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Extravertebral low back pain: a scoping review
Get PDFBackground
Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.
Methods
A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.
Results
The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.
Discussion
Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.
Conclusion
The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms
Early identification and awareness of child abuse and neglect among physicians and teachers
Get PDFBackground
Child abuse and neglect (CAN) causes enormous suffering for those affected.
Objective
The study investigated the current state of knowledge concerning the recognition of CAN and protocols for suspected cases amongst physicians and teachers.
Methods
In a pilot study conducted in Mecklenburg-Western Pomerania from May 2020 to June 2021, we invited teachers and physicians working with children to complete an online questionnaire containing mainly multiple-choice-questions.
Results
In total, 45 physicians and 57 teachers responded. Altogether, 84% of physicians and 44% of teachers were aware of cases in which CAN had occurred in the context of their professional activity. Further, 31% of physicians and 23% of teachers stated that specific instructions on CAN did not exist in their professional institution or that they were not aware of them. All physicians and 98% of teachers were in favor of mandatory training on CAN for pediatric residents and trainee teachers. Although 13% of physicians and 49% of teachers considered a discussion of a suspected case of CAN to constitute a breach of confidentiality, 87% of physicians and 60% of teachers stated that they would discuss a suspected case with colleagues.
Conclusion
Despite the fact that a large proportion of respondents had already been confronted with suspected cases of CAN, further guidelines for reporting procedures and training seem necessary. There is still uncertainty in both professions on dealing with cases of suspected CAN
Endoscope-assisted microvascular decompression in hemifacial spasm with a teflon bridge
Get PDFBackground
Microvascular conflicts in hemifacial spasm typically occur at the facial nerve’s root exit zone. While a pure microsurgical approach offers only limited orientation, added endoscopy enhances visibility of the relevant structures without the necessity of cerebellar retraction.
Methods
After a retrosigmoid craniotomy, a microsurgical decompression of the facial nerve is performed with a Teflon bridge. Endoscopic inspection prior and after decompression facilitates optimal Teflon bridge positioning.
Conclusions
Endoscope-assisted microsurgery allows a clear visualization and safe manipulation on the facial nerve at its root exit zone
The role of fatigue in patients with complex regional pain syndrome
Get PDFBackground and Purpose
Fatigue affects patients across a variety of neurological diseases, including chronic pain syndromes such as complex regional pain syndrome (CRPS). In CRPS, fatigue is often underestimated, as the focus lies in the assessment and managing of pain and sensorimotor deficits. This study aimed to investigate the prevalence, characteristics, and influence of fatigue on CRPS severity and quality of life in these patients. Such insights could enhance the clinical management of this challenging condition.
Methods
In this prospective study, 181 CRPS patients and 141 age and gender-matched individuals with injury but without chronic pain were interviewed using the Fatigue Scale for Motor and Cognitive Function to assess fatigue. Depressive symptoms and quality of life (QoL) were also evaluated as additional outcome measures. Statistical analysis was performed to examine differences in fatigue prevalence between the groups, as well as associations with CRPS severity, pain levels, and clinical phenotype. In addition, best subsets regression was used to identify the primary factors influencing QoL. Fatigue was tested in a mediation analysis as a mediator between pain and depression.
Results
CRPS patients showed significantly higher fatigue levels compared to controls (CRPS: 75 [IQR: 57–85] vs. controls: 39 [IQR: 25–57]). Based on the FSMC, 44.2% in the control group experienced fatigue, while 85% of patients with CRPS experienced fatigue (p<0.001), of which 6% were mild, 15% moderate, and 67% severe. In CRPS severe fatigue was associated with higher pain intensities compared to no fatigue (pain at rest: p = 0.003; pain during movement: p = 0.007) or moderate fatigue (pain during movement: p = 0.03). QoL in our cohort was mainly influenced by pain (pain during movement: adj.R2 = 0.38; p<0.001, pain at rest: Δadj.R2 = 0.02, p = 0.007) and depressive symptoms (Δadj.R2 = 0.12, p<0.001). Subsequent analyses indicated that pain and depressive symptoms primarily impact QoL in CPRS whereas fatigue may exert an indirect influence by mediating the connection between pain and depression (p<0.001).
