Predictors of colonization with Staphylococcus species among patients scheduled for cardiac and orthopedic interventions at tertiary care hospitals in north-eastern Germany-a prevalence screening study.

As methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in humans are a global challenge. In Mecklenburg and Western Pomerania (Germany) 1,517 patients who underwent surgical interventions were systematically screened for MRSA and MSSA colonization on the day of hospital admission and discharge. Demographic data, risk factors and colonization status of the (i) nose, (ii) throat, (iii) groin, and (iv) thorax or site of surgical intervention were determined. Of the 1,433 patients who were included for further evaluation, 331 (23.1%) were colonized with MSSA, while only 17 (1.2%) were MRSA carriers on the day of hospital admission. A combination of nose, throat and groin swabs returned a detection rate of 98.3% for MSSA/MRSA. Trauma patients had lower prevalence of MRSA/MSSA (OR 0.524, 95% CI: 0.37-0.75; p < 0.001) than patients with intended orthopedic interventions. Males showed significantly higher nasal S. aureus carrier rates than females (odds ratio (OR) = 1.478; 95% CI: 1.14-1.92; p = 0.003). Nasal S. aureus colonization was less frequent among male smokers as compared to non-smokers (chi2 = 16.801; phi = 0.154; p < 0.001). Age, gender and smoking had a significant influence on S. aureus colonization. Combining at least three different swabbing sites should be considered for standard screening procedure to determine S. aureus colonization at patients scheduled for cardiac or orthopedic interventions at tertiary care hospitals.

Population-based study of the incidence of congenital hip dysplasia in preterm infants from the Survey of Neonates in Pomerania (SNiP).

BACKGROUND: Some etiological factors involved in developmental dysplasia of the hip (DDH) occur in the last trimester of pregnancy, which could result in a decreased incidence of DDH in preterm infants. The aim of this study was to compare the incidence of DDH between preterm and term infants. METHODS: Ultrasound of the hip joint was performed in 2,534 term infants and 376 preterm infants within the population-based Survey of Neonates in Pomerania (SNiP) study. RESULTS: A total of 42 (1.66%) term infants had DDH (Graf type II c, 0.8%; type D, 0.3% left and 0.4% right; type III a, 0.2% left). Eighteen infants had bilateral findings. Hip dysplasia occurred more frequently in female neonates (32/1,182 vs. 10/1,302, p < 0.023; 95% CI 0.012-0.022, χ 2 test). A familial disposition for DDH was found in 169 (6.7%) term infants and 181 (7.1%) infants in the overall population. In preterm infants, dysplasia of the hip was found in only three late preterm infants with gestational age between 36 and 37 weeks (n = 97) and not in preterm infants <36 weeks gestational age (n = 279). Regression analysis revealed a narrowly significant association between gestational week of birth and DDH (relative risk = 1.17; 95% confidence interval 0.99-1.37; p = 0.065). CONCLUSION: Our study suggests that preterm infants <36 weeks gestational age have a decreased risk of DDH.

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.

[Antibiotic prophylaxis in dermatologic and soft tissue surgery]. / Perioperative Antibiotikaprophylaxe bei Haut- und Weichteileingriffen.

In Germany, over half a million operations are done in dermatologic surgery in a hospital setting every year, as well as a less well quantified number of procedures in private offices. In spite of this large number, specific guidelines concerning the use of perioperative antibiotics in dermatologic surgery are sparse. In contrast to procedures in general, visceral or gynecological surgery, general guidelines on perioperative antibiotics issued by the Paul-Ehrlich Institutes and the AWMF do not specifically consider dermatologic operations. Several surveys indicate that familiarity with current recommendations on perioperative antibiotics is suboptimal and resulted in a considerable overuse of perioperative antibiotics in dermatologic surgery. Given the increasing antimicrobial resistance among important pathogens and the inherent risks of antibiotic administration, the decision for the use of prophylactic antibiotics should be based on the individual risk profile of the patient and of the surgical procedure. In the following, we will critically discuss the evidence for perioperative antibiotics in dermatologic surgery.

[Significance and prevention of post-operative wound complications]. / Bedeutung und Prävention postoperativer Wundkomplikationen.

Although surgical site infections (SSI) in dermatologic operative procedures are extremely rare, it is important to understand risks and etiological factors to initiate risk assessment and specific preventive measures. SSI commonly are associated with a complicated, long-term and expensive outcome. Typical wound pathogens of these infections include a variety of multiresistant organisms along with Staphylococcus aureus, Staphylococcus epidermidis, hemolytic streptococci and the gram-negative bacilli Escherichia coli and Pseudomonas aeruginosa. Effective hygienic measures as part of an adequate quality management system should consider the critical points in the development of SSI, particularly in the setting of an outpatient dermatologic unit, such as preparation of the operative area, preoperative skin antisepsis, hand hygiene, safe and skilled technique by surgeons, and barrier nursing to prevent spread of pathogens. The baseline infection incidence in dermatologic surgery inherently is low; nevertheless significant improvements can be achieved by implementation of risk-adapted infection control measures.

[Diagnosis and management of peripheral vascular injuries]. / Diagnostik und Management peripherer Gefäßverletzungen.

