. Safety precautions, such as preparing the kite with two persons, wearing safety equipment and using bars with a safety leash can prevent severe injuries.

[Current practice in coagulation and transfusion therapy in multiple trauma patients: A German nation-wide online survey]. / Stand der Gerinnungs- und Transfusionstherapie beim Schwerverletzten : Eine deutschlandweite Online-Umfrage.

BACKGROUND: In recent years, the treatment of trauma-associated coagulopathy and bleeding has advanced enormously. The aim of this study was to assess the current practice of coagulation and transfusion management in Germany. PATIENTS AND METHODS: From October 2011 until January 2012 we conducted a survey via online-questionnaire that was sent per E-Mail to all members of the German Society for Trauma Surgery. It comprised 12 questions with respect to current treatment of coagulopathy and haemorrhage in trauma patients. RESULTS: The response rate was 145/3006 (5 %). The respondents had following specialties: 77.2 % trauma surgery 15.9 % anesthesiology, 6.9 % others. 64 % of respondents were employed by a Level 1 trauma centre, wheras 17 % worked in a local level 3 centre. The majority (94 %) claimed to treat hypothermia regularly. Only about half of the participants reported to follow a massive transfusion protocol in their institution. The potential components of these protocols were reported in varying rates, being it well-established components (e.g. FFP 78 %; Fibrinogen 75 %) or therapies with poor evidence in multiple trauma (Desmopressin 39 %, rFVIIa 47 %). Calcium was provided by only 48 % of respondents although generally recommended in all guidelines. CONCLUSION: The current study suggests that in Germany strategies and principles regarding management of trauma-associated coagulopathy are standardized only poorly. Level 1 centres appear to apply a more advanced approach, however to much variability exists with respect to the components of the transfusion protocols. The low response rate indicates that most German trauma surgeons consider coagulation and hemorrhage as "expert-topics" beyond their field of duty.

[Daily routine in orthopedics and traumatology - results of a nationwide survey of residents]. / Der klinische Alltag in Orthopädie und Unfallchirurgie - Ergebnisse einer nationalen Umfrage unter Assistenzärzten in O und U.

BACKGROUND: The subject orthopedics and traumatology suffers by a loss of attractiveness which results in a lack of young blood. The aim of this study of the Youth Forum of the German Society of Orthopedics and Traumatology (DGOU) is to register the working conditions of residents in orthopedics. MATERIAL AND METHODS: In the months September and October 2013 we performed a survey on members of the following German societies: German Society of Orthopedics and Traumatology (DGOU), German Society of Traumatology (DGU) and the German Society of Orthopedics and Orthopedic Surgery (DGOOC), (age < 40). Our questionnaire includes 15 questions. RESULTS: We achieved 28,9 % (n = 331) answered questionnaires. The mean working time per week is 55 hours. 73 % of all participants do more than 5 emergency services per month. 52 % are more than 3 times on duty for 24 hours. Only 13 % of all residents have well ordered working hours. Normally working time is divided into three parts: one third for bureaucracy, one for operation theatre and the last for other activities (e.g. ward round). 35,6 % do only one surgery per week, 12 % do not perform any surgeries. An annual report is performed only in 45 %. A structured concept of training only exists in 16 % of all hospitals. In addition to clinical work 45 % are involved in scientific projects, mostly in their spare-time. Finally 58 % of all surgeons would still recommend orthopedics and traumatology. CONCLUSION: In order to maintain orthopedics and traumatology as an attractive it is necessary to implement flexible working time models and to reorganize and improve training-concepts.

The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?

Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.

[Penetrating neck injury of a blacksmith by splitter projectile]. / Penetrierende Halsverletzung durch ein Splitterprojektil bei Schmiedearbeiten.

Laryngeal injuries are rare but potentially life-threatening injuries. Due to the topography of the neck, accompanying injuries of the greater blood vessels, cervical nerves, thoracic organs and spinal cord are common. Therefore in initial diagnostics, these must be excluded from injuries which determine the prognosis. A patient presented with ventral perforation of the larynx, initial dyspnea, hematemesis and left-sided emphysema of the neck. Cause of the findings, we treated the patient non-operatively in interdisciplinary consensus.

Differential Susceptibility of 39 Tomato Varieties to Phytophthora infestans Clonal Lineage US-23.

During the summers of 2012 and 2013, 39 tomato (Solanum lycopersicum) lines or varieties were evaluated for resistance to late blight in three separate field trials. In each trial, late blight was caused by field isolates of Phytophthora infestans clonal lineage US-23. Varieties with the late blight resistance genes Ph-1, Ph-2, Ph-3, and Ph-2 + Ph-3 were included, along with several heirloom varieties with grower-reported resistance and varieties with no known resistance. All six varieties with Ph-2 + Ph-3, along with NC25P, which is homozygous for Ph-3 only, showed a high level of resistance. Plum Regal F1, which is heterozygous for Ph-3 only, showed moderate resistance. Legend, the only variety with Ph-2 alone, also showed moderate resistance. Three heirloom varieties, Matt's Wild Cherry, Lemon Drop, and Mr. Stripey, showed a high level of resistance comparable with that of varieties with Ph-2 + Ph-3. New Yorker, possessing Ph-1 only, showed no resistance. Indeterminate varieties had significantly less disease than determinate varieties in two of the three trials. Overall, this study suggests that tomato varieties with both Ph-2 and Ph-3 can be used to effectively manage late blight caused by P. infestans clonal lineage US-23. Varieties possessing only Ph-2, or heterozygous for Ph-3, were better protected than those without any late blight resistance but might still require supplemental fungicide applications, while the variety that was homozygous for Ph-3 was highly resistant. Several heirloom varieties were also highly resistant, and the unknown mechanism of their resistance warrants further research. Finally, the plasticity observed in United States P. infestans populations over the past several decades necessitates continued monitoring for genetic changes within P. infestans that could lead to the breakdown of resistance reported here.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]. / Schockraummanagement Polytrauma : ATLS® und S3-Leitlinie.

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.