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Abstract Objective Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure. Methods 13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score > 16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)). Results From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (> 10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%). Conclusions Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice. [ABSTRACT FROM AUTHOR]

Background: The TraumaNetwork DGU® (TNW) connects hospitals with different capacities for the treatment of severely injured patients who work together as superregional (STC), regional (RTC) and local trauma centres (LTC). The standards of treatment and equipment are defined on the basis of current guidelines as published in the'White book of the Treatment of Severely Injured Patients'. An external audit process evaluates the organisation and structure of participating hospitals as well as the cooperation of the trauma centres within a regional TNW. Results: In May 2013 a total of 618 hospitals were visited and assessed according to the White book and 39 fully certified regional TNWs covered around 85% of the area of Germany. Treatment quality in the certified TCs was analyzed on the basis of 25,249 severely injured patients in the TraumaRegister DGU® (2008-2011) and significant differences between the expected and observed mortality rates were found. These differences were most obvious in superregional and regional trauma centres. Conclusion: The TraumaNetwork represents an innovative, cooperative project for successfully improving the treatment of severely injured patients. [ABSTRACT FROM AUTHOR]

The Klebsiella oxytoca species complex is part of the human microbiome, especially during infancy and childhood. K. oxytoca species complex strains can produce enterotoxins, namely, tilimycin and tilivalline, while also contributing to colonization resistance (CR). The relationship between these seemingly contradictory roles is not well understood. Here, by coupling ex vivo assays with CRISPR-mutagenesis and various mouse models, we show that K. oxytoca provides CR against Salmonella Typhimurium. In vitro, the antimicrobial activity against various Salmonella strains depended on tilimycin production and was induced by various simple carbohydrates. In vivo, CR against Salmonella depended on toxin production in germ-free mice, while it was largely toxin-independent in mice with residual microbiota. This was linked to the relative levels of toxin-inducing carbohydrates in vivo. Finally, dulcitol utilization was essential for toxin-independent CR in gnotobiotic mice. Together, this demonstrates that nutrient availability is key to both toxin-dependent and substrate-driven competition between K. oxytoca and Salmonella., (© 2024. The Author(s).)

Background: The evaluation of electronic patient-reported outcomes (ePROs) is increasingly being used in clinical studies of patients with cancer and enables structured and standardized data collection in patients' everyday lives. So far, few studies or analyses have focused on the medical benefit of ePROs for patients., Objective: The current exploratory analysis aimed to obtain an initial indication of whether the use of the Consilium Care app (recently renamed medidux; mobile Health AG) for structured and regular self-assessment of side effects by ePROs had a recognizable effect on incidences of unplanned consultations and hospitalizations of patients with cancer compared to a control group in a real-world care setting without app use. To analyze this, the incidences of unplanned consultations and hospitalizations of patients with cancer using the Consilium Care app that were recorded by the treating physicians as part of the patient reported outcome (PRO) study were compared retrospectively to corresponding data from a comparable population of patients with cancer collected at 2 Swiss oncology centers during standard-of-care treatment., Methods: Patients with cancer in the PRO study (178 included in this analysis) receiving systemic therapy in a neoadjuvant or noncurative setting performed a self-assessment of side effects via the Consilium Care app over an observational period of 90 days. In this period, unplanned (emergency) consultations and hospitalizations were documented by the participating physicians. The incidence of these events was compared with retrospective data obtained from 2 Swiss tumor centers for a matched cohort of patients with cancer., Results: Both patient groups were comparable in terms of age and gender ratio, as well as the distribution of cancer entities and Joint Committee on Cancer stages. In total, 139 patients from each group were treated with chemotherapy and 39 with other therapies. Looking at all patients, no significant difference in events per patient was found between the Consilium group and the control group (odds ratio 0.742, 90% CI 0.455-1.206). However, a multivariate regression model revealed that the interaction term between the Consilium group and the factor "chemotherapy" was significant at the 5% level (P=.048). This motivated a corresponding subgroup analysis that indicated a relevant reduction of the risk for the intervention group in the subgroup of patients who underwent chemotherapy. The corresponding odds ratio of 0.53, 90% CI 0.288-0.957 is equivalent to a halving of the risk for patients in the Consilium group and suggests a clinically relevant effect that is significant at a 2-sided 10% level (P=.08, Fisher exact test)., Conclusions: A comparison of unplanned consultations and hospitalizations from the PRO study with retrospective data from a comparable cohort of patients with cancer suggests a positive effect of regular app-based ePROs for patients receiving chemotherapy. These data are to be verified in the ongoing randomized PRO2 study (registered on ClinicalTrials.gov; NCT05425550)., Trial Registration: ClinicalTrials.gov NCT03578731; https://www.clinicaltrials.gov/ct2/show/NCT03578731., International Registered Report Identifier (irrid): RR2-10.2196/29271., (©Andreas Trojan, Christian Kühne, Michael Kiessling, Johannes Schumacher, Stefan Dröse, Christian Singer, Christian Jackisch, Christoph Thomssen, Gerd A Kullak-Ublick. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.05.2024.)

Background: Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed., Objective: The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications., Material and Method: Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective., Conclusion: With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: It is estimated that in total almost 10 million people are injured in accidents in Germany every year, most of which are in the household milieu and leisure sector. It is estimated that of these more than 32,000 seriously injured patients are admitted to the emergency room every year. It is recommended that the decision of the prehospital treatment team or the first examiner in the hospital as to whether a potentially severely injured patient should be admitted via the emergency room of the hospital should be based on a catalogue of criteria., Material and Method: Against the background of the update of the S3 guidelines on the treatment of multiple trauma/severely injured patients and on the basis of the current literature, an overview with respect to the composition of the team and the criteria for which an emergency room team is or should be activated is given., Results: Alerting the emergency room team is still recommended if a certain injury pattern is present or if a prehospital intervention is necessary. The B‑criteria based on the course of the accident or mechanism, which have recently been the subject of increasing criticism, have been adapted. Recommendations for geriatric patients could also be formulated., Discussion: Compared to the S3 guidelines from 2016 the emergency room alarm criteria could be revised on the basis of new literature and have been included in the revised guidelines. There is no doubt that further optimization. e.g., based on prehospital algorithms or using point of care diagnostics, are possible and desirable in the future., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

