In cases of bone density of >0.6 g/cm3 in the proximal femur (DEXA), the standard implants for the fixation of unstable trochanteric fractures could guarantee fixation without cutting out. The critical value of sufficient bone density in our few cases seems to be around 0.6 g/cm3 as measured by DEXA. Further investigation is needed to define the limits of bone mineral density for a successful osteosynthesis. An appropriate augmentation of the trabecular bone of the femoral head or a new design of the central loading device could increase the load-bearing capacity and thus help to reduce the cutting out phenomenon. Another alternative could be the primary implantation of an endoprosthesis in the treatment of these patients.

SummaryThrombophilia is a well-established risk factor for a venous thromboembolic event (VTE), and it has been proposed that hereditary thrombophilia may substantially contribute to the development of VTE in young patients. We aimed to analyse the prevalence of thrombophilia with special regard to the age of VTE manifestation. The study cohort consisted of 1490 patients (58% females) with a median age 43 years at the time of their first VTE. At least one thrombophilic disorder was identified in 50Á1% of patients. The probability of detecting a hereditary thrombophilia declined significantly with advancing age (from 49Á3% in patients aged 20 years and younger to 21Á9% in patients over the age of 70 years; P < 0Á001). This may be primarily attributed to the decreasing frequencies of the F5 R506Q (factor V Leiden) mutation and deficiencies of protein C or protein S with older age at the time of the initial VTE event. Moreover, thrombophilia was more prevalent in unprovoked compared with risk-associated VTE (57Á7% vs. 47Á7%; P = 0Á001). The decline in the prevalence of hereditary thrombophilia with older ages supports the use of a selected thrombophilia screening strategy dependent on age and the presence or absence of additional VTE risk factors.

Fractures of the proximal end of the femur, together with vertebral fractures, are greatly exacerbated by osteoporosis and can be regarded as the most typical and most serious complications of this disease. The demand for prompt mobilisation with full loading of the affected limb, combined with a desire for the gentlest of treatments, becomes increasingly difficult to meet in ageing patients with advanced osteoporosis. The advantages of osteosynthesis in respect to these demands when operating on elderly patients with fractures do not apply due to the inability of the osteoporotic bone to hold the osteosynthetic components sufficiently until fracture healing occurs. This inability is related to the anatomy of the proximal end of the femur and its loading patterns. Under eccentric loading, high bending loads occur, leading to failure of the osteosynthetic anchorage at the center of the femoral head. This leads subsequently to stressful revision operations for the patient. The prosthetic replacement is a good option in cases of dislocated intracapsular fractures, but in cases of trochanteric fractures it is still debated. Therefore, it is vital for the trauma surgeon to have specific knowledge of the patient's bone quality in order to optimise the result of the preferred procedure. With reference to our own experimental research and a study of the current literature, this knowledge can be summarised as follows: the most stable anchorage for the implant is achieved by placing the implant through the midpoint of the femoral head (highest bone mineral density) or just below ("best backing"). Anchoring femoral head implants so that they are stable in rotation within the head-neck fragment will significantly raise their load bearing capacity. This is also true for intramedullary load bearing devices in trochanteric fractures. The distance between the load-bearing device in the femoral neck and the articular surface is inversely correlated to the stability at yield, as other studies have already shown. There seems to be a limit for a successful realisation of an osteosynthesis that lies at a femoral head bone mineral density of 250 mg/cm(3) calcium-hydroxyapatite (CaHAp). Nevertheless, high precision surgery in regard to fracture reduction and implant placement is a essential requirement for a successful osteosynthesis. Reproducible local measurements of bone mineral density and trabecular alterations, as well as quick screening methods, are very much desired by the authors.

BackgroundTuberculous spondylitis (Pott's disease) is an ancient human disease. Because it is rare in high-income, tuberculosis (TB) low incidence countries, misdiagnoses occur as sufficient clinical experience is lacking.Case presentationWe describe a fatal case of a patient with spinal TB, who was mistakenly irradiated for suspected metastatic lung cancer of the spine in the presence of a solitary pulmonary nodule of the left upper lobe. Subsequently, the patient progressed to central nervous system TB, and finally, disseminated TB before the accurate diagnosis was established. Isolation and antimycobacterial chemotherapy were initiated after an in-hospital course of approximately three months including numerous health care related contacts and procedures.ConclusionThe rapid diagnosis of spinal TB demands a high index of suspicion and expertise regarding the appropriate diagnostic procedures. Due to the devastating consequences of a missed diagnosis, Mycobacterium tuberculosis should be considered early in every case of spondylitis, intraspinal or paravertebral abscess. The presence of certain alarm signals like a prolonged history of progressive back pain, constitutional symptoms or pulmonary nodules on a chest radiograph, particularly in the upper lobes, may guide the clinical suspicion.

