Kidney Transplantation in Abernethy Malformation: A Case Report.

Abernethy malformation is a rare disorder defined by congenital portosystemic shunt. Advances in clinical imaging have led to increased identification of this anomaly, which has proven to be more common and more clinically diverse than previously assumed. Late presentations are not uncommon. We present a 35-year-old patient with type Ia Abernethy malformation and biopsy-confirmed mesangiocapillary glomerulonephritis who was referred for deceased donor kidney transplantation. After the diagnosis was confirmed, the patient remained stable and asymptomatic on a supervised low-protein, high-carbohydrate diet. The patient received the kidney transplant from a brain-dead donor with standard characteristics. The procedure was uneventful; no vascular or vesical abnormalities could be identified at the surgical site. Recovery was uneventful with excellent graft function. Unique issues with immunosuppression were identified. Pharmacologic adjustments accounting for congenital complete portosystemic shunting affecting liver first pass effect as well as multiple drug interactions were necessary and sufficient. Abernethy malformation may follow indolent course into adulthood and may be an unrelated finding in a patient with chronic kidney disease. Kidney transplantation proved to be feasible and safe in this young male with apparently efficient compensatory mechanisms.

Biosystem models, generated from a complex rule/reaction/influence network and from two functionality prototypes.

In this work we have further developed the Direct Computer Mapping (DCM) based modelling and simulation methodology. A unified, transition-based representation of complex rule, reaction and influence networks has been introduced and two prototypes (one general state- and another general transition-prototype) have been developed for the unified functional modelling of the state and transition nodes. Starting from the network and from the functional prototypes, an automatic generation method of the graphically editable and extensible GraphML description of biosystem models has been elaborated. The new developments have been implemented in the improved kernel of DCM models. The applied knowledge representation makes possible the unified generation and execution of the balance-based quantitative and influence- or rule-based qualitative, as well as optionally time-driven, multiscale biosystem models. Application of the developed methodology has been illustrated by the improved implementation of the formerly studied and upgraded example biosystem model for combining the detailed, quantitative p53/miR34a signalling system with the pathological model through an extended rule-based coupling model.

[Treatment of Tibial Shaft Fractures with the Stable Angle Tibial Nail Targon TX]. / Versorgung von Unterschenkelfrakturen mit dem winkelstabilen Unterschenkelmarknagel Targon TX.

Tibial shaft fractures are among the most common long bone fractures in humans. The incidence is 1-2 per 100,000. The gold standard of treatment for AO type 42 A-C fractures is a locking intramedullary nail. The development of new implants has extended the indications for this minimally invasive technique, so that now AO types 41 and 43 can also be treated with special nails. Fixed-angle screw anchors increase primary stability and supplemental locking devices located proximally and distally extend the spectrum of use to metaphyseal fractures. The cannulated Targon TX titanium nail can be introduced, either with or without reaming. Using an operative video, the treatment of a tibial fracture with an intramedullary nail is demonstrated in stages and the operative steps further illustrated on artificial bone.

Prognostic Value of Proinflammatory Markers in Patients After Kidney Transplantation in Relation to the Presence of Diabetes.

BACKGROUND: Patients who are receiving immunosuppressive treatment after kidney transplantation are at greater risk of developing new-onset diabetes after transplantation (NODAT). New biochemical markers that may contribute to a better assessment of the prognosis of renal failure for patients diagnosed with diabetes mellitus (DM) are needed. The aim of this study was to assess selected proinflammatory markers in patients after kidney transplantation depending on the prevalence of DM and to evaluate the predictive value of these cytokines. METHODS: A total of 82 patients were divided into 3 groups after kidney transplantation and were included in the analysis: group I, no DM; group II, DM diagnosed before transplantation; and group III, NODAT. Selected marker levels (platelet-derived growth factor, transforming growth factor ß1, tumor necrosis factor receptor II [TNF-RII], and high-sensitivity interleukin-6 [IL-6 HS]) were assessed by using enzyme-linked immunosorbent assays. For summary endpoint, a return to dialysis treatment and/or death of the patient was adopted. RESULTS: Patients with NODAT were characterized by higher levels of IL-6 HS and body mass index. There were no statistically significant differences in the levels of other assessed markers among the 3 analyzed groups. The summary endpoint was observed in 16 cases (19.5%). Patients with summary endpoint during the observation time at baseline had higher levels of TNF-RII (7180 vs 4632 pg/mL; P = .0002) and IL-6 HS (4.58 vs 2.72 pg/mL; P = .033). CONCLUSIONS: Levels of inflammatory markers in patients after kidney transplantation did not differ between groups with and without DM. In the study population, DM was not a significant risk factor for graft loss or death. Patients who experienced these complications at baseline were characterized by higher values of TNF-RII and IL-6 HS.