This in-vitro study was designed to investigate whether conventionally produced casts and printed casts for orthodontic purposes show comparable full-arch accuracy. To produce casts, either a conventional impression or a digital data set is needed. A fully dentate all ceramic master cast was digitized with an industrial scanner to obtain a digital reference cast [REF]. Intraoral scans [IOS] and alginate impressions were taken from the master cast so that ten printed and ten gypsum casts were obtained. The printed casts [DLP] were digitized by an industrial scanner and as well as the gypsum casts [GYPSUM]. The following absolute mean trueness evaluations by superimposition were accomplished: [REF vs. GYPSUM]; [REF vs. DLP]; [REF vs. IOS]; [IOS vs. DLP]. For precision analysis the data sets of [GYPSUM], [IOS] and [DLP] were available. The absolute mean trueness values were 68 μm ± 15 μm for [REF vs. GYPSUM], 46 μm ± 4 μm for [REF vs. DLP], 20 μm ± 2 μm for [REF vs. IOS] and 41 μm ± 4 μm for [IOS vs. DLP]. [REF vs. GYPSUM] and [REF vs. DLP], [REF vs. IOS], [REF vs. DLP] and [IOS vs. DLP] showed statistically significant differences. The precision values were 56 μm ± 17 μm for [GYPSUM], 25 μm ± 9 μm for [DLP] and 12 μm ± 2 μm for [IOS] and differed significantly among each other. In the present study the print workflow revealed superior results in comparison to the conventional workflow. Due to contrary deviations in the [REF vs. IOS] and the [IOS vs. DLP] data sets the overall trueness deviations was enhanced., Competing Interests: The author S.R. (Sven Reich) has or had commercial relationships with the following companies including consulting, presentation activities, and third party-funded research: 3M OralCare, 3Shape, Amann Girrbach, Camlog, Oral Reconstruction Foundation, DCS, Dentaurum, Dentsply Sirona, Ivoclar Vivadent, Straumann, Vita Zahnfabrik. Sa.B., Ha.H., and S.R. (Stefan Raith) and CH.K. declare no conflict of interest., (Copyright: © 2023 Reich et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite advances, the morbidity and mortality rates of patients with spondylodiscitis remains high, with an increasing incidence worldwide. Although conservative therapy has progressed, several cases require surgical intervention. However, the indication and opportunities for surgical treatment are still disputable., Methods: In a joint consensus, the members of the 'Spondylodiscitis' working group of the Spine Section of the German Society for Orthopaedics and Trauma Surgery considered current literature, particularly the newly published S2k guideline of the AWMF, and examined the surgical indications and treatment strategies for thoracolumbar spondylodiscitis., Results: Surgical intervention for spondylodiscitis is only required in a small percentage of patients. In studies comparing conservative and surgical therapies, most patients benefitted from surgery, regardless of the surgical technique selected. Presently, the standard procedure is a combined dorsoventral approach, in which a monolateral attempt should always be made. The choice of material (PEEK, titanium) for ventral support does not influence the clinical result., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Bouldering is a famous new sport with an increasing number of athletes. It became an Olympic sport in 2020. As no major sports equipment is required, everybody can take up bouldering even with little knowledge. However, despite the low climbing height there is a high risk of severe joint injuries, especially in the lower limb. Increasing numbers of climbers have led to an increase in injuries. New floor designs are supposed to reduce these risks. Improved documentation and specific research in bouldering should provide more insight into risks, injury patterns and prevention., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim: To test four different measurement methods to evaluate deviations between planned and actual implant positions within a digital workflow applying 3D-printed surgical guides., Materials and Methods: A fully digital workflow was applied to simulate the single implant insertion to replace a maxillary missing central incisor and first molar in 10 gypsum casts (n = 10). Surgical guides (n = 10 per site) were printed by digital light processing for implant bed preparation and implant insertion. Four methods were used to analyze 3D deviations between the planned (target) and achieved implant positions: Methods 1 and 2 used an automated computer program (ACP) to assess deviations between the initial planning file and a file that represented the actual implant position either by the implant bed [ACP_BED] or by the inserted implant [ACP_IMP]. For Method 3, a standard tessellation language dataset representing the actual implant position was used and equipped with reference planes. This dataset was registered with the target planning, allowing manual measurements [MAN_MEAS]. Method 4 used a reverse engineering approach based on 3D high-resolution scans [REVERSE]., Results: Mean 3D deviations, including for anterior and posterior implant sites, ranged between 0.26 ± 0.11 mm [REVERSE] and 0.40 ± 0.09 mm [ACP_BED] at the implant shoulder, between 0.52 ± 0.24 mm [REVERSE] and 0.91 ± 0.24 mm [ACP_BED] at the implant apex, and between 1.68 and 2.35 degrees in angular deviation. Implant sites did not differ significantly, while some of the evaluation methods differed for shoulder and apex., Conclusion: [REVERSE] revealed the smallest deviations between planned and actual implant position. 3D implant deviations were comparable with findings in the literature or even lower.

