Profound Expertise Research Articles

German cardiac CT registry: indications, procedural data and clinical consequences in 7061 patients undergoing cardiac computed tomography.

Cardiac computed tomography permits quantification of coronary calcification as well as detection of coronary artery stenoses after contrast enhancement. Moreover, cardiac CT offers high-resolution morphologic and functional imaging of cardiac structures which is valuable for various structural heart disease interventions and electrophysiology procedures. So far, only limited data exist regarding the spectrum of indications, image acquisition parameters as well as results and clinical consequences of cardiac CT examinations using state-of-the-art CT systems in experienced centers. Twelve cardiology centers with profound expertise in cardiovascular imaging participated in the German Cardiac CT Registry. Criteria for participation included adequate experience in cardiac CT as well of the availability of a 64-slice or newer CT system. Between 2009 and 2014, 7061 patients were prospectively enrolled. For all cardiac CT examinations, patient parameters, procedural data, indication and clinical consequences of the examination were documented. Mean patient age was 61 ± 12 years, 63% were males. The majority (63%) of all cardiac CT examinations were performed in an outpatient setting, 37% were performed during an inpatient stay. 91% were elective and 9% were scheduled in an acute setting. In most examinations (48%), reporting was performed by cardiologists, in 4% by radiologists and in 47% of the cases as a consensus reading. Cardiac CT was limited to native acquisitions for assessment of coronary artery calcification in 9% of patients, only contrast-enhanced coronary CT angiography was performed in 16.6% and combined native and contrast-enhanced coronary CT angiography was performed in 57.7% of patients. Non-coronary cardiac CT examinations constituted 16.6% of all cases. Coronary artery calcification assessment was performed using prospectively ECG-triggered acquisition in 76.9% of all cases. The median dose length product (DLP) was 42mGycm (estimated effective radiation dose of 0.6mSv). Coronary CT angiography was performed using prospectively ECG-triggered acquisition in 77.3% of all cases. Tube voltage was 120kV in 67.8% of patients and 100kV in 30.7% of patients, with a resultant median DLP of 256mGycm (estimated effective dose of 3.6mSv). Clinical consequences of cardiac CT were as follows: in 46.8% of the cases, invasive coronary angiography could be avoided; ischemia testing was recommended in 4.7% of the cases, invasive coronary angiography was recommended in 16.4% of the cases and change in medication in 21.6% of the examinations. Cardiac CT is performed in the majority of patients for non-invasive evaluation of the coronary arteries. CT frequently resulted in medication change, and otherwise planned downstream testing including invasive angiography could be avoided in a high percentage of patients. Radiation exposure in experienced centers is relatively low.

Why Strive after Clinical Social Medicine? From Epidemiological Association to Personalized Social Medicine: a Case of Breast Cancer Care

Advances in biomedicine, especially molecular biology and genetics, gave rise to the concept of personalized medicine targeting the patient's individual characteristics and needs to ensure the best possible therapy and healthcare. This concept, however, can be successfully implemented only if due consideration is given to (psycho-)social factors, as is shown for instance by considerably reduced post-therapy survival rates among cancer patients in regions with lower socioeconomic status, How breast cancer patients, for instance, find their way back to daily life and work after initial treatment at a breast center is substantially determined by multiple factors going beyond pure medical care. These factors critically affect health status and therapy outcomes, but are missing in current research agenda. A profound expertise in social medicine is required to respond in ways tailored to the individual's healthcare needs that go beyond just medical therapy. This expertise comprises, in particular, knowledge of inequality of access to healthcare due to varying health competence that in turn, results in inequality of health outcome and care. Competence in social medicine both in the clinic and outpatient care can help to individually target negative factors that originate from the social environment as well as from deficits in communication and coordination in the healthcare system and have an effect on the health status of patients..This, however, requires institutionalization of (clinical) social medicine and in particular, better opportunities for advanced training in social medicine in clinical departments and outpatient units.

