Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era.

BACKGROUND: COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes. MATERIAL AND METHODS: An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up. RESULTS: Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%. CONCLUSIONS: These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

[Diagnosis of chronic venous insufficiency]. / Diagnostische Verfahren bei chronischer venöser Insuffizienz.

For the treatment of chronic venous insufficiency (CVI), various therapeutic options are available. In addition to conservative compression therapy, classical vein surgery, sclerotherapy and endoluminal therapies are increasingly being used to treat varicose veins. For a differentiated indication and correct treatment planning, a stepwise diagnosis with clinical examination and documentation of typical symptoms, dynamic vein function measurement to assess the global venous status as well as a qualitative assessment of the exact insufficient vein segments by means of color-coded duplex sonography is required. Due to the non-invasiveness of the examination and the good assessability of therapeutically relevant parameters such as anatomic conditions, diameter, and reflux of insufficient veins, color-coded duplex sonography is considered the gold standard for imaging diagnostics.

[Telemedical aftercare of patients with skin diseases]. / Telemedizinische Nachsorge von Patient*innen mit Hauterkrankungen.

BACKGROUND: Improved technologies, an increased need for medical healthcare as well as the shortage of specialist personnel lead to a growing importance of telemedical applications. Dermatology is especially suitable for telemedical applications because of the visual appearance of skin diseases. This can contribute to optimizing the care and aftercare of patients with skin diseases. OBJECTIVE: An analysis of patient satisfaction with teledermatological aftercare at the University Hospital Greifswald using the teledermatological application Mobil Skin® (Infokom, Neubrandenburg, Germany) was carried out. Factors that influence patient satisfaction and the suitability of the teledermatological aftercare for different skin diseases were also analyzed. MATERIAL AND METHODS: The evaluation of standardized questionnaires, analysis of demographic data of the patient collective and analysis of usage data concerning the teledermatological system Mobil Skin® were carried out. RESULTS: A total of 91 out of 118 telemedically treated patients participated in the survey. The majority of the patients reported a high degree of satisfaction with the teledermatological aftercare. Patient satisfaction was independent of where the patients lived (minor center or middle center/main center). Patient satisfaction correlated with the frequency of use and the number of answers received through the teledermatological system. The aftercare with the teledermatological system Mobil Skin® was suitable for all diagnosis groups surveyed. Both older and younger patients as well as children benefited from this kind of aftercare.

[Innovations in medical compression therapy]. / Innovationen der medizinischen Kompressionstherapie.

For the treatment of phlebological and lymphological diseases as well as constitutional edema diseases, a discussion of innovative concepts of medical compression therapy is essential. It is recommended that medical compression stockings should always be prescribed based on symptoms and with the lowest effective interface pressure to optimize the tolerability of compression therapy. Likewise, medical compression stockings with an integrated care formula, but also the application of additional skincare can improve the quality of life and compliance in patients with chronic venous insufficiency. Optimization of ulcer therapy can be achieved by using two-component compression stocking systems. These consist of an understocking and a firm outer compression stocking, which improve the venous and capillary hemodynamics with good wearing comfort and lead to the healing of venous ulcerations. Multicomponent compression bandages and short stretch bandages are proven in the decongestion phase of edema. Multicomponent bandages ensure a sustained interface pressure for at least 5 days and are ideal for outpatient treatment with less frequent dressing changes. For compression therapy in patients with arterial-venous leg ulcers (ABI [ankle brachial index] >0.5), specially developed "lite" versions of the multicomponent dressings can be used.

Better wearing comfort of knee-length elastic compression stockings with an interface pressure of 18-21 mmHg compared to 23-32 mmHg in elderly people after a one day trial - Influence on foot deformities, rheumatism and arthritis.

BACKGROUND: Although the efficacy of compression therapy through knee-length compression stockings with an interface pressure of 18-21 mmHg for leg oedemas has been confirmed by many studies, 91% of patients are still treated with a higher interface pressure. METHOD: In this prospective open randomised monocentric study 19 patients (age ≥65, movement restrictions and symptomatic leg oedema) received knee-length compression stockings with an interface pressure of 18-21 mmHg (stocking type 1) and 23-32 mmHg (stocking type 2). On two consecutive days each of the two compression stocking types were worn for at least 8 hours. After this test period, both stocking types were assessed subjectively and skin changes were recorded. RESULT: A significantly (p-value <0.001) subjective improvement of the symptoms and complaints based on leg oedema was reported with the knee-length compression stockings. The Stocking type 1 recorded a significantly (p = 0,045) better wearing comfort. In addition, the Stocking type 2 was significantly too large amongst women in the front foot area (p = 0.044). The most common side effects were constrictions on the proximal lower leg (stocking type 1 = 73,7% (14/19); stocking type 2 = 78,9% (15/19)). Subjects with arthritis (p = 0.006), hallux valgus (p = 0.034) and/or digitus flexus (p = 0.021) found the socking type 1 significantly more comfortable. CONCLUSION: In order to achieve optimal patient compliance it is recommended to prescribe knee-length compression stockings with an interface pressure of 18-21 mmHg if the following criteria are met: age ≥65 years, female sex, arthritis, digitus flexus (claw toe) or hallux valgus.

