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Introduction: Despite the growing numbers of physicians in outpatient care, continuing discussion about the planning of physician requirements suggests remaining problems in this field, which could be due to focussing on the ratio of physician to population rather than on morbidity-based evaluations. Against this background, this paper tries to depict the latent need in outpatient care, illustrates supply and demand and further tests the hypothesis that there is a relative inequality in distribution due to physicians preferring to locate in socially privileged areas in the German state of Brandenburg., Methods: We aggregated all data available on a small scale with potential impact on demand and examined it via principal component analysis. The generated factor was mapped together with the locations of general practitioners and specialists in general care. Using linear regressions, the number of practitioners was compared to the local index value to determine regional inequalities., Results: The PCA suggested a one factor solution; that factor was designated Social Structure Index due to its values. The mapping showed a tendency of higher index values towards the central areas of Brandenburg surrounding Berlin. Regressions of the number of practitioners against the index values revealed no significant differences between communities with high and low index values., Conclusion: The extension of factors concluding the evaluation of physician demand in outpatient care confirms the problems of physician supply in rural areas, where sparse populations meet social disadvantages and poor accessibility. An underlying inequality in distribution in terms of physicians preferring socially privileged areas could not be detected., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim of the Study: In a nationwide comparison, the state of Brandenburg has one of the highest morbidity and mortality rates of ischemic heart disease. Access to medical care infrastructure is considered to be one possible explanation for regional health inequalities. Accordingly, the study aims to calculate the distances to different types of cardiology care at the community level and to consider these in the context of local care needs., Methodology: Preventive sports facilities, general practitioners, outpatient specialist care, hospitals with cardiac catheterization laboratory and outpatient rehabilitation were chosen and mapped as essential facilities for cardiological care. Thereafter, the distances across the road network from the center of each Brandenburg community to the nearest location of each care facility was calculated and divided into quintiles. Medians and interquartile ranges of the German Index of Socioeconomic Deprivation and the proportion of the population over 65 were used as measures of the need for care. They were then related to the distance quintiles per type of care facility., Results: For 60% of Brandenburg's municipalities, general practitioners were found to be within 2.5 km, preventive sports facilities within 19.6 km, cardiology practices within 18.3 km, hospitals with cardiac catheterization laboratories within 22.7 km, and outpatient rehabilitation facilities within 14.7 km. The median of the German Index of Socioeconomic Deprivation rose with increasing distance for all types of care facilities. The median of the proportion of over 65-year-olds showed no significant variation between distance quintiles., Conclusions: The results show that a high proportion of the population lives far away from cardiology care services, while a high proportion seems to be able to reach a general practitioner. In Brandenburg, a regional and locally oriented cross-sectoral care seems to be necessary., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Fracture lines in unfavorable locations are referred to as "bad splits" in a mandibular sagittal split osteotomy (SSO). Several modifications of the technique by Obwegeser have been introduced to minimize this risk. This in vitro study was performed to determine whether the shape of the osteotomy cut affects the torque and the fracture pattern of an SSO in pig mandibles., Materials and Methods: In a split-mouth model, 16 mandibles were split according to the Hunsuck-Dal Pont modification of the Obwegeser technique. Using an oscillating saw, sharp-edged osteotomies were created on one side of the mandible and round-edged osteotomies were created on the contralateral side using a Lindemann bur. Torque forces were measured during the splitting, and the lingual fracture pattern of each split was classified., Results: Torque forces were significantly (P < .05 by paired t test) decreased by 0.77 N-m (15.6%) when a saw was used for the osteotomy. In the 2 groups, fractures were produced along the mandibular canal. The mandible was more often completely fractured, including the lower mandibular border, when the fracture was created with an oscillating saw (P = .06 by Pearson χ 2 test). No correlation was found between the torque used and the fracture pattern., Conclusion: Compared with round-edged osteotomies, sharp-edged osteotomies in pig mandibles facilitated the Hunsuck-Dal Pont modification of the Obwegeser sagittal splitting procedure and produced predictable results with decreased torque., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: By adding an osteotomy of the inferior border of the mandibular body to the classic sagittal split osteotomy, the authors expected to prevent unfavorable splits and damage to the inferior alveolar nerve., Materials and Methods: Thirty-five human mandibles were used to perform 70 sagittal split osteotomies as an in vitro study. Conducted as a split-mouth model, each mandible was split at the midline. One side of the mandible was split using the traditional Obwegeser-Dal Pont technique, and the other side was split in the same manner with an additional osteotomy of the inferior mandible border. The torque used to split the mandible was measured, and the fracture line of the mandible was recorded., Results: The average torque associated with the original technique was 1.38 Nm (standard deviation, 0.60 Nm), with a fracture line along the mandibular canal. The average torque required to split the hemimandible with the modified technique was 1.02 Nm (standard deviation, 0.50 Nm), a significant (P < .001) difference, with a fracture line parallel to the posterior ramus of the mandible. The fracture pattern depended significantly on the technique used (P < .001), but not on the applied torque force., Conclusion: By adding an osteotomy of the inferior mandibular border to the sagittal split osteotomy, less torque was needed to split the mandible. The fracture line was more predictable, even when all the surgical manipulations were performed at a safe distance from the inferior alveolar nerve., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In 1953, the sagittal ramus split osteotomy was introduced by Obwegeser. For many years, and in some countries still, this technique has defined the term oral and maxillofacial surgery., Methods: The basic design of the sagittal ramus split surgical procedure evolved very quickly. The original operation technique by Obwegeser was shortly after improved by Dal Pont's modification. The second major improvement of the basic technique was added by Hunsuck in 1967. Since then, the technical and biological procedure has been well defined. Resolution of the problems many surgeons encountered has, however, taken longer. Some of these problems, such as the unfavorable split or the damage of the inferior alveolar nerve, have not been satisfactorily resolved., Results: Further modifications, with or without the application of new instruments, have been introduced by Epker and Wolford, whose modification was recently elaborated by Böckmann. The addition of a fourth osteotomy at the inferior mandibular border in an in vitro experiment led to a significant reduction of the torque forces required for the mandibular split., Conclusions: The literature was reviewed, and the last modifications of the successful traditional splitting procedure are presented narrowly. It indicates the better the split is preformatted by osteotomies, the less torque force is needed while splitting, giving more controle, a better predictability of the lingual fracture and maybe less neurosensory disturbances of the inferior alveolar nerve.

