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Die kongenitale Pseudarthrose der Tibia (CPT) ist eine seltene Erkrankung, die Unfallchirurgen und Orthopaden seit langer Zeit herausfordert. Klinisch imponieren eine meist zunehmende Antekurvations- und Varusfehlstellung der Tibia im Sauglings- und im Kleinkindalter. Oft ist die CPT mit einer Neurofibromatose oder fibrosen Dysplasie vergesellschaftet. Eine Diskontunitat der Tibia und/oder Fibula kann bei Unkenntnis des Krankheitsbildes als einfache Fraktur fehlgedeutet werden. Histopathologische Untersuchungen lassen vermuten, dass eine pathologische Veranderung des Periosts im Bereich der Pseudarthrose, das Hamartom, im Wesentlichen fur dieses Krankheitsbild verantwortlich zu sein scheint. Somit muss zur Heilung der CPT auch eine Resektion des Hamartoms erfolgen. Multimodale Therapieansatze mit Vereinigung medikamentoser und operativer Ansatze wie z. B. die X‑Union-Technik von Paley scheinen im Verlauf eine gunstigere Prognose aufzuzeigen.

Skoliosen im Kindes- und Jugendalter benotigen haufig aufwendige konservative und operative Therapieverfahren. Zur Vermeidung unerfreulicher Verlaufe ist die detaillierte Kenntnis des Wachstumsverhaltens, der Prognose und von Begleitproblematiken unerlasslich. Kenntnisse zu Atiologie, Prognose, Diagnostik und Therapie von Wirbelsaulendeformitaten im Wachstumsalter sollen vermittelt werden. Die vorliegende Arbeit beruht auf einer selektiven Literaturrecherche und auf den Ergebnissen mehrerer eigener prospektiver und retrospektiver Untersuchungen. Abhangig von Atiologie und Patientenalter ist eine detaillierte und interdisziplinare Diagnostik notig. Konservative Therapien, z. B. die Versorgung mithilfe eines Cheneau-Korsetts, konnen Krummungen bestenfalls aufhalten, aber nicht auf lange Sicht umkehren. Operative Therapien mit wachstumsfreundlichen Implantaten sind aufwendig sowie mit Komplikationen und Mehrfacheingriffen verbunden. Von extern zu verlangernde, magnetische Implantate vermindern die Zahl notwendiger operativer Eingriffe, tragen aber nicht zur Erhohung der Lebensqualitat bei. Unterschiedliche Formen der Skoliose benotigen verschiedene Therapieansatze. Wichtig ist die Kenntnis von der Art der Skoliose und dem wahrscheinlichen Verlauf. Abhangig davon muss die Familie entsprechend beraten und ein Therapiekonzept entwickelt werden. Wachstumsfreundliche Implantate werden als Ubergangslosung bis zur Wirbelsaulenversteifung eingesetzt.

Spinal muscular atrophy (SMA) is a fatal neurodegenerative disease of newborns and children caused by mutations or deletions of the survival of motoneuron gene 1 resulting in low levels of the SMN protein. While neuromuscular degeneration is the cardinal symptom of the disease, the reduction of the ubiquitously expressed SMN additionally elicits non-motoneuron symptoms. Impaired bone development is a key feature of SMA, but it is yet unknown whether this is an indirect functional consequence of muscle weakness or caused by bone-intrinsic mechanisms. Therefore, we radiologically examined SMA patients in a prospective, non-randomized cohort study characterizing bone size and bone mineral density (BMD) and performed equivalent measurements in pre-symptomatic SMA mice. BMD as well as lumbar vertebral body size were significantly reduced in SMA patients. This growth defect but not BMD reduction was confirmed in SMA mice by μCT before the onset of neuromuscular symptoms indicating that it is at least partially independent of neuromuscular degeneration. Interestingly, the number of chondroblasts in the hypertrophic zone of the growth plate was significantly reduced. This was underlined by RNAseq and expression data from developing SMA mice vertebral bodies, which revealed molecular changes related to cell division and cartilage remodeling. Together, these findings suggest a bone intrinsic defect in SMA. This phenotype may not be rescued by novel drugs that enhance SMN levels in the central nervous system only.

Reduktion und Retention des Krummungswinkels bei Kindern mit neuromuskularen Erkrankungen und progredienten Wirbelsaulendeformitaten. Progressive neuromyopathische Skoliose, welche konservativ nicht beherrscht werden kann (v. a. beim nicht gehfahigen Kind), und/oder Entwicklung eines Thoraxinsuffizienzsyndroms (TIS). Ungenugende Weichteildeckung, Korpergewicht 25 oder >50 kg, fehlende knocherne Verankerungsstrukturen (Rippen), ausgewachsenes Skelett (normalerweise Alter 50 % erzielt und eine Progression uber Jahre effektiv verhindert werden. Bei 495 ambulanten Verlangerungsprozeduren betrug die Rate an operationspflichtigen implantatassoziierten Komplikationen 3,7 %. Im Verlauf erhielten 29 % der 45 Kinder eine operative Revision. Mit der vorgestellten operativen „No-touch“-Technik zur Skoliosekorrektur kindlicher neuromyopathischer Deformitaten kann eine effektive Reduktion des Skoliosekrummungswinkels erreicht und gehalten werden. Vorteile der Methode sind ein teilweiser Erhalt der Wirbelsaulenflexibilitat und eine Reduktion wirbelsaulennaher Ossifikationen, was die definitive dorsale Spondylodese als Endpunkt der Behandlung erleichtert.

In recent decades, magnetically controlled growing rods (MCGR) were established to treat progressive early-onset scoliosis. The aim of this investigation was to assess the effect of long-term MCGR with continuous distraction on intervertebral discs in scoliotic children. Magnetic resonance imaging (MRI) of 33 children with spinal muscular atrophy was analyzed by grading intervertebral disc degeneration (IDD) and measuring intervertebral disc volume. Cohort I (n = 17) were children who had continuous spinal distraction with MCGRs for 5.1 years and MRI before (av. age 8.1) and after (av. age 13.4) MCGR treatment. Cohort II (n = 16, av. age 13.7) were patients without prior surgical treatment. Lumbar intervertebral disc volume of cohort I did not change during 5.1 years of MCGR treatment, whereas disc volumes were significantly larger in age- and disease-matched children without prior treatment (cohort II). Cohort I showed more IDD after MCGR treatment in comparison to early MRI studies of the same patients and children without surgical treatment. MRI data showed a volume reduction and disc degeneration of lower thoracic and lumbar intervertebral discs in scoliotic children after continuous spinal distraction with MCGRs. These effects were confirmed in the same subjects before and after treatment as well as in surgically untreated controls.