[Influence of nutrition, common autoimmune diseases and smoking on the incidence of foot mycoses]. / Einfluss von Ernährung, autoimmunen Volkskrankheiten und Rauchen auf die Erkrankungshäufigkeit von Fußmykosen.

BACKGROUND: Foot mycoses, including onychomycoses, are worldwide infectious diseases. As part of a regional survey using randomly selected residents of in Mecklenburg-Western Pomerania, we investigated the impact of dietary habits, the presence of most frequent autoimmune diseases and current smoking on fungal skin infections in order to reveal potential new risk factors to elucidate potential preventive interventions. OBJECTIVES: The identification of potential new factors that influence the development of mycosis was performed in order to derive possible preventive measures. METHODS: In the Study of Health in Pomerania (SHIP) in Mecklengburg-Western Pomerania, 2523 inhabitants were examined for mycotic lesions and asked about nutritional habits, the presence of atopic dermatitis, allergic rhinitis, psoriasis and smoking habits. RESULTS: In all, 8% of probands were diagnosed with mycosis, 6.5% onychomycosis, 3.7% tinea pedis and 0.2% tinea corporis. Psoriasis, allergic rhinitis and atopic dermatitis and frequent consumption of cooked potatoes, oatmeal and corn flakes, cereals, pasta and rice were significantly associated with tinea pedis. Onychomycosis was positively associated with consumption of cooked potatoes. Cigarette consumption proved protective for tinea pedis and dermatophyte colonization. CONCLUSIONS: The autoimmune disorders psoriasis and atopic dermatitis and allergic rhinitis seem to predispose to foot mycosis. Recalcitrant mycosis should raise the question of diets high in carbohydrates. Nicotine abuse seems to protect against skin mycosis and colonization.

Increased Dental Use May Affect Changes in Treated and Untreated Dental Caries in Young Children.

INTRODUCTION: From 1999-2004 to 2011-2014, untreated dental caries prevalence decreased among US children aged 2 to 5 y, regardless of family income. Policies were concurrently initiated for children to increase access to preventive dental services in dental, primary, and community settings and to restorative care in dental settings. OBJECTIVES: We aimed to examine 1) whether changes in prevalence and severity of untreated and treated caries between the periods varied by family income and 2) to what degree increased past-year dental visit (PYDV) contributed to the changes. METHODS: We used data for 3,822 children in the National Health and Nutrition Examination Survey 1999 to 2004 and 2011 to 2014. Caries prevalence included prevalence of untreated caries with ≥1 decayed teeth (dt) and prevalence of treated caries with ≥1 filled teeth (ft). Caries severity included number of dt and ft among those with ≥1 dt or ft. We estimated changes in caries outcomes among low- and higher-income children with models-one controlling for sociodemographics and another controlling for sociodemographics and PYDV. Significant changes ( P < 0.05) becoming insignificant after controlling for PYDV provide insight on the contribution of PYDV to changes in outcomes. RESULTS: Prevalence of untreated caries decreased for low- and higher-income children, with a slightly larger decrease for low-income children; dt decreased only for low-income children; and estimated decreases did not vary by model. An increase in prevalence of treated caries was observed only among low-income children but became minimized and insignificant after controlling for PYDV. Similarly, after controlling for PYDV, the increase in ft among low-income children lost significance, whereas the increase among higher-income children remained. CONCLUSION: Untreated caries among children aged 2 to 5 y declined from 1999-2004 to 2011-2014, with larger declines among low-income children. While changes in PYDV contributed to increases in treated caries, particularly for low-income children, additional factors appear to have contributed to decreased untreated caries. KNOWLEDGE TRANSFER STATEMENT: For young children, the degree and direction of changes in caries over the last decade varied by outcome measure (e.g., untreated or treated) and family poverty status. Examining the effect of increased dental utilization on changes in untreated and treated caries outcomes can help identify those policies that contribute to changes in these outcomes and highlight the potential role of the different caries assessment criteria used in dental offices versus those in a population-based survey.

[Teledermatology for emergency patient care : Two-year experience with teledermatological emergency care]. / Teledermatologie zur notfallmedizinischen Patientenversorgung : Zweijahreserfahrungen mit teledermatologischer Notfallversorgung.