Objectives: The aim of this study was to evaluate the use of model mandibles made preoperatively by additive manufacturing, which were used to prebend reconstruction plates prior to mandibular resection and reconstruction with microvascular bony flaps., Materials and Methods: Computer Tomography (CT) or Cone Beam Tomography (CBT) scans acquired preoperatively were used to obtain DICOM data sets to produce a model of the mandible using rapid prototyping. This model was used as a template to prebend and then sterilize a 2.3 or 2.7 reconstruction plate, which was used to reconstruct the mandible with a microvascular bony flap. This technique was used in 20 consecutive patients who required mandibular resection and reconstruction because of a tumour or osteoradionecrosis., Results: The prebent plate was used in all patients intraoperatively without the need for any further bending. The average time to bend a plate on a nonsterile model was 0.42 h (range 0.25-0.68 h). This is felt to represent the minimum amount of time saved during the operation. Additive manufacture of the mandible prior to resection and reconstruction with a microvascular flap is a useful technique which reduces the operating time., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: This study investigated a new technique for the bilateral sagittal split osteotomy (BSSO) by adding a new osteotomy line at the inferior border of the mandible in the Obwegeser-Dal Pont operation., Material and Methods: For this purpose a test system was designed and 100 pig mandibles were split to assess the test's reliability, to compare the torque necessary to split the mandible in both techniques and to record the fracture lines. The splitting technique was standardized, avoiding any contact with the inferior alveolar nerve. All outcomes were statistically examined by paired t-tests., Results: By using the new technique, we demonstrated a decrease in the torque force required to split the mandible of 29.7% (t(69)=-12.68; p<0.05, paired t-test) compared to the Obwegeser-Dal Pont technique. The fracture lines were close to ideal., Conclusion: The additional osteotomy facilitates the BSSO technique and it reduces the likelihood of bad splits and damage to the inferior alveolar nerve in pig mandibles., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The experience with 191 flaps from the anterolateral thigh is described with special regard to variations of vascular anatomy and possible flap designs., Patients: Since 1992, 191 flaps from the anterolateral thigh donor site were used in 187 patients. The size of the defects varied from 3 x 5 cm to 21 x 10 cm, being located in nearly all areas of the head and neck region including the skull base., Methods: The functional and aesthetic outcome was routinely evaluated during follow-up of the patients. All complications and secondary procedures were documented during the whole follow-up period ranging from 4 weeks to 11.2 years., Results: Six different patterns of variations were observed concerning the flap pedicle, but none of these resulted in failure of flap raising except for two patients, in whom no perforators could be found. Poor functional results were observed in 17 patients, and debulking procedures or scar revisions were carried out in 58 of the 187 patients. Nine flap types reaching from voluminous and large myocutaneous flaps to ultra-thin cutaneous perforator flaps were used, enabling closure of virtually any type of soft tissue defect. Twelve flaps were lost, resulting in a success rate of 93.7%., Conclusion: Due to the combined advantages of minimal donor site morbidity, the option of simultaneous flaps and the satisfying results, the anterolateral thigh can be considered a universal donor site which is ideally suited for soft tissue reconstruction in cranio-maxillofacial surgery.