Like other members of the superfamily of nuclear receptors, the peroxisome proliferator-activated receptor γ (PPARγ), is a ligand-activated transcription factor known for its insulin-sensitizing actions in the periphery. Despite only sparse evidence for PPARγ in the CNS, many reports suggest direct PPARγ-mediated actions in the brain. This study aimed to (i) map PPARγ expression in rodent brain areas, involved in the regulation of cognitive, motivational, and emotional functions, (ii) examine the regulation of central PPARγ by physiological variables (age, sex, obesity); (iii) chemotypically identify PPARγ-expressing cells in the frontal cortex (FC) and hippocampus (HP); (iv) study whether activation of PPARγ by pioglitazone (Pio) in FC and HP cells can induce target gene expression; and (v) demonstrate the impact of activated PPARγ on learning behavior and motivation. Immunoreactive PPARγ was detectable in specific sub-nuclei/subfields of the FC, HP, nucleus accumbens, amygdala, hypothalamus, thalamus, and granular layers of the cerebellum. PPARγ protein levels were upregulated during aging and in high fat diet-induced obesity. PPARγ mRNA expression was upregulated in the amygdala of females (but not males) that were made obese. Neural precursor cells, mature neurons, and astrocytes in primary FC and HP cultures were shown to express PPARγ. Pioglitazone dose-dependently upregulated PPARγ target genes in manner that was specific to the origin (FC or HP) of the cultures. Lastly, administration of Pio impaired motivation and associative learning. Collectively, we provide evidence for the presence of regulatable PPARγ in the brain and demonstrate their participation the regulation of key behaviors., Competing Interests: Conflicts of Interest The authors have no competing intellectual or financial interests to declare., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Major depressive disorder (MDD) is a complex and debilitating illness whose etiology remains unclear. Small RNA molecules, such as micro RNAs (miRNAs) have been implicated in MDD, where they display differential expression in the brain and the periphery. In this study, we quantified miRNA expression by small RNA sequencing in the anterior cingulate cortex and habenula of individuals with MDD and psychiatrically-healthy controls. Thirty-two miRNAs showed significantly correlated expression between the two regions (False Discovery Rate < 0.05), of which four, miR-204-5p, miR-320b, miR-323a-3p, and miR-331-3p, displayed upregulated expression in MDD. We assessed the expression of predicted target genes of differentially expressed miRNAs in the brain, and found that the expression of erb-b2 receptor tyrosine kinase 4 (ERBB4), a gene encoding a neuregulin receptor, was downregulated in both regions, and was influenced by miR-323a-3p in vitro. Finally, we assessed the effects of manipulating miRNA expression in the mouse ACC on anxiety- and depressive-like behaviors. Mice in which miR-323-3p was overexpressed or knocked-down displayed increased and decreased emotionality, respectively. Additionally, these mice displayed significantly downregulated and upregulated expression of Erbb4, respectively. Overall, our findings indicate the importance of brain miRNAs in the pathology of MDD, and emphasize the involvement of miR-323a-3p and ERBB4 in this phenotype. Future studies further characterizing miR-323a-3p and neuregulin signaling in depression are warranted., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

Many bacteria use the flagellum for locomotion and chemotaxis. Its bidirectional rotation is driven by a membrane-embedded motor, which uses energy from the transmembrane ion gradient to generate torque at the interface between stator units and rotor. The structural organization of the stator unit (MotAB), its conformational changes upon ion transport, and how these changes power rotation of the flagellum remain unknown. Here, we present ~3 Å-resolution cryoelectron microscopy reconstructions of the stator unit in different functional states. We show that the stator unit consists of a dimer of MotB surrounded by a pentamer of MotA. Combining structural data with mutagenesis and functional studies, we identify key residues involved in torque generation and present a detailed mechanistic model for motor function and switching of rotational direction., Competing Interests: Declaration of Interests The authors declare no competing interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The long external filament of bacterial flagella is composed of several thousand copies of a single protein, flagellin. Here, we explore the role played by lysine methylation of flagellin in Salmonella, which requires the methylase FliB. We show that both flagellins of Salmonella enterica serovar Typhimurium, FliC and FljB, are methylated at surface-exposed lysine residues by FliB. A Salmonella Typhimurium mutant deficient in flagellin methylation is outcompeted for gut colonization in a gastroenteritis mouse model, and methylation of flagellin promotes bacterial invasion of epithelial cells in vitro. Lysine methylation increases the surface hydrophobicity of flagellin, and enhances flagella-dependent adhesion of Salmonella to phosphatidylcholine vesicles and epithelial cells. Therefore, posttranslational methylation of flagellin facilitates adhesion of Salmonella Typhimurium to hydrophobic host cell surfaces, and contributes to efficient gut colonization and host infection.

Dysregulation of the corticotropin-releasing hormone (CRH) system has been implicated in stress-related psychopathologies such as depression and anxiety. Although most studies have linked CRH/CRH receptor 1 signaling to aversive, stress-like behavior, recent work has revealed a crucial role for distinct CRH circuits in maintaining positive emotional valence and appetitive responses under baseline conditions. Here we addressed whether deletion of CRH, specifically from GABAergic forebrain neurons ( Crh CKO -GABA mice) differentially affects general behavior under baseline and chronic stress conditions. Expression mapping in Crh CK O-GABA mice revealed absence of Crh in GABAergic neurons of the cortex and limbic regions including the hippocampus, central nucleus of the amygdala and the bed nucleus of the stria terminals, but not in the paraventricular nucleus of hypothalamus. Consequently, conditional CRH knockout animals exhibited no alterations in circadian and stress-induced corticosterone release compared to controls. Under baseline conditions, absence of Crh from forebrain GABAergic neurons resulted in social interaction deficits but had no effect on other behavioral measures including locomotion, anxiety, immobility in the forced swim test, acoustic startle response and fear conditioning. Interestingly, following exposure to chronic social defeat stress, Crh CKO-GABA mice displayed a resilient phenotype, which was accompanied by a dampened, stress-induced expression of immediate early genes c-fos and zif268 in several brain regions. Collectively our data reveals the requirement of GABAergic CRH circuits in maintaining appropriate social behavior in naïve animals and further supports the ability of CRH to promote divergent behavioral states under baseline and severe stress conditions., (Copyright © 2019 Dedic, Kühne, Gomes, Hartmann, Ressler, Schmidt and Deussing.)

Medical confidentiality is a fundamental prerequisite in the patient-physician relationship based on trust and goes back to the Hippocratic oath. It is clearly defined in the German Constitution as well as the medical professional code of conduct. A breach of confidentiality can result in criminal sanctions and professional consequences as well as civil claims for damages and compensation by the affected patients. In routine clinical practice situations repeatedly occur which lead to uncertainty regarding the limits of confidentiality, the right to silence and the obligation to disclosure. The purpose of this article is to explain the legal foundations of medical confidentiality, the right to silence and the obligation to disclosure and to provide practical support for critical questions in routine clinical practice.

Based on pharmacological studies, corticotropin-releasing hormone (CRH) and its receptors play a leading role in the inhibition of the hypothalamic-pituitary-gonadal (HPG) axis during acute stress. To further study the effects of CRH receptor signaling on the HPG axis, we generated and/or employed male mice lacking CRH receptor type 1 (CRHR1) or type 2 (CRHR2) in gonadotropin-releasing hormone neurons, GABAergic neurons, or in all central neurons and glia. The deletion of CRHRs revealed a preserved decrease of plasma luteinizing hormone (LH) in response to either psychophysical or immunological stress. However, under basal conditions, central infusion of CRH into mice lacking CRHR1 in all central neurons and glia, or application of CRH to pituitary cultures from mice lacking CRHR2, failed to suppress LH release, unlike in controls. Our results, taken together with those of the earlier pharmacological studies, suggest that inhibition of the male HPG axis during acute stress is mediated by other factors along with CRH, and that CRH suppresses the HPG axis at the central and pituitary levels via CRHR1 and CRHR2, respectively.