Effects of Immunosuppressive Drugs on Serum Fatty Acids of Phospholipids Fraction in Renal Transplant Recipients.

BACKGROUND: Immunosuppressive medications often cause posttransplant hyperlipidemia. The effects of cyclosporine (CsA) and tacrolimus (Tac) on lipid profile is well-known; however, there are very few studies related to the effect of these immunosuppressants on fatty acids (FA) of phosholipids fraction (PL) in renal transplant recipients (RTR). We sought to analyze the FA profile in PL fraction of RTR treated with Tac or CsA. METHODS: The study included 65 renal transplant patients on CsA (n = 24, group I) or Tac (n = 41, group II), and 14 healthy controls. Individual serum FA concentrations were measured by gas chromatography. Chemstation software was used to analyze the data. RESULTS: No differences between studied groups and controls were noted for monounsaturated FA, polyunsaturated n-3 FA (PUFA n-3), PUFA n-6, or the ratio of PUFA n-6 to PUFA n-3. The following mean values of FA were significantly higher in the CsA-RTR and Tac-RTR as compared with controls: total FA (P < .01 in both cases), saturated FA (SFA; P < .02 in both cases), C12 (P < .003 in both cases), C18 (P < .003 in both cases), and C18:2 (P < .01 for CsA RTR; P < .02 for Tac RTR). No differences between the measurements in patients on CsA and in patients on Tac were noticed. Significant correlation between SFA and eGFR was observed only in the CsA RTR group (P < .05). A negative relationship between PUFA n-6 and the estimated glomerular filtration rate was seen, but the correlation was not significant. CONCLUSIONS: Immunosuppressive drugs may affect FA metabolism, but the FA profile does not depend on the type of immunosuppressive drug administered.

Psychological Predictors of Cooperation in the Chronic Treatment of Kidney Transplantation Patients.

INTRODUCTION: A patient who complies with doctor recommendations is an indicator of proper cooperation in treatment. It is affected by environmental factors, soft competences of the doctors, and properties of the human personality. We investigated the psychological characteristics of patients that may facilitate human contact and promote healthy behaviors. The aim of the study was to analyze the importance of psychological factors for the occurrence of health-related behaviors necessary for cooperation in treatment. MATERIAL AND METHODS: The study was conducted in a group of 105 patients (62 males and 43 females) aged from 25 years to 82 years old (mean, 50.4 years) after kidney transplantation who remained in follow-up at the Outpatient Transplant Clinic. We used two questionnaires: one for the patients and one for their doctors, including an assessment of healthy behaviors listed in 10 categories. The patients also completed the tests exploring the sense of self-efficacy (generalized self-efficacy scale), optimism (life orientation test - revised) and the control of emotions (Courtauld emotional control scale) in a Polish adaptation by Zygfryd Juczynski. In the statistical analysis, the Spearman rank correlation coefficient and the Kanonicza analysis were used, adopting the significance level of P < .05. RESULTS: We found significant correlations between psychological factors and behaviors of the patients. The patients controlling the expression of anxiety often concentrated on cleanliness and hygiene (P = .013). The patients controlling the expression of anger (P = .008) and anxiety (P = .049) were less likely to perform self-observation, being of the opinion that the role of the physicians was to evaluate the development of the disease and advances in treatment. The patients with higher levels of optimism were perceived by the physicians as better cooperating in conducting self-observation (P = .024) and adherence to hygiene (P = .047); they were also less frequently struggling with ophthalmic problems (P = .004). The relationship between the factors associated with the disease and treatment (pressure, the efficiency of the transplanted kidney, and duration of treatment) and psychological factors (optimism, emotional control, and self-efficacy) has been confirmed. The emerged factors significantly affected each other, which indicated the matching of the model (P = .08). CONCLUSIONS: The analysis of the results shows that psychological and somatic functioning of patients has a strong relationship with certain pro-health behaviors that determine the collaboration in treatment. This can serve as a basis for modifying the rules of managing the patients.

[No Blister-Wrapped Pills: Perforation after Ingestion a Blister-Pack]. / Keine Tabletten im Blister: Perforation nach Verschlucken von Tabletten im Blister.

BACKGROUND: Pills in sharp packaging that are accidentally swallowed (blisters) can cause perforations in the gastrointestinal tract, which are only clinically apparent after the emergence of mediastinitis or peritonitis. Mortality is high. PATIENTS: We have seen two cases in cognitively limited patients, one with oesophageal and one with ileal perforation. RESULTS: Despite surgery, the patient with oesophageal perforation died 3 weeks later of multi-organ failure. The patient with ileal perforation survived sepsis after multiple procedures. CONCLUSION: As a consequence, a hospital-wide policy was implemented prohibiting the issue of tablets in blister packaging at the bedside. No more cases have emerged since that time.

