Effectiveness of safety vests in pediatric horseback riding.

BACKGROUND: Despite the benefit of safety vests to the reduction of torso injuries in children and adolescents is unclear, its' use is recommended. The aim of the present study is to determine the effectiveness of safety vests actually used in pediatric equestrian activities. PATIENTS AND METHOD: In this case-control-study, we analyzed the accidents of 92 riders aged 18 or younger who fell off a horse onto his/her torso during a period of 18 months. Data were gathered from the clinical records. Additionally, a questionnaire was administered on the day of trauma by the patients and/or their parents. RESULTS: The cases comprised 31 patients who sustained torso injuries. The controls were 61 riders with injuries of other body parts than to the torso. Safety vest use was not associated with a lower risk of torso injuries (OR=1.18, 95% CI (0.50, 2.81), p=0.707). Post hoc power analysis revealed that within such a setting an odds ratio of 0.266 could be found with a power of 80%. CONCLUSION: This study is not able to show an association between wearing a torso protector and protection from torso injuries, probably due to confounding. We did not detect a high effect of safety vest usage in our study population. Whether the development of a new generation of safety vests might be more effective remains unclear. An effective vest should be adapted to the requirements of children and adolescents and should protect the thorax and abdomen, but also the cervical and the lumbar spine.

[Social integration and life satisfaction of childless women and men in mid- and late-life]. / Soziale Integration und Lebenszufriedenheit kinderloser Frauen und Männer im mittleren und höheren Erwachsenenalter.

OBJECTIVES: Adult children are important members of the social network of older persons. Children are particularly important in facilitating the social integration of the aged. Against this backdrop, this paper explores possible effects of childlessness on the social integration and life satisfaction of middle and older aged women and men. MATERIALS AND METHODS: The data used in this study are drawn from the German Socio-Economic Panel (GSOEP), an annual survey of private households in Germany. The analysis is restricted to respondents aged between 45 and 84 who live in a marital or nonmarital partnership. Multivariate models are used to examine the effect of childlessness on contacts with relatives and friends, civic, political, and religious participation, as well as life and family satisfaction. RESULTS: Cohabiting childless women and men in mid- and late life are only slightly less socially integrated than parents living in a partnership. Compared to parents, childless elders have fewer social contacts. However, childless men and women do not differ from empty nest parents in their civic, political and religious participation. Moreover, childless elders do not have a lower level of life satisfaction than mothers and fathers. Quite the contrary, childless men und women are happier than parents who coreside with their adult children. CONCLUSIONS: The results presented here revise the common assumption that childlessness negatively affects the social integration and life satisfaction of middle- and older-aged persons.

[Enchondroma of the hand - treatment and long-term outcome]. / Enchondrome des Handskeletts - Therapeutisches Vorgehen und funktionelle Langzeitergebnisse.

BACKGROUND: An enchondroma is with up to 90% the most common benign tumour of the hand. Functional long-term outcome studies of the several treatments do not exist. The aim of this study is thus to evaluate the information from our 147 patients about diagnostics, operative treatment and follow-up treatment. METHODS: 147 patients with 183 histologically secured enchondromas of the hand, who had been treated between 1973 and 2004, were analysed by follow-up examination and radiological findings retrospectively. RESULTS: We found 136 mono- and 11 polyostotic lesions. The proximal phalanx was afflicted most commonly (44.8%). There was no preference for one special finger, only the thumb was afflicted below average (9.8%). The most common symptoms were pain and swelling (51.7%) or pathological fracture (25%). We found 11 relapses (7.5%) after an average of 4.4 years. In two cases we found a grade 1 chondrosarcoma. 84.2% of the patients achieved a "very good" or a "good" functional long-term outcome, 11.7% a "fair" and 4.2% a "poor" outcome. CONCLUSION: Standard treatment should be the accurate extirpation of the tumour and subsequent filling of the defect with cancellous bone. Only very small, asymptomatic lesions can be treated conservatively with six-month check-up examinations.

[Extraosseous calcifications in dermatomyositis. A rare differential diagnosis of a benign heterotropic ossification]. / Extraossäre Kalzifikationen bei Dermatomyositis. Eine seltene Differenzialdiagnose bei benignen heterotopen Ossifikationen.

Juvenile dermatomyositis is rare but still the most common idiopathic inflammatory myopathy of the childhood. Operative treatment may be indicated, whenever joint motion and patients mobility is limited through the manifestation of calcinosis cutis. Although Vitamin K dependent coagulation pathways have been described, the entire pathophysiological mechanism of its occurrence is currently not clarified. Standard therapy includes the systemic application of steroids and cytotoxins, other options involve aluminum-hydroxid or diltiazem. Only in serious functional obstructions operative resection may be indicated. The case of a 39-year-old female with a 24 year history of dermatomyositis involving most areas of the upper and lower extremities like a coat of mail is presented. Surgical resection of the calcification revealed a good functional recovery of the joint but because of a high recurrency rate the operation is only indicated in special cases.

[Surgical indications in intraosseous lipoma of the calcaneus. Case report and critical review of the literature]. / Zur operativen Indikation beim intraossären Kalkaneuslipom. Kasuistik und kritischer Literaturüberblick.

Intraosseous lipomas represent a small number of benign bone tumors with incidence rates of approximately 0.1%. In about 15% these neoplasias are localized within the calcaneus, mostly at Ward's triangle. The tumors usually remain clinically inapparent and diagnosis is often obtained incidentally. Although CT scan and MRI provide specific and sensitive diagnostic tools that can distinguish morphology and dignity, surgical treatment is not standardized yet. In conjunction with a case report, we summarize and critically compare current treatment strategies.

[A new irrigation-suction boring system facilities low-pressure intramedullary boring of isolated swine femurs]. / Ein neues Spül-Saug-Bohrssystem ermöglicht die druckarme Markraumbohrung an isolierten Schweinefemora.

AIM: Intramedullary nailing is the treatment of choice for the stabilization of fractures of long tubular bones. An important disadvantage of this method is the increase in intramedullary pressure and the resulting release of fat into the venous blood system during reaming of the medullary canal. We have developed a new type of rinsing-suction-reamer (SSB) in order to minimize these disadvantages. Trials were initiated to investigate whether it is possible to ream the medullary canal with the SSB without pressure increase in comparison with the standard AO-reamer (AOB). METHODS: Reamed intramedullary nailing was performed in 20 isolated pig femora. The intramedullary pressure was recorded continuously. RESULTS: While stepwise reaming was performed, the pressure only rose above the physiological level in AOB. During insertion of the guide wire and the nail, comparable values were measured for AOB and SSB. CONCLUSION: Our experiments show that reaming of the medullary canal is possible without a pressure increase using the SSB in comparison with AOB.

[How are beginning students in surgery selected? Results of a survey of German consultant surgeons]. / Wie werden Berufsanfänger in der Chirurgie ausgewählt? Ergebnisse einer Umfrage unter deutschen Chefärzten.

AIM: After finishing medical school it is getting more and more difficult for medical students to get one of the rare positions in a surgical training program. Only a good career plan and an intelligent strategy for the first steps in surgical life seem to be an advantage for that competition. On the other hand the selection of basic surgical trainees only based on the curriculum vitae and brief interviews may not be satisfying. The aim of this investigation was to answer the following questions: 1. How do consultant surgeons select their basic trainees? 2. How important is the applicant's record and the interview? 3. Which educational and personal criteria are important for the selection? 4. How can medical students improve their chance of getting a position in a surgical training program. METHODS: Using an anonymous and standardized questionnaire 39 chiefs of university departments of surgery and 44 consultant surgeons each from general and local hospitals were interviewed concerning their selection process and criteria required for application in their training program. The candidates were chosen from an official address list (Deutsche Chirurgie 98, Berufsverband der Deutschen Chirurgen). The questionnaire was sent to the candidates by official postal service together with a prepaid return envelope. RESULTS: Twenty-eight chiefs of university departments of surgery (71.8%) and 29 (65.9%) and 20 (45.5%) of the interviewed consultant surgeons in general and local hospitals responded to the 89-item questionnaire. It turned out that the majority of applications were send to the clinics at the applicant's initiation. Personal relationships or networks are important. Position advertisements are not important. 85.1% of the responders are satisfied with their procedure of selection, nevertheless, 43.4% are interested in recruiting markets. In detail, chiefs of surgical departments in university clinics get a mean of 12.3 (5-50) applications for basic surgical training per month, consultant surgeons in general hospitals 6.5 (4-20), those in local hospitals 5.6 (2-10). The completion and the contents of the doctor's thesis, former research efforts, foreign languages, computer knowledge and other qualifications are the most important criteria in the selection process. Reliability, loyalty, physical and psychological stability, organising and planning ability, stamina, sociability and independence are the most valued personal skills. CONCLUSIONS: Despite the satisfaction with the established common selection process, the high rate of participation in our study shows how important this subject is ranked by leading surgeons. It turned out that besides professional qualification, personal skills are a major criterion in the selection of basic surgical trainees.

Outcome of surgical intervention for rectoneovaginal fistulas in Mayer-Rokitansky-Kuester-Hauser syndrome.

Creation of a neovagina to treat vaginal atresia or aplasia in Mayer-Rokitansky-Kuester-Hauser syndrome must always be followed by long-term application of dilators to avoid shrinkage. However, rectoneovaginal fistulas are caused by chronic alteration and consecutive necrosis of the posterior neovaginal wall. We evaluated retrospectively the postoperative outcome of rectal wall and neovaginal reconstruction using a standardized surgical technique in an exclusive collection of women. Eight women with a mean age of 28 years (range 22-31 years) were treated for rectoneovaginal fistulas in our clinic. Preoperatively, proctoscopy, sphincter manometry, endoluminal rectal ultrasonography, and colonoscopy were performed; and regular postoperative follow-up by digital examination and rectoscopy were obligate. The standard surgical procedure via a perineal approach included fistulectomy and closure of the mucosa and rectal wall followed by a levatorplasty. All but one woman had a temporary colostomy. After 2 weeks the patients were allowed to wear vaginal dilators of a smaller size. Within the mean follow-up period of 20 months, reintervention was necessary twice because of late fistula relapse detected by proctoscopy, barium enema, and subjective symptoms. Morbidity was 25% (n = 2) due to secondary superficial wound healing or urinary tract infection. The average time of the hospital stay was 13 days (10-14 days). One patient complained of vaginal shrinkage and underwent local estrogen therapy with a good functional result 3 months later. Proper fistulectomy and surgical reconstruction with interpositioning of well perfused muscle layers achieved good functional outcome with an acceptable number of minor morbidities. Local estrogen treatment is helpful for avoiding scarification and decreasing the neovaginal size.

The anastomosis between renal polar arteries and arteria epigastrica inferior in kidney transplantation: an option to decrease the risk of ureter necrosis?

Ureteral necrosis after renal transplantation is often the result of impaired perfusion due to loss of donor polar arteries. A way of preserving polar arteries is their anastomosis with the A. epigastrica inferior. In three cases (aged 49-, 58-, and 63 years), 9.3 % of 33 living donors, we detected donor polar arteries on both sides, and anastomosed the polar artery to the A. epigastrica inferior with microsurgical methods. Intraoperatively, the flow was measured by flowmeter, in the postoperative course duplexsonography and MR-angiography was performed. In all three cases we noted a bluish, ischemic parenchym mass of 10-25 % of the kidney and ureter. It recovered immediately, however, after the polar artery had been reconstructed. Intraoperative measurement showed a high flow on the polar- and the main renal artery. Duplexsonography and MR-angiography documented a good flow on the A. epigastrica anastomosis. There have been no signs of ureteral problems at all. After a mean follow-up time of 26 months, the mean creatinine level is 1.46 mg/ml. Ureteral necrosis after kidney transplantation is mostly the result of a lack of perfusion of the polar arteries of the lower kidney pole. If arteriosclerotic lesions inhibit an anastomosis with the renal artery, the anastomosis with the A. epigastrica inferior seems to be a useful alternative.

Native pyeloureterostomy after kidney transplantation: experience in 48 cases.

Necrosis and stenosis of the ureter are severe complications after kidney transplantation and occur with mean incidence of 2,9-13,4 %. Several surgical techniques like simple nephrostomy or complex urinary tract reconstruction have been applied for repair. In this study, our experience with native pyeloureterostomy (NPUS) using the native ureter is presented. Between March 1978 and June 1996, 2,592 kidney transplantations were performed in our institution. In 48 patients (1,9%), secondary urinary tract reconstruction by NPUS was necessary. These patients were evaluated retrospectively by review of the case notes. At the time of operation the mean age was 45 +/- 14 years. Indications for NPUS were distal ureteral stenosis (n = 29), necrosis (n = 17), bleeding (n = 1) or iatrogenic lesion of the ureter (n = 1). The mean time period between transplantation and urinary tract reconstruction was 20 +/- 23 days (range: 1-90 days) for necrosis and 404 +/- 637 days (range: 14-2,385 days) for stenosis. A pyeloureterostomy was technically feasible in all patients using the recipient's ipsilateral ureter. In 40 out of 48 patients the graft developed a normal function postoperatively (follow up: 39 +/- 48 months). A graft nephrectomy was necessary only in one patient, because of complete pyelonnecrosis 6 days after NPUS. Two grafts were lost due to acute rejection. Data of five patients were not available > 15 years after successful reconstruction. We can conclude that NPUS is a safe and simple rescue technique for the treatment of distal ureteral complications after kidney transplantation. Therefore, this technique should be the therapy of choice when secondary reconstruction by re-ureteroneocystostomy is not possible.

Recurrent rectoneovaginal fistula caused by an incidental squamous cell carcinoma of the neovagina in Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: Mayer-Rokitansky-Küster-Hauser syndrome is a congenital malformation characterized by an absence of the vagina associated with a variable abnormality of the uterus and the urinary tract but functional ovaries. Surgical correction requires the creation of a neovaginal canal by the performance of a neovaginoplasty and an accurate long-term application of an artificial phallus phantom to avoid secondary shrinkage of the canal. Due to the chronic alteration of the posterior neovaginal wall, ulcers and consecutive fistulae may occur. We report the clinical course of a female who required surgical intervention for a rectoneovaginal fistula and developed a recurrence of the fistula due to one of the extremely rare squamous cell carcinomas of the neovaginal epithelium in order to show potential diagnostic and therapeutic features. METHOD: The systematic report of a case is presented. RESULT: Almost 13 years following the initial construction of a neovagina the patient developed a single-tract rectoneovaginal fistula. After surgical repair she represented with a recurrence due to a vast squamous cell carcinoma of the former operation site. Tumor en bloc resection was performed and currently (follow-up: 4 months) she has no signs of new tumor progression. CONCLUSION: Creation of a neovagina is the standard procedure for treating vaginal atresia or aplasia. Because of the long clinical course postoperatively, complications may occur. This report of a case of a malignant transformation in neovaginal epithelium shows the potential risk of malignancy and underlines the necessity of a close follow-up.

Recurrent cardiocirculatory arrest after kidney transplantation related to intravenous methylprednisolone bolus therapy.

BACKGROUND: Intravenous bolus therapy with steroids is often used in standard immunosuppression initially after organ transplantation and to treat acute graft rejection. Although this regimen in generally is safe, severe adverse effects can occur. METHODS: This letter gives a picture of the eventful clinical course of a patient with preexisting heard problems after renal transplantation. RESULTS: This case report proves lethal cardiopulmonary complications closely related to the recurrent intravenous administration of methylprednisolone in a risk patient. CONCLUSIONS: Severe side effects after the application of high-dose steroids are possible. If risk patients are identified, steroid bolus therapy should be avoided or, if not possible, should only be done under close monitoring.

Conditioned immunosuppression makes subtherapeutic cyclosporin effective via splenic innervation.

The present study investigated the mechanisms by which conditioned immunosuppression enhances the effectiveness of cyclosporin A (CsA) treatment in prolonging heart allograft survival. Dark Agouti rats that were administered subtherapeutic CsA (7 x 2 mg/kg on alternate days) rejected heart allografts at the same time as non-CsA-treated rats. The addition of a behavioral conditioning regimen (conditioned stimulus, saccharin; unconditioned stimulus, 20 mg/kg CsA) to the subtherapeutic CsA protocol produced a significant prolongation of graft survival, including long-term survival (>100 days) in 20% of the animals. Prior sympathetic denervation of the spleen completely blocked this effect. In nontransplanted rats both conditioning and CsA treatment reduce interleukin-2 and interferon (IFN)-gamma in the supernatant of proliferating splenocytes. Additionally, therapeutic CsA treatment decreased the number of IFN-gamma-producing CD4(+) naive and memory T cells in the spleen. In contrast, behavioral conditioning increased that number. These data indicate that behavioral conditioning prolongs heart allograft survival by inhibiting the release of these cytokines in the spleen via sympathetic innervation, supplementing the inhibited cytokine production induced by CsA treatment.

[Peritoneal lavage in standardized peritonitis models]. / Die Abdominal-Lavage im standardisierten Peritonitismodell.

The peritoneal lavage in peritonitis can be studied in a standardized manner only in animal models, because peritonitis is too variable and dependent on too many patient related factors. In this article answers are given to questions on the influence of different lavage substances on survival, local and systemic concentrations of bacteria, endotoxin, and TNF as well as on mesothelial adherence of bacteria. These data refer to results from acute models of infection published in the literature. Furthermore, we show from our own chronic peritonitis model the influence of the peritoneal lavage on abscess formation and translocation. After inoculation of a Bacteroides fragilis suspension, a chronic abscess forming peritonitis was induced. At day 3/7/14 intraabdominal abscesses were found in 2/4/6 of 8/5/6 animals in an untreated, in 1/3/5 of 5/5/5 animals in a saline lavaged, and in 5/0/2 of 5/5/5 animals in a Taurolidin lavaged group, respectively. Both, the intraabdominal and the systemic bacterial dissemination were more effectively inhibited by the Taurolidin lavage than by the saline lavage.

Behaviorally conditioned immunosuppression using cyclosporine A: central nervous system reduces IL-2 production via splenic innervation.

Bi-directional interactions between the central nervous system (CNS) and immune system are demonstrated by the modification of immune function using behavioral conditioning. However, the mechanisms by which the CNS achieves conditioned immunomodulation are still in question. Here, we report that the immunosuppressive effects of cyclosporine A (CsA) can be behaviorally conditioned in rats using saccharin as a gustatory conditioned stimulus. The conditioned effects were compared to control groups that received CsA paired with water (sham-conditioned), CsA injection on test days (CsA-treated), and unhandled rats (untreated). In conditioned animals, the mitogen-induced lymphocyte proliferation in the spleen is significantly suppressed, and the survival time of heterotopic heart allografts prolonged. These effects are paralleled by conditioned inhibition of IL-2 and IFN-gamma synthesis by splenocytes. Furthermore, the CNS-induced immunosuppression is mediated neuronally and not via the blood, since the conditioned reduction of proliferation and cytokine production is completely abrogated after surgical denervation of the spleen. Thus, during conditioning, the CNS learns to reinstate at demand a CsA-like immunosuppression via splenic innervation. This might be used as a supportive therapy for controlling immune functions.

Cyclosporine A affects open field behavior in DA rats.

Since the introduction of Cyclosporine A (CsA) for immunosuppression in solid-organ transplantation, the rate of allograft rejection has decreased substantially. However, treatment with CsA induces neuropsychological complications in patients, including affective disorders such as anxiety, disorientation, depression, aggression, paranoia, and apathy. These CsA-induced affective side effects cannot be extensively studied in humans. Therefore, this study investigates the effects of intraperitoneal CsA (20 mg/kg) injections on the open-field behavior of male Dark Agouti (DA) rats 1, 6, 12, and 23 h after drug administration on 3 consecutive days. CsA induced an increase in emotionality in DA rats 6 h after injection, reflected by decreased ambulatory activity in the open field and increased defecation. In addition, a decrease in rearing activity was observed 12 h after CsA administration. These behavioral alterations are discussed in the view of changes in cytokine profiles induced by CsA.

Behaviorally conditioned effects of Cyclosporine A on the immune system of rats: specific alterations of blood leukocyte numbers and decrease of granulocyte function.

Immunosuppression induced by Cyclosporine A (CsA) can be behaviorally conditioned. It is unknown, however, whether a taste aversion paradigm using CsA as an unconditioned stimulus (UCS) induces alterations of blood leukocyte numbers and function. Results obtained by three-colour flow cytometry and granulocyte chemiluminescence response demonstrate that in conditioned rats, absolute numbers of lymphocyte subsets, including B, CD8+ T cells and CD4+ naive and memory T cells, and granulocyte numbers and function were significantly decreased. In contrast to the conditioned response, CsA treatment alone increased lymphocyte numbers and did not affect granulocyte function. Thus, our data demonstrate that behaviorally conditioned CsA effects can be monitored in the blood. In addition, results indicate that the CNS mediates the behaviorally conditioned immunosuppression by reducing the availability and function of granulocytes and lymphocytes.

Conditioned taste aversion produced by cyclosporine A: concomitant reduction in lymphoid organ weight and splenocyte proliferation.

The classical conditioning of immune parameters is commonly conducted within a conditioned taste aversion (CTA) paradigm. In this study, the immunosuppressive drug cyclosporine A (CsA) was investigated for its ability to produce both taste aversion to a novel stimulus and conditioned alterations in immune functioning. The paradigm comprised the pairing of a 0.2% saccharin solution (the conditioned stimulus; CS) with an intraperitoneal injection of 20 mg/kg CsA (the unconditioned stimulus; UCS). Upon saccharin re-presentation, a marked reduction in fluid consumption was observed, indicating aversion to the novel substance (=CTA). By using a single CsA/saccharin pairing the CTA lasted for one CS representation. However, by implementing three pairings, this effect could be extended for up to seven representations. No noticeable difference was recorded by adjusting the saccharin representation from every consecutive day to every second day. The most effective paradigm in creating CTA was subsequently investigated for its effectiveness in producing conditioned immune alterations. Animals were killed on the day of the third CS re-presentation, and immune functions assessed. Conditioned animals displayed a significant reduction in thymus and spleen weights. Effects on the spleen were further investigated, revealing a significantly reduced proliferative ability of isolated splenocytes to concanavalin A. These results demonstrate that the physiological effects produced by CsA are sufficiently salient to elicit CTA. Furthermore, the reduction in lymphoid organ weight and splenocyte proliferation induced by CsA are also conditionable using this paradigm.

Work technique training for patients with chronic pain in neck, shoulder and arm. A questionnaire pilot study after a comprehensive exercise-oriented rehabilitation program.

Syftet med denna studie var att följa upp hur patienter såg på sin arbetsmiljö och arbetsteknik samt hur föreslagna arbetsplatsanpassningar hade genomförts efter deltagande i ett multimodalt intensivträningsinriktat rehabiliteringsprogram. Programmet inkluderade en väsentlig del av individuell ergonomisk analys, individuell ergonomisk rådgivning och specifik arbeetsteknikträning på arbetsterapiavdelningen. Patienterna hade kronisk muskuloskelettal smärta i armen. Efter rehabiliteringsprogrammet skickades ett frågeformulär till 181 patienter, varav 135 patienter (109 kvinnor och 26 män) (75%) svarade. Mer än halften av patienterna rapporterade att de oftere än en gång i veckan tänkte tillbaka på den individuella ergonomiska rådgivningen som gavs i samband med att videofilmen tagen på deras arbetsplats presenterades. Deras skattningar visade på en hög medvetandegrad när det gällde att la mikropauser under arbetet (dvs atl räta upp ryggen kombinerat med muskelavslappning), att arbeta med armarna nära kroppen och att lyfta bördor nära kroppen. Hälften av patienterna hade använt sig av möjligheten att ändra arbetsställning mer än en gång per timme. Resultatet indikerar att patienterna var medvetna om sin arbetsteknik efter deltagandet i rehabiliteringsprogrammet.