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Systemic sclerosis (SSc) is a rare, chronic autoimmune disorder associated with disability, diminished physical function, fatigue, pain, and mental health concerns. We assessed minimal detectable changes (MDCs) of the Health Assessment Questionnaire–Disability Index (HAQ‐DI), Patient‐Reported Outcomes Measurement Information System‐29 Profile version 2.0 (PROMIS‐29v2.0) domains, and Patient Health Questionnaire (PHQ)‐8 in people with SSc. Scleroderma Patient‐Centered Intervention Network Cohort participants completed the HAQ‐DI, PROMIS‐29v2.0 domains, and PHQ‐8 at baseline assessments from April 2014 until August 2023. We estimated MDC95 (smallest change that can be detected with 95% certainty) and MDC90 (smallest change that can be detected with 90% certainty) with 95% confidence intervals (CIs) generated via the percentile bootstrapping method resampling 1,000 times. We compared MDC estimates by age, sex, and SSc subtype. A total of 2,571 participants were included. Most were female (n = 2,241; 87%), and 38% (n = 976) had diffuse SSc. Mean (±SD) age was 54.9 (±12.7) years and duration since onset of first non‐Raynaud phenomenon symptom was 10.8 (±8.7) years. MDC95 estimate was 0.41 points (95% CI 0.40–0.42) for the HAQ‐DI, between 4.88 points (95% CI 4.72–5.05) and 9.02 points (95% CI 8.80–9.23) for the seven PROMIS‐29v2.0 domains, and 5.16 points (95% CI 5.06–5.26) for the PHQ‐8. MDC95 estimates were not materially different across subgroups. MDC95 and MDC90 estimates were precise and similar across age, sex, and SSc subtype groups. HAQ‐DI MDC95 and MDC90 were substantially larger than previous estimates of HAQ‐DI minimal important difference from several small studies. Minimally important differences of all measures should be evaluated in large studies using anchor‐based methods.

Our objectives were to quantify the relationships among fatigue, pain interference, and physical disability in children with juvenile idiopathic arthritis (JIA) and to test whether fatigue mediates the relationship between pain interference and physical disability in JIA. Patients enrolled within three months of JIA diagnosis in the Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) Registry between February 2017 and May 2023 were included. Their parents completed the Patient‐Reported Outcomes Measurement Information System fatigue and pain interference short proxy questionnaires and the Childhood Health Assessment Questionnaire disability index at registry enrollment. Associations were assessed using Pearson correlations and multiple linear regression. Structural equation modeling (SEM) was used to test if fatigue mediates the relationship between pain interference and physical disability. Among 855 patients (61.4% female, 44.1% with oligoarthritis), most reported fatigue and pain interference scores similar to those in the reference population, but 15.6% reported severe fatigue and 7.3% reported severe pain interference, with wide variation across JIA categories. Fatigue was strongly correlated with pain interference (r = 0.72, P< 0.001) and with physical disability (r= 0.60, P< 0.001). Pain interference (β = 0.027, P< 0.001) and fatigue (β = 0.013, P< 0.001) were both associated with physical disability after controlling for each other and potential confounders. SEM supported our hypothesis that fatigue partially mediates the relationship between pain interference and physical disability. Our findings suggest both fatigue and pain interference are independently associated with physical disability in children newly diagnosed with JIA, and the effect of pain interference may be partly mediated by fatigue.

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organizationoverturned its landmark decisions in Roe v Wadethat established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wadehaving been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

T lymphocytes and myeloid cells express the immunoglobulin-like glycoprotein cluster of differentiation (CD)101, notably in the gut. Here, we investigated the cell-specific functions of CD101 during dextran sulfate sodium (DSS)-induced colitis and Salmonella entericaTyphimurium infection. Similar to conventional CD101−/−mice, animals with a regulatory T cell-specific Cd101deletion developed more severe intestinal pathology than littermate controls in both models. While the accumulation of T helper 1 cytokines in a CD101-deficient environment entertained DSS-induced colitis, it impeded the replication of Salmonellaas revealed by studying CD101−/−x interferon-g−/−mice. Moreover, CD101-expressing neutrophils were capable to restrain Salmonellainfection in vitroand in vivo. Both cell-intrinsic and -extrinsic mechanisms of CD101 contributed to the control of bacterial growth and spreading. The CD101-dependent containment of Salmonellainfection required the expression of Irg-1and Nox2and the production of itaconate and reactive oxygen species. The level of intestinal microbial antigens in the sera of inflammatory bowel disease patients correlated inversely with the expression of CD101 on myeloid cells, which is in line with the suppression of CD101 seen in mice following DSS application or Salmonellainfection. Thus, depending on the experimental or clinical setting, CD101 helps to limit inflammatory insults or bacterial infections due to cell type-specific modulation of metabolic, immune-regulatory, and anti-microbial pathways.