Flexible flatfoot is among the most common skeletal disorders in childhood. This study describes the dynamic and static correction effects of subtalar arthroereisis in adolescents with flexible symptomatic flatfeet in comparison to normal subjects as well as to results before and after removal of metal. Eighteen adolescents with 25 symptomatic flexible flatfeet were treated surgically with a subtalar arthroereisis at a mean of 12.5 (10-16) years. At follow-up (mean 3.9 years, range 0.4-8), patients filled out the American Orthopaedic Foot and Ankle Society questionnaire, received radiographs and were examined using dynamic and static pedobarography as well as static hindfoot axis examination. Results were compared to healthy controls (n = 13; 26 feet). Surgically treated feet (n = 25) had better questionnaire results after surgery than before, but lower scores than healthy feet. Radiological parameters improved significantly after surgery. Removal of metal did not influence post-surgical results (follow-up 2.8 years). Surgically treated feet had larger contact areas than normal feet with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of treated feet compared to controls. When comparing pedobarography data of treated versus untreated feet of the same patients (subgroup n = 11 feet), there were no differences. Subtalar arthroereisis was able to effectively treat symptomatic flexible flatfeet in this population. Results improved significantly evaluating a questionnaire, radiographs, dynamic and static weight distribution, but were still worse than results of healthy feet. There was no relapse after removal of metal.

Childhood tumors of the central nervous system (CNS) and other entities affecting the spine are rare. Treatment options vary from surgical biopsy to partial, subtotal, and total resection, to radiation, to chemotherapy. The aim of this study is to investigate spinal deformity and subsequent surgical interventions in this patient cohort. A retrospective review at our institution identified children with CNS tumors, spinal tumors, and juxta-spinal tumors, as well as spinal deformities. Tumor entity, treatment, mobilization, and radiographic images were analyzed relative to the spinal deformity, using curve angles in two planes. Conservative or surgical interventions such as orthotic braces, growth-friendly spinal implants, and spinal fusions were evaluated and analyzed with respect to treatment results. Tumor entities in the 76 patients of this study included CNS tumors (n = 41), neurofibromatosis with spinal or paraspinal tumors (n = 14), bone tumors (n = 12), embryonal tumors (n = 7), and others (n = 2). The initial treatment consisted of surgical biopsy (n = 5), partial, subtotal, or total surgical resection (n = 59), or none (n = 12), followed by chemotherapy, radiotherapy, or both (n = 40). Out of 65 evaluated patients, 25 revealed a moderate or severe scoliotic deformity of 71&deg, (range 21&ndash, 116&deg, ), pathological thoracic kyphosis of 66&deg, (range 50&ndash, 130&deg, ), and lordosis of 61&deg, (range 41&ndash, 97&deg, ). Surgical treatment was performed on 21 patients with implantation of growth-friendly spinal implants (n = 9) as well as twelve dorsal spinal fusions (two with prior halo distraction). Surgical interventions significantly improved spinal deformities without additional neurological impairment. With the increasing number of children surviving rare tumors, attention should be focused on long-term problems such as spinal deformities and consequent disabilities. A significant number of children with CNS tumors, spinal tumors or juxta-spinal tumors required surgical intervention. Early information about spinal deformities and a close follow-up are mandatory for this patient group.

Purpose Growth-friendly spinal implants (GFSI) were established for scoliotic children as an interim solution until definite spinal fusion could be performed during puberty. While deformity control was clearly proven, the effects on vertebral shape and morphology are still unclear. Our prospective study assesses the effect of GFSI with continuous distraction on vertebral body shape and volume in SMA children in comparison with previously untreated age-matched SMA patients. Methods Cohort I (n = 19, age 13.2 years) were SMA patients without prior surgical scoliosis treatment. Cohort II (n = 24, age 12.4 years) were children, who had continuous spinal distraction with GFSI for 4.5 years. Radiographic measurements and computed tomography (CT) 3D volume rendering were performed before definite spinal fusion. For cohort II, additional radiographs were analyzed before the first surgical implantation of GFSI, after surgery and every year thereafter. Results Our analysis revealed decreased depth and volume in scoliotic patients with prior GFSI compared to scoliotic patients without prior implants. This difference was significant for the lower thoracic and entire lumbar spine. Vertebral body height and pedicle size were unchanged between the two cohorts. Conclusion CT data showed volume reduction in the vertebral body in scoliotic children after GFSI treatment. This effect was more severe in the lumbar and lower thoracic area. While vertebral height was identical in both groups, vertebral depth was reduced in the GFSI-treated group. Reduced vertebral depth and altered vertebral morphology should be considered before instrumenting the spine in previously treated scoliotic SMA children. Level of evidence III Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

ZusammenfassungDer kindliche Knick-Senk-Fuß ist eine 3-dimensionale Fußfehlstellung mit vermehrter Valgusstellung der Ferse, Abflachung der medialen Längswölbung und Abduktion des Vorfußes. Man unterscheidet die flexible von der kontrakten (rigiden) Form. Die Diagnostik gliedert sich in Anamnese, klinische Untersuchung, apparative Diagnostik wie Pedobarografie und die Ganganalyse sowie bildgebende Verfahren. Wichtig ist die Einbeziehung in ein Therapieschema von eventuell vorliegenden pädiatrischen oder neuropädiatrischen Erkrankungen (z. B. Muskeldystrophien, Ehlers-Danlos- oder Marfan-Syndrom u. Ä.). Es zeigt sich, dass bei Kindern ≤ 6 Jahre der flexible Knick-Senk-Fuß fast ausschließlich physiologisch vorkommt (bei 97% aller 19 Monate alten Kinder). Bis zum Alter von 10 Jahren bildet sich die mediale Fußlängswölbung zunehmend aus. Bei einem kleinen Anteil (10-jährige Kinder 4%) persistiert der Knick-Senk-Fuß oder wird progredient. Oberhalb von 10 Jahren besteht die Gefahr der Dekompensation mit zunehmender Rigidität. Nur die Minderheit der Kinder entwickelt eine Schmerzsymptomatik (

Background Context In several studies, vertical expandable prosthetic titanium rib (VEPTR) implants have shown good scoliosis control in children with the longest reported follow-up of 3.6 years. For growing rods, recent studies suggest a decreased efficiency of correction starting just after that time. To our knowledge, no long-term results of children with VEPTR treatment are available. Purpose This study aimed to evaluate spinal deformity in scoliotic children and to investigate correction potential of VEPTR implants at several time points of treatment, particularly after long-term follow-up. Study Design/Setting We performed a retrospective case series of 32 children with spinal deformity and VEPTR treatment with analysis of clinical and radiological data pre- and post-VEPTR implantation and every 2 years during the follow-up period. Patient Sample Thirty-two patients with spinal deformity and VEPTR treatment comprised the patient sample. Outcome Measures Patients had a primary VEPTR implantation due to spinal deformity and thoracic insufficiency syndrome and repeated lengthening procedures every 6 months. Clinical data were assessed and radiological parameters were analyzed. The main thoracic scoliotic curve and associated curves as well as kyphosis, lordosis, pelvic obliquity, and spinal length were measured in all radiographs until the end of VEPTR treatment or the last available examination. Methods Development of the different parameters during follow-up was evaluated and statistical analysis was performed with Statistica version 13.0. No funding was obtained for this study. The authors have no conflicts of interest to declare. Results Directly after VEPTR implantation, thoracic and lumbar curves corrected significantly, were stable at 2.8-year follow-up, and increased at 5.5-year follow-up, whereas cervical scoliosis was not affected by the treatment. The sagittal profile was initially improved both in kyphosis and lordosis. However, at 5.5-year follow-up, hyperkyphosis had deteriorated beyond the initial deformity. Pelvic obliquity was significantly restored especially in neuromuscular patients, and increasing spinal length was achieved within the 5.5-year follow-up. Conclusion In children with spinal deformity, implantation of the VEPTR device sufficiently corrected the deformity in all planes. During long-term follow-up, scoliosis increased slightly and was rather well controlled, whereas the implant system was not able to prevent deterioration of hyperkyphosis. Pelvic obliquity was well balanced and spinal lengthening was achieved during long-term follow-up.

