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Hintergrund: Weltweite terroristische Aktivitäten seit „9/11“ und folgend auch im europäischen Raum haben im Rahmen der Bewertung von kritischer Infrastruktur in Deutschland zu einem Umdenken auch hinsichtlich der Sicherheit an und in Kliniken geführt. Ziel der Arbeit: Die vorliegende Publikation befasst sich mit der Bewertung vorliegender Konzepte zu Themen wie „Alarmierung“, „Sicherheit“, „Kommunikation“ und „Vorbereitung“ im vorgenannten Kontext. Material und Methoden: Anhand einer Literatursichtung sowie einer Umfrage unter den Teilnehmern*innen der 3. Notfallkonferenz der DGU (Deutsche Gesellschaft für Unfallchirurgie) werden diese Thematik und die aktuell vorliegende Situation weiter analysiert und vorgestellt. Ergebnisse: Die gewonnenen Daten verdeutlichen, dass ein Großteil der Kliniken zwar über eine Krankenhausalarm- und Einsatzplanung verfügt, jedoch die Frequenz der Aktualisierungen und die innerklinische Kommunikation zur Steigerung der Wahrnehmung eine deutliche Streuung zeigen. Diskussion: Zusammenfassend scheint die latente Bedrohung durch terroristische Aktivitäten dazu geführt zu haben, dass sich deutsche Kliniken in der Bewertung als kritische Infrastruktur mit der Thematik „Krankenhausalarm- und Einsatzplanung“ auseinandergesetzt und diese überwiegend auch umgesetzt haben. Allerdings zeigt sich für die nachgeordneten Bereiche und die aus der Alarmplanung ableitbaren Konsequenzen noch nicht die nötige Stringenz, um letztendlich adäquate Reaktionen in diesen besonderen Szenarien im Hinblick auf die Sicherheit in und an deutschen Kliniken zu gewährleisten.

Hintergrund: Weltweite terroristische Aktivitäten seit „9/11“ und folgend auch im europäischen Raum haben im Rahmen der Bewertung von kritischer Infrastruktur in Deutschland zu einem Umdenken auch hinsichtlich der Sicherheit an und in Kliniken geführt. Ziel der Arbeit: Die vorliegende Publikation befasst sich mit der Bewertung vorliegender Konzepte zu Themen wie „Alarmierung“, „Sicherheit“, „Kommunikation“ und „Vorbereitung“ im vorgenannten Kontext. Material und Methoden: Anhand einer Literatursichtung sowie einer Umfrage unter den Teilnehmern*innen der 3. Notfallkonferenz der DGU (Deutsche Gesellschaft für Unfallchirurgie) werden diese Thematik und die aktuell vorliegende Situation weiter analysiert und vorgestellt. Ergebnisse: Die gewonnenen Daten verdeutlichen, dass ein Großteil der Kliniken zwar über eine Krankenhausalarm- und Einsatzplanung verfügt, jedoch die Frequenz der Aktualisierungen und die innerklinische Kommunikation zur Steigerung der Wahrnehmung eine deutliche Streuung zeigen. Diskussion: Zusammenfassend scheint die latente Bedrohung durch terroristische Aktivitäten dazu geführt zu haben, dass sich deutsche Kliniken in der Bewertung als kritische Infrastruktur mit der Thematik „Krankenhausalarm- und Einsatzplanung“ auseinandergesetzt und diese überwiegend auch umgesetzt haben. Allerdings zeigt sich für die nachgeordneten Bereiche und die aus der Alarmplanung ableitbaren Konsequenzen noch nicht die nötige Stringenz, um letztendlich adäquate Reaktionen in diesen besonderen Szenarien im Hinblick auf die Sicherheit in und an deutschen Kliniken zu gewährleisten.

Gunshot injuries, blast injuries, and major contusions can cause extensive extremity defects. In countries with damaged or destroyed infrastructure, local national patients with these injuries pose a challenge. Deployed medical facilities of the German Armed Forces provide medical care to these patients as part of their humanitarian activities. Reconstructive techniques, for example, microvascular free tissue transfer, can be used only to a limited extent in such settings, which require safe and simple (outpatient) procedures. The focus of treatment is not on cosmetic aspects but on rapidly restoring function. Low-resource settings require ethical and medical compromises. It is still a topic of the discussion which reconstructive surgical procedures could be performed in a deployment mission and which should be in the portfolio of the deployed surgeon.

Treatment of osseous defects of the extremities is a constantly recurring challenge in modern reconstructive surgery. This applies, in particular, to military surgery, especially to the sequelae of gunshot and blast injuries. Severe soft-tissue damage and inevitable contamination lead to an increased rate of infection. Repetitive surgical debridement involving the bone must be performed at regular intervals. Frequent outcomes are osseous defects that call for a consistent therapeutic concept adapted to the individual patient. The Masquelet technique is an additional bone reconstruction method with which to sufficiently treat initially infected long bone defects in multiple operations. Following radical debridement, the resulting bone defect is completely filled with a bone cement spacer loaded with antibiotics. At the boundary layer between the spacer and soft tissue, a membrane expressing growth factors will develop over several weeks. This has a favorable effect on the successful transplantation and ossification of autologous cancellous graft following spacer removal. This technique will be illustrated by a case study. Since this technique has already proved successful in reconstructing defects of up to 25 cm, it is an alternative to various callus distraction methods as well as vascularized bone transfer.

