[Postoperative wound infections : Diagnosis, classification and treatment]. / Der postoperative Wundinfekt : Diagnose, Klassifikation und Behandlung.

BACKGROUND: Surgical site infections are a frequent complication of surgery and a severe burden for the patient as well as for the healthcare system. Sound knowledge of the disease pattern is an essential prerequisite for effective therapy. OBJECTIVE: This article presents an overview of the diagnosis, classification and treatment options for surgical site infections. MATERIAL AND METHODS: Based on the existing experience, the currently available evidence and pathophysiological considerations, an overview of the diagnostic possibilities, the existing classification systems and the treatment options is presented. RESULTS: The diagnosis of surgical site infections is based on the clinical symptoms and can particularly be supported by the microbiological analysis of wound samples. There is no validated classification system but the definition of the Centers for Disease Control and Prevention is most commonly used. After initial bedside processing, debridement and wound cleansing are the basis for the further treatment, which is supplemented by the rational use of antiseptics and antibiotics. The use of modern dressings with the aim of maintaining a physiological moist wound environment promotes wound healing. The negative pressure wound therapy is an available treatment option. Rare diseases need to be considered. CONCLUSION: The low level of evidence and critical consideration of the treatment options have been discussed in many guidelines, consensus documents and systematic reviews on the basis of which this article was written. Strengthening the evidence situation through intensive, targeted research should be the goal.

Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease.

AIM: Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA). METHODS: This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors. RESULTS: The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04). CONCLUSION: Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

Self-tolerance in the immune privileged CNS: lessons from the entorhinal cortex lesion model.

Upon peripheral immunization with myelin epitopes, susceptible rats and mice develop T cell-mediated demyelination similar to that observed in the human autoimmune disease multiple sclerosis (MS). In the same animals, brain injury does not induce autoimmune encephalomyelitis despite massive release of myelin antigens and early expansion of myelin specific T cells in local lymph nodes, indicating that the self-specific T cell clones are kept under control. Using entorhinal cortex lesion (ECL) to induce axonal degeneration in the hippocampus, we identified possible mechanisms of immune tolerance after brain trauma. Following ECL, astrocytes upregulate the death ligand CD95L, allowing apoptotic elimination of infiltrating activated T cells. Myelin-phagocytosing microglia express MHC-II and the costimulatory molecule CD86, but lack CD80, which is found only on activated antigen presenting cells (APCs). Restimulation of invading T cells by such immature APCs (e.g. CD80 negative microglia) may lead to T cell anergy and/or differentiation of regulatory/Th3-like cells due to insufficient costimulation and presence of high levels of TGF-beta and IL-10 in the CNS. Thus, T cell -apoptosis, -anergy, and -suppression apparently maintain immune tolerance after initial expansion of myelin-specific T lymphocytes following brain injury. This view is supported by a previous metastatistical analysis which rejected the hypothesis that brain trauma is causative of MS (Goddin et al., 1999). However, concomitant trauma-independent proinflammatory signals, e.g., those evoked by clinically quiescent infections, may trigger maturation of APCs, thus shifting a delicate balance from immune tolerance and protective immune responses to destructive autoimmunity.

A double-blind comparative multicentre study of controlled-release remoxipride, immediate-release remoxipride and haloperidol in schizophrenia.