[Zwipp Percutaneous Suture of the Achilles Tendon with the Dresden Instruments]. / Die perkutane Achillessehnennaht nach Zwipp mit dem Dresdner Instrumentarium.

OBJECTIVE: Rupture of the Achilles tendon is the most common rupture of a tendon in man. Acute rupture of the Achilles tendon may be treated in a variety of manners, including conservative treatment, open suture and percutaneous suture. Surgical treatment of active patients is recommended, as the risk of re-rupture is greater after non-surgical treatment. The aim of surgery is adequate treatment of Achilles tendon rupture with a low rate of complications, high comfort for patients and fast social and occupational rehabilitation. INDICATION: The indication for surgical treatment of Achilles tendon rupture predominantly includes ruptures in active patients, with the goal of optimal functional rehabilitation. Furthermore, the percutaneous technique protects soft tissue, with a lower rate of wound healing disorders and infection than with open surgical treatment. METHOD: In our clinic we perform the percutaneous suturing technique with the Dresden instruments. The surgical technique and functional aftercare are shown in a video clip. Between 2007 and 2013, we treated 212 patients with acute Achilles tendon rupture by surgery with the Dresden instruments. There were 7 re-ruptures (3.3 %) and one case of infection within one year of surgery. SUMMARY: Percutaneous Achilles tendon suture technique with the Dresden instruments is a safe operation that protects soft tissue. Patient satisfaction is high and the rate of complications is low. This allows rapid social and occupational rehabilitation.

[Percutaneus Suture of Achilles Tendon Rupture--Operation for Beginners?]. / Perkutane Achillessehnennaht--eine sich lohnende Anfängeraufgabe?

BACKGROUND: Acute rupture of the Achilles tendon is the most common tendon injury, with an incidence of 30/100,000 population. With the Dresden instruments, operative tendon suture can be standardised and is safe, quick and minimally invasive. With post-operative functional therapy in a walking boot, very good clinical results can be achieved. QUESTION: Is this operation suitable as an educational procedure and is its performance still economic? MATERIALS AND METHODS: Between 1 January 2007 and 31 December 2013, 212 patients with acute rupture of the Achilles tendon were operated using the Dresden instruments. There were 167 males and 45 females, with an average age of 46 years. 99 operations were performed by trainees, 46 by attending surgical staff, and 57 by a senior surgeon. RESULTS: With the trainees, the mean duration of the operation was 29:53 minutes, and with the attending staff 29:10 minutes (n. s., p > 0.1). The rate of complications (re-rupture, infection, and sural nerve damage) was 5/99 (5 %) for the trainees, 4/46 (8.7 %) for the attending staff, and 3/57 (5.3 %) for the senior surgeon. A total cost analysis yielded a total operative cost of 445.76 € for outpatient surgery. With a billed sum of 490.11 €, net income of 44.35 € per case is generated. In patients with reasonable indications for 2-day short inpatient treatment, total treatment cost was 3232.70 €. CONCLUSION: Percutaneous suture of the Achilles tendon with the Dresden instruments is a standardised and cost-effective surgical procedure. It is suitable as a "beginner's" procedure that can be performed quickly, safely, and cost-effectively.

[Secondary Splenic Rupture after Initially Inconspicuous CAT Scan]. / Sekundäre Milzruptur bei primär unauffälliger Computertomografie.

BACKGROUND: Splenic injuries occur in 1-5 % of blunt abdominal trauma cases. After initial haemorrhagic compression, secondary delayed spleen rupture can occur with a latency of one day to a month or longer. Mortality is then up to 15 %. The spleen injury is almost always recognisable on CT or ultrasound. CASE HISTORY: In one case from our clinic, secondary splenic rupture occurred in a patient after discharge from hospitalisation, even though the initial CT and ultrasound were unremarkable. The patient survived, and underwent emergent splenectomy 8 days after the trauma. An expert review of the case identified no errors in treatment. CONCLUSION: No case of secondary splenic rupture after initially unremarkable diagnostic studies and clinical course has previously been published. Secondary splenic rupture has a high mortality rate. Patients should be advised of potential complications after hospital discharge, and should return to the hospital immediately in case of symptoms.

[Balloonsacroplasty: C-arm or CT controlled application? : Experience with 46 patients]. / Ballonsakroplastie: C-Bogen-kontrolliert oder CT-gesteuert? : Erfahrungen bei 46 Patienten.