Purpose: To provide standardized follow-up of patients who underwent oral cancer treatment, the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DOSAK) established a schedule of check-up examinations for a 5-year period., Materials and Methods: On the basis of a questionnaire, we investigated oncologic follow-up in respect to early detection of recurrences, cost and outcome efficiencies, and physician and patient judgment in the development of impairments., Results: Only 11% of all operated patients participated regularly in the follow-up program within the first 3 years. Ultrasound was the most effective imaging for the detection of recurrences. Swallowing, speaking, tongue mobility, and facial appearance were the most common problems. Troubles with swallowing were mainly induced by poorly fitted dentures, discontinuity of the mandible, osteomyelitis, and xerostomia. Outer appearance was mostly impaired by scars, missing facial muscle function, and edema. The problem of chronic pain remained unsolved., Conclusion: Due to the sequelae of treatment, this study shows the need for close medical and psychological follow-up., (Copyright 2002 American Association of Oral and Maxillofacial Surgeons)

There is accumulating evidence that the coordinate transcription of the virulence genes in Listeria monocytogenes constitutes a very complex regulation mechanism which might require other factors in addition to PrfA. We previously described an unknown proteinaceous component from crude bacterial cell extracts, which, together with PrfA, formed a specific complex (CI) in electrophoretic mobility shift assays (EMSA) with an hly promoter probe. Here we identify the RNA polymerase (RNAP) of L. monocytogenes as an essential component of the CI complex. Addition of purified RNAP plus PrfA to the hly promoter probe allowed reconstitution of a complex migrating at the same height as CI. By using EMSA and DNaseI footprint experiments it could be shown that PrfA leads to an enhanced and specific binding of RNAP. Transcriptional activity of RNAP in vitro, using the actA promoter, was strictly dependent on PrfA.

Most Listeria monocytogenes virulence genes are positively regulated by the PrfA protein, a transcription factor sharing sequence similarities with cyclic AMP (cAMP) receptor protein (CRP). Its coding gene, prfA, is regulated by PrfA itself via an autoregulatory loop mediated by the upstream PrfA-dependent plcA promoter. We have recently characterized prfA* mutants from L. monocytogenes which, as a result of a single amino acid substitution in PrfA, Gly145Ser, constitutively overexpress prfA and the genes of the PrfA virulence regulon. Here, we show that about 10 times more PrfA protein is produced in a prfA* strain than in the wild type. Thus, the phenotype of prfA* mutants is presumably due to the synthesis of a PrfA protein with higher promoter-activating activity (PrfA*), which keeps its intracellular levels constantly elevated by positive feedback. We investigated the interaction of PrfA and PrfA* (Gly145Ser) with target DNA. Gel retardation assays performed with a DNA fragment carrying the PrfA binding site of the plcA promoter demonstrated that the PrfA* mutant form is much more efficient than wild-type PrfA at forming specific DNA-protein complexes. In footprinting experiments, the two purified PrfA forms interacted with the same nucleotides at the target site, although the minimum amount required for protection was 6 to 7 times lower with PrfA*. These results show that the primary functional consequence of the Gly145Ser mutation is an increase in the affinity of PrfA for its target sequence. Interestingly, similar mutations at the equivalent position in CRP result in a transcriptionally active, CRP* mutant form which binds with high affinity to target DNA in the absence of the activating cofactor, cAMP. Our observations suggest that the structural similarities between PrfA and CRP are also functionally relevant and support a model in which the PrfA protein, like CRP, shifts from transcriptionally inactive to active conformations by interaction with a cofactor.