Background: The role of autosomal dominant polycystic kidney disease (ADPKD) as a risk factor for renal cell carcinoma (RCC) is still under discussion. Data on prevalence of RCC in ADPKD are limited, especially on a large population scale. The aim of this study was to analyze the prevalence of RCC in ADPKD kidneys and characterize the clinical features of this coincidence. Methods: Based on our histopathological registry for ADPKD and the Else Kröner-Fresenius Registry, we retrospectively reviewed malignant and benign renal lesions in patients with ADPKD who had undergone renal surgery from 1988 to 2011. Results: 240 ADPKD patients underwent 301 renal surgeries. Mean age at surgery was 54 years. Overall, 16 malignant and 11 benign lesions were analyzed in 301 kidneys (5.3%; 3.7%), meaning that 12/240 (5%; 1:20) patients presented with malignant renal lesions. 66.7% (8/12) of these patients had undergone dialysis prior to surgery. We found 10/16 (63%) papillary RCC, 5/16 (31%) clear cell RCC, and 1/16 (6%) papillary noninvasive urothelial cancer. Regarding all renal lesions, 6/17 (35.3%) patients had more than one histological finding in their kidneys. In 2 cases, metachronous metastases were removed. Mean follow-up was 66.7 months. Conclusion: Kidney-related prevalence of RCC in ADPKD kidneys was surprisingly high. Whether or not this is due to chronic dialysis or due to the underlying disease is still speculative. Like other cystic renal diseases with an increased risk for RCC, the attending physician should be aware of the malignant potential of ADPKD, especially with concomitant dialysis.

We examined 245 patients with chronic rhinosinusitis not responding to prolonged antibiotic treatment and tested each patient for humoral antibody deficiencies. Low immunoglobulin levels were found in 22 patients. Five of them had defects of two or more immunoglobulin isotypes that were diagnosed as common variable immunodeficiency (CVI). Seventeen had an IgG-subclass deficiency. Before and after immunization with pneumococcal vaccine, serotype-specific pneumococcal antibody levels were determined to further evaluate the relevance of the underlying deficiency. Significantly reduced antibody titers of pneumococcal serotypes were found in CVI patients (n = 5), while immunization of 17 patients with IgG-subclass deficiency gave different results. Three of the 17 patients responded poorly to pneumococcal immunization and were prone to a polysaccharide specific immunodeficiency. Patients with CVI or IgG-subclass deficiency failing to produce protective antibody levels in more than five serotypes were chosen for antibiotic and/or immunoglobulin substitution therapy. Since recurrent sinusitis in these patients did not resolve with adequate conservative therapy, endonasal microsurgery was then performed and was seen to be a valuable therapeutic option. Our study suggests that an IgG-subclass deficiency may be the first sign of a basic immunological change, resulting in persisting sinus infections.

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Abstract.We have sampled atmospheric ice nuclei (IN) and aerosol in Germany and in Israel during spring 2010. IN were analyzed by the static vapor diffusion chamber FRIDGE, as well as by electron microscopy. During the Eyjafjallajökull volcanic eruption of April 2010 we have measured the highest ice nucleus number concentrations (>600 l −1 ) in our record of 2 yr of daily IN measurements in central Germany. Even in Israel, located about 5000 km away from Iceland, IN were as high as otherwise only during desert dust storms. The fraction of aerosol activated as ice nuclei at −18 • C and 119 % rh ice and the corresponding area density of ice-active sites per aerosol surface were considerably higher than what we observed during an intense outbreak of Saharan dust over Europe in May 2008.Pure volcanic ash accounts for at least 53-68 % of the 239 individual ice nucleating particles that we collected in aerosol samples from the event and analyzed by electron microscopy. Volcanic ash samples that had been collected close to the eruption site were aerosolized in the laboratory and measured by FRIDGE. Our analysis confirms the relatively poor ice nucleating efficiency (at −18 • C and 119 % ice-saturation) of such "fresh" volcanic ash, as it had recently been found by other workers. We find that both the fraction of the aerosol that is active as ice nuclei as well as the density of ice-active sites on the aerosol surface are three orders of magnitude larger in the samples collected from ambient air during the volcanic peaks than in the aerosolized samples from the ash collected close to the eruption site. From this we conclude that the ice-nucleating properties of volcanic ash may be altered substantially by aging and processing during long-range transport in the atmosphere, and that global volcanism deserves further attention as a potential source of atmospheric ice nuclei.