Numerous risk factors for lower limb amputations are known; however, this study aimed to identify risk factors for re-amputation in patients within 6 months from an initial lower limb amputation procedure.

Cardiac function relies on the autonomous molecular contraction mechanisms in the ventricular wall. Contraction is driven by ordered motor proteins acting in parallel to generate a macroscopic force. The averaged structure can be investigated by diffraction from model tissues such as trabecular and papillary cardiac muscle using collimated synchrotron beams, offering high resolution in reciprocal space. In the ventricular wall, however, the muscle tissue is compartmentalized into smaller branched cardiomyocytes, with a higher degree of disorder. We show that X-ray diffraction is now also capable of resolving the structural organization of actomyosin in single isolated cardiomyocytes of the ventricular wall. In addition to the hexagonal arrangement of thick and thin filaments, the diffraction signal of the hydrated and fixated cardiomyocytes was sufficient to reveal the myosin motor repeat (M3), the troponin complex repeat (Tn), and the sarcomere length. The sarcomere length signal comprised up to 13 diffraction orders, which were used to compute the sarcomere density profile based on Fourier synthesis. The Tn and M3 spacings were found in the same range as previously reported for other muscle types. The approach opens up a pathway to record the structural dynamics of living cells during the contraction cycle, toward a more complete understanding of cardiac muscle function.

Die 1919 gegründete Zeitschrift „Der Landarzt“ ist die Vorgängerin der heutigen „Zeitschrift für Allgemeinmedizin“. Von 1933 bis 1936 trug der „Landarzt“ vorübergehend den Titel „Zentralblatt für Landärzte“. Neben medizinischen Inhalten adressierte das Journal traditionell berufspolitische und alltagspraktische Themen für Landärzte. Bereits 1929 erschienen im „Landarzt“ Artikel zur „Rassenhygiene“, sodass die nationalsozialistische Machtübernahme 1933 in dieser Hinsicht keine besondere Zäsur darstellte. Seit 1937 erschien die Zeitschrift im Stuttgarter Hippokrates-Verlag. In der Folge verstärkte sich die schon vorher bestehende Tendenz zur Naturheilkunde und Homöopathie, was zur Ausrichtung der nationalsozialistischen Gesundheitspolitik in jener Zeit passte. Hoffnungen auf eine nachhaltige Unterstützung der Landärzte durch die Nationalsozialisten erfüllten sich nur teilweise und waren spätestens im Zweiten Weltkrieg obsolet. Im Herbst 1944 musste der „Landarzt“ sein Erscheinen kriegsbedingt einstellen.

Currently, real-world data on doravirine are scarce. In a national prospective cohort, we assessed the effectiveness and tolerability of switching to doravirine-based antiretroviral therapy (ART) in people with HIV.

Improved living conditions have led to an increase in life expectancy worldwide. However, as people age, the risk of vascular disease tends to increase due to the accumulation and buildup of plaque in arteries. Vascular stents are used to keep blood vessels open. Biodegradable stents are designed to provide a temporary support vessel that gradually degrades and is absorbed by the body, leaving behind healed blood vessels. However, biodegradable metals can suffer from reduced mechanical strength and/or inflammatory response, both of which can affect the rate of corrosion. Therefore, it is essential to achieve a controlled and predictable degradation rate. Here, we demonstrate that the corrosion resistance of biodegradable Zn surfaces is improved by electroless deposition of zinc hydroxystannate followed by UV-grafting with silicone oil (PDMS). Potentiodynamic polarization, electrochemical impedance spectroscopy, respiratory kinetic measurements, and long-term immersion in three simulated body fluids were applied. Although zinc hydroxystannate improves the corrosion resistance of Zn to some extent, it introduces a high surface area with hydroxyl units used to UV-graft PDMS molecules. Our results demonstrate that hydrophobic PDMS causes a 3-fold reduction in corrosion of Zn-based materials in biological environments and reduces cytotoxicity through the uncontrolled release of Zn ions.