The interplay between corticotropin-releasing hormone (CRH) and the dopaminergic system has predominantly been studied in addiction and reward, while CRH-dopamine interactions in anxiety are scarcely understood. We describe a new population of CRH-expressing, GABAergic, long-range-projecting neurons in the extended amygdala that innervate the ventral tegmental area and alter anxiety following chronic CRH depletion. These neurons are part of a distinct CRH circuit that acts anxiolytically by positively modulating dopamine release.

Understanding the mechanism of interactions of nanomaterials at biointerfaces is a crucial issue to develop new antimicrobial vectors. In this work, a series of water-soluble fullerene-polyglycerol sulfates (FPS) with different fullerene/polymer weight ratios and varying numbers of polyglycerol sulfate branches are synthesized, characterized, and their interactions with two distinct surfaces displaying proteins involved in target cell recognition are investigated. The combination of polyanionic branches with a solvent exposed variable hydrophobic core in FPS proves to be superior to analogs possessing only one of these features in preventing interaction of vesicular stomatitis virus coat glycoprotein (VSV-G) with baby hamster kidney cells serving as a model of host cell. Interference with L-selectin-ligand binding is dominated by the negative charge, which is studied by two assays: a competitive surface plasmon resonance (SPR)-based inhibition assay and the leukocyte cell (NALM-6) rolling on ligands under flow conditions. Due to possible intrinsic hydrophobic and electrostatic effects of synthesized compounds, pico- to nanomolar half maximal inhibitory concentrations (IC 50 ) are achieved. With their highly antiviral and anti-inflammatory properties, together with good biocompatibility, FPS are promising candidates for the future development towards biomedical applications., (© 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

Advances in the rescue chain and first aid of polytrauma patients, which have consequently increased their chance of survival, have led to an increase in demands for rehabilitation. However, there is still a large hole in the continuity of rehabilitation between acute patient care and in-patient rehabilitation, the so-called "rehab-hole". The consequences are untapped rehabilitation potential, loss of strength, endurance and motivation as well as impairment of function of the patient.Based on the phase model of neurological/neurosurgical rehabilitation, we propose a step model for the rehabilitation of polytrauma patients that ensures an uninterrupted chain of rehabilitation. After acute patient care (phase a) and a potentially required early patient rehabilitation (phase b), trauma rehabilitation should seamlessly continue on to phase c. The implementation of phase c after acute patient rehabilitation requires changes in the structure of "orthopaedic" rehabilitation clinics and financial support due the large consumption of resources by more complexly injured patients in this phase. The subsequent rehabilitation in phase d is well established and complies with current rehabilitation measures (AHB, BGSW). Further rehabilitation measures may be essential for social and occupational reintegration of the patient (phase e), depending on the complexity of their injuries after the accident. For patients with long-lasting results after an accident, it is crucial to implement continuous follow-ups (phase f) to ensure a better long-term outcome.In order to implement this phase model it is necessary to establish specialized facilities that meet the particular requirements needed for phase c. This tri-phased treatment model in trauma centres can therefore be used in trauma rehabilitation. In addition to the already established local and regional rehabilitation centres, nationwide trauma rehabilitation centres have adopted phase c rehabilitation.

A series of water-soluble, hydroxylated and sulphated, polyglycerol (PG) dendronised, monofunctional perylene bisimides (PBIs) were synthesised in three generations. Their photophysical properties were determined by absorption and emission spectroscopy and their suitability as potential biolabels examined by biological in vitro studies after bioconjugation. It could be shown that the photophysical properties of the PBI labels can be improved by increasing the sterical demand and ionic charge of the attached dendron. Thereby, charged labels show superior suppression of aggregation over charge neutral labels owing to electrostatic repulsion forces on the PG-dendron. The ionic charges also enabled a reduction in dendron generation while retaining the labels' outstanding fluorescence quantum yields (FQYs) up to 100 %. These core-unsubstituted perylene derivatives were successfully applied as fluorescent labels upon bioconjugation to the therapeutic antibody cetuximab. The dye-antibody conjugates showed a strongly enhanced aggregation tendency compared to the corresponding free dyes. Biological evaluation by receptor-binding, cellular uptake, and cytotoxicity studies revealed that labelling did not affect the antibody's function, which renders the noncharged and charged dendronised PBIs suitable candidates as fluorescent labels in biological imaging., (© 2017 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Due to the increasing number of elderly patients, trauma surgeons are often confronted with end-of-life treatment decisions. Advance directives can help reduce the lack of clarity in those situations., Objectives: The aim of this study was to identify the presence of living wills, durable power of attorney, legal guardianship and appointment of guardianship in the geriatric trauma center of a university hospital., Materials and Methods: The data of all patients treated in our geriatric trauma center from 01/01/2013 to 03/31/2014 were analyzed regarding the presence of a living will, durable power of attorney, legal guardianship and appointment of guardianship as well as the procedure of documenting those items., Results: Out of 181 patients, 63 % (n = 114) had one or more of these documents. Most frequently used was the durable power of attorney in 33 % (n = 59), followed by a living will in 27 % (n = 48), legal guardianship in 20 % (n = 37) and appointment of guardianship in 7 % (n = 12). The existence of those documents was recorded in 88 % (n = 100) of patients within 24 h after admission; documentation in the medical records was found in 58 % (n = 66)., Conclusion: A large proportion of patients had one or more of the documents named above. In this respect, standardized documentation of advance directives in the medical record is an important issue for all persons involved.