Peripheral vascular injuries are the cause of high morbidity in trauma patients. Up to 5 % of all patients with injuries of the extremities present with concomitant vascular lesions. While open peripheral vascular injuries are associated with a high mortality at the scene of the accident, closed vascular injuries present the danger of developing critical tissue ischemia with a high risk of amputation and limb loss. Early diagnosis is crucial in order to rapidly restore and maintain adequate blood flow and downstream tissue perfusion. A correct diagnosis and early treatment of peripheral vascular injuries place enormous demands on interdisciplinary teams consisting of emergency physicians, orthopedic surgeons, vascular surgeons, anesthesiologists and radiologists. The top priority in the context of emergency care is hemorrhage control by applying direct pressure and dressings until definitive surgical treatment. Hypovolemic shock, reperfusion injury and compartment syndrome are complications of peripheral vascular injuries that must be recognized and treated in the early stages.

[Open dislocation of the mobile bearing in a unicondylar knee arthroplasty. A rare complication]. / Offene Luxation der mobilen Plattform einer Schlittenprothese. Eine seltene Komplikation.

Unicompartmental knee arthroplasty can be viewed as a procedure with reliable medium- to long-term success. However, complications occur. To the authors' knowledge, this is the first report on an open dislocation of the tibial component (polyethylene plate) of a mobile bearing unicondylar knee prosthesis. Twelve days after a unicompartmental knee arthroplasty a 69-year-old patient suffered an open knee trauma due to a simple fall on the ground. The clinical examination showed wound dehiscence of the former mid-line approach, ventral dislocation of the polyethylene plate and a rupture of the anterior cruciate ligament. A pragmatic surgical treatment consisting of a jet lavage with saline solution, disinfection and relocation of the polyethylene plate and application of prophylactic antibiotics was performed. No peri- or postoperative complications were observed. The 6-month follow-up revealed a range of motion of 0-0-120° for extension-flexion and an isolated anterior instability. The patient was satisfied. This case report adds an uncommon and previously unpublished complication associated with unicompartmental knee arthroplasty. Surgical management in revision knee arthroplasty is challenging, although pragmatic approaches might be successful. Open dislocation of the bearing in a unicondylar knee prosthesis demands immediate revision. The manner of treatment depends on clinical findings and the surgeon's experience with arthroplasty.

[Pathologic fracture of the distal femur in total knee arthroplasty. Polyethylene-wear-induced osteolysis? A case report]. / Pathologische Fraktur des distalen Femurs bei Knie-TEP. Polyethylenabriebinduzierte Osteolyse? - ein Fallbericht.

Malignant bone tumors and osteitis of the distal femur are common at every age. These conditions must be considered in patients with total knee arthroplasty and suspicious x-rays. A patient with gross polyethylene-wear-induced osteolysis and periprosthetic fracture is described. Neoplasm and infectious granuloma were excluded through biopsy, and the bone defect was bridged with a rotating hinged distal femoral replacement.

Subinternship in Radiology - A Practical Start to the Specialization?

Purpose: To identify factors influencing medical students to choose radiology in the four-month clinical elective in the final year of medical school following radiology subinternships. Materials and Methods: A subsample of medical students in a nationwide German online survey evaluated a subinternship in radiology (19 items). They were divided into four groups: Students who could imagine doing a clinical elective in radiology in the practical year based on their experiences during the subinternship ("yes, based on subinternship"), students who could not ("no, based on subinternship") and students who had made this decision prior to the subinternship ("yes, prior to subinternship" and "no, prior to subinternship"). Results: 94 medical students evaluated a radiology subinternship (54.4 % females). Based on their experiences during the subinternship, 54 students (57.4 %) intended to do a final year clinical elective in radiology, 39 of them (41.5 %) being encouraged by the subinternship. 40 (42.6 %) reported having a negative attitude towards a clinical elective in radiology, 16 of them (17.0 %) having made this decision based on their subinternship experience. Groups did not differ regarding gender (p = 0.396) and age (p = 0.853). Students motivated to do a final year clinical elective in radiology experienced excellent academic teaching (p = 0.001) and practical involvement (p = 0.003), achieved their learning goals more often (p = 0.001), were better integrated into the team (p = 0.001), and acquired more practical skills (p = 0.003). Overall satisfaction was higher in these groups (p = 0.001). Conclusion: Satisfaction with a radiology subinternship is crucial for motivating medical students to do a final year clinical elective in radiology. A structured subinternship and continuous mentoring should be targeted to keep students connected to radiology. Key Points: • Radiology subinternships influence further interest in the specialization.• The quality and structure of teaching critically influence student satisfaction.• Team integration and practical involvement positively affect the attitude towards a specialization. Citation Format: • Kasch R, Wirkner J, Hosten N et al. Subinternship in Radiology - A Practical Start to the Specialization? Fortschr Röntgenstr 2016; 188: 1024 - 1030.

Genetic variability at the esterase-6 locus in natural populations of Drosophila simulans in relation to environmental heterogeneity.

The allozymic variation at at the esterase-6 locus examined in fourteen samples of natural populations of Drosophila simulans collected in two different localities. The samples were collected from different species of fruits in the two localities and from banana baits located some meters apart from the fruits. The analysis was done by sequential electrophoresis, using varied gel concentrations and buffers. By this technique, we detected 27 alleles at the esterase