[The situation of education in ENT-residency-training in Germany]. / Die Weiterbildungssituation in der HNO-Heilkunde in Deutschland.

BACKGROUND: As a starting point for developing concrete suggestions for optimizing specialty training in German ENT departments, the present study analysed the current status of residency training in order to identify weaknesses. METHODS: Residents at German ENT departments were invited to participate in an online survey. The questionnaire comprised 78 individual questions. RESULTS: The questionnaire was answered by 223 ENT residents. Educational deficits such as a lack of regular feedback from supervisors, only moderately rated mediation of specialist competencies, capriciousness of the trainers in charge regarding the organisation of training, and time and personnel shortages were identified. Some of the mandatory recommendations of the specialty training regulations, including determination of concrete training goals during regular meetings or the use of a logbook, have only been implemented in limited cases. Demands for development of more external training opportunities (job shadowing/rotation) and an external objective review of the residency training (e.g., by a representative of the German Society of Otorhinolaryngology, Head and Neck Surgery, DGHNOKHC) in the sense of quality assurance are discussed. CONCLUSION: Implementation of structured and standardized ENT residency training in Germany, for which DGHNOKHC reviewal is also possible, can generate a basis for more effective compulsory residency training.

Cerebellar parcellation in schizophrenia and bipolar disorder.

OBJECTIVE: The cerebellum is involved in cognitive processing and emotion control. Cerebellar alterations could explain symptoms of schizophrenia spectrum disorder (SZ) and bipolar disorder (BD). In addition, literature suggests that lithium might influence cerebellar anatomy. Our aim was to study cerebellar anatomy in SZ and BD, and investigate the effect of lithium. METHODS: Participants from 7 centers worldwide underwent a 3T MRI. We included 182 patients with SZ, 144 patients with BD, and 322 controls. We automatically segmented the cerebellum using the CERES pipeline. All outputs were visually inspected. RESULTS: Patients with SZ showed a smaller global cerebellar gray matter volume compared to controls, with most of the changes located to the cognitive part of the cerebellum (Crus II and lobule VIIb). This decrease was present in the subgroup of patients with recent-onset SZ. We did not find any alterations in the cerebellum in patients with BD. However, patients medicated with lithium had a larger size of the anterior cerebellum, compared to patients not treated with lithium. CONCLUSION: Our multicenter study supports a distinct pattern of cerebellar alterations in SZ and BD.

Anisotropy of the magnetoviscous effect in a ferrofluid with weakly interacting magnetite nanoparticles.

The anisotropy of the magnetoviscous effect of a ferrofluid has been studied in a specially designed slit die viscometer, which allows three distinct orientations of the magnetic field with respect to the fluid flow. The corresponding Miesowicz viscosity coefficients were determined in dependence of the shear rate and the magnetic field intensity to gain a comprehensive magnetorheological characterization of the fluid. The particles in the fluid have a mean diameter of 13 nm corresponding to an interaction parameter of λ ≈ 1.3 for magnetite. Thus, the fluid can be expected to show a transition from non-interacting individual particles to microstructures with chain-like associated particles when the magnetic field intensity is increased and the shear rate is decreased. The observed field and shear dependent anisotropy of the magnetoviscous effect is explained coherently in terms of these microstructural changes in the fluid.

Cerebellar volume in schizophrenia and bipolar I disorder with and without psychotic features.

OBJECTIVE: There is growing evidence that cerebellum plays a crucial role in cognition and emotional regulation. Cerebellum is likely to be involved in the physiopathology of both bipolar disorder and schizophrenia. The objective of our study was to compare cerebellar size between patients with bipolar disorder, patients with schizophrenia, and healthy controls in a multicenter sample. In addition, we studied the influence of psychotic features on cerebellar size in patients with bipolar disorder. METHOD: One hundred and fifteen patients with bipolar I disorder, 32 patients with schizophrenia, and 52 healthy controls underwent 3 Tesla MRI. Automated segmentation of cerebellum was performed using FreeSurfer software. Volumes of cerebellar cortex and white matter were extracted. Analyses of covariance were conducted, and age, sex, and intracranial volume were considered as covariates. RESULTS: Bilateral cerebellar cortical volumes were smaller in patients with schizophrenia compared with patients with bipolar I disorder and healthy controls. We found no significant difference of cerebellar volume between bipolar patients with and without psychotic features. No change was evidenced in white matter. CONCLUSION: Our results suggest that reduction in cerebellar cortical volume is specific to schizophrenia. Cerebellar dysfunction in bipolar disorder, if present, appears to be more subtle than a reduction in cerebellar volume.