The optimal management of perforated appendicitis remains controversial. Many studies advocate for antibiotics and an interval appendectomy whereas others suggest that performing an appendectomy at the time of presentation decreases post-operative morbidity. Confounding this argument further are the patients who fail non-operative management and end up requiring surgery during their initial hospitalization. This study aims to determine if early operative intervention should be considered for perforated appendicitis.

This article examines the public communication of COVID-19-related ‘preprints’ (unreviewed research studies) in a digital media environment. To understand how preprint research flows from preprint server, to media story, to social media audience, we analysed engagement with ‘second-order citations’ – social media posts linking to media coverage of research – using a sample of 41 media stories published by the research amplifier platform The Conversation (TC)that mentioned preprint research during the early months of the pandemic. We applied content analyses to the Facebook and Twitter accounts sharing these stories and analysed the engagement that the posts received. We found that TCstories mentioning preprints were shared among a diverse collection of Facebook and Twitter accounts, providing a second layer of social media amplification of preprint research. Still, posts by a small proportion of ‘elite’ actors – people with prominent roles in media and communications, politics or academia – tended to generate more engagement.

AbstractIn this article, we use the strategies to engage students in a 5E lesson on static electricity (partially addressing MS-PS2-3). We start the engage phase by using a “magic trick” as a hook to engage students about static electricity. During the explain phase, students get the chance to interact with a variety of static electricity phenomena and write down what they are curious about. Next, we help students make sense of the experiences through teacher questioning in the explore phase. In the elaborate phase, we encourage student speculation and questions by having them generate their own research questions. In the evaluate phase, we use novel scenarios related to what students learned to assess their thinking and maintain curiosity. Throughout all of the 5E, we strive to model curiosity by looking excited, asking speculative questions, and being interested in students’ ideas.

Polymers that degrade on demand have the potential to facilitate chemical recycling, reduce environmental pollution and are useful in implant immolation, drug delivery or as adhesives that debond on demand. However, polymers made by radical polymerization, which feature all carbon-bond backbones and constitute the most important class of polymers, have proven difficult to render degradable. Here we report cyclobutene-based monomers that can be co-polymerized with conventional monomers and impart the resulting polymers with mechanically triggered degradability. The cyclobutene residues act as mechanophores and can undergo a mechanically triggered ring-opening reaction, which causes a rearrangement that renders the polymer chains cleavable by hydrolysis under basic conditions. These cyclobutene-based monomers are broadly applicable in free radical and controlled radical polymerizations, introduce functional groups into the backbone of polymers and allow the mechanically gated degradation of high-molecular-weight materials or cross-linked polymer networks into low-molecular-weight species.

Background: Living kidney donors are screened pre-donation to estimate the risk of end-stage kidney disease (ESKD). We evaluate Machine Learning (ML) to predict the progression of kidney function deterioration over time using the estimated GFR (eGFR) slope as the target variable. Methods: We included 238 living kidney donors who underwent donor nephrectomy. We divided the dataset based on the eGFR slope in the third follow-up year, resulting in 185 donors with an average eGFR slopeand 53 donors with an accelerated declining eGFR-slope. We trained three Machine Learning-models (Random Forest [RF], Extreme Gradient Boosting [XG], Support Vector Machine [SVM]) and Logistic Regression (LR) for predictions. Predefined data subsets served for training to explore whether parameters of an ESKD risk score alone suffice or additional clinical and time-zero biopsy parameters enhance predictions. Machine learning-driven feature selection identified the best predictive parameters. Results: None of the four models classified the eGFR slope with an AUC greater than 0.6 or an F1 score surpassing 0.41 despite training on different data subsets. Following machine learning-driven feature selection and subsequent retraining on these selected features, random forest and extreme gradient boosting outperformed other models, achieving an AUC of 0.66 and an F1 score of 0.44. After feature selection, two predictive donor attributes consistently appeared in all models: smoking-related features and glomerulitis of the Banff Lesion Score. Conclusions: Training machine learning-models with distinct predefined data subsets yielded unsatisfactory results. However, the efficacy of random forest and extreme gradient boosting improved when trained exclusively with machine learning-driven selected features, suggesting that the quality, rather than the quantity, of features is crucial for machine learning-model performance. This study offers insights into the application of emerging machine learning-techniques for the screening of living kidney donors. Graphical abstract:

Membranes are widely used for separation processes in applications such as water desalination, batteries and dialysis, and are crucial in key sectors of our economy and society1. The majority of technologically exploited membranes are based on solid polymers and function as passive barriers, whose transport characteristics are governed by their chemical composition and nanostructure. Although such membranes are ubiquitous, it has proved challenging to maximize selectivity and permeability independently, leading to trade-offs between these pertinent characteristics2. Self-assembled biological membranes, in which barrier and transport functions are decoupled3,4, provide the inspiration to address this problem5,6. Here we introduce a self-assembly strategy that uses the interface of an aqueous two-phase system to template and stabilize molecularly thin (approximately 35 nm) biomimetic block copolymer bilayers of scalable area that can exceed 10 cm2without defects. These membranes are self-healing, and their barrier function against the passage of ions (specific resistance of approximately 1 MΩ cm2) approaches that of phospholipid membranes. The fluidity of these membranes enables straightforward functionalization with molecular carriers that shuttle potassium ions down a concentration gradient with exquisite selectivity over sodium ions. This ion selectivity enables the generation of electric power from equimolar solutions of NaCl and KCl in devices that mimic the electric organ of electric rays.

Der Nationale Krebsplan (NKP) wurde 2008 in Deutschland durch das Bundesministerium für Gesundheit gemeinsam mit drei gemeinnützigen Organisationen initiiert. Neben den Initiatoren waren an diesem Koordinations- und Kooperationsprogramm alle in der Onkologie relevanten Organisationen, Verbände und Interessengruppen beteiligt. Nach anfänglicher Schwerpunktbildung wurden in vielen von Experten besetzten Arbeitsgruppen Ziele formuliert. Die breite Beteiligung im NKP stellte sich bereits bei der Formulierung der Ziele und auch bei deren Umsetzung als eine besondere Herausforderung dar. Neben der Einstimmigkeit gab es keinen festgelegten Einigungsprozess. Insbesondere Umsetzungsprozesse mit vielen Beteiligten auf unterschiedlichen Ebenen haben gezeigt, dass eine Anpassung der Abläufe und der Governance-Struktur des NKP notwendig ist. Dies wird aktuell im Bundesministerium für Gesundheit unter Einbeziehung von Mitinitiatoren und langjährig am NKP Beteiligten vorbereitet.

The European Society for Clinical Microbiology and Infectious Diseases recommends 3rd generation cephalosporins and metronidazole for empirical treatment of community-acquired brain abscesses. In 53 retrospectively analyzed pediatric patients with community-acquired brain abscesses at a German University Hospital Staphylococcus aureuswas identified as a relevant pathogen (21%). Therefore, it may be reasonable to cover S. aureuswhen selecting empirical therapy.

The accurate estimation of time‐to‐collision (TTC) is essential for the survival of organisms. Previous studies have revealed that the emotional properties of approaching stimuli can influence the estimation of TTC, indicating that approaching threatening stimuli are perceived to collide with the observers earlier than they actually do, and earlier than non‐threatening stimuli. However, not only are threatening stimuli more negative in valence, but they also have higher arousal compared to non‐threatening stimuli. Up to now, the effect of arousal on TTC estimation remains unclear. In addition, inconsistent findings may result from the different experimental settings employed in previous studies. To investigate whether the underestimation of TTC is attributed to threat or high arousal, three experiments with the same settings were conducted. In Experiment 1, the underestimation of TTC estimation of threatening stimuli was replicated when arousal was not controlled, in comparison to non‐threatening stimuli. In Experiments 2 and 3, the underestimation effect of threatening stimuli disappeared when compared to positive stimuli with similar arousal. These findings suggest that being threatening alone is not sufficient to explain the underestimation effect, and arousal also plays a significant role in the TTC estimation of approaching stimuli. Further studies are required to validate the effect of arousal on TTC estimation, as no difference was observed in Experiment 3 between the estimated TTC of high and low arousal stimuli.

Female sexual dysfunction (FSD) affects an estimated 40% of women. Unfortunately, FSD is understudied, leading to limited treatment options for FSD. Neuromodulation has shown some success in alleviating FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD.