BACKGROUND Almost all children with spinal muscular atrophy (SMA) develop a scoliosis during childhood and adolescence. In the last decades, growth-friendly spinal implants have been established as an interim solution for these patients until definite spinal fusion can be performed. The effect of those implants on the final outcome has yet to be described. OBJECTIVE To assess the effect of prior growth-friendly spinal surgical treatment on the outcome after spinal fusion in SMA children in comparison to untreated SMA patients through the prospective study. METHODS A total of 28 SMA patients with (n = 14) and without (n = 14) prior surgical treatment with growth-friendly implants were included. Average surgical treatment prior to definite spinal fusion was 4.9 yr. Scoliotic curve angle, pelvic obliquity, spinal length, kyphosis, and lordosis were evaluated for children with prior treatment and before and after dorsal spondylodesis for all children. RESULTS The curve angle before definite spinal fusion averaged at 104° for SMA patients without prior treatment and 71° for patients with prior treatment. Spondylodesis reduced the scoliotic curve to 50° and 33°, respectively, which equals a correction of 52% vs 54%. Pelvic obliquity could be improved by spinal fusion in all patients with better results in the pretreated group. Results for spinal length, kyphosis, and lordosis were similar in both groups. CONCLUSION These data show the positive effect of prior growth-friendly surgical treatment on radiographic results of spinal fusion in children with SMA. Both scoliotic curve angles and pelvic obliquity showed significantly better values when patients had growth-friendly implants before definite spinal fusion.

ZusammenfassungAngeborene vaskuläre Malformationen sind häufig mit Problemen des muskuloskeletalen Systems vergesellschaftet. Stimulatives Wachstum führt zu Hypertrophien und Mehrwachstum, wie dies beispielsweise beim Klippel-Trenaunay-Syndrom mit einer zunehmenden Beinlängendifferenz vorkommt. Eine frühzeitige engmaschige klinische und radiologische kinderorthopädische Betreuung ist nötig, um rechtzeitig konservative oder operative Maßnahmen durchzuführen. Gravierende Beinlängendifferenzen im Wachstumsalter können in der Folge zu Skoliosen, aber auch rigiden Kontrakturen führen. Nach entsprechender Beobachtung und Planung sind wachstumshemmende operative Maßnahmen wie beispielsweise eine temporäre Epiphyseodese aufwändigeren verlängernden Verfahren oder Operationen nach Wachstumsabschluss vorzuziehen. Im Vorfeld einer Operation müssen zur Vermeidung von Komplikationen sorgfältige interdisziplinäre Abklärungen und Interventionen erfolgen beispielsweise zur Behandlung von Koagulopathien oder vorbereitenden Embolisationen im Operationsgebiet.

OBJECTIVEDuring childhood, early-onset scoliosis (EOS) may show severe progressive deformity, which consequently leads to aggressive treatment strategies, such as serial casting, long-term bracing, or surgical interventions. The latter usually includes repeated surgeries for implant lengthening every 6 months in order to allow sufficient growth of the thorax and spine. In 2011, the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) was introduced to measure health-related quality of life for this patient group and their families. Since then, cross-culturally adapted versions of the EOSQ-24 have been published in Spanish, Turkish, traditional Chinese, and Norwegian. The purpose of the study was to transculturally adapt the original English version of the EOSQ-24 into the German language and evaluate the reliability of the German version.METHODSAfter adaptation and forward/backward translation, the German version of the EOSQ-24 was given to the parents or caregivers of 67 EOS patients (33 male, 34 female) Data quality was evaluated by mean, standard deviation, percentage of data missing, and extent of ceiling and floor effects. Reliability was estimated by internal consistency using Cronbach α and item-total correlations.RESULTSIn the study group (n = 67), 12 children were either observed (n = 7) or treated with a brace (n = 5). The other 55 patients were treated surgically with growth-friendly implants. The item response to the German EOSQ-24 was high with a minimum of missing data (1.7%). All items showed very good to excellent internal consistencies (0.879–0.903). Floor effects for the 24 items were between 0% and 31% and ceiling effects between 9% and 78%. The calculated Cronbach α for the 24-item scale was 0.9003, indicating excellent reliability.CONCLUSIONSThe German adaptation of the EOSQ-24 shows excellent reliability and therefore is a valid tool to measure objective health-related quality of life in children with EOS.

Background The impact of backpack carrying on body postural changes in schoolchildren has been discussed intensively. However, findings are inconsistent mainly due to the lack of long-term results. Objective The purpose of this investigation was to study the influence of backpack weight on body posture and prevalence of back pain. Methods In our prospective, comparative study, we investigated the influence of backpack weight on 77 schoolchildren (average age 10.8 ± 0.7 years) over a 1-year period. Participants were evaluated at the beginning of the study by clinical examination and formal static posture analysis. Forty-nine students comprised the control group while 28 students in the intervention cohort had the weight of their backpacks reduced by 2 kg. All students were reevaluated after 6 and 12 months by formal postural examination. Results Children with reduced backpack weights had a significantly improved bending posture when wearing their backpacks when compared to the participants of the control group, whereas the analysis of the children while they did not wear their backpacks revealed no difference between the groups. Within the follow-up period all postural changes were reversible once the backpack weight was removed. Conclusions Schoolchildren with heavy backpack loads show postural changes while carrying their backpack but this impact was reversible when backpacks were removed. Continuous reduction of backpack loads minimizes prevalence of back pain.