Ischemic Tissue Injury in the Dorsal Skinfold Chamber of the Mouse: A Skin Flap Model to Investigate Acute Persistent Ischemia

Despite profound expertise and advanced surgical techniques, ischemia-induced complications ranging from wound breakdown to extensive tissue necrosis are still occurring, particularly in reconstructive flap surgery. Multiple experimental flap models have been developed to analyze underlying causes and mechanisms and to investigate treatment strategies to prevent ischemic complications. The limiting factor of most models is the lacking possibility to directly and repetitively visualize microvascular architecture and hemodynamics. The goal of the protocol was to present a well-established mouse model affiliating these before mentioned lacking elements. Harder et al. have developed a model of a musculocutaneous flap with a random perfusion pattern that undergoes acute persistent ischemia and results in ~50% necrosis after 10 days if kept untreated. With the aid of intravital epi-fluorescence microscopy, this chamber model allows repetitive visualization of morphology and hemodynamics in different regions of interest over time. Associated processes such as apoptosis, inflammation, microvascular leakage and angiogenesis can be investigated and correlated to immunohistochemical and molecular protein assays. To date, the model has proven feasibility and reproducibility in several published experimental studies investigating the effect of pre-, peri- and postconditioning of ischemically challenged tissue.

Ischemic tissue injury in the dorsal skinfold chamber of the mouse: a skin flap model to investigate acute persistent ischemia.

Despite profound expertise and advanced surgical techniques, ischemia-induced complications ranging from wound breakdown to extensive tissue necrosis are still occurring, particularly in reconstructive flap surgery. Multiple experimental flap models have been developed to analyze underlying causes and mechanisms and to investigate treatment strategies to prevent ischemic complications. The limiting factor of most models is the lacking possibility to directly and repetitively visualize microvascular architecture and hemodynamics. The goal of the protocol was to present a well-established mouse model affiliating these before mentioned lacking elements. Harder et al. have developed a model of a musculocutaneous flap with a random perfusion pattern that undergoes acute persistent ischemia and results in ~50% necrosis after 10 days if kept untreated. With the aid of intravital epi-fluorescence microscopy, this chamber model allows repetitive visualization of morphology and hemodynamics in different regions of interest over time. Associated processes such as apoptosis, inflammation, microvascular leakage and angiogenesis can be investigated and correlated to immunohistochemical and molecular protein assays. To date, the model has proven feasibility and reproducibility in several published experimental studies investigating the effect of pre-, peri- and postconditioning of ischemically challenged tissue.

Komplikationsmanagement nach Resektion und Defektrekonstruktion hüftgelenknaher Tumoren

Tumorous destruction of the periacetabular region and the proximal femur are a consequence of either primary malignant bone tumor manifestation or metastatic disease, which is observed much more frequently and occurs typically in these skeletal segments. Pathological fractures of the proximal femur and periacetabular regions of the pelvis have a high incidence and ultimately lead to severe pain and immobilization. Advanced resection techniques and different types of defect reconstruction, allowing for oncologically sufficient resection of extensive tumors have contributed to a marked increase in the limb salvage rate. However, these procedures are associated with an increasing rate of several, sometimes severe intraoperative and postoperative complications. Compared to elective total hip arthroplasty, the rate of postoperative deep infections, dislocations, the incidence of pathological and periprosthetic fractures and the prevalence of deep vein thrombosis are increased with high rates of postoperative mortality and local tumor recurrence, being the most serious complications. Pelvic involvement and subsequent periacetabular resection have the highest complication rate when compared to proximal femur resection with endoprosthetic treatment. In order to minimize the risk of these intraoperative and postoperative complications wide resection and advanced reconstruction as well as complicated palliative stabilization due to malignant bone tumor growth around the hip joint should be performed in musculoskeletal tumor centers with profound expertise in osteosynthetic and endoprosthetic reconstruction of the pelvis and the proximal femur. Only in specialized centers an effective, multidisciplinary emergency management of these complications and, more importantly, reliable prevention of complications can be ensured.