Cobalamin (vitamin B12, herein referred to as B12) is an essential cofactor for most marine prokaryotes and eukaryotes1,2. Synthesized by a limited number of prokaryotes, its scarcity affects microbial interactions and community dynamics2–4. Here we show that two bacterial B12auxotrophs can salvage different B12building blocks and cooperate to synthesize B12. A Colwelliasp. synthesizes and releases the activated lower ligand α-ribazole, which is used by another B12auxotroph, a Roseovariussp., to produce the corrin ring and synthesize B12. Release of B12by Roseovariussp. happens only in co-culture with Colwelliasp. and only coincidently with the induction of a prophage encoded in Roseovariussp. Subsequent growth of Colwelliasp. in these conditions may be due to the provision of B12by lysed cells of Roseovariussp. Further evidence is required to support a causative role for prophage induction in the release of B12. These complex microbial interactions of ligand cross-feeding and joint B12biosynthesis seem to be widespread in marine pelagic ecosystems. In the western and northern tropical Atlantic Ocean, bacteria predicted to be capable of salvaging cobinamide and synthesizing only the activated lower ligand outnumber B12producers. These findings add new players to our understanding of B12supply to auxotrophic microorganisms in the ocean and possibly in other ecosystems.

ABSTRACTThis text compares four essays dealing with war, state terror in dictatorships, social violence such as racism, mourning and the avoidance of mourning. It shows that dictatorships share similarities in their techniques of manipulation, linguistic style and reference to history. They seek to exploit national myths through manipulative alienation. Myths are a central element of cultural memory, and their effect can be understood through a model of internal dialogue. This dialogue determines whether the regime's attempts at manipulation are successful.

Die chirurgischen Optionen und insbesondere die perioperativen Therapien haben sich bei gastroösophagealen Karzinomen erheblich weiterentwickelt. Durch kurative multimodale Therapiekonzepte bei lokal fortgeschrittenen Karzinomen kann mittlerweile eine 5‑Jahres-Überlebensrate von nahezu 50 % erreicht werden. In Tumorboards und chirurgischen Fallbesprechungen stellt sich daher vermehrt die Frage, welche Art der Therapie individuellen Patienten mit ihren Vorerkrankungen die besten onkologischen und funktionellen Ergebnisse ermöglicht. Dabei gilt es, sorgfältig abzuwägen, ob in Zukunft auch organerhaltende Therapien in Betracht kommen oder in welcher Form minimal-invasive oder robotische Operationen Vorteile bieten können. Gleichzeitig verschieben sich gegenwärtig die Grenzen der operativen und onkologischen Therapie, um auch kurative Behandlungen für vorerkrankte Patienten oder Patienten mit einer oligometastatischen Erkrankung zu ermöglichen. Mit der Integration künstlicher Intelligenz in Entscheidungsprozesse stehen zunehmend neue Möglichkeiten der Informationsverarbeitung zur Verfügung, um in Zukunft noch mehr Daten in unsere Entscheidungsfindung einbeziehen zu können.

Artificial cells are biomimetic microstructures that mimic functions of natural cells, can be applied as building blocks for molecular systems engineering, and host synthetic biology pathways. Here we report enzymatically synthesized polymer-based artificial cells with the ability to express proteins. Artificial cells were synthesized using biocatalytic atom transfer radical polymerization-induced self-assembly, in which myoglobin synthesizes amphiphilic block co-polymers that self-assemble into structures such as micelles, worm-like micelles, polymersomes and giant unilamellar vesicles (GUVs). The GUVs encapsulate cargo during the polymerization, including enzymes, nanoparticles, microparticles, plasmids and cell lysate. The resulting artificial cells act as microreactors for enzymatic reactions and for osteoblast-inspired biomineralization. Moreover, they can express proteins such as a fluorescent protein and actin when fed with amino acids. Actin polymerizes in the vesicles and alters the artificial cells’ internal structure by creating internal compartments. Thus, biocatalytic atom transfer radical polymerization-induced self-assembly-derived GUVs can mimic bacteria as they are composed of a microscopic reaction compartment that contains genetic information for protein expression upon induction.

A core outcome set for appendicitis was constructed using Delphi methodology to facilitate future outcome standardization. 16 international appendicitis experts achieved consensus on 17 core outcomes for incorporation into future appendicitis studies.