Conclusions
This pioneering study investigates the prevalence of fatigue in CRPS patients and its relation to disease characteristics. Our results indicate a high prevalence of severe fatigue, strongly correlated with pain intensity, and its importance in the interaction between pain and depression in CRPS. These findings underscore the significant role of fatigue as a disease factor in CRPS. Therefore, the evaluation of CRPS-related disability should include a standardized assessment of fatigue for comprehensive clinical management
Unveiling the role of novel carbohydrate‐binding modules in laminarin interaction of multimodular proteins from marine Bacteroidota during phytoplankton blooms
Get PDFLaminarin, a β(1,3)‐glucan, serves as a storage polysaccharide in marine microalgae such as diatoms. Its abundance, water solubility and simple structure make it an appealing substrate for marine bacteria. Consequently, many marine bacteria have evolved strategies to scavenge and decompose laminarin, employing carbohydrate‐binding modules (CBMs) as crucial components. In this study, we characterized two previously unassigned domains as laminarin‐binding CBMs in multimodular proteins from the marine bacterium Christiangramia forsetii KT0803T, thereby introducing the new laminarin‐binding CBM families CBM102 and CBM103. We identified four CBM102s in a surface glycan‐binding protein (SGBP) and a single CBM103 linked to a glycoside hydrolase module from family 16 (GH16_3). Our analysis revealed that both modular proteins have an elongated shape, with GH16_3 exhibiting greater flexibility than SGBP. This flexibility may aid in the recognition and/or degradation of laminarin, while the constraints in SGBP could facilitate the docking of laminarin onto the bacterial surface. Exploration of bacterial metagenome‐assembled genomes (MAGs) from phytoplankton blooms in the North Sea showed that both laminarin‐binding CBM families are widespread among marine Bacteroidota. The high protein abundance of CBM102‐ and CBM103‐containing proteins during phytoplankton blooms further emphasizes their significance in marine laminarin utilization
Modified gluteus maximus transfer for hip abductor deficiency
Get PDFOperationsziel
Durchführung eines Transfers des M. gluteus maximus mit Refixation am Trochanter major zur Therapie der glutealen Insuffizienz.
Indikationen
Symptomatische gluteale Insuffizienz mit Atrophie und fettiger Degeneration der Glutealmuskeln > 50 % (Grad 3 nach Quartile) bei guter Kraftentwicklung des M. gluteus maximus.
Kontraindikationen
Geringe Atrophie oder fettige Degeneration von weniger als 50 % der Glutealmuskulatur, eingeschränkte Kraft des M. gluteus maximus, Infektionen.
Operationstechnik
Zunächst wird die Fascia lata dorsal des M. tensor fasciae latae inzidiert, wobei die Inzision bis ca. 1,5 cm proximal des Beckenkammes reicht. Eine zweite Inzision halbiert den M. gluteus maximus in Längsrichtung der Muskelfasern und wird in Richtung der Fascia lata nach distal des Trochanter major fortgesetzt. Durch die Inzisionen resultiert ein dreieckiger Muskellappen, welcher angehoben und in einen vorderen und einen hinteren Teil geteilt wird. Der posteriore Lappen wird über den Schenkelhals nach ventral gelegt und an der vorderen Kapsel und vorderen Kante des Trochanter major fixiert. Der anteriore Lappen wird direkt auf das proximale Femur platziert. Hierfür wird mit einer Kugelfräse eine Rinne im Bereich des proximalen Femurs präpariert, um den künftigen Footprint anzufrischen. Der anteriore Lappen wird von der Spitze des Trochanter major in Richtung des Ansatzes des M. vastus lateralis positioniert. Anschließend wird der anteriore Lappen mit transossären Nähten an der geschaffenen Rinne und unter dem angehobenen M. vastus lateralis in 15° Abduktion des Beines fixiert. Zur zusätzlichen Stabilisierung des sehnigen Teils des anterioren Lappens wird distal des Trochanter major eine Schraube eingebracht. Der M. vastus lateralis wird an der distalen Spitze des anterioren Lappens befestigt, und der verbleibende M. gluteus maximus wird mit der Fascia lata vernäht, um den anterioren Lappen abzudecken. Ergänzend kann ein Lappen des M. tensor fasciae latae mobilisiert und auf die Rekonstruktion adaptiert werden. Schichtweiser Wundverschluss.