Akutes Kompartmentsyndrom und Komplextrauma des Fußes

Acute posttraumatic compartment syndrome of the foot is generally the consequence of a severe foot trauma. If the compartment syndrome is left unrecognized and untreated foot deformities and a variety of different functional impairments will follow, making secondary surgical interventions necessary. At present 9 or 10 clinically relevant compartments can be defined anatomically. The early diagnosis particularly in the unconscious patient is based essentially on measurement of the tissue pressure in the corresponding compartments. An effective compartment release depending on the extent of injury and involvement of the specific compartments needs knowledge of three different approaches. A complex foot trauma represents a clearly defined term (Zwipp score or zones-of-injury concept) which still has a quite ominous prognosis if it is not treated according to a stringent regime based on a profound expertise in this quite variable injury entity. An interdisciplinary approach is often deemed to be essential for a reasonable outcome. None of the accepted scores have proven to be useful for primary decision-making of amputation or for the assessment of the long-term prognosis.

Modelling and simulation of electron beam melting

In recent years, the scientific and industrial relevance of additive layer manufacturing (ALM) has grown. In the metal area of ALM, the capacity of laser technologies is noticeably limited. This is mainly due to an inertial beam deflection device, which is also referred to as a mirror galvanometer. In contrast, the electron beam technology offers high power density as well as considerable scanning rates. Therefore, electron beam melting (EBM) seems to be suitable for processing a broad variety of alloys in an economic way. In particular, the enormous scanning rates which can be realized by use of an electron beam enable an economic manufacture of high quality parts. However, profound expertise is required in order to establish EBM as an industrial production technology. By means of mathematical–physical modelling, process stability of the melting step is being increased. Moreover, by solving a detailed thermal model using the finite element method (FEM), substantial knowledge of adequate parameter settings in dependence of the utilised material is developed. Finally, a process window as a function of scan speed and beam power is developed based on experimental results.

Revisionseingriffe nach bariatrischen Operationen – Überblick über Komplikationsspektrum und derzeitige therapeutische Optionen

Obesity is increasing worldwide at an alarming rate. Particularly in Western countries, obesity and related problems have become a serious medical problem and an enormous socio-economic burden. Currently, surgery is the only avail-able treatment for patients with severe obesity which leads to sustained weight loss and cure of co-morbidities in the majority of the patients. The increase in the number of bariatric operations and the occasional failure and complications of these surgical procedures have resulted in an increased need for revision surgery. Overall, 10-25 % of patients are expected to need a revision for failure of the primary bariatric procedure. The main indications for revision procedures are inadequate weight loss, surgery-related complications as well as surgical emergencies and long-term complications caused by malnutrition or -vitamin deficiencies. Unfortunately, there are currently no randomised trials to answer the question as to which operation should be performed in which patient and after which procedure. Decisions are often influenced by the expertise and preference of the operating surgeon as well as by patient's preference. Thus, a systematic review of published data to this complex issue appears to be helpful and important for daily surgical practise. Revision bariatric procedures are technically more complex and associated with increased postoperative complications. These operations should basically be performed in centres with profound expertise in this field of surgery, and - whenever possible - laparoscopically. However, every abdominal surgeon should be able to diagnose and treat some acute complications. After failed restrictive procedures, revision is recommended only in cases of complications but with adequate weight loss at the time of failure. Otherwise, conversion to combined procedures should be considered. After the failure of combined procedures, further weight loss or successful treatment of complications can be achieved by adding more restriction and/or malabsorption components. The latter is associated with an increased risk of nutritional sequelae.

Sport as a Political Tool: Tanzania and the Liberation of Africa

I must say that I was fortunate to have been supervised by Professor James Anthony Mangan during my Ph.D. studies. Professor Mangan's international status is well known. He was a wonderful mentor. His profound expertise was a unique asset and his attention to detail, his continual patience, his unfailing support and his analytical rigour proved to be inestimable supervisory qualities. I also will never forget his generosity – often taking myself and my fellow Ph.D. students for lunch when he felt that we were exhausted after spending long hours in the library. Thank you, Professor Mangan. This chapter is a token of my appreciation.