BACKGROUND: Internationally telemedicine has become an important element of health care. Up to now it plays, however, a minor role in the German health care system. Taking skin diseases as an example we examined over a 2­year period whether teledermatology is appropriate to care for patients presenting to the emergency department (ED) with symptomatic skin diseases. METHODS: During 2016 and 2017, 190 patients aged between 18 and 88 years with skin diseases who presented to the ED of the University Medicine Greifswald (UMG) were cared for by a core team consisting of surgeons who were supported by the on-call dermatologist of the UMG via teledermatology (mSkin Doctor®, InfoKom, Neubrandeburg, Germany). Patients presented nearly exclusively outside the regular working hours: 59% on weekends and public holidays, 39% after 4 p.m. on working days. Furthermore, 33% of patients came from rural areas (<10,000 inhabitants), 41% from regional centres or mid-sized centres. Patients travelled 23 km (median) from their homes to the emergency department. RESULTS: In all, 59 of the 190 patients immediately assessed the teledermatology-based care they received in the emergency department: 76% of the patients felt that they had received adequate care, 81% trusted the medical decisions. The teledermatologically based care outside normal working hours was deemed appropriate by 68% of the patients; 32% of the patients, however, wanted the dermatologist to be present at any time at day and night. CONCLUSION: Patients with skin diseases were cared for safely by the core team of the ED which was supported by the on-call dermatologist via teledermatology. The use of teledermatology within the context of emergency-based care has gained a high degree of patients' acceptance and confidence.

Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part II1.

BACKGROUND: Chronic venous disease (CVD) is extremely common worldwide with prevalence increasing with age. It is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. In this retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany a holistic evaluation of varicose vein surgeries has been undertaken. Part I covered postoperative complications in relation to co-morbidities, co-medication and clinical presentation. Part II of this article presents now the hemodynamic results in relation to the perioperative evolution of CVI specific symptoms. METHODS: Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed with regards to perioperative hemodynamics. Evolution of CVI symptomology was accessed postoperatively with the help of a questionnaire and patient records in the case of complication development. Venous hemodynamics was analysed in the whole patient population and with regards to complication subgroups: no events (NE), neglectable adverse events (NAE) and non-neglectable adverse events (NNAE). RESULTS: Postoperatively, patients' CVI-symptoms like pain (p < 0.001), swelling (p < 0.001) and itching (p = 0.003) significantly improved. The venous refill time and venous pump capacity improved significantly after open vein surgery (p < 0.05). Regardless of the development of postoperative complications there was a significant improvement of venous function at 6 weeks- and one-year postoperative in follow-up (p < 0.05). Symptom regression was strongly correlated with hemodynamic improvement. CONCLUSION: A significant improvement of patients' symptoms was achieved by means of open-surgery, regardless of postoperative complication development. This was in accordance with the improvement of venous hemodynamics. A strong correlation between symptom regression and improvement in venous hemodynamics could be proven.

[Evidence of compression therapy]. / Evidenz der Kompressionstherapie.

BACKGROUND: Medical compression therapy is widely used to treat phlebologic diseases. Compression bandages as well as compression stockings are used. Compression has been identified to be an effective conservative therapy for the healing of venous ulcers and other indications. Thus, the evidence for the use of medical compression therapy and for which indications is presented. MATERIALS AND METHODS: Review and systematic presentation of the evidence-based use of compression. The current literature, guidelines, and consensus statements were searched and the indications for compression therapy are presented. RESULTS: There is a high level of evidence that compression therapy is effective to heal venous ulcers and to prevent recurrent ulcers. The use of compression bandages and hosiery after interventional and surgical procedures for varicose veins is based on experience but not on randomized controlled trials. According to clinical experience, the healing of inflammatory skin diseases (e.g., erythema nodosum, pyoderma gangrenosum, necrobiosis lipoidica, cutaneous leukocytoclastic vasculitis, and psoriasis of the extremities) is supported by compression therapy. Compression therapy in patients suffering from venous ulcers is highly recommended.

Guidelines for the Treatment of Head Injury in Adults.

The workshop of scientific medical faculties (Arbeitsgemeinschaft wissenschaftlicher medizinischer Fakultäten [AWMF]) of Germany has asked societies of specific medical disciplines to jointly publish guidelines on the treatment of diseases and injuries. On behalf of the Deutsche Gesellschaft für Neurochirurgie, its commission on guidelines initiated an interdisciplinary approach to publish guidelines on the treatment of head injury in adults. These guidelines were published in German by the AWMF in late 2015. Because these guidelines have received widespread attention in Germany and became fundamental for research in head injuries, we have translated the German version into English to make it accessible to the international scientific community.

Treating onychomycosis with the short-pulsed 1064-nm-Nd:YAG laser: results of a prospective randomized controlled trial.