The bacterial flagellum enables directed movement of Salmonella enterica towards favorable conditions in liquid environments. Regulation of flagellar synthesis is tightly controlled by various environmental signals at transcriptional and post-transcriptional levels. The flagellar master regulator FlhD4 C2 resides on top of the flagellar transcriptional hierarchy and is under autogenous control by FlhD4 C2 -dependent activation of the repressor rflM. The inhibitory activity of RflM depends on the presence of RcsB, the response regulator of the RcsCDB phosphorelay system. In this study, we elucidated the molecular mechanism of RflM-dependent repression of flhDC. We show that RcsB and RflM form a heterodimer that coordinately represses flhDC transcription independent of RcsB phosphorylation. RcsB-RflM complex binds to a RcsB box downstream the P1 transcriptional start site of the flhDC promoter with increased affinity compared to RcsB in the absence of RflM. We propose that RflM stabilizes binding of unphosphorylated RcsB to the flhDC promoter in absence of environmental cues. Thus, RflM is a novel auxiliary regulatory protein that mediates target specificity of RcsB for flhDC repression. The cooperative action of the RcsB-RflM repressor complex allows Salmonella to fine-tune initiation of flagellar gene expression and adds another level to the complex regulation of flagellar synthesis., (© 2016 John Wiley & Sons Ltd.)

Signaling by the corticotropin-releasing factor receptor type 1 (CRFR1) plays an important role in mediating the autonomic response to stressful challenges. Multiple hypothalamic nuclei regulate sympathetic outflow. Although CRFR1 is highly expressed in the arcuate nucleus (Arc) of the hypothalamus, the identity of these neurons and the role of CRFR1 here are presently unknown. Our studies show that nearly half of Arc-CRFR1 neurons coexpress agouti-related peptide (AgRP), half of which originate from POMC precursors. Arc-CRFR1 neurons are innervated by CRF neurons in the hypothalamic paraventricular nucleus, and CRF application decreases AgRP(+)CRFR1(+) neurons' excitability. Despite similar anatomy in both sexes, only female mice selectively lacking CRFR1 in AgRP neurons showed a maladaptive thermogenic response to cold and reduced hepatic glucose production during fasting. Thus, CRFR1, in a subset of AgRP neurons, plays a regulatory role that enables appropriate sympathetic nervous system activation and consequently protects the organism from hypothermia and hypoglycemia., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Despite intense research efforts the molecular mechanisms affecting stress-vulnerable brain regions in posttraumatic stress disorder (PTSD) remain elusive. In the current study we have applied global transcriptomic profiling to a PTSD mouse model induced by foot shock fear conditioning. We compared the transcriptomes of prelimbic cortex, anterior cingulate cortex (ACC), basolateral amygdala, central nucleus of amygdala, nucleus accumbens (NAc) and CA1 of the dorsal hippocampus between shocked and non-shocked (control) mice, with and without fluoxetine treatment by RNA sequencing. Differentially expressed (DE) genes were identified and clustered for in silico pathway analysis. Findings in relevant brain regions were further validated with immunohistochemistry. DE genes belonging to 11 clusters were identified including increased inflammatory response in ACC in shocked mice. In line with this finding, we noted higher microglial activation in ACC of shocked mice. Chronic fluoxetine treatment initiated in the aftermath of the trauma prevented inflammatory gene expression alterations in ACC and ameliorated PTSD-like symptoms, implying an important role of the immune response in PTSD pathobiology. Our results provide novel insights into molecular mechanisms affected in PTSD and suggest therapeutic applications with anti-inflammatory agents., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The frequency of urological traumata and the need for interventions in severely injured patients in Germany are unknown. The aim of this study was to determine the frequency of urological traumata in about 90,000 severely injured patients (Injury Severity Score, ISS ≥ 16)., Materials and Methods: Data of 90,000 patients from the TraumaRegister DGU® were retrospectively analyzed. All patients with an ISS of ≥ 16 were included. The kind of urological traumata and the need for urological intervention within 24 hours were assessed, as well as the kind of accident, additional traumata and the clinical course., Results: 48,797 patients fulfilled the inclusion criteria. Urological trauma was existent in 7.1 %, especially in men (78 %). Kidneys were affected most frequently (4.8 %) compared to ureters (0.2 %), urinary bladder (1.2 %), urethra (0.5 %) and genitals (0.4 %). Traffic accidents and falls from higher levels represented the main cause for urological traumata (> 90 %). It was associated with additional pelvis, thorax and abdomen traumata (each 7.1 %) and showed a distinct increase dependent on the abbreviated injury scale (AIS). Ureter (10.6%) and urethra (6.3%) trauma was deferred diagnosed most, this was associated with a higher rate of urological operations. The general duration of hospital stay and that in the intensive care unit were prolonged by urological traumata., Discussion: The data showed the prevalence of urological trauma in severely injured patients analyzed in a huge patient cohort of the TraumaRegister DGU®. For the first time the number, degree and medical care in the reality of urological traumata in severely injured patients were available.

Introduction: Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals., Objectives: This article aims to give a first representative overview of the expectations and actual achievements., Material and Methods: An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel., Results: With 326 responses, a response rate of 48.9% of all active hospitals was achieved. Of the participating hospitals 64.1% (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4% (236) felt that there was a need for improvement in the care of severely injured patients and 46.6% (152) in the transfer of patients. In 47.2% (142) no improvement in cooperation with the ambulance service could be determined, 25.2% (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9% (306) of all hospitals wanted to participate in the trauma network in the future., Discussion: It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

Background: In recent years, there has been an ongoing improvement in the treatment and structural aspects of acute trauma care. Because of the definition of rehabilitation as a post-acute part of the treatment of traumatic injuries, especially in multiple injured patients, there is need to improve the interaction and cooperation between acute care hospitals and rehabilitation clinics. This article gives a survey of the current state of rehabilitation in Germany., Materials and Methods: Based on a directory of rehabilitation clinics and an internet search, all rehabilitation clinics were identified and included in the analysis for clinic location, structural and equipment attributes., Results: In total 551 rehabilitation clinics with expertise in the treatment of traumatic and orthopedic injuries were identified. In detail, broad differences between the federal states could be observed. The number of rehabilitation clinics per state ranged from 1 to 136 and the number of beds from 70 to 18040. The average catchment area covered by a rehabilitation clinic is 648 km(2) (range 149-2106 km(2)) with an average of 1584 patients per clinic per year. Of the clinics 68% can treat patients with methicillin-resistant Staphylococcus aureus (MRSA) infections and 62.1% are able to deal with patients who need renal dialyses. Almost all clinics provide an x-ray facility (96.4%) while computed tomography (CT) and magnetic resonance imaging (MRI) are available in 52.6% and 50.3%, respectively., Conclusion: The number of rehabilitation clinics available seems to be adequate for all patients with traumatic injuries but there are enormous differences between the federal states. Because rehabilitation is important for the outcome of multiple injured patients, a further improvement of the quality and integration into the regional trauma network seem to be necessary.