Spine-based fixation of magnetically controlled lengthening devices has been successfully performed for children with early-onset scoliosis. However, spinal manipulation may lead to ossifications, stiffness, and autofusion as previously described. To avoid these problems, a surgical technique combining bilateral externally controlled magnetic device implantation with a rib cradle and pelvic hook fixation was introduced by us in 2011. By using a bilateral single-rib or double-rib cradle fixation and a pelvic hook, the magnetic device is percutaneously inserted. The spine corrects indirectly without further manipulation. In small rib diameter or severe osteoporosis, double-rib cradles are used. Our introduced technique enables modification of the rib vertebral angle, which may be beneficial in children with spinal muscular atrophy and rib-cage deformity. This nonrandomized prospective study describes 18 children with neuromuscular scoliosis treated first by this method. All patients followed the same protocol, with expansion procedures being performed 5 months after surgery and every 3 months thereafter. Clinical, radiologic, and complication data were analyzed, showing a significant reduction in scoliosis and pelvic obliquity and an increase in spinal length, which could be maintained over a follow-up period of 1.2 years. The overall complication rate was lower than previously described, with 8%, 2 of them requiring surgery.

Bacterial colonization of spinal implants may cause severe complications in patients with early-onset scoliosis. Correct diagnosis and detection of microbiologic formation is crucial to prevent delayed infections caused by bacterial colonization. The purposes of this study were to estimate the rate and risk factors of colonization of vertical expandable prosthetic titanium rib (VEPTR) implants in children and to compare the different methods for detecting microbiologic formation on the spinal implants.We evaluated prospectively a group of 42 children with spinal deformities with an overall of 95 lengthening surgeries and applied different methods to detect potential bacterial colonization of VEPTR implants: swab of the implant, swab with culture of tissue, analysis of the removed lock, polymerase chain reaction (PCR), and confocal microscopy. Potential risk factors were evaluated.Of 42 patients, 17 (40%) were rated positive for bacterial colonization with Propionibacterium acnes and coagulase-negative staphylococci being the most commonly found bacteria. Risk factors for colonization were increasing age, body height, and weight. The swab with culture of removed tissue yielded most positive results, whereas direct microscopy and PCR were the least sensitive detection methods. Furthermore, commonly used infectious blood parameters were inconclusive.Although the impact of bacterial colonized implants on the health of the patients is not fully elucidated, clinicians aim for prevention of microbiologic formation on implanted devices. Therefore, reliable, inexpensive, and easy to apply diagnostic tools are indispensable to detect colonization. Based on our data, the swab together with tissue culture has the potential to become the method of choice for future diagnosis.

Frakturen des proximalen Radiusendes im Wachstumsalter weisen 3 Besonderheiten auf: Das Radiuskopfchen artikuliert mit 2 Gelenkpartnern und ist somit fur eine ungestorte Ellbogenfunktion unerlasslich. Die Versorgung des proximalen Radiusendes erfolgt durch periostale Gefase im Sinne einer Endstrombahn. Hieraus resultiert eine extreme Vulnerabilitat, sodass bei schweren Traumata – sei es durch Unfall oder Behandlung – Teil- oder Vollnekrosen mit Verplumpungen im Kopf-Hals-Bereich entstehen. Irreversible Komplikationen bilden die radioulnare Synostose und die chronische Epiphysenlosung, welche auch nach exzessiver Physiotherapie entstehen kann. Trotz einer niedrigpotenten Fuge zeigt das proximale Radiusende beim jungen Patienten eine enorme Spontankorrektur von Abkippungen. Seit-zu-Seit-Verschiebungen werden allerdings nicht remodelliert. Therapeutisch sollte moglichst atraumatisch vorgegangen werden. Wegen der Blutversorgungssituation sollten bei entsprechender Indikation unbedingt die Spontankorrektur und eine kurze Ruhigstellungszeit ohne Physiotherapie in ein Therapiekonzept integriert werden. Falls operiert werden muss, sind wiederholte traumatisierende Repositionsmanover zu unterlassen, im Zweifelsfall kann mit einem intramedullaren Nagel geschlossen oder schonend offen reponiert werden. Um den Besonderheiten des proximalen Radiusendes therapeutisch gerecht zu werden, mussen Vulnerabilitat und Korrekturpotenz gegeneinander abgewogen werden. Die Therapie muss so atraumatisch wie moglich sein. Das Spontankorrekturpotenzial sollte in die Primartherapie integriert werden, ohne dieses Potenzial in Bezug auf Ausmas und Alter der Patienten zu uberfordern.

Study Design. Retrospective analysis of 1328 spinal radiographs of 57 patients after vertical expandable prosthetic titanium rib (VEPTR) implantation with an average follow-up of 30 months. Objective. To evaluate the incidence, time of onset, as well as the underlying factors influencing the occurrence of ossifications in children treated with VEPTR. Summary of Background Data. Spontaneous spinal fusions and ossifications are well known in children treated with spinal implants. In theory, children with spinal deformity and VEPTR implantation are less likely to develop these complications because of either little or no implant contact to the spine. Methods. Fifty-seven patients had a primary VEPTR implantation due to spinal deformity and thoracic insufficiency syndrome and repeated lengthening procedures. The mean age at the time of primary surgery was 7.7 years, the mean duration of follow-up was 29.8 months, and the mean number of operations was 5.9. A total of 1328 spinal radiographs were analyzed with respect to the occurrence and growth of ossifications, implant migration, and other complications. Results. Overall, 24% of the patients (n = 13) had ossifications, which affected in 92% the main load sharing VEPTR implant. The fusions involved in 54% of cases the lumbar spine and in each 23% the ribs and the iliac crest. Ossifications developed in 11% of children within the first year of treatment and increased by about the same rate per annum. After 53 months, 48% of the radiographs showed some ossifications. There was a significant correlation to the stiffness of the deformity and the number of surgical procedures. Conclusion. Contrary to previous assumptions, it was shown that in children treated with the VEPTR system, 48% of children showed ossifications after 53 months. Ossifications were observed significantly more often in children with stiff deformities and after multiple surgical procedures. It is a much more common problem than previously thought. Conclusion. Level of Evidence: 3

Study design Case Series. Objective To describe the post-VEPTR (vertical expandable prosthetic titanium rib) treatment changes in early-onset spinal deformity (EOSD), which may influence the final correction spondylodesis. Summary of background data The VEPTR device, originally developed for the treatment of congenital rib cage malformation, is nowadays more widely used in the treatment of EOSD. At present, only a few reports describe the possible complications that may occur with repeated lengthening procedures of the VEPTR, thereby making the final spondylodesis more complicated and less satisfactory. Methods X-rays of 5 children treated for EOSD with 2 unilateral VEPTR (each rib to rib and rib to lumbar lamina) were analyzed for curve patterns and Cobb angles before, during, and at the end of VEPTR treatment, and after the final spondylodesis. Intraoperative observations during the spondylodesis, which influenced the possibilities of the curve correction, were documented. Results All patients showed a marked decompensation of the frontal balance and a high degree of rigidity of the main curve and the compensatory curves after treatment with the VEPTR device. Because of this spontaneous autofusion of spinal segments, migration of the rib cradles and/or the laminar hook, and a change in the curve patterns, the final fusion had to be longer in all patients than the primary deformity would have intended. Conclusions If an EOSD is treated with VEPTR, the curve progression and, in particular, the development of a high thoracic hyperkyphosis or rotation of the main curve should be critically observed. Autofusion of ribs and vertebral bodies may make the final correction spondylodesis even more challenging and risky for the patient and the end result less satisfactory.