BACKGROUND: The role of the short-pulsed 1064-nm-Nd:YAG laser in treating onychomycosis has been the subject of controversial discussion ever since it received FDA approval in 2010. Research to date provides no valid conclusions supporting its use from an evidence-based perspective. OBJECTIVE: In this prospective randomized controlled pilot study, we analysed the effect of the short-pulsed 1064-nm-Nd:YAG laser on the rate of mycological remission and clinical improvement after excluding relevant confounders with regard to our previous studies. PATIENTS AND METHODS: Twenty patients with a total of 82 mycotic toenails were randomized to the treatment group (short-pulsed 1064-nm-Nd:YAG laser) or control group (no laser treatment). We conducted four laser treatments at 4- to 6-week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12 months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events. RESULTS: Mycological remission was not achieved in either study group. A comparison of both groups yielded no difference in the OSI score, both at the beginning of the trial (P = 0.9873) and after 12 months (P = 0.4317). In the treatment group, the OSI score worsened by a mean 2.0 points, and in the control group, by a mean 3.5 points. On a visual analogue scale (0 = 'no pain' to 10 = 'most intense pain'), pain in the treatment group was indicated at a mean score of five. Other adverse events were not reported. CONCLUSIONS: The short-pulsed 1064-nm-Nd:YAG laser shows no long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.

Antimicrobial efficacy of preoperative skin antisepsis and clonal relationship to postantiseptic skin-and-wound flora in patients undergoing clean orthopedic surgery.

Nosocomial surgical site infections (SSI) are still important complications in surgery. The underlying mechanisms are not fully understood. The aim of this study was to elucidate the possible role of skin flora surviving preoperative antisepsis as a possible cause of SSI. We conducted a two-phase prospective clinical trial in patients undergoing clean orthopedic surgery at a university trauma center in northern Germany. Quantitative swab samples were taken from pre- and postantiseptic skin and, additionally, from the wound base, wound margin, and the suture of 137 patients. Seventy-four patients during phase I and 63 during phase II were investigated. Microbial growth, species spectrum, and antibiotic susceptibility were analyzed. In phase two, the clonal relationship of strains was additionally analyzed. 18.0 % of the swab samples were positive for bacterial growth in the wound base, 24.5 % in the margin, and 27.3 % in the suture. Only 65.5 % of patients showed a 100 % reduction of the skin flora after antisepsis. The microbial spectrum in all postantiseptic samples was dominated by coagulase-negative staphylococci (CoNS). Clonally related staphylococci were detected in ten patients [nine CoNS, one methicillin-susceptible Staphylococcus aureus (MSSA)]. Six of ten patients were suspected of having transmitted identical clones from skin flora into the wound. Ethanol-based antisepsis results in unexpected high levels of skin flora, which can be transmitted into the wound during surgery causing yet unexplained SSI. Keeping with the concept of zero tolerance, further studies are needed in order to understand the origin of this flora to allow further reduction of SSI.

A 3D morphometric follow-up analysis after frontoorbital advancement in non-syndromic craniosynostosis.

OBJECTIVE: Frontoorbital advancement (FOA) in patients with non-syndromic craniosynostosis mainly addresses the aesthetic and functional correction of the frontoorbital region. To help define the operative strategy and any follow-up assessments after surgical correction, objective parameters describing the critical regions of skull deformity are essential. Based on 3D morphometric analysis, new parameters for the documentation of changes of the frontoorbital bandeau were developed in a prospective study. METHODS AND MATERIALS: In a prospective series, 13 children with non-syndromic craniosynostosis (seven metopic, four unilateral coronal, and two bilateral coronal) treated with frontoorbital advancement, underwent detailed morphometric and volumetric evaluation using a 3D light optical scan system (3D-Shape, Erlangen, Germany). Measurements were obtained preoperatively and at 3, 6 and 12 months postoperatively with newly developed parameters generated by cephalometric analysis software (Onyx Ceph, Image Instruments, Chemnitz, Germany). RESULTS: In most patients, frontoorbital advancement resulted in stable long-term results without growth inhibition and with normalization or improvement of ongoing skull development. The mean frontal angle was 145° and the frontoparietal angle 137-140°. The cephalic index was normalized or markedly improved. Head circumference and head height increased significantly (p = 0.001 and p = 0.002, respectively). These changes were confirmed in all postoperative measurements. CONCLUSION: During the 12-month follow-up period all angle parameters proved to be stable and no major impairment of normal skull growth was observed after FOA. The frontoorbital angle is a useful parameter in evaluating long-term outcome. The frontoparietal angle is important for the stability of the frontoparietal region, in which a certain growth inhibition may be observed postoperatively.