INTRODUCTION: Sacral insufficiency fractures are often overlooked and lead to severe therapy-resistant pain. These fractures can be most sensitively detected with magnetic resonance imaging (MRI). Similar to balloon kyphoplasty, sacroplasty provides fixation of these fractures with cement. OBJECTIVES: This study was carried out to investigate whether pain is reduced using this method and whether computed tomography (CT)-guided cement application results in less cement extravasation and fewer complications than C-arm controlled application. MATERIAL AND METHODS: In a retrospective multicenter study, 46 patients (41 female, 5 male) with an average age of 75 years were treated by sacroplasty. The procedure was performed with CT-guidance for 25 patients and with C-arm control for 21 patients. Pain was evaluated using a visual analog scale. Patients were followed up for 6 months. RESULTS: The average operation time was 35 min and postinterventional hospital stay averaged 4 days. In the CT group pain decreased from an average score of 8.8 ± 0.7 preoperatively to 2.6 ± 0.6 postoperatively (p < 0.001) and in the C-arm group pain decreased from 8.2 ±1.0 to 2.2± 1.4 (p < 0.001). There were no cases of cement extravasation in the CT group (0 out of 25 = 0 %) and 8 asymptomatic cases in the C-arm group (8 out of 21 = 38 %). In addition, there were two injuries to the superior gluteal artery with hematoma in the area of puncture, one requiring operative treatment. There were two mortalities in the CT group from lung disease and stroke during the study but this was unrelated to the operation. CONCLUSION: Balloon sacroplasty results in a reliable and significant reduction in pain for sacral insufficiency fractures. The C-arm controlled cement application resulted in more frequent extravasation and complications than CT-guided application.

[Hemi-prosthesis in femoral neck Fracture in the Elderly--OP video and our results]. / Hemi-Prosthesis in Femoral Neck Fracture in the Elderly--OP Video and Our Results.

BACKGROUND: In geriatric patients with Pauwels II and III type femoral neck fractures, endoprosthesis is the therapy of choice. We want to demonstrate the operation technique of implantation of a hemiprosthesis (dual head prosthesis) by video in an 87-year-old female patient. In addition, we analyse the long-term results after surgery more than one year after endoprosthesis in patients with femoral neck fractures. METHOD: From 2007 to 2010, 219 public health insurance (AOK) patients with displaced femoral neck fractures were treated surgically at our hospital. This number of included patients puts us in the 97th percentile of all hospitals in Germany. Because the patients were publicly insured, all health information was available including completely retrospective post-hospital discharge as well as inpatient course and one-year mortality. RESULTS: There were 77 % female and 23 % male patients in the study with an average age of 83.5 years. In addition to the femoral neck injury, 19 % of the patients had an accompanying PCCL of 3, and 44 % had a PCCL of 4. 16 % suffered from heart failure, 23 % from diabetes, and 19 % from renal insufficiency. Time to surgery averaged one day post-injury. A dual head prosthesis (hemiprosthesis) was implanted in 81.4 % of cases, and a total joint prosthesis in 18.6 %. Average operative time skin to skin was 53 minutes. Average inpatient stay was 13 days. 71 % of patients could ambulate independently on discharge. Of the remaining patients, two-thirds were already not ambulating independently prior to the fracture. Hospital mortality averaged 6 % (national average 8.1 %), and 30-day and 90-day mortality rates were 6 % and 16.3 %. Within one year, 22.2 % of patients had died (national average 26.8 %), with a natural mortality probability of 7.1 % for an age of 83.5 years. 11 patients were re-admitted, for contralateral prosthetic implantation (n = 6) or revision after periprosthetic fracture (n = 4). 54.6 % of patients were admitted to hospital during the year for other diseases (national average 53.8 %). CONCLUSION: Endoprosthesis placement for displaced femoral neck fractures is a common, safe procedure. However, patients are old and have comorbidities. Despite recent decreases in hospital mortality, the risk of death remains more than twice as high within one year than that for uninjured patients of the same age.

[Is there Sense in Having a Certified Centre for Geriatric Trauma Surgery?]. / Lohnt sich ein zertifiziertes Zentrum für Alterstraumatologie?