Ergebnisse
Die gezeigte Technik eines M.-gluteus-maximus-Transfers stellt eine Methode zur Behandlung chronischer glutealer Insuffizienzen dar und verbessert in kurzzeitigen Follow-ups die Abduktionsfunktion sowie das Gangbild. Es wurden 15 Patienten (durchschnittliches Alter zum Operationszeitpunkt 62 Jahre) nach einem durchschnittlichen Follow-up von 2,5 Jahren nachuntersucht. Der modified Harris Hip Score (mHHS) verbesserte sich von 48 Punkten präoperativ auf 60 Punkte zum Follow-up. Präoperativ wiesen 100 % ein positives Trendelenburg-Zeichen auf, zum Follow-up Zeitpunkt waren es ca. 50 %.Objective
Transfer of the gluteus maximus with refixation at the greater trochanter for treatment of abductor deficiency.
Indications
Symptomatic abductor deficiency with atrophy and fatty degeneration of the gluteal muscles > 50% (grade 3 by quartile) with good strength of the gluteus maximus.
Contraindications
Low atrophy or fatty degeneration of less than 50% of the gluteal muscles, limited strength of the gluteus maximus, infection.
Surgical technique
First, the fascia lata is incised dorsally to the tensor fascia latae muscle, with the incision extending approximately 1.5 cm proximal to the iliac crest. A second incision divides the gluteus maximus muscle longitudinally along the muscle fibers and continues towards the fascia lata distal to the greater trochanter. These incisions result in a triangular muscle flap, which is elevated and divided into anterior and posterior portions. The posterior flap is positioned ventrally over the femoral neck and fixed to the anterior capsule and the anterior edge of the greater trochanter. The anterior flap is placed directly on the proximal femur. For this purpose, a groove is prepared in the area of the proximal femur using a spherical burr to freshen up the future footprint. The anterior flap is positioned from the tip of the greater trochanter towards the insertion of the vastus lateralis muscle. Subsequently, the anterior flap is fixed to the created groove with transosseous sutures and positioned under the elevated vastus lateralis muscle in 15° abduction of the leg. To provide additional stabilization to the tendinous part of the anterior flap, a screw is inserted distally to the greater trochanter. The vastus lateralis muscle is attached to the distal tip of the anterior flap, and the remaining gluteus maximus muscle is sutured to the fascia lata to cover the anterior flap. Additionally, a flap of the tensor fascia latae muscle can be mobilized and adapted to the reconstruction. Layered wound closure is performed.