The interaction of the purified PrfA transcription factor with the regulatory sequences located upstream of the PrfA-dependent listeriolysin (hly) and internalin (inlA) genes was studied in the presence and in the absence of Paf (PrfA-activating factor)-containing extracts. It is shown that PrfA protein is able to bind, independently of additional factors, to a 109bp DNA fragment including the entire hly promoter sequence with the anticipated PrfA binding site ('PrfA-box'). PrfA alone, but not in combination with Paf, can also bind to a shorter target sequence of 28 bp comprising essentially the PrfA-box of the hly promoter. The addition of a Paf-containing extract does not lead to significant protein binding to these two hly target sequences in the absence of PrfA but converts the complex (CIII) consisting of PrfA and the 109 bp hly DNA fragment to a slower migrating PrfA-Paf-DNA complex (CI). Incubation of cell-free extracts of wild-type Listeria monocytogenes with the 109 bp DNA fragment leads to the formation of CI. The addition of polyclonal PrfA antibodies causes a supershift of CIII. Purified PrfA and PrfA-Paf also bind to a DNA fragment containing the PrfA-dependent promoter P2 of inlA, albeit at a lower rate when compared with the corresponding hly sequence. In contrast to the hly target DNA, the inlA promoter sequence efficiently binds Paf alone, and this Paf binding reduces that of PrfA and PrfA-Paf to the inlA target DNA. DNase I footprint experiments show that purified PrfA protects sequences of dyad symmetry previously proposed as PrfA binding sites in the hly and in the inlA promoter regions.

The interaction of Listeria monocytogenes with human umbilical vein endothelial cells was studied. We show that L. monocytogenes invades human umbilical vein endothelial cells independently of internalin A, internalin B, internalin C, and ActA. L. monocytogenes replicates efficiently inside the cells and moves intracellularly by the induction of actin polymerization. We further show that L. monocytogenes-infection of human umbilical vein endothelial cells induces interleukin-6 and interleukin-8 expression during the first 6 h of infection. The expression of MCP-1 and the adhesion molecules VCAM-1 and ICAM-1 was not altered under the experimental conditions used here.

The PrfA protein, which is a member of the Crp/Fnr family of prokaryotic transcription activators, regulates the virulence genes of Listeria monocytogenes. In this work, specific binding of PrfA to its target DNA was determined by electrophoretic mobility-shift assays (EMSAs) using cell-free extracts from the two L. monocytogenes strains EGD and NCTC 7973. PrfA-specific binding differs between the two strains, even when the concentration of PrfA was adjusted to similar levels. Both strains exhibited increased PrfA-specific binding after a shift into minimal essential medium (MEM) without showing a significant change in the amount of PrfA protein, relative to extracts from bacteria grown in brain-heart infusion (BHI). The purified PrfA protein from strain EGD produced in Escherichia coli did not exhibit specific binding to the target DNA but did so upon addition of PrfA-free extracts from various Listeria species and Bacillus subtilis. The observed activation of PrfA seems to be caused by a PrfA-activating factor (Paf), which is probably a protein since elevated temperature, but not RNase treatment, destroyed the activation potential of such PrfA-free extracts. Moreover, fractionation of these extracts by sucrose gradient centrifugation yielded the Paf activity in a fraction sedimenting at 3.2 S. Specific binding of PrfA-containing extracts from strain EGD to the hly and actA promoter sequences was strongly inhibited by iron, whereas that of extracts from strain NCTC 7973 was only slightly reduced. The iron effect seems to be mediated by Paf rather than by PrfA itself.

A new developed partial artificial heart system is presented, which allows pulsatile perfusion of vital organs. The results presented reveal the possibility to duplicate pressure curves and peak systolic pressure in the perfused area-similar to physiological preoperative measurements. The kidney function remains intact. Angiographically there is no damage of the kidney vessels evident. The results are compared with datas of other investigators. Especially there opinion about the disturbance of renal flow and function under nonpulsatile conditions are critically evaluated. A possible connnection between the postoperative renal failure after cardio-pulmonary bypass and non-pulsatile perfusion and other pathophysiological mechanisms are discussed.