A double-blind multicentre study comparing the efficacy and safety of remoxipride in controlled-release formulation (REM-CR), given once a day, and immediate-release formulation (REM-IR) and haloperidol, given twice daily, was conducted in patients with schizophrenic illness. In total, 150 inpatients were randomized: 49, 51 and 50 in the REM-CR, REM-IR, and haloperidol groups, respectively. The mean daily dose of REM-CR during the last week of treatment was 361 mg, that of REM-IR 332 mg. In the haloperidol group the corresponding dose was 12.5mg per day. The study treatment period was four weeks. The median BPRS total score was 37.5 in the REM-CR group at start of treatment, and 14.5 at last rating (n = 38). For the REM-IR group and the haloperidol group the corresponding figures were 36.0 and 38.0 at start of treatment and 18.0 (n = 43) and 16.5 (n = 40) at last rating. No statistically significant differences were found between the treatments. Therapy-emergent extrapyramidal symptoms (Simpson & Angus rating scale) were significantly (p less than 0.05) more frequent and more severe during haloperidol than during REM-CR and REM-IR treatment, despite significantly higher concurrent use of anticholinergic drugs in the haloperidol group.--REM-CR was comparable in efficacy and tolerability to REM-IR. The tolerability profile favoured both remoxipride formulations over haloperidol. Evaluation of the clinical chemistry, haematology, and cardiovascular data showed no clinically significant deleterious effects on any organ system for either drug.

A double-blind multicentre study comparing remoxipride, two and three times daily, with haloperidol in schizophrenia.

A double-blind multicentre study comparing the efficacy and safety of remoxipride in relation to haloperidol was conducted in 160 inpatients with schizophrenic illness diagnosed according to DSM-III. The study period was 4 weeks. The mean daily dose of remoxipride (whether given twice or three times daily) during the last week of treatment was 395 mg; the corresponding dose of haloperidol was 17 mg per day. No significant difference in therapeutic efficacy was found; Brief Psychiatric Rating Scale (BPRS) median total scores dropped from 41 to 20 (remoxipride twice daily, n = 51), 43 to 20 (remoxipride three times daily, n = 44) 40 to 19 (haloperidol three times daily, n = 48) at last valid rating. According to Clinical Global Impression (CGI) 68% in the remoxipride twice daily, 58% in the three times daily and 60% in the haloperidol group were very much or much improved. Treatment-emergent extrapyramidal checklist symptoms (hypokinesia, rigidity and tremor) were statistically significantly more frequent and more severe during haloperidol than during remoxipride treatment despite a statistically significantly higher concurrent use of anticholinergic drugs in the haloperidol group. Haloperidol treated patients reported more tiredness and drowsiness than remoxipride treated patients. Also, haloperidol treated patients had a significantly higher frequency of extrapyramidal symptoms on 8 out of 10 items of the Simpson and Angus scale.

A double-blind multicentre study comparing remoxipride, controlled release formulation, with haloperidol in schizophrenia.

A double-blind multicentre study was undertaken to compare the efficacy and safety of remoxipride in a controlled release (CR) formulation given once daily with haloperidol twice daily in patients with schizophrenic illness. In total, 114 patients were included. All were diagnosed as schizophrenic or schizophreniform according to DSM-III. Their mean daily dose of remoxipride CR during the last week of treatment was 385 mg. In the haloperidol group the corresponding dose was 17 mg per day. The intended study period was 4 weeks with at least a one-day washout. No significant differences were found between treatments regarding efficacy variables. The median total Brief Psychiatric Rating Scale (BPRS) score was 40 in the remoxipride CR group at start of treatment and 21 at last valid rating. For the haloperidol group the corresponding figures were 40 and 22. Treatment-emergent extrapyramidal symptoms (Simpson and Angus rating) occurred statistically significantly more frequently and were more severe during haloperidol than during remoxipride CR treatment despite a statistically significantly higher concurrent use of anticholinergic drugs in the haloperidol group.

[Unchanged ability following temporal gunshot injury with multiple intracerebral gunshot pellets]. / Ungestörte Handlungsfähigkeit nach temporaler Schussverletzung mit zahlreichen intrazerebralen Schrotkugeln.

The case of a 25-year-old male schizophrenic patient is reported, who with suicidal intent wounded himself in the left temporal region, using a shotgun. Despite having about 30 intacerebral smallshot, he remained continuously conscious. The clinical neurological status did not reveal any abnormalities in the course of treatment. The differing results of CT and NMR examination are reported. Finally, the complications reported in the literature are discussed.