Results
The technique of a gluteus maximus transfer represents a method for the treatment of chronic abductor deficiencies and improves abduction function as well as the gait pattern in short-term follow-ups. Fifteen patients (mean age at time of surgery 62 years) had after a mean follow-up of 2.5 years. The modified Harris Hip Score (mHHS) improved from 48 points preoperatively to 60 points at follow-up. Preoperatively, 100% had a positive Trendelenburg sign; at follow-up, this was about 50%
Diversity of hirudin and hirudin-like factor genes in the North-African medicinal leech, Hirudo troctina
Get PDFMedicinal leeches of the genus Hirudo inhabit large areas of the Palaearctic realm. The distribution range of Hirudo troctina includes the southern Iberian peninsula and the northwestern regions of Africa. H. troctina is used for medical purposes, but only very little is known about the components of its salivary gland secretion. Hirudins, bivalent inhibitors of thrombin, are probably the best known leech-derived bioactive factors. Hirudin-like factors (HLFs) represent another class of salivary gland components that share characteristic genetic and structural markers with hirudins. Hirudin is not a single entity but exists in at least four different variants. However, there are differences among the European members of the genus Hirudo with respect to the actual number of hirudin and HLF genes that are present within their genomes. Here, we describe the identification and molecular cloning of 11 genes that encode for putative hirudin and HLF variants in H. troctina . Three of the genes consist of exons and introns that originate from different “archetype” genes and are likely the result of recombination events. The diversity of hirudin and HLF genes in H. troctina surpasses that of all other European members of the genus Hirudo . The putative hirudin variants and representatives of the HLFs of H. troctina were expressed as recombinant proteins, purified and functionally characterized for their thrombin-inhibiting potencies. Phylogenetic analyses based on hirudin and HLF gene sequences of the leech genera Hirudo , Hirudinaria , and Whitmania supported the hypothesis that hirudins and HLFs diverged early in leech evolution
DiscovEpi: automated whole proteome MHC-I-epitope prediction and visualization
Get PDFBackground
Antigen presentation is a central step in initiating and shaping the adaptive immune response. To activate CD8 + T cells, pathogen-derived peptides are presented on the cell surface of antigen-presenting cells bound to major histocompatibility complex (MHC) class I molecules. CD8 + T cells that recognize these complexes with their T cell receptor are activated and ideally eliminate infected cells. Prediction of putative peptides binding to MHC class I (MHC-I) is crucial for understanding pathogen recognition in specific immune responses and for supporting drug and vaccine design. There are reliable databases for epitope prediction algorithms available however they primarily focus on the prediction of epitopes in single immunogenic proteins.
Results
We have developed the tool DiscovEpi to establish an interface between whole proteomes and epitope prediction. The tool allows the automated identification of all potential MHC-I-binding peptides within a proteome and calculates the epitope density and average binding score for every protein, a protein-centric approach. DiscovEpi provides a convenient interface between automated multiple sequence extraction by organism and cell compartment from the database UniProt for subsequent epitope prediction via NetMHCpan. Furthermore, it allows ranking of proteins by their predicted immunogenicity on the one hand and comparison of different proteomes on the other. By applying the tool, we predict a higher immunogenic potential of membrane-associated proteins of SARS-CoV-2 compared to those of influenza A based on the presented metrics epitope density and binding score. This could be confirmed visually by comparing the epitope maps of the influenza A strain and SARS-CoV-2.
Conclusion
Automated prediction of whole proteomes and the subsequent visualization of the location of putative epitopes on sequence-level facilitate the search for putative immunogenic proteins or protein regions and support the study of adaptive immune responses and vaccine design
Silver Diammine Fluoride Use in Paediatric Dentistry: A Retrospective and Cross-sectional Analysis
Get PDFZiel: Ziel dieser Studie ist es, die Wirksamkeit der Behandlung mit Silber-Diamin-Fluorid (SDF) nach einem Follow-up von 24 Monaten an einer Abteilung für Kinderzahnheilkunde einer Uniklinik zu bewerten. Die Meinung der Eltern und Erfahrung der Zahnärzte wurde auch erforscht.
Materialien und Methoden: Es wurde eine retrospektive Analyse durchgeführt an alle Patienten, die im Zeitraum von Januar 2017 bis Februar 2020 behandelt wurden. Behandelte Zähne ohne klinische oder röntgenologische Pulpabeteiligung wurden analysiert. Die Wirksamkeit der SDF- Behandlung wurde je nach Erfolgsraten bzw. Misserfolg bewertet. Akzeptanz und Erfahrung der Behandlung aus Sicht der Eltern und Zahnärzte wurde durch Fragebögen auch erfasst.