Telehematology: critical determinants for successful implementation

AbstractDespite modern technologies, such as immunophenotyping and molecular probing, cytomorphologic examination of stained peripheral blood smears by microscopy remains the mainstay of diagnosis in a large variety of diseases. This holds true especially in underdeveloped or rural areas where profound expertise and equipment are not easily available. Although communication technologies have been dramatically improved, telehematology has not become routine. To date, little information is available on which procedures are critical for successful implementation. Therefore, a study evaluating possible factors that prevented implementation of telehematology was initiated. We found that staining technique, smearing procedure, training skills, number of captured images, and prevalent disease influenced the accuracy of diagnosis by the reference laboratory. Using realtime teleconferencing allowed for overcoming these deficits. Together, when certain rules are observed, telehematology allows for rapid, accurate, standardized, and cheap expert advice. This technology should improve treatment of patients in remote areas where expertise is not available.

Rapid generation of detailed loss of heterozygosity profiles for routine diagnosis of gliomas.

Aberrations in the genomes of gliomas seem to correlate well with clinical parameters. Pertinent studies, however, rely on highly sophisticated methods, they require large amounts of high-quality sample material and/or they demand profound analytical expertise. Consequently, molecular tumour analysis has not yet been widely implemented in routine laboratory applications. We have developed an easy-to-perform approach for the rapid derivation of a detailed loss-of-heterozygosity profile from individual gliomas. DNA of PCR quality is extracted in a one-step procedure from routinely obtained material. A microsatellite-based marker set is used to detect the deletion status of genomic regions (i) with established diagnostic relevance, (ii) recurrently found deleted in gliomas, or (iii) generally associated with tumour suppressor activity. The complete profile comprises 25 regions and is generated from 64 markers multiplexed into 18 reactions. Illustratively, we present findings from an anaplastic oligodendroglioma; the molecular data for this tumour allow refined diagnostic and prognostic statements that could not be derived from histology alone. Our approach should prove useful in the routine diagnosis of gliomas. Simultaneously, research data for many highly relevant regions are generated in a comparatively simple and inexpensive way.

Zum gegenwärtigen Stand der Hornhautpathologie in Deutschland: Ergebnisse einer Umfrage unter den Mitgliedern der Sektion Kornea in der DOG

The current situation of corneal pathology is widely unknown. Especially, there are no data available how corneal tissue is processed after penetrating keratoplasty. In November 2002 a questionnaire with 15 questions was sent to all registered members of the cornea section of the German Ophthalmological Society (DOG) ( www.sektionkornea.org ) via email. Only one answer per eye clinic was allowed. Answers were obtained from 40 eye hospitals in which 3070 penetrating keratoplasties had been performed in 2001. 90 % of the surgeons believe that ophthalmopathological investigations of excised corneal specimens are always or at least in some cases important, and 80 % examine 75 to 100 % of all corneal buttons. However, the corneoscleral rim is investigated only exceptionally. 45 % of all corneal buttons are examined by a pathologist within the hospital while 33 % of the corneal specimens are investigated by an ophthalmopathologist in an ophthalmopathological laboratory. In most cases the hospital itself has to bear the cost. Clinics with a high number of corneal transplantations do not differ from the average regarding the fate of corneal buttons. Morphological investigations and publications concerning the cornea are more frequent when an ophthalmopathological laboratory is available in the hospital. For most eye hospitals performing keratoplasties, the histopathological examination of excised corneal buttons is very important. It is carried out to a large extent by pathologists, but specialised ophthalmopathological laboratories are consulted when a profound expertise is needed. Thus, this survey is an argument for the preservation of these laboratories too. Based on the obtained data and on several comments by the section members initiatives to intensify histopathological investigations of excised corneal specimens should be undertaken.

Sloan Foundation Scholarship Program: Mentoring Undergraduates toward Doctoral Degrees

AbstractIn the last decade rapid advances and complex nature of new and improved technologies and fierce competition are demanding a more profound expertise at all professional levels in Chemical Engineering related industries. Graduate programs are an attractive option to fill this need. This and other factors led the chemical engineering department at the University of Puerto Rico Mayagüez campus to implement several programs and initiatives in order to encourage students to pursue doctoral degrees. A key component of this strategy is the Sloan Foundation Undergraduate Scholarship Program. During the first three years a significant increase (from 2 to 10% of the graduating BS class) resulted in those continuing to graduate school. The main components of the program are mentoring, undergraduate research, summer internships, and graduate school orientation seminars.