Despite surgical and technological advances, managing combat-related injuries remains challenging both within and outside of the war theater. Unique characteristics of a war theater such as environmental contamination, varying evacuation procedures, and differing levels of medical care, add to the complexity. The advent of body armor has increased blast survival rates and soldiers are surviving with increasingly mangled limbs that require lengthy, multifaceted care. An inherent high risk of infection contraindicates immediate closure for these wounds. There is growing reported use of negative pressure wound therapy with reticulated open-cell foam (NPWT/ROCF) as delivered by vacuum-assisted closure (VAC) therapy (KCI Licensing Inc., San Antonio, TX) as an adjunctive therapy in these open soft-tissue combat wounds. This review evaluates the efficacy of NPWT/ROCF for adjunctive treatment of wartime wounds. Following a literature review, data are summarized and presented.

There is controversy about the origin of the alterations in T helper 1 (TH1)/TH2 cell activity after major surgical procedures such as on-pump cardiac surgery. We hypothesized that a postoperative decrease in interferon (IFN) -producing TH1 lymphocyte activity may be the sole cause of this TH1/TH2 shift and that the addition of recombinant IL-12 can reverse TH1 suppression. Peripheral blood mononuclear cell fractions from 20 low-risk elective cardiac surgery patients were analyzed preoperatively (d0) and on the first (d1), third (d3), and sixth (d6) postoperative days. We determined the absolute numbers of T helper lymphocytes, IFN--producing TH1 cells, and IL-4-producing TH2 cells after stimulation and measured IFN- and IL-4 levels in the supernatants of stimulated peripheral blood mononuclear cell cultures, absolute monocyte counts, human leukocyte antigen-DR expression, and intracellular IL-12 synthesis under comparable conditions. Recombinant IL-12 alone or in combination with a neutralizing antibody was added. T helper lymphocyte counts were reduced postoperatively from d1 to d6 (P< 0.05). Absolute IFN-- and IL-4-positive T helper lymphocyte counts were reduced on d1 (P< 0.05). Intracellular IL-4 production in T helper lymphocytes remained postoperatively unchanged. Interferon synthesis was significantly reduced until d3 (P= 0.001) and significantly increased after IL-12 addition (P< 0.05). This effect was reversed by the addition of a neutralizing anti-IL-12 antibody. The TH1/TH2 shift after cardiac surgery seems to be caused primarily by a decrease in cellular IFN- synthesis in TH1 lymphocytes. Because TH1 suppression can be reversed by IL-12, it is more likely to be the result of altered stimulation pathways than cellular defects.

HLA-DR expression on peripheral blood monocytes is reduced after cardiac surgery. Little is known about the reconstitution of HLA-DR expression on peripheral blood monocytes in patients suffering from early non-fatal perioperative complications. We conducted a prospective study to prove whether these complications adversely affect the recovery of HLA-DR expression. Before surgery (d0), on the first (d1), third (d3), fifth (5th) postoperative days, blood samples were collected from 90 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB). HLA-DR expression was analysed flow cytometrically. Eleven patients experienced postoperative complications [mechanical ventilation of 24-48 h (n=6); reinstitution of CPB (n=2) intraoperatively; laparotomy (n=1), re-thoracotomy (n=1), re-intubation (n=1) within the first 24 h after surgery]. All patients showed a reduced HLA-DR expression after surgery with nadirs at d1 and d3. Whereas the values increased from d3 to d5 in patients with an uneventful clinical course, HLA-DR expression remained suppressed in patients with complications. HLA-DR expression is reduced after cardiac surgery with CPB. A delayed recovery of HLA-DR expression is seen in patients with early perioperative complications. These non-fatal complications appear to represent a 'second hit' resulting in a prolonged deficiency of the innate immune system. This might predispose to further infectious and septic complications.

The objective of the present study was to assess the physical fitness of patients after apical resection and partial apical pleurectomy for the treatment of primary spontaneous pneumothorax (PSP). Between 1982 and 1999, 58 patients received surgical treatment for PSP in our department. Twelve patients needed bilateral surgical intervention. At an average of 121 months after surgery (range, 16-231 months), the patients underwent follow-up assessments. Information was obtained on the basis of a questionnaire and from clinical examinations, including spirometry/body plethysmography and exercise testing with a bicycle ergometer. High-resolution computed tomography was used to identify postoperative changes of the lung apex. Forty-eight of 58 patients took part in the study, and all were found to be fully fit. High-resolution computed tomography gave evidence of new postoperative fibrocystic processes in 26 of the 31 affected apexes. One recurrence was observed (3.2%). Because apical resection cannot counteract pathogenetic mechanisms underlying parenchymal destruction and the formation of postoperative bullae among patients with a history of PSP, additional treatment of the apical pleura is necessary to prevent recurrences. Our results suggest that the physical fitness of patients with PSP can be completely restored postoperatively.