Erectile dysfunction (ED) is often associated with increased cardiovascular risk. There is increasing evidence suggesting that dysfunction of the vascular endothelium with reduced bioavailability of nitric oxide (NO) may be the pathogenetic link between ED and cardiovascular disease. The crucial importance of the NO-guanylatecyclase-cGMP-phosphodiesterase pathway for penile erection is mirrored by the efficacy of phosphodiesterase-5 (PDE5) inhibitors in the treatment of ED. In contrast to other currently available PDE5 inhibitors with a half-life time of about 4 h Tadalafil has a half-life time of about 17.5 h resulting in erectile responsiveness for up to 36 h after 1 single dose. Most clinical experience has been reported with on-demand use of PDE-5 inhibitors, but meanwhile several studies were able to demonstrate that Tadalafil given daily in low (2.5 and 5 mg) doses is both highly effective and well-tolerated. In three randomized, double-blind, placebo-controlled multi-center trials, various validated measures of erectile function indicated that once daily Tadalafil at doses of 2.5, 5, and 10 mg was significantly superior to placebo.In another mono-center trial, once daily Tadalafil has shown significant efficacy even after failure of on-demand treatment. In a controlled cross-over study of on-demand versus daily Tadalafil treatment, 72% of the patients preferred once daily administration, mainly because of superior and longer efficacy allowing a more spontaneous sexual life. Interestingly in a pilot study of on-demand versus chronic administration of Tadalafil for 4 weeks, only regular dosing improved several markers of endothelial function.

Bei Kindern und Jugendlichen mit spastischer Hemiparese sind Torsionsdifferenzen an der unteren Extremitat bekannt, wahrend Torsionsverhaltnisse der oberen Extremitat weitgehend unerforscht sind. Die Torsionsanderungen der unteren Extremitat beeinflussen das Gangbild und Veranderungen der Drehverhaltnisse der oberen Extremitat (etwa nach Frakturen) fuhren zu Bewegungseinschrankungen der Arme bzw. zum geanderten Bewegungsradius der Arme. In der vorliegenden Studie wurde an Kindern und Jugendlichen mit spastischer Hemiparese untersucht, ob eine Torsionsdifferenz zwischen dem Humerus der gesunden und der erkrankten oberen Extremitat besteht, von welchen Faktoren eine mogliche Differenz abhangig ist und inwieweit diese sich auf die Beweglichkeit des Armes auswirken. Anamnestisch, klinisch, photographisch und mittels einer neuartigen sonographischen Methode wurden 33 Kinder und Jugendliche mit spastischer Hemiparese [Mittel 9,7 (3–16) Jahre] sonographisch untersucht. Eine Einteilung nach dem Grad der Spastik erfolgte in 3 Gruppen. Die Humerustorsionsmessungen wurden mit den Ergebnissen eines Normalkollektivs verglichen (n=149). Bei etwa der Halfte (n=16; 48,5%) der Kinder und Jugendlichen war die sonographisch gemessene Humerustorsion der erkrankten Seite mehr nach innen, bei 17 (51,5%) der Kinder war die Humerustorsion im Vergleich zur gesunden Seite mehr nach ausen gerichtet. Die Veranderung der Humerustorsion der erkrankten Seite im Vergleich zum gesunden Arm war mit p

AIM Inter- and intraobserver reliability and learning curve using Graf's ultrasonographic hip examination were assessed. MATERIAL AND METHODS 189 participants of the basic, advanced and final courses on hip ultrasound using the Graf method (DEGUM) were asked to answer a questionnaire and to measure 34 normal and pathological sonographic hip examinations. Measurement differences and the learning curve during the different courses were evaluated. RESULTS There was a significant (p = 0.001) improvement of the average angle between the basic (6.74 degrees [+/- 1.46 degrees ]) and the advanced course (6.22 degrees [+/- 1.17 degrees ]). However, there were no better results in the final course and no additional improvement. Participants had higher variations when measuring the beta-angle than the alpha-angle. A significant improvement was seen if the participants performed a large number of hip ultrasounds between the courses. Higher measurement differences were seen in pathological hip ultrasounds and in ultrasonographic examinations of poorer quality. CONCLUSIONS During the educational courses on hip ultrasound using the Graf method, a high intra- and interobserver variability was seen. These findings were most prominent in measurement of the beta-angle, in pathological hip ultrasounds and in ultrasonographic hip examinations of poorer quality. The best results were achieved by participants who had performed a large number of examinations between courses. For the improvement of ultrasonographic measurements, a large number of self-performed examinations and a training in potential mistakes seem to be of great importance.

Consecutive outbreaks of acute aflatoxicosis in Kenya in 2004 and 2005 caused > 150 deaths. In response, the Centers for Disease Control and Prevention and the World Health Organization convened a workgroup of international experts and health officials in Geneva, Switzerland, in July 2005. After discussions concerning what is known about aflatoxins, the workgroup identified gaps in current knowledge about acute and chronic human health effects of aflatoxins, surveillance and food monitoring, analytic methods, and the efficacy of intervention strategies. The workgroup also identified public health strategies that could be integrated with current agricultural approaches to resolve gaps in current knowledge and ultimately reduce morbidity and mortality associated with the consumption of aflatoxin-contaminated food in the developing world. Four issues that warrant immediate attention were identified: a) quantify the human health impacts and the burden of disease due to aflatoxin exposure; b) compile an inventory, evaluate the efficacy, and disseminate results of ongoing intervention strategies; c) develop and augment the disease surveillance, food monitoring, laboratory, and public health response capacity of affected regions; and d) develop a response protocol that can be used in the event of an outbreak of acute aflatoxicosis. This report expands on the workgroup’s discussions concerning aflatoxin in developing countries and summarizes the findings.

Background Children with congenital thoracic scoliosis associated with fused ribs and unilateral unsegmented bars adjacent to convex hemivertebrae will inevitably develop thoracic insufficiency syndrome and curve progression with hemithorax compression without treatment. It is assumed that the concave side of such curves and their unilateral unsegmented bars do not grow. In the past early spinal fusion was performed with consecutive short thoracic spines and loss of lung volume. Little attention has been paid to lung function. These patients often suffered from lung failure and early death due to a small thorax. Method A new surgical technique is based on an indirect deformity correction and enlargement of the thorax due to a longitudinal implant, the vertical expandable prosthetic titanium rib (VEPTR). The spine is not fused, thus promoting growth of the spine, the thorax and the lungs. Elongation of the implant is done every six months. Since 2002 this method has been performed on fifteen children in Basel as the first European center. Results Patients (mean age 6 years; 11 months to 12 years) were suffering from thoracic insufficiency syndrome due to unilateral unsegmented bars with fused ribs (n = 4), absent ribs (n = 2), bilaterally fused ribs (n = 2), hemivertebrae (n = 3) or neuromuscular scoliosis (n = 6). Doing fifteen primarily implantations and thirteen elongations there were three complications (two hook dislocations, one skin breakage). All patients improved cosmetically, functionally and radiologically which was shown on X-rays as a reduction of the Cobb angle from an average of 76 degrees (40-110 degrees ) to 55 degrees (30-67 degrees ). Conclusions Expansion thoracoplasty and VEPTR implantation is a new treatment concept for children with thoracic insufficiency syndrome due to spinal deformities, which is based on distraction and expansion of the thorax thus allowing growth of the spine, the thorax and probably lungs. Presently it seems to be superior to any other method for the treatment of small children with progressive scoliosis and thoracic insufficiency syndrome.