A new class of fully synthetic shell cleavable multivalent polysulfates is prepared by introducing degradable linkers into a stable biocompatible dendritic polyglycerol scaffold and subsequent sulfation. The sulfated polymers show different degradation profiles, low anticoagulant and high anti-inflammatory properties, are able to efficiently bind to L-selectin and inhibit the complement activation at very low concentrations in vitro., (© 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Salmonella enterica utilizes flagellar motility to swim through liquid environments and on surfaces. The biosynthesis of the flagellum is regulated on various levels, including transcriptional and posttranscriptional mechanisms. Here, we investigated the motility phenotype of 24 selected single gene deletions that were previously described to display swimming and swarming motility effects. Mutations in flgE, fliH, ydiV, rfaG, yjcC, STM1267 and STM3363 showed an altered motility phenotype. Deletions of flgE and fliH displayed a non-motile phenotype in both swimming and swarming motility assays as expected. The deletions of STM1267, STM3363, ydiV, rfaG and yjcC were further analyzed in detail for flagellar and fimbrial gene expression and filament formation. A ΔydiV mutant showed increased swimming motility, but a decrease in swarming motility, which coincided with derepression of curli fimbriae. A deletion of yjcC, encoding for an EAL domain-containing protein, increased swimming motility independent on flagellar gene expression. A ΔSTM1267 mutant displayed a hypermotile phenotype on swarm agar plates and was found to have increased numbers of flagella. In contrast, a knockout of STM3363 did also display an increase in swarming motility, but did not alter flagella numbers. Finally, a deletion of the LPS biosynthesis-related protein RfaG reduced swimming and swarming motility, associated with a decrease in transcription from flagellar class II and class III promoters and a lack of flagellar filaments.

Introduction: We describe an alternative to the Letournel ilioinguinal approach for anterior column acetabular fractures that is performed with a unique retraction device that decreases the rate of soft-tissue complications., Step 1 Position the Patient and Identify the Sites for the Incisions: Identify the sites for both incisions with the help of an image intensifier., Step 2 Make the First Incision to Expose the Anterior Column and the Linea Terminalis Pelvic Brim: Make the first incision to expose the central area of the fracture., Step 3 Make the Second Incision to Expose the Symphysis and the Ipsilateral Pubic Bone: Make the second incision to expose the area for the distal plate fixation., Step 4 Maintain Exposure of the Linea Terminalis Using a Soft-Tissue Retraction System: For better visualization, use a soft-tissue retraction system., Step 5 Reduce the Fracture: Clean and reduce the fracture through the first incision., Step 6 Fix the Fracture: Perform temporary and definitive fixation according to the standards for anterior acetabular fracture fixation., Step 7 Close the Wound: After radiographic documentation in three views, close the wound., Results: We reported the results of a case-control study of the first twenty-six patients operated on with the two-incision minimally invasive technique.IndicationsContraindicationsPitfalls & Challenges.

Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter-defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.

Background: Interferon gamma release assays (IGRA) have been developed to support easy and fast diagnosis of diseases like tuberculosis, and CMV in transplant patients. IGRAs focus on cellular immunity especially memory T cells and thus also allow rapid screening prior to complex flow cytometric testing. Here, we describe a novel, sensitive whole blood based cytokine release assay capable of assessing T cell responsiveness to HBV antigens in Hepatitis B patients and assessing hepatitis B vaccination status in healthy individuals., Methods: Seventy two chronic Hepatitis B patients (CHB), 8 acute hepatitis B patients (AHB) and 80 healthy controls (HC) were tested by ELISA for IFNγ- and IL2-secretion in whole blood after challenge with synthetic peptide libraries of hepatitis B core antigen (HBcAg) or hepatitis B surface antigen (HBsAg)., Results: The developed IGRA test reliably differentiated between Hepatitis B patients, vaccinees and unvaccinated healthy controls. Treatment naïve and treated CHB patients showed a weaker IFNγ response to HBcAg (16 ± 5 and 35 ± 28 pg/ml, respectively) compared to the AHB group (82 ± 39 pg/ml), whereas HC remained unresponsive (6 ± 1 pg/ml). IL2 levels after HBcAg challenge were also higher in the AHB group compared to naive and treated CHB as well as HC (47 ± 21 vs. 12 ± 3, 15 ± 10 and 12 ± 9 pg/ml, respectively). HBsAg stimulation led to increased IFNγ and IL2 levels in the AHB group (33 ± 12 and 22 ± 12 pg/ml) and even higher levels in HC due to a high hepatitis B vaccination rate (41 ± 10 and 167 ± 58 pg/ml). Naive and treated CHB patients developed no or only weaker IFNγ or IL2 responses to HBsAg (5 ± 2 and 12 ± 7 pg/ml, for naive CHB, 12 ± 10 and 18 ± 15 pg/ml, for treated CHB). For HC, IL2 release after HBsAg stimulation depicted hepatitis B vaccination status with a diagnostic sensitivity and specificity of 85 % and 90 %., Conclusion: Our novel whole blood based cytokine release assay constitutes an easy and robust tool for screening HBV specific cellular immunity as alternative to flow cytometry or ELISPOT assays.

Background: The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment., Methods: All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality., Results: At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC)., Conclusions: The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

Corticotropin-releasing hormone (CRH) is a central integrator in the brain of endocrine and behavioral stress responses, whereas activation of the endocannabinoid CB1 receptor suppresses these responses. Although these systems regulate overlapping functions, few studies have investigated whether these systems interact. Here we demonstrate a novel mechanism of CRH-induced anxiety that relies on modulation of endocannabinoids. Specifically, we found that CRH, through activation of the CRH receptor type 1 (CRHR1), evokes a rapid induction of the enzyme fatty acid amide hydrolase (FAAH), which causes a reduction in the endocannabinoid anandamide (AEA), within the amygdala. Similarly, the ability of acute stress to modulate amygdala FAAH and AEA in both rats and mice is also mediated through CRHR1 activation. This interaction occurs specifically in amygdala pyramidal neurons and represents a novel mechanism of endocannabinoid-CRH interactions in regulating amygdala output. Functionally, we found that CRH signaling in the amygdala promotes an anxious phenotype that is prevented by FAAH inhibition. Together, this work suggests that rapid reductions in amygdala AEA signaling following stress may prime the amygdala and facilitate the generation of downstream stress-linked behaviors. Given that endocannabinoid signaling is thought to exert "tonic" regulation on stress and anxiety responses, these data suggest that CRH signaling coordinates a disruption of tonic AEA activity to promote a state of anxiety, which in turn may represent an endogenous mechanism by which stress enhances anxiety. These data suggest that FAAH inhibitors may represent a novel class of anxiolytics that specifically target stress-induced anxiety., (Copyright © 2015 the authors 0270-6474/15/353879-14$15.00/0.)