Cardiac surgery with cardiopulmonary bypass CPB is known to induce an immune response whose nature has been increasingly elucidated during the recent decade. Clinically, patients usually show two to three of the four symptoms, which define the socalled systemic inflammatory response syndrome SIRS. In addition, all parameters of the innate, nonspecific immune system, e.g., polymorphonuclear cells, elastase, and complement, are activated. This also applies to the proinflammatory mediators interleukin IL1, 6, and 8, and tumor necrosis factor TNF. Within the adaptive, specific immune system, a decrease of T lymphocytes and T helper TH cells is observed, whereas suppressor cytotoxic T cells and B cells appear to be nearly unaffected. Cytokine measurements provide more detailed information IL2 and IL12, which are important for the activation of the type1 THcell TH1mediated immune response, are depressed following cardiac operation. In contrast, IL10 and transforming growth factor essential to TH2mediated humoral or antiinflammatory immune response, are upregulated. In vivotests, e.g., delayed type hypersensitivity skin reaction and tetanus antibody production, confirm the polarization of the adaptive immune response towards the TH2 pathway. However, all these alterations usually do not result in clinical adverse events. Therefore, more information is needed about the immune response of patients at high preoperative risk or with serious perioperative complications to find out whether clinically relevant events are correlated to alterations of immune response. For this purpose, more readily available, standardized methods for immunologic monitoring appear highly desirable.

InDrosophila the Polycomb group (Pc-G) proteins are responsible for the stable and heritable silencing of genes. The Pc-G apparently uses heterochromatin-like mechanisms to transcriptionally inactivate developmental regulators such as the homeotic genes. The Polycomb (Pc) protein is part of a large multimeric complex composed of other members of the Pc-G. We have identified functionally relevant domains of the Pc protein by sequencing differentPc alleles. Additionally, using a Pc-ßgal fusion protein with deleted internal histidine repeats, we found that this mutant protein cannot bind to four particular target loci, but otherwise does not change the remaining overall binding pattern. We show that, in contrast to the dotted subnuclear localization of the wild-type protein, the nuclear distribution of mutant proteins becomes homogeneous. Surprisingly, inPc mutants the polyhomeotic protein, another member of the Pc-G, is also redistributed in the nucleus. Our results indicate that the appropriate subnuclear localization of the two proteins is critical for the silencing function of the Pc-G complex.

In Drosophila, dosage compensation occurs by transcribing the single male X chromosome at twice the rate of each of the two female X chromosomes. This hypertranscription requires four autosomal male-specific lethal(msl) genes and is negatively regulated by the Sxl gene in females. Two of the msls, the mle and msl-1 genes, encode proteins that are associated with hundreds of specific sites along the length of the male X chromosome. MLE and MSL-1 X chromosome binding are negatively regulated by Sxl in females and require the functions of the other msls in males. To investigate further the regulation of dosage compensation and the role of the msls in this process, we have cloned and molecularly characterized another msl, the msl-3 gene. We have found that MSL-3 is also associated with the male X chromosome. We have further investigated whether Sxl negatively regulates MSL-3 X-chromosome binding in females and whether MSL-3 X-chromosome binding requires the other msls. Our results suggest that the MLE, MSL-1 and MSL-3 proteins may associate with one another in a male-specific heteromeric complex on the X chromosome to achieve its hypertranscription.

In Drosophila equalization of the amounts of gene products produced by X-linked genes in the two sexes is achieved by hypertranscription of the single male X chromosome. This process, dosage compensation, is controlled by a set of male-specific lethal (msl) genes, that appear to act at the level of chromatin structure. The properties of the MSL proteins have been extensively studied in the polytene salivary gland chromosomes where they bind to the same set of sites along the male X chromosome in a co-dependent manner. Here we report experiments that show that the MSL proteins first associate with the male X chromosome as early as blastoderm stage, slightly earlier than the histone H4 isoform acetylated at lysine 16 is detected on the X chromosome. MSL binding to the male X chromosome is observed in all somatic tissues of embryos and larvae. Binding of the MSLs to the X chromosome is also interdependent in male embryos and prevented in female embryos by the expression of Sex-lethal (Sxl). A delayed onset of binding of the MSLs in male progeny of homozygous mutant msl-1 or mle mothers coupled with the previous finding that such males have an earlier lethal phase supports the idea that msl-mediated dosage compensation begins early in embryogenesis. Other results show that the maleless (MLE) protein on embryo and larval chromosomes differs in its reactivity with antibodies; the functional significance of this finding remains to be explored.