Die Epiphyseolysis capitis femoris (ECF) wird definiert als nichttraumatische Epiphysenlosung in der Schenkelhalsepiphysenfuge wahrend des pubertaren Wachstumsschubes. Abhangig von der Anamnesedauer wird die akute von der chronischen und der akut auf chronischen Form unterschieden. Die Atiologie der Erkrankung ist bis heute nicht endgultig geklart, wobei von einem multifaktoriellen Geschehen ausgegangen wird. Die typische, in der Pubertat auftretende Form, wird von der atypischen ECF unterschieden. Letztere ist haufig mit endokrinologischen Erkrankungen oder Therapien assoziiert. Pradisponierende Faktoren fur die typische ECF in der Pubertat sind das mannliche Geschlecht, Hochwuchs und v. a. Ubergewicht. Wahrscheinlich findet haufig vor dem Abrutsch ein Wachstumsschub statt. Die Adipositas der Patienten ist mit einer verminderten femoralen Antetorsion assoziiert, welche zusatzlich durch Scherkrafte eine ungunstige mechanische Auswirkung auf die Epiphysenfuge hat. Die Therapie der ECF ist operativ und richtet sich nach der Erkrankungsform. Die akute ECF ist wegen der moglichen Gefahrdung der Huftkopfdurchblutung ein Notfall. Als Komplikationen sind nach ECF v. a. die Huftkopfnekrose und Chondrolyse gefurchtet.

Kinder mit kongenitaler thorakaler Skoliose, assoziiert mit Rippenfusionen, einseitigen unsegmentierten Spangen und kontralateraler Halbwirbelbildung, haben ohne Therapie eine massive Kurvenprogression. Aufgrund der Annahme, dass die unsegmentierten Spangen nicht wachsen, wurde in der Vergangenheit fruh operativ fusioniert, was eine verkurzte Wirbelsaulenlange und ein vermindertes Lungenwachstum zur Folge hatte. Durch ein neues Operationsverfahren mit einem an den Rippen verankerten Langsimplantat, dem „vertical expandable prosthetic titanium rib“ (VEPTR), erfolgt eine Aufrichtung der Deformitat und eine Vergroserung des Thorax.

Ellipse MAGEC rod implantation in combination with a bilateral VEPTR fixation from rib to pelvis is a sufficient method in treating flexible scoliosis in children with SMA without instrumentation of the spine.

Expansion thoracoplasty and vertical expandable prosthetic titanium rib (VEPTR; Synthes Spine Co., West Chester, Pennsylvania, USA) implantation is a new method for the treatment of thoracic insufficiency syndrome and congenital spinal deformity in children. The longitudinal rib implant expands the thorax and indirectly corrects spinal deformity, thus allowing spinal, thoracic and probably lung growth. VEPTR has been used since 1989 in San Antonio, USA, and was introduced to Europe in 2002. This paper describes the preliminary experience with the European patients. Fifteen children with progressive scoliosis had a VEPTR implantation at a mean age of 6 years (11 months to 12 years). Nine children had thoracic insufficiency syndrome due to unilateral unsegmented bars (n = 4), absent ribs (n = 1), hemivertebrae (n = 2) or bilateral fused ribs (n = 2). Six children had severe thoracolumbar scoliosis and pelvic obliquity due to neuromuscular scoliosis. After VEPTR implantation, families and patients reported improvement of the thoracic insufficiency syndrome and better sitting abilities in the neuromuscular patients, as well as radical cosmetic improvement. There were three complications (skin breakage, lumbar hook displacement, rib fracture) after performing fifteen primary VEPTR implantations and 13 expansion surgeries in eight patients. Our experience suggests that expansion thoracoplasty and VEPTR implantation is a safe and efficient method for the treatment of thoracic insufficiency syndrome in young children with severe scoliosis.

We compared the electromyographic (EMG) signals of lower extremity muscle groups in 10 children with hemiplegic cerebral palsy (CP) while walking barefoot and in a hinged ankle-foot orthosis (HAFO). All children had excessive plantarflexion and initial toe-contact on the affected side when walking barefoot, a typical gait pattern for hemiplegic patients. The patients walked with a physiological heel-toe gait pattern when wearing the HAFO. The peak activity of the tibialis anterior muscle was reduced by 36.1% at initial contact and loading response phase and by 57.3% just after toe-off when using a HAFO. The decrease in activity was thought to result from the change in gait pattern from a toe-gait to a heel-toe gait as well as the use of a HAFO. The HAFO also slightly decreased muscle activity in the proximal leg muscles mainly during swing phase, improved stride length, decreased cadence, improved walking speed, increased peak hip flexion, improved kinematics in loading response phase at the knee, and reduced the excessive ankle plantarflexion.

Background: Children with congenital thoracic scoliosis associated with fused ribs with a unilateral unsegmented bar adjacent to convex hemivertebrae will invariably have curve progression without treatment. Surgery has been thought to have a negligible growth-inhibition effect on the thoracic spine in such patients because it has been assumed that the concave side of the curve and the unilateral unsegmented bar do not grow, but we are unaware of any conclusive studies regarding this assumption. Methods: The changes in the length of the concave and convex sides, anterior and posterior vertebral edges, posterior arch, and unilateral unsegmented bars of the thoracic spine were measured in the twenty-one children with congenital scoliosis and fused ribs after expansion thoracoplasty had been carried out with use of a vertical, expandable titanium prosthetic rib. Three of these children had undergone posterior spinal fusion previously. Measurements were made with use of a three-dimensional software program that analyzed baseline and follow-up computed tomography scans. The technique was validated through measurement of the thorax of a small female adult cadaver. Results: The patients without spine fusion had an average age of 3.3 years at the time of the baseline computed tomography scan, and the average duration of follow-up was 4.2 years. On the average, these patients showed significant growth (p < 0.0001) of the concave side of the thoracic spine (an increase in length of 7.9 mm/yr, or 7.1%/yr) and the convex side (8.3 mm/yr, or 6.4%/yr) compared with the baseline lengths. There was no significant difference in the increases in length (p = 0.38) between the concave and convex sides. Eleven patients with an unsegmented bar had an average 7.3% increase in the length of the bar (p < 0.0001). In the three children with prior spinal fusion, the increase in length averaged only 4.6 mm/yr (3%/yr) on the concave side of the thoracic spine and 3.7 mm/yr (2.2%/yr) on the convex side; both increases were significant (p < 0.0001). Conclusions: Longitudinal growth of the thoracic spine in a normal child has been estimated to be 0.6 cm/yr between the ages of five and nine years. After expansion thoracoplasty, growth of the thoracic spine was approximately 8 mm/yr in our series of children with congenital scoliosis and fused ribs. After expansion thoracoplasty, both the concave and the convex side of the thoracic spine and unilateral unsegmented bars appeared to grow in these patients. When a thorax is already foreshortened by congenital scoliosis, control of spine deformity with expansion thoracoplasty allows growth of the thoracic spine, and it is likely that the longer thorax provides additional volume for growth of the underlying lungs with probable clinical benefit. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