INTRODUCTION: By 2030, 30 % of German residents will be over 70 years of age. In 2009, we conceptualised a TÜV (German Technical Inspection Authority) certified interdisciplinary centre for geriatric trauma care. All treatment pathways were agreed upon by all disciplines. Complex geriatric therapy was established, and patients were seen by trauma surgeons, geriatricians, therapists, and a pharmacist. Cases were discussed in team meetings. Morbidity and mortality conferences were conducted. In 2014, supplementary DGU (German Society for Trauma Surgery) certification was achieved. QUESTION: Have these measures led to improved quality of care and have the increased costs been covered? Is the formation of such a centre worthwhile for patients and hospitals? METHODS: This interdisciplinary treatment was implemented for all patients over 70 admitted with proximal femur, proximal humerus, and vertebral fractures. In 2012, there were 208 proximal femur, 171 vertebral, and 69 humeral fractures. The following parameters were defined for quality control: admission and diagnosis completed within 90 minutes, over 80 % of operations performed within 24 hours, reoperation rate under 12 %, decubitus rate under 5 %, mobilisation within 24 hours of surgery in 75 %, discharge to the previous environment in over 80 % of cases, and minimal mortality rates. RESULTS: Surgery performed within 24 hours fell just short of target in 2012 with 78 %, and 2013 with 81 %. The target time for diagnosis was reached in only 30 % of patients in 2012 and in 42 % in 2013; thus, more outpatient personnel was added. Mobilisation within 24 hours of surgery was completed in 79 % of patients in 2012. Implementation of decubitus standards reduced the rate of decubitus formation from 8 to 3.2 %. Reoperation rate was 5.2 % in 2012 and 3.1 % in 2013. In 2012, 6.4 % and in 2013, 9.3 % of discharged patients required short- and long-term care facilities for the first time, and the rest were discharged to rehabilitation or directly back home. Mortality rates for proximal femur fractures were 5.7 % in 2010, 5.1 % in 2011, 2.9 % in 2012, and 3.0 % in 2013. The implementation of complex geriatric therapy generated 103 treatments in 2012 with revenue of 912,000 €, and 160 treatments in 2013 with revenue of 1.35 million €. CONCLUSION: Interdisciplinary geriatric-trauma therapy for older patients resulted in improved measurable outcomes. Interdisciplinary geriatric trauma care with implementation of complex therapy benefits both patients and hospitals.

[Pertrochanteric femur fracture - our technique and results]. / Pertrochantäre Femurfraktur - Technik und eigene Ergebnisse.

BACKGROUND: In patients over 65 years, pertrochanteric proximal femur fractures are very common, with an incidence of 966/100,000. Treatment of choice is nailing or dynamic hip screws. The operative approaches are standardised and easy to learn. PURPOSE: We want to demonstrate the operation technique by video and our own results of the last two years. PATIENTS: From 1 January 2012 until 31 December 2013, 210 patients with an average age of 80.7 years and pertrochanteric fractures underwent treatment. RESULTS: Preoperative delay averaged one day. Skin to skin operative time averaged 48 minutes. There were 6 misplaced implants and cutouts (2.8 %), one infection (0.5 %), and 6 operative revisions because of hematoma or seroma (2.8 %). Four patients (1.9 %) died of cardiovascular failure with ASA 3 and 4 during the inpatient stay. CONCLUSION: Internal fixation with nailing in pertrochanteric femur fractures is a standard operative approach. It is quickly learnt and easily performed.

[New minimally invasive approach for palmar plating in distal radius fractures]. / Ein neuer Zugang zur minimalinvasiven palmaren Plattenosteosynthese bei distaler Radiusfraktur.

Distal radius fractures are among the most common fractures. Types A3 and C2 make up almost half of these. Volar fixed-angle plate fixation is the gold standard of treatment today. We wanted to minimise the approach to the distal radius through a transverse 2-3 cm incision in the wrist flexor fold, tunnelling beneath the pronator muscle. The operative technique is demonstrated here. 11 patients, averaging 70 years of age, underwent surgery for 7 A3 and 4 C2 type fractures. Average operating time was 50 minutes. Length of admission averaged 2.9 days. Using a visual analogue scale, pain decreased from 6/10 preoperatively to 3/10 on post-op day one and 2/10 on post-op day three. After 6 weeks, flexion and extension averaged 45-0-45°, and radial and ulnar deviation 20-0-20°. Pronation and supination averaged 85-0-85°. Grip strength with manometer averaged 90 % compared to the contralateral side at 6 weeks and 96 % at 3 months. As comparison, from 1 January 2008 until 31 May 2013, we treated 908 patients with distal radius fractures with volar fixed-angle plates through a conventional longitudinal incision of 5-8 cm. The average skin to skin time was 46 minutes, with an average length of admission of 5.6 days. A minimally invasive approach to treat distal radius fractures with volar plate fixation and sparing of the pronator muscle is possible. The initial patients treated with this approach experienced minimal post-operative pain, shorter hospital admissions, and rapid grip strength recovery with almost undisturbed rotational motion.