Background: Vagus nerve stimulation is increasingly applied to treat epilepsy, psychiatric conditions and potentially chronic heart failure. After implanting vagus nerve electrodes to the cervical vagus nerve, side effects such as voice alterations and dyspnea or missing therapeutic effects are observed at different frequencies. Cervical vagus nerve branching might partly be responsible for these effects. However, vagus nerve branching has not yet been described in the context of vagus nerve stimulation., Materials and Methods: Branching of the cervical vagus nerve was investigated macroscopically in 35 body donors (66 cervical sides) in the carotid sheath. After X-ray imaging for determining the vertebral levels of cervical vagus nerve branching, samples were removed to confirm histologically the nerve and to calculate cervical vagus nerve diameters and cross-sections., Results: Cervical vagus nerve branching was observed in 29% of all cases (26% unilaterally, 3% bilaterally) and proven histologically in all cases. Right-sided branching (22%) was more common than left-sided branching (12%) and occurred on the level of the fourth and fifth vertebra on the left and on the level of the second to fifth vertebra on the right side. Vagus nerves without branching were significantly larger than vagus nerves with branches, concerning their diameters (4.79 mm vs. 3.78 mm) and cross-sections (7.24 mm2 vs. 5.28 mm2)., Discussion: Cervical vagus nerve branching is considerably more frequent than described previously. The side-dependent differences of vagus nerve branching may be linked to the asymmetric effects of the vagus nerve. Cervical vagus nerve branching should be taken into account when identifying main trunk of the vagus nerve for implanting electrodes to minimize potential side effects or lacking therapeutic benefits of vagus nerve stimulation.

Introduction: Takotsubo cardiomyopathy is an apical ballooning syndrome, which can be triggered by stress. Only few case reports describe the onset of Takotsubo as a complication of neurosurgery procedures., Clinical Presentation: A case of a 53 year-old female with a spinal neurinoma and surgery-associated Takotsubo cardiomyopathy is demonstrated. The patient developed typical signs of a myocardial infarction with circulation depression and ST elevation, but normal cardiac enzymes at the end of surgery. Cardiac catheterization and levocardiography confirmed the absence of any critical coronary disease but the presence of a typical apical ballooning and midventricular hypokinesis. The patient recovered completely under supportive conservative and cardiological therapy, showing regular left ventricular pump function., Conclusion: Interventions in neurosurgery and perioperative care should be kept as stress free as possible. Due to the possibility of neurogenic mechanisms related to cardiomyopathy, Takotsubo cardiomyopathy as an entity of stress-induced complications should be taken into consideration., (Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.)

Aim of the Study: Treatment strategies in distal radius fractures differ nationally and internationally. Conservative and operative treatment options compete as well as implants, postoperative therapy regimens and the necessity of implant removal. In our institution operative treatment is favoured. In the following the results of 721 surgically treated patients are presented., Patients: PATIENTS who underwent operative treatment of their distal radius fractures in our institution between 2008 and 2011 were retrospectively analysed. Following patient characteristics have been surveyed regarding age, sex, location of plate osteosynthesis, operation time, time of cast immobilisation and complications like infections, tendon ruptures, need of revision surgery., Results: 721 patients (mean age: 59.03 years) were retrospectively analysed. 514 of them (71.29 %) were female. Time of operation was after a mean duration of 5.48 days. In 558 (77.39 %) patients we performed palmar plate osteosynthesis. 89 (12.34 %) had dorsal plate osteosynthesis and 74 (10.3 %) cases were treated with either K-wires or screws. 18 (2.5 %) patients had concomitant traumatic carpal tunnel syndrome and a concomitant SL rupture was seen in 38 (5.27 %) patients. 40 (5.55 %) patients underwent operative revision because of posttraumatic carpal tunnel syndrome (n = 15), tendon ruptures (n = 7), malposition of screws (n = 6), loss of reduction (n = 6) and infection (n = 3). Mean duration of in-hospital stay after operation was 6.6 days. Implant removal was performed in 77 (10.7) patients; 59 (8.2 %) patients had palmar plate osteosynthesis and 18 (2.5 %) patients had dorsal plating., Conclusion: Because of the low complication rate after operative treatment of distal radius fractures, osteosynthesis of this fracture seems to be warranted. Regarding the patients' higher age we have seen an unexpectedly long in-hospital stay with a mean time of 6.6 days. Herein attempts should be made to reduce time of in-hospital stay. In our opinion implant removal should not be recommended routinely., (Georg Thieme Verlag KG Stuttgart · New York.)

Infection of intestinal epithelial cells is dependent on the Salmonella enterica serovar Typhimurium pathogenicity island 1 (Spi1)-encoded type III injectisome system and flagellar motility. Thus, the expression of virulence and flagellar genes is subject to tight regulatory control mechanisms in order to ensure the correct spatiotemporal production of the respective gene products. In this work, we reveal a new level of cross-regulation between the Spi1 and flagellar regulatory systems. Transposon mutagenesis identified a class of mutants that prevented flhDC autorepression by overexpressing HilD. HilD, HilC, RtsA, and HilA comprise a positive regulatory circuit for the expression of the Spi1 genes. Here, we report a novel transcriptional cross talk between the Spi1 and flagellar regulons where HilD transcriptionally activates flhDC gene expression by binding to nucleotides -68 to -24 upstream from the P5 transcriptional start site. We additionally show that, in contrast to the results of a previous report, HilA does not affect flagellar gene expression. Finally, we discuss a model of the cross-regulation network between Spi1 and the flagellar system and propose a regulatory mechanism via the Spi1 master regulator HilD that would prime flagellar genes for rapid reactivation during host infection.