Ergebnisse: Insgesamt wurden 93 Patienten aufgenommen, mit einem mittleren Alter von 5,3 ± 2,9 Jahren. 455 Zähne (418 Milchzähne/91,9%; 37 bleibende Zähne/8,1%) wurden behandelt und analysiert nach einem Follow-up von 24 Monaten (19,9 ± 10,5 Mo.). SDF wurde hauptsächlich bei Karies verwendet (98,2%) und MIH-Überempfindlichkeit (1,8%). Die Mehrheit der Zähne zeigten keinen Therapiemisserfolg (Erfolgsrate von 84,2%). 5 Zähne (1,1%) zeigten kleine Misserfolge und 67 Zähne (14,7%) zeigten große Misserfolge (p = 0,001). Die Erfolgsraten bzw. Misserfolge sind nicht von anderen Faktoren wie Kooperationsbereitschaft des Kindes, Geschlecht, Gebiss, oder Behandler abhängig (p > 0.05). Insgesamt haben 30 Eltern teilgenommen (Mittelwert Alter 36,8 ± 6,4 Jahre). SDF wurde an Frontzähnen (n = 2/6.7%), Backenzähnen (n = 15/50%) und Front/Backenzähnen verwendet (n = 13/43.3%). Nach einer Woche Follow-up, 80% der Eltern haben die schwarze Verfärbung gemerkt. Therapie Akzeptanz war höher bei Backenzähnen (95,2%) als Frontzähne (36,4%; p < 0.001). 27 Zahnärzte haben an der Umfrage teilgenommen. Die Mehrheit der Teilnehmer findet, SDF sei eine gute Therapieoption in der Kinderzahnheilkunde angenommen (n = 23; 85%).
Schlussfolgerung: Zusammenfassend wurden hohe Erfolgsraten der SDF-Behandlung aufgewiesen und die Behandlung wurde gut angenommen von Eltern und Zahnärzten einer Uniklinik als Therapieoption um Karies zu inaktivieren bei Kindern.Background and Objectives: Silver diamine fluoride (SDF) has been incorporated into the treatment of dental caries in children, mainly in countries with high caries prevalence. In Europe, however, SDF started to gain popularity during the COVID-19 pandemic. This study aimed to investigate the efficacy of SDF and to evaluate dentists’/parents’ acceptance of SDF use in paediatric patients treated in a German university setting.
Materials and Methods: A retrospective analysis of all patients treated with SDF between 2017 and 2020 was carried out. Only teeth with no reported clinical/radiographic evidence of irreversible pulpal inflammation were included. The outcome measures were success, minor failures (caries progression, reversible pulpitis) and major failures (irreversible pulpitis, abscess). The treatment acceptance by dentists and the parents of SDF-treated children was cross-sectionally evaluated using questionnaires.
Results: A total of 93 patients (mean age 5.3 ± 2.9 years) with 455 treated teeth (418 primary/91.9%; 37 permanent/8.1%) were included and followed up for up to 24 months (19.9 ± 10.5 months). SDF was used for dental caries (98.2%) and hypersensitivity relief on MIH teeth (1.8%). Most teeth did not show any failure (total success 84.2%). A total of 5 teeth (1.1%) showed minor failures, and 67 teeth (14.7%) showed major failures (p = 0.001). Success/failure rates were not affected by patient compliance, gender, dentition, or operator (p > 0.05). In total, 30 questionnaires were collected from parents (mean age 36.8 ± 6.4 years). SDF was applied on anterior (n = 2/6.7%), posterior (n = 15/50%) and anterior/posterior teeth (n = 13/43.3%). At the 1-week follow-up, 80% of parents noticed black teeth discoloration. Treatment satisfaction was higher for posterior (95.2%) than for anterior teeth (36.4%; p < 0.001). In the 27 responses from clinicians, SDF was generally considered a viable option in paediatric dentistry (n = 23; 85%).