The anti-CD25 immunotoxin RFT5.dgA was constructed by coupling the monoclonal antibody RFT5 via a sterically hindered disulfide linker to deglycosylated ricin A-chain and was administered to patients with relapsed Hodgkin's lymphoma in four bolus infusions over 7 days (day 1, 3, 5 and 7). The maximum tolerated dose in these patients as defined in a previous phase I study was 15 mg/m2. Subsequently, further patients were enrolled at the maximum tolerated dose and a total of 18 patients were treated at this level. All patients had signs of progressive disease and were heavily pretreated. Side-effects in this trial were moderate and related to vascular leak syndrome. Five of 18 patients experienced NCI grade III toxicities including weakness, edema, dyspnea, and myalgia. Eleven of 16 (69%) patients receiving two or more cycles produced human anti-ricin antibodies and human anti-mouse antibodies (/=1.0 microg/ml). Seventeen of 18 patients were evaluable for clinical response. These included two partial remissions. One patient demonstrated minor response and five patients stable diseases. We conclude that RFT5.dgA is of moderate clinical efficacy in this group of heavily pretreated refractory patients. Leukemia (2000) 14, 129-135.

Lectins from Erythrina cristagalli (EGA) and Erythrina corallodendron (ECorA) are well-known to detect type 2 chain oligosaccharides (Gal beta 1-4GlcNAc). These carbohydrate moieties are the biosynthetic precursors of various ABH and Lewis blood group antigens and are therefore also related to tumor-associated carbohydrate antigens. For this reason, we investigated the expression of ECA and ECorA binding sites in a series of gastric, colorectal and pancreatic carcinomas as well as corresponding normal tissues. Additionally, a series of hyperplastic and adenomatous colorectal polyps was analyzed. According to our results, both lectins exhibited a strong reactivity with the great majority of gastrointestinal carcinomas. Regarding gastric carcinomas, a stronger reactivity with intestinal-type compared to the diffuse-type species could be observed. Some poorly differentiated tumors were not or only very faintly stained. In the case of colorectal carcinomas, liver metastases which were investigated comparatively, exhibited the same binding pattern as the primary tumors. Colorectal adenomas were stained in about half of the cases without significant relation to the grade of cellular atypia. Positivity observed in normal epithelia (i.e, gastric superficial epithelia, fundus neck cells and deep pyloric mucous glands, pancreatic acini and ductal structures) is in keeping with histogenetic relations between these normal histological structures and corresponding neoplasms. In areas exhibiting intestinal metaplasia, various portions showed cytoplasmic staining of columnar cells and/or of goblet cell vacuoles. On the other hand, columnar and goblet cells in normal colorectal tissue were only weakly stained in a number of specimens. Therefore, it can be concluded that Gal beta 1-4GlcNAc is overexpressed in neoplastic colorectal tissues. Summarized, ECA and ECorA are suitable tools to analyze the expression of Gal beta 1-4GlcNAc, the common precursor substance of various tumor-associated type 2 chain antigens in neoplastic tissues.

Es wird uber eine vergleichende bakteriologische Untersuchung wahrend Scheinoperationen sowohl im konventionell belufteten Operationsraum, als auch in einer stromungstechnisch analysierten Sterilboxe mit Luftbakterienfiltern berichtet, und zwar einerseits bei Tragen eines geschlossenen Helmes mit Atemabluftabsaugung und andererseits mit und ohne Mundschutz. In der Sterilboxe zeigte sich im Vergleich zum konventionell belufteten Operationsraum eine statistisch gesicherte Verringerung des Keimpegels im Operationsbereiche, die durch eine Atemabluftabsaugung nicht mehr signifikant verbessert werden konnte. Es kann festgehalten werden: 1. das die Keimverminderung pro Zeiteinheit sicher bedeutungsvoll sein kann, das aber die Verminderung des eigentlichen Infektionsrisikos fur den Patienten lediglich die 10% der Infekte betreffen, welche durch Luftkeime verursacht sind. 2. Das Tragen von Helm und Absaugevorrichtung scheint die Prophylaxe nicht wesentlich zu verbessern, so das vor allem bei Operationen mit kleinem Operationsgebiet auf diese Masnahme verzichtet werden darf.

For many of today's clean-contaminated surgical operations antibiotic prophylaxis is a generally accepted and proven procedure. On the basis of a literature survey the parameters to be considered are analyzed: bactericidal spectrum, pharmacokinetics (peak plasma and tissue concentrations, tissue penetration, persistence at high-risk sites and elimination), minimal toxicity, absence of (above all, serious) adverse drug reactions (coagulation disorders, etc.), avoidance of resistance, suitability for single-dose prophylaxis even when the operation is unforeseeably delayed after the administration of the antibiotic, or when the operation lasts a very long time. Finally, the antimicrobial chosen must be cost-effective. The decisive factor, however, remains the proven clinical efficacy for the procedure concerned. There should be no prejudging of any issue until the relevant data have been collected, especially in the case of facts suggesting that single-dose antimicrobial agents are effective even in colorectal surgery, and that cephalosporins of the third generation might offer advantages over those of the first.

Present data available on ceftriaxone (Rocephin) dealing with microbiology, pharmacokinetics (long half-life, tissue penetration ability, tissue concentration present during vulnerable period, etc.), results of clinical trials, and world-wide experience seem to be in favor of ceftriaxone as the antimicrobial of choice for single-dose antibiotic prophylaxis in abdominal and biliary surgery. Single-dose surgical prophylaxis is cost-effective, has a low rate of adverse drug events, and so far does not increase danger of resistance.