Background: During the treatment of severely injured patients, rehabilitation takes an important role. In this study we examined the present structures in acute care hospitals, which influence the process of rehabiliation., Materials and Methods: The data was captured in a questionnaire. The questions deal with the personal and structural situation of acute care hospitals in Germany. The questionnaires were sent to all clinics, which are registered in the TraumaNetwork DGU., Results: 424 hospitals answered the questionnaire. This is a response rate of 57.3% regarding 740 acitve clinics in the TraumaNetwork DGU. 58% have no opportunity for rehabilitation. The majority of the hospitals have a physiotherapy, (98.6%) or an occupational therapy (71.0%); 33.3% have a case management. Only 17.0% of the hospitals have rehabilitation teams which take care during the hospital stay. These teams consist mainly of internal rehabilitation physicians and physical therapists. Supraregional Trauma Center have better organized structures, as hospitals with lower level of care. Only 56.6% of all hospitals reported that they were familiar with the cooperating rehabilitation hospitals. There are special cooperations with rehabilita­tion hospitals in 34.4% of all cases., Conclusion: The early mobilisation of severely injured patients is an integral part of the postoperative course in German hospitals. While on the one hand a large number of hospitals have good structural conditions on the other hand these structures are little integrated in the daily treamtment. There are major gaps and uncertainties in the cooperation between acute care clincs and rehabilitation hospitals. The integra­tion of rehabilitation hospitals in the TraumaNetwork DGU could be a good chance to improve this collaboration., (© Georg Thieme Verlag KG Stuttgart · New York.)

The GABAergic system is the main source of inhibition in the mammalian brain. Consequently, much effort is still made to develop new modulators of GABAergic synaptic transmission. In contrast to glutamatergic postsynaptic potentials (PSPs), accurate monitoring of GABA receptor-mediated PSPs (GABAR-PSPs) and their pharmacological modulation in brain tissue invariably requires the use of intracellular recording techniques. However, these techniques are expensive, time- and labor-consuming, and, in case of the frequently employed whole-cell patch-clamp configuration, impact on intracellular ion concentrations, signaling cascades, and pH buffering systems. Here, we describe a novel approach to circumvent these drawbacks. In particular, we demonstrate in mouse hippocampal slices that selective optogenetic activation of interneurons leads to prominent field inhibitory GABAAR- and GABABR-PSPs in area CA1 which are easily and reliably detectable by a single extracellular recording electrode. The field PSPs exhibit typical temporal and pharmacological characteristics, display pronounced paired-pulse depression, and remain stable over many consecutive evocations. Additionally validating the methodological value of this approach, we further show that the neuroactive steroid 5α-THDOC (5 μM) shifts the inhibitory GABAAR-PSPs towards excitatory ones.

Introduction: Occipital condyle fractures (OCFs) are considered to be rare injuries. OCFs are now diagnosed more often because of the widespread use of computed tomography. Our aim is to report the incidence, treatment and long term outcome of 8 patients with OCFs., Materials and Methods: All patients presenting with multiple trauma from 1993 to 2006 were analyzed retrospectively. Characteristics and course of the treatment were evaluated. Follow-up was performed after 11,7 years (range 5,9 to 19,3 years)., Results: Nine cases of OCF in 8 patients were identified. All injuries resulted from high velocity trauma. The average scores on the ISS Scale were 39,6 (24-75) and 7,3 (3-15) on the GCS. According to Anderson's classification, 5 cases of Type III and 4 cases of Type I fractures were identified. According to Tuli's classification, 5 cases of Type IIA and 4 cases of Type I were found. Indications for immobilization with the halo-vest were type III injuries according to Anderson's classification or Tuli's type IIA injuries, respectively. Patients with Tuli's type I injuries were treated with a Philadelphia collar for 6 weeks. In one patient with initial complete tetraplegia and one with incomplete neurological deficits the final follow-up neurologic examination showed no neurological impairment at all (Frankel-grade A to E, respectively B to E). At follow-up, 3 patients were asymptomatic. Four patients suffered from mild pain when turning their head, pain medication was necessary in one case only., Discussion: OCF's are virtually undetectable using conventional radiography. In cases of high velocity, cranio-cervical trauma or impaired consciousness, high resolution CT-scans of the craniocervical junction must be performed. We suggest immobilization using a halo device for type III injuries according to Anderson's classification or Tuli's type IIa injuries, respectively. Patients with Tuli's type I injuries should be treated with a Philadelphia collar.

Stress impairs cognition via corticotropin-releasing hormone receptor 1 (CRHR1), but the molecular link between abnormal CRHR1 signaling and stress-induced cognitive impairments remains unclear. We investigated whether the cell adhesion molecule nectin-3 is required for the effects of CRHR1 on cognition and structural remodeling after early-life stress exposure. Postnatally stressed adult mice had decreased hippocampal nectin-3 levels, which could be attenuated by CRHR1 inactivation and mimicked by corticotropin-releasing hormone (CRH) overexpression in forebrain neurons. Acute stress dynamically reduced hippocampal nectin-3 levels, which involved CRH-CRHR1, but not glucocorticoid receptor, signaling. Suppression of hippocampal nectin-3 caused spatial memory deficits and dendritic spine loss, whereas enhancing hippocampal nectin-3 expression rescued the detrimental effects of early-life stress on memory and spine density in adulthood. Our findings suggest that hippocampal nectin-3 is necessary for the effects of stress on memory and structural plasticity and indicate that the CRH-CRHR1 system interacts with the nectin-afadin complex to mediate such effects.

Background: The aim of this study was to compare the results of the single (STR) versus double TightRope™ (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance., Patients and Methods: A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0-21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated., Results: Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%)., Conclusion: The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.

The treatment of the severely injured is, just as the injury severity and combinations, often highly complex and leaves little leeway for delay, dissent or even error. In order to reduce this to a minimum, trained emergency room teams in addition to optimal technical and structural prerequisites are necessary. This must function in an interdisciplinary fashion according to fixed consensus algorithms which are known to all team members and have been agreed by all participants. The White Paper on treatment of the severely injured of the German Society of Trauma Surgery (DGU) and the recently published S3 guidelines offer evidence-based recommendations on the structural, technical, organizational and personnel prerequisites.