Conclusions: SDF was found to be effective and well-accepted by parents and dentists for caries inactivation in a paediatric dentistry German university setting
Virtuelle Stabsarbeit in Zeiten der Pandemie – Entwicklung digitaler Übungsformate in der zivilen Gefahrenabwehr eines Massenanfalls von Erkrankten im Hafen während der Coronapandemie
Get PDFDank der mehrjährigen intensiven interdisziplinären Forschung im direkten Austausch mit den verschiedenen Stakeholder*Innen und Endnutzer*Innen konnte im Projekt ARMIHN ein Mehrwert für das Management und daraus resultierend eine Resilienzsteigerung für den Ereignisfall eines MANE im Hafen geschaffen werden. Die vorgebrachten Analysen über stattgefundene Ereignisse in Häfen und auf Schiffen, über die Strukturen der exemplarischen Region der Freien und Hansestadt Hamburg, sowie die durchgeführten Übungen, sorgten hierbei nicht nur für einen fundierten Erkenntnisgewinn innerhalb der Forschungskonsortiums, sondern ebenfalls für die involvierten Behörden und Organisationen. Die innerhalb der Forschungszeit aufgetretene Covid-19-Pandemie mit all den dazugehörigen Einschränkungen motivierte das Forschungskonsortium die Chance zu nutzen, aktuelle Ereignisse und Studien in Echtzeit zu analysieren und mehr digitale und präsenzunabhängige Formate testen und im Austausch etablieren zu können. Wie die Forschung hierbei gezeigt hat, bot das digitale Konzept eine geeignete Alternative zu Übungen in Präsenzformaten. Auch aus infektiologischer Sicht zeigte sich der Ansatz angesichts der Vermeidung von Infektionsketten als geeignetes Mittel in der durch soziale Einschränkungen geprägten Zeit der Pandemie. Zusammenfassend lässt sich ganz pragmatisch feststellen, dass während der Projektlaufzeit aus der Not eine Tugend gemacht wurde und die Einschränkungen somit innovative Ansätze in der Gesamtheit förderten.
Hinsichtlich der Gefahrenabwehr von Großschadensereignissen, wie einem Massenanfall von Verletzten oder von Erkrankten, hat sich auch im ARMIHN Projekt gezeigt, dass regelmäßige Übungen einen hohen Stellenwert zur Vorbereitung und Resilienz darstellen. Im Ereignisfall auf erfahrene Einsatzkräfte zurückgreifen zu können, ist eine wesentliche Komponente für den Erfolg. Als pandemiebedingt Übungen abgesagt werden mussten und allenfalls nur in kleinen Personengruppen möglich waren, resultierte daraus die Erkenntnis, dass so den Übenden keine realitätsnahen Szenarien eines MANV oder MANE vermittelt werden konnten. Die Abbildung einer Großschadenslage als Groß- und Vollübung mit Darsteller*Innen war zu diesem Zeitpunkt nicht möglich. Zur Vermeidung eines Infektionsrisikos für Übungsteilnehmende wurde innerhalb des Forschungsprojektes folgend auf eine digitale Plattform zur Durchführung von Übungen zurückgegriffen. So konnte der Personaleinsatz in Präsenz auf ein Minimum reduziert werden. Die digitalen Lösungsansätze wurden zur Evaluation in Bezug auf ihre Endnutzer*Innenakzeptanz wissenschaftlich begleitet. Das Feedback durch die Anwender*Innen war überwiegend positiv, auch wenn eine gewisse Diskrepanz zwischen den genutzten digitalen Übungsformaten zu Realübungen nicht vermieden werden konnte. Darüber hinaus wurden weitere Erkenntnisse und Forschungsergebnisse zu den etablierten Strukturen in fast drei Jahren Forschungszeit im ARMIHN Projekt durch die Forschungsgruppe generiert. Für die jeweiligen detaillierten Eindrücke wird auf die erstellten Arbeitspakete, die vorgestellten Fachpublikationen sowie abschließend auf die noch zu veröffentlichenden weiteren Studienergebnisse verwiesen. Hierbei ist auf den fortgeschrittenen Zustand bei der Entwicklung eines Triagierungsalgorithmus im MANE im maritimen Setting/ Hafen zu verweisen, so wie noch weitere ausstehende Veröffentlichungen zu den Evaluationsergebnissen, die im Rahmen der Projektübungen generiert werden konnten