Durch eine kontinuierliche Verbesserung der technischen Möglichkeiten, digitale Innovationen sowie Fortschritte in multimodalen Therapiekonzepten und schließlich eine Verbesserung in der perioperativen Versorgung von Patienten und weitere Zentralisierung ergibt sich eine Verschiebung von Grenzen in der onkologischen Chirurgie. So ergeben sich Indikationserweiterungen für Patienten mit einer Oligometastasierung. Die Metastasenchirurgie ist für Patienten mit einem kolorektalen Karzinom seit Langem etabliert und wird aktuell in klinischen Studien auch für Patienten mit einem Pankreaskarzinom oder für Magen- und Ösophaguskarzinome überprüft. Ausgewählte Patienten mit einer limitierten Peritonealkarzinose können heute auch von einer zytoreduktive Chirurgie mit anschließender hyperthermer intraperitonealer Chemotherapie (HIPEC) profitieren. Für nichtresektable kolorektale Lebermetastasen wird die Organtransplantation aktuell in zahlreichen klinischen Studien evaluiert. Eine neue Herausforderung stellt der Umgang mit dem Vorliegen einer klinischen Komplettremission bei Durchführung total neoadjuvanter Therapien dar, mit der Forderung nach Organ- und Funktionserhalt. Durch ein verbessertes perioperatives Management kann die Morbidität von komplexen onkologischen Eingriffen reduziert werden, und schließlich kann die onkologische Chirurgie auch in palliativen Situationen bei sehr guter und individualisierter Indikationsstellung einen Stellenwert haben.

Soft polymer nanocapsules and microgels, which can adapt their shape and, at the same time, sequester and release molecular payloads in response to an external trigger, are a challenging complement to vesicular structures like polymersomes. In this work, we report the synthesis of such capsules by photo-cross-linking of coumarin-substituted polyglycidyl ethers, which we prepared by Williamson etherification of epichlorohydrin (ECH) repeating units with 7-hydroxycoumarin in copolymers with tert-butyl glycidyl ether (tBGE). To control capsule size, we employed the prepolymers in an o/w miniemulsion, where they formed a gel layer at the interface upon irradiation at 365 nm by [2π + 2π] photodimerization of the coumarin groups. Upon irradiation at 254 nm, the reaction could be reversed and the gel wall could be repeatedly disintegrated and rebuilt. We further demonstrated (i) reversible hydrophilization of the gels by hydrolysis of the lactone rings in coumarin dimers as a mechanism to manipulate the permeability of the capsules and (ii) binding functional molecules as amides. Thus, the presented nanogels are remarkably versatile and can be further used as a carrier system.

Der Stellenwert der Thymektomie in der Therapie der thymomfreien Myasthenia gravis blieb bis vor einiger Zeit umstritten. Die relativ geringe Inzidenz und Prävalenz der Erkrankung, die uneinheitliche Dokumentation in den verschiedenen Studien sowie die notwendige Langzeitbeobachtung zur Erfassung therapeutischer Effekte erschwerten das Generieren valider Daten. Die Veröffentlichung des MGTX-Trials 2016 im New England Journal of Medicinelieferte die ersten randomisiert-kontrollierten Daten, nach denen Patienten mit Acetylcholin-Rezeptor-Antikörper-positiver generalisierter Myasthenia gravis im Alter von 18 bis 65 Jahren von der chirurgischen Resektion des Thymus über eine mediane Sternotomie profitieren. Trotz fehlender Validierung des Vorteils der Thymektomie über minimal-invasive Techniken durch randomisiert-kontrollierte Studien scheinen diese das Outcome bestimmter Patientengruppen in ähnlicher Form positiv zu beeinflussen. So haben videoassistiert-thorakoskopische, roboterassistierte, subxiphoidale und transzervikale Zugangswege nicht nur ästhetische Vorteile, sondern zeigen in der Beeinflussung des Krankheitsverlaufs der Myasthenia gravis keine relevante Unterlegenheit gegenüber der medianen Sternotomie. Doch nicht nur der Nutzen und das ästhetische Ergebnis differieren, sondern auch die Erfolgsaussichten im Hinblick auf die Remission sind bei den Unterformen der Myasthenia gravis unterschiedlich. Die heterogene Gruppe der Myasthenien unterscheidet sich bezüglich des Auftretens von Autoantikörpern, der betroffenen Körperregionen und des Alters der Patienten bei Erstdiagnose. Schließlich ist die Thymektomie eine wirksame kausale Therapie der Myasthenia gravis.

Als zentrales Stoffwechselorgan des menschlichen Organismus steht die Leber in besonders enger struktureller und funktioneller Beziehung zum Dünn- und Dickdarm und zur gastrointestinalen Mikrobiota. Im Rahmen der dekompensierten Leberzirrhose ist die Darm-Leber-Achse empfindlich gestört, was sich in einer veränderten intestinalen Mikrobiota im Sinne einer bakteriellen Fehlbesiedlung und Verlust der Diversität mit Zunahme pathologischer Taxa, gesteigerter intestinaler Permeabilität, pathologischer bakterieller Translokation, immunologischem Toleranzverlust gegenüber intestinalen Antigenen und Mikroorganismen und nachfolgender Inflammation äußert. Zirrhoseassoziierte Veränderungen der Darmmikrobiota und der intestinalen Barrierefunktion korrelieren mit dem Auftreten einer hepatischen Enzephalopathie, portaler Hypertension, bakterieller Infektionen und eines akut-auf-chronischen Leberversagen. Als möglichen therapeutischen Ansatz zur Modulation der Mikrobiota, Restauration einer Eubiose und Prophylaxe von Komplikationen der Leberzirrhose wurde die Sicherheit des fäkalen Mikrobiotatransfers (FMT) in klinischen Studien mit kleinen Fallzahlen untersucht. Größere klinische Studien zur Sicherheit und Verträglichkeit, der optimale Verabreichungsweg, die Behandlungsdauer, Indikationsgebiete und die ausrechende Definition des Therapieerfolgs stehen aber noch aus.

Zusammenfassung: Die Indikationsstellung zur Resektion benigner Pankreastumoren ist gegeben, wenn es sich um einen symptomatischen Tumor handelt oder – bei einem Zufallsbefund – um einen Tumor mit Potenzial zur malignen Entartung. Dies besteht bei der Mehrzahl der benignen Pankreastumoren, insbesondere bei der intraduktalen papillären muzinösen Neoplasie (IPMN) oder muzinösen Zystadenomen. Operativer Abklärung bedürfen auch Tumoren, die unter Ausschöpfung aller diagnostischer Möglichkeiten nicht eindeutig klassifizierbar sind. An chirurgischen Therapieverfahren stehen verschiedene Techniken zur Verfügung. Die Wahl des Verfahren hängt von der Größe und Lokalisation des Tumors ab und von der Frage, ob eine maligne Entartung bereits stattgefunden hat. Das onkologisch korrekte Standardresektionsverfahren bei Tumoren des Pankreaskopfes ist die partielle Duodenopankreatektomie, bei Tumoren des Pankreasschwanzes die Pankreaslinksresektion. Eine segmentale Resektion des Pankreaskorpus oder eine duodenumerhaltende Pankreaskopfresektion sind Verfahren ohne onkologische Radikalität; sie sollten nur bei zweifelsfrei benignen Tumoren mit geringem malignem Potenzial angewendet werden.

Background: The ergonomic advantages and potential challenges that robotic surgery poses to the well-being of surgeons are mainly unexplored. The most recent surgical robot introduced on the European market is the Hugo™ RAS System by Medtronic. This study aims to evaluate the ergonomic benefits of the Hugo™ RAS System, which is available in our training laboratory, CeMIT (Center for Medical Innovation and Technology Cologne). Methods and procedures: Using the previously established Cologne Ergonomic Measurement Setup for Robotic Surgery (CEMRobSurg), we measured three parameters related to ergonomic posture from subjects with different levels of surgical expertise (laypeople, medical students, surgical residents, and expert robotic surgeons). The heart rate was measured continuously using a polar band. The noise level was measured while using the Hugo™ RAS System, and automated photographs using our locally developed methodology were captured of the participant every 2 s to assess body posture. The ergonomic measurements were conducted while the subject performed the same standardized robotic training exercises (Peg Board, Rope Walk, and Ring Walk). Results: A total of 53 participants were enrolled in this study. The average noise level during all measurements was 54.87 dB. The highest stress level was measured in surgical residents with a sympathetic nervous system index (SNS index) of 1.15 (min − 1.43, max 3.56). The lowest stress level was measured in robotic experts with an SNS index of 0.23 (min − 0.18, max 0.91). We observed a risk-prone positioning of the neck and elbow in medical students (mean 39.6° and 129.48°, respectively). Robotic experts showed a risk positioning in the knee and hip region (mean 107.89° and 90.31°, respectively). Conclusion: This is the first study to analyze and objectify the ergonomic posture of medical students, surgical trainees, surgeons, and laypeople using the open console, modular Hugo™ RAS System. Our findings offer recommendations for operating surgeons and allow for a comparative analysis between the different robotic systems. Further evaluations in real-time operative scenarios will follow.

Zusammenfassung: Eine adäquate Pflanzenernährung und Pflanzenschutz müssen im ökologischen Kartoffelanbau weitgehend durch präventive langfristige Managementstrategien erreicht werden. Die Kraut- und Knollenfäule, durch Phytophthora infestans Mont. De Bary verursacht, ist hierbei eine der wichtigsten Krankheiten, die weitgehend immer noch durch den limitierten Einsatz von kupferbasierten Fungiziden bekämpft wird. Dies widerspricht zumindest im derzeitigen Umfang dem Nachhaltigkeitsgedanken des ökologischen Anbaus. Die vorgestellten Ergebnisse zeigen, dass auch unter hohem Befallsdruck eine massive Reduzierung des Mitteleinsatzes auf 1–1,5 kg Reinkupfer pro ha mithilfe eines für den Bioanbau entwickelten Vorhersagemodells BioPhyto-PRE möglich ist. Um die Effizienz weniger wirksamer Pflanzenschutzmittel im ökologischen Anbau zu steigern, sollte der Befallsdruck soweit möglich reduziert werden. In Praxisversuchen auf vier Betrieben wurde gezeigt, dass durch den Anbau von Kartoffeln in 12–16 m breiten Streifen, die von Weizen oder Möhren benachbart waren, der Befallsdruck reduziert werden konnte. Eine Kosten-Nutzen-Rechnung basierend auf den Preisen von 2004 ergab, dass der Anbau der Kartoffeln ohne Behandlung in den meisten Fällen die lukrativste Variante war, mit geringfügig höheren Einnahmen aus unbehandelten Streifen. Schrittweise multiple Regressionen zeigen, dass die Ertrags-Verlust-Relation von P. infestans nur unter Einbezug der N-Aufnahme der Pflanzen zu unterschiedlichen Zeitpunkten ermittelt werden kann. Insgesamt wurden wegen der Stickstofflimitierung in vielen Fällen durch den Einsatz von Kupferfungiziden nur geringe bis keine Ertragssteigerungen im ökologischen Anbau erreicht. Ein integriertes Vorhersagemodell für den ökologischen Anbau muss neben der Befallsvorhersage, das Wachstumsstadium und die bereits erfolgte Stickstoffaufnahme und sortenspezifische Eigenschaften einbeziehen, um einen wirkungsvollen, minimierten Fungizideinsatz zu ermöglichen.

Zusammenfassung: Solide pseudopapilläre Tumoren des Pankreas (SPTP) sind seltene Entitäten mit niedrigem Malignitätsgrad, die überwiegend bei jungen Frauen auftreten, typischerweise aus soliden, zystischen und zentral hämorrhagischen Komponenten bestehen und eine sehr gute Prognose haben. In der bildgebenden Diagnostik stellen sie sich relativ charakteristisch dar: rund bis ovalär, glatt begrenzt mit einer fibrotischen Pseudokapsel, die das meist gemischt solide und zystisch-hämorrhagische Tumorgewebe umgibt. Nach Kontrastmittelgabe zeigen SPTP eine protrahierte randständige Kontrastmittelaufnahme. Kalzifikationen können im Randbereich des Tumors vorkommen. Die MRT ist der CT bei der Diagnostik der hämorrhagischen Veränderungen überlegen. Das Bewusstsein und die Kenntnis der SPTP bei Radiologen und Chirurgen ist eine der wichtigsten Voraussetzungen für die korrekte Diagnose dieser seltenen Tumorentität mit exzellenter Prognose nach chirurgischer Therapie.