As an alternative to the extraluminal methods of Noble and Childs-Phillips, the intraluminal splinting of small bowel with the Baker-Tube offers a new possibility in the operative treatment of ileus secondary to adhesions. We report our experiences in 28 patients, using this procedure. An unselected group with severe adhesions was treated with the Baker-Tube, in the majority of the cases at the time of the emergency operation. The immediate postoperative course as well as the results of follow-up examinations 1/2 to 3 1/2 years after the operation are reported. Our experiences can be summarized as follows: 1. Generalized, extensive adhesions are the best indication for the intraluminal splinting. The Baker-Tube should be used with reserve in cases of early and often complicated relaparotomies, especially in the presence of diffuse peritonitis, because of the danger of bowel perforation at the tip of the Tube. 2. The procedure is less time consuming than Noble's operation and in addition allows immediate decompression of the small bowel while advancing the tube. A careful technique is important to prevent complications:--tight closure of the jejunostomy at the insertion point.--fixation of the jejunal loop to the abdominal wall with non absorbable sutures.--in cases of compromised lumen at the insertion point, an entero-entero-anastomosis between afferent and efferent loop should be done. With these precautions, fistulas, detachment of the jejunostoma and stenosis of the jejunal loop can be prevented. 3. Postoperative bowel function is usually rapidly restored, a distinct advantage when compared to the Noble procedure. 4. The rate of complications in our patients is lower than in a reported comparable group with Noble technique. 5. The recurrence rate is much lower than in a reported comparable group with Noble technique. Intraluminal splinting with the Baker-Tube can be recommended as an effective procedure in the treatment of ileus secondary to adhesions.

Prolactin secretion is affected by various diseases as well as by many drugs in humans and animals. While marked hyperprolactinaemia suggests the presence of a pituitary tumor, moderate changes may also occur in various endocrine or non-endocrine disorders. Drugs can interfere with prolactin regulation via complex mechanisms at the hypothalamus or at the pituitary site, but possible changes in prolactin metabolism are poorly understood as yet. This survey of the literature up to June 1986 covers the influence of various groups of drugs and agents on the plasma prolactin level under various conditions. It contains information that will facilitate evaluation of whether hyper- or hypoprolactinaemia may result from therapeutic intervention or must be related to an underlying disease. It is obvious that more subtle changes can be revealed by the use of dynamic tests either to stimulate or to suppress prolactin secretion.

In den Jahren 1970–1973 wurden wegen Verdachts auf Appendicitis insgesamt 1333 Patienten in das Kantonsspital Basel eingewiesen. 87,5 %. wurden primar operiert, wobei sich an der Appendix in 89,8 % der Falle ein operationswurdiger Befund ergab. Die Incidenz der Appendicitis perforata betrug 13,5 %. 100 der 167 primar ohne Operation nach stationarer Uberwachung entlassenen Patienten wurden 5 Jahre spater nachkontrolliert, wobei die Halfte der Patienten in der Folge ein Rezidiv der Schmerzattacke hatten und 20 zwischenzeitlich doch noch appendektomiert werden musten. In 17 dieser Falle liegt die histologische Diagnose vor: Appendicitis ulcero-phlegmonosa (3), Appendicitis perforata und appendicitischer Abscess (2), Appendicitis subacuta (5), Appendicitis chronica cicatricea (5), Salpingitis (1), lymphoretikulares Sarkom (1). Eine Umfrage ergab, das 42 % der nicht primar appendektomierten Patienten die abwartende Haltung des Chirurgen nicht als Vorteil empfand. Die hohe Zahl der in der 5-Jahres-Periode doch noch appendektomierten Patienten zeigt, das auch eine kurzfristige stationare Uberwachung von 1–2 Tagen auf die Dauer die Appendektomie in mehr als 1/5 der Falle nicht erspart hat. Wir pladieren deshalb fur den Leitsatz: In Dubio Pro Appendektomia.

Die beste Katastrophenorganisation bleibt ein Papiertiger, wenn die entsprechende breitbasige Ausbildung fehlt. Ein Grundunterricht in Erster Hilfe mus von der Schule aus die ganze Bevolkerung erfassen, und er setzt sich in der Samariterbewegung fort. Die aktive Mitarbeit der Arzte, unabhangig ihrer Fachrichtung, in grosen wie in kleinen Ortschaften, im Zivil- wie im Militardienst ist unabdingbare Voraussetzung zur wirkungsvollen Katastrophenhilfe. Im heutigen Zeitalter der Spezialisierung werden viele Kollegen Grundsatze und Praxis der Katastrophenmedizin bald vergessen, wenn eine entsprechende Ausbildung im Studium nicht eingeplant und spater kontinuierlich erganzt wird. Auch ein gut vorbereiteter Arzt vermag in der Katastrophensituation allein wenig auszurichten, wenn er nicht personell und materiell massivst unterstutzt wird. Die Hilfe insgesamt wird nur optimal wirksam, falls eine entsprechende leitende Hilfsorganisation vorhanden ist und Plane fur alle Eventualitaten jederzeit abrufbar sind. Dabei ist eine Koordination aller beteiligten Helfer und aller umliegenden Spitaler anzustreben. Auch jedes Krankenhaus sollte innerbetrieblich entsprechende Vorsorgemasnahmen treffen und ein Alarmsystem besitzen. Nur mittels solcher prophylaktischer Masnahmen kann die Tragik einer Katastrophe fur die Allgemeinheit gelindert und die Uberlebenschance fur alle Betroffenen entscheidend gunstig beeinflust werden.

A primary resection and reanastomosis of the colon is often the procedure of choice, even in the presence of a significant stenotic element, provided there are no mayor disturbances of water-electrolyte homeostasis. In a series of 100 consecutive colonic resections (23 complicated by perforation, 9 by ileus, and 2 by bleeding), 97 patients were treated by primary resection (92 without a protective colostomy). No untoward effects were noted specifically due to this technique. The overall mortality rate was 4%, a favorable result when compared with the cumulative risk of a multiple stage procedure.

Fundoplication, using an abdominal approach, is advocated to create an adequate substitute for the insufficient sphincter in gastroesophageal reflux associated with hiatus hernia. To achieve success, correct indications for surgical treatment are important. Based on experience with approximately 1,400 patients over the past 20 years, these include: (a) a retrosternal burning sensation (in 90% of our cases); (b) objective confirmation of reflux by means of x-ray and endoscopic examination, together with biopsy examination of the esophageal mucosa and gastric acid evaluation; and (c) evidence of organic complications such as endobrachyesophagus with ulcerostenotic changes at the junction between the esophageal and gastric mucosa. Long-term follow-up of 590 patients with simple reflux esophagitis who underwent fundoplication showed that 87.5% were symptom free. In 44 patients with complicated gastroesophageal reflux disease, fundoplication produced clinical healing in 84.1%.

A historical survey based on the most important literature is presented as a starting point for further discussion on the significance of possible adverse reactions reported after prescription of cotrimoxazole. The often changing and contradictory assessments made of the situation in different countries and at different times are outlined, and the difficulty of making a balanced and just evaluation of long established drugs is shown, particularly if the available data are derived primarily from spontaneous reports which, besides being almost impossible to verify, are often incomplete.