[Peer teaching and peer assessment are appropriate tools in medical education in otorhinolaryngology]. / Peer Teaching und Peer Assessment sind effektive Lehrinstrumente in der HNO-Heilkunde.

BACKGROUND: The use of student tutors (peers) is an accepted method in medical education. In 2011, final year students of the otorhinolaryngology (ORL) department of the University Hospital in Dresden were appointed as peers for the clinical ORL examination. They assisted in the instruction of the clinical ORL examination (peer teaching, PT) and served as examiners (peer assessment, PA) in the final objective structured clinical examination (OSCE). The effect on the quality of education and examination was examined. MATERIAL AND METHODS: 248 medical students (5(th) year) were divided in 2 groups. They were trained and finally examined in the standardized clinical ORL examination by peers and/or physicians. Group I (n=118) was exclusively trained and examined by physicians and group II (n=130) by peers and physicians. The results of the OSCE were stratified for the 2 groups and in group II for the subgroups according to the instructors' and examiners' qualification (peer or physician). The students evaluated the internship and the instructors' and examiners' quality with a validated questionnaire. RESULTS: In the OSCE, group I scored in the mean 59.9±4.9 points (max. 65). In group II the mean score was 58.3±4.3 points examined by the peers and 59.5±4.8 points for same performance assessed by the physicians. There were no statistical significant differences in the examination results when stratified for the instructors' and examiners' qualification. The evaluation results were consistently positive and identical when compared to the previous year without use of PT and PA and between the 2 groups and subgroups. CONCLUSIONS: When using a standardized clinical examination routine peers can be used for PT and PA to appropriate tools in student's medical education without any decrease in the teaching and examination quality.

[Current practice of tumour endoscopy in German ENT-clinics]. / Praxis der Tumorendoskopie an deutschen HNO-Kliniken.

BACKGROUND: Second primary carcinomas (SPC) essentially influence therapy and the outcome in head and neck cancer. This study presents the current status of tumour endoscopy in German ENT-clinics. MATERIAL AND METHODS: A standardised questionnaire regarding indication, time of event, examined anatomical region and technique of tumour endoscopy was compiled, sent to all German ENT-clinics (n=159) and subsequently analysed. RESULTS: In 94-100% of the clinics, tumour endoscopy is being conducted when primary carcinoma lies within oral cavity, pharynx, larynx or is a CUP-syndrome. In 80%, 2-stage surgical procedure is preferred. Nasal cavity and tracheobronchial system (47%, 74%) are often not included in the examination. When primary cancer is seen, in 7% of the clinics a standardised biopsy of unsuspicious anatomic areas is conducted. In CUP-syndrome, unsuspicious surfaces within the pharynx do not undergo routine biopsy in 10-20% of the clinics. In tracheobronchoscopy (63.0%) and esophagoscopy (93.3%) rigid scopes are mainly used. 65% of the clinics conduct endoscopy as follow-up care. CONCLUSION: Practice of tumour endoscopy in German ENT-clinics is widespread but does not follow standardised mechanisms. Current international literature shows that there is no common consensus on value and techniques of tumour endoscopy, however, due to highly developed radiological diagnostics, risks of rigid endoscopies and unknown incidence of second primary tumours it is discussed more and more negative. To establish future guidelines, controlled studies or analysis of large populations seem to be necessary.

[Exophytic tumor of the neck]. / Exophytischer gestielter Halstumor.

Malignant melanomas are the most frequent skin tumors and, due to the early tendency to metastasize, are linked with an unfavorable prognosis. In the early stage of illness surgical resection is the treatment of choice. This case shows that even large exulcerated tumors of the neck can originate from a dermal tumor.

Improvement and long-term stability of neuromuscular adaptation in implant-supported overdentures.

OBJECTIVES: In edentulous patients, implant-supported overdentures can improve chewing efficiency and patient satisfaction, and even a positive impact on bone tissue preservation has been observed. The objective of this long-term study was to investigate whether kinesiographic and electromyographic (EMG) parameters would also benefit from implant placement and whether the status achieved would remain consistent over time. MATERIAL AND METHODS: The functional adaptability of the neuromuscular system in edentulous patients has been recorded in four different states of restoration: (1) insufficient old dentures, (2) new complete dentures, (3) implant-supported overdentures, and (4) implant-supported overdentures 10 years in use. In each state of restoration, the neuromuscular adaptation was assessed during masticatory activity on the basis of myodynamic parameters such as vertical opening, frontal extension and closing velocity. EMG parameters, i.e. Musculus masseter and Musculus temporalis activities were recorded simultaneously. RESULTS: The results revealed a general increase in the myodynamic and EMG-parameters. All of them clearly approached the values for normal dentate subjects and maintained this level over a period of 10 years. The significant changes between states 2 and 3 indicate that implant stabilization of dentures is accompanied by an immediate increase of the neuromuscular parameters. CONCLUSIONS: In elderly edentulous patients, the treatment with two interforaminal implants provides evidence of neuromuscular adaptation towards values of healthy dentate. Thus, the known benefits of implant placement such as tissue perseverance and improved function are complemented by improved neuromuscular adaptation.

[APC resistance due to factor V Leiden mutation presenting as acute hemorrhagic jejunal infarction--case report]. / Akuter hämorrhagischer Jejunuminfarkt als Erstmanifestation einer APC-Resistenz bei Faktor-V-Leiden-Mutation--ein Fallbericht.

We report on a 43-year-old patient presenting to the emergency department with acute abdominal pain the source of which turned out to be acute hemorrhagic jejunal infarction due to portal and mesenteric vein occlusion with no apparent cause. In spite of a lacking history of hereditary thrombophilic risk factors, further diagnostic procedures revealed heterozygous factor V Leiden mutation. Diagnosis, therapy and clinical course are described. An overview on acute mesenteric venous occlusion with special reference to genetically determined thrombophilic disorders is given.

Optimised surgery (so-called TME surgery) and high-resolution MRI in the planning of treatment of rectal carcinoma.

BACKGROUND: Since November 1998, we have applied the concept of total mesorectal excision (TME) to rectal carcinoma together with a standardised pathological quality assessment. Participation in the European MERCURY study [The MERCURY Study Group Radiology (in press), 2006] required us to establish the indication for neoadjuvant radiochemotherapy on the basis of an magnetic resonance imaging (MRI) scan. The aim of the present retrospective study is to evaluate the quality of the surgery, the efficacy of the MRI and the oncological outcomes achieved. MATERIALS AND METHODS: Between November 2001 and October 2005, 68 out of 109 patients with carcinoma of the rectum were submitted to radical surgery in curative intent and 23/68 (34%) were given neoadjuvant therapy. In an interdisciplinary study group, each patient was evaluated pre-operatively and post-operatively using standardised MRI and histopathological methods. RESULTS: The quality of surgery was established on the basis of the pathological examination of the surgical specimen. The rates of incomplete mesorectal excision, intra-operative tumour cell dissemination and positive circumferential margins were all low at 4%, 7% and 3%, respectively. The effectiveness of MRI proved to be greatest in predicting the tumour status at the circumferential resection margin: in the admittedly limited number of patients it proved possible to correctly predict the tumour status for every patient. The assessment of the anatomic extent of the primary tumour and of the regional lymph node metastasis according to the TNM system, in contrast, was considerably less successful at 73% and 75%, and 37% and 57%, respectively. CONCLUSION: By applying the TME concept and MRI-based therapy planning, excellent results can be achieved and, at the same time, the number of patients requiring neoadjuvant treatment is considerably reduced.

Stress and inflammation as a detrimental combination for peri-implant bone loss.

The causes of peri-implant bone loss continue to be controversial. To determine the impact of biomechanical stress and inflammation, we investigated a total of 80 interforaminal implants in situ for more than 10 years. Two stress groups, with 14 patients each, were established: a low-stress situation with single-standing implants, and an increased-stress situation with splinted implants. To categorize inflammation, we introduced a Composite Inflammation Score using 4 inflammatory parameters. Peri-implant bone loss was calculated from digital panoramic radiographs. To differentiate between the effects of stress and inflammation, we compared bone loss in both stress groups at equivalent levels of inflammation. With greater Composite Inflammation Score values, a clear discrepancy between single-standing and splinted implants was evident (p = 0.117/0.000, regression analysis; p = 0.135/0.000, analysis of variance; p = 0.002, t tests). While stress and inflammation alone may not necessarily be detrimental factors, the presence of stress heightens peri-implant bone loss significantly as inflammation increases.

[Regression of germ cell tumors after chemotherapy]. / Regression von Keimzelltumoren nach Chemotherapie.

Today the treatment of gonadal germ cell tumors is standardized. The cisplatin containing chemotherapy and the multi-modal therapy strategies have increased the rate of successful treatment enormously. Germ cell tumors are almost always treated surgically. Following the rare, primary chemotherapy, the residual tumor must be classified according to the WHO as accurately as possible. A binding system for the documentation of tumor regression does not exist. The diagnostic retroperitoneal lymphadenectomy is also rare. Here as well, the classification is performed according to the WHO and the TNM classification. The examination of the tissue samples from a retroperitoneal lymphadenectomy after chemotherapy is problematic. The morphology is often bizarre, preparatory and terminological standards do not exist. Is there still vital tumor present then it can most often be diagnosed as a teratoma. In that case a classification takes place as to whether it is "mature" or "immature". If a tissue sample contains other differentiations, the classification is performed in detail according to the WHO classification of germ cell tumors. Sarcomas or carcinomas must be reliably distinguished and classified, as they lead to different therapeutic consequences. The terminology must be defined in a binding manner between both the pathology and the clinic, due to the lack of global definitions.

[Endocrine tumors of the testis]. / Endokrine Tumoren des Hodens.

The most characteristic endocrine tumours of the testis are germ cell tumours and sex cord/gonadal stromal tumours. They include the primary carcinoid, the relation of which to teratomas is still unclear. In general, gonadal stromal tumours are rare, however, endocrine activity occurs in at least 10%-20%. Among gonadal stromal tumours, only Leydig cell tumours and Sertoli cell tumours are of practical importance. Endocrine disorders are mostly related to Leydig cell tumours (gynaecomastia, pubertas praecox). Although less frequent than the other gonadal stromal tumours, they can, in principle, occur. The large cell calcifying Sertoli cell tumour occurs in association with other complex disorders (i.e. Peutz-Jeghers syndrome). Valuable markers are: inhibin, calretinin, cytokeratin, melan-A, CD-99, Ki-67, androgen receptor and p53. As the conventional morphology and immunohistological markers frequently overlap, unclear cases should be referred to specialised centres.

Seabirds at risk around offshore oil platforms in the north-west Atlantic.

Seabirds aggregate around oil drilling platforms and rigs in above average numbers due to night lighting, flaring, food and other visual cues. Bird mortality has been documented due to impact on the structure, oiling and incineration by the flare. The environmental circumstances for offshore hydrocarbon development in North-west Atlantic are unique because of the harsh climate, cold waters and because enormous seabird concentrations inhabit and move through the Grand Banks in autumn (storm-petrels, Oceanodroma spp), winter (dovekies, Alle alle, murres, Uria spp), spring and summer (shearwaters, Puffinus spp). Many species are planktivorous and attracted to artificial light sources. Most of the seabirds in the region are long-distance migrants, and hydrocarbon development in the North-west Atlantic could affect both regional and global breeding populations. Regulators need to take responsibility for these circumstances. It is essential to implement comprehensive, independent arm's length monitoring of potential avian impacts of offshore hydrocarbon platforms in the North-west Atlantic. This should include quantifying and determining the nature, timing and extent of bird mortality caused by these structures. Based on existing evidence of potential impacts of offshore hydrocarbon platforms on seabirds, it is difficult to understand why this has not been, and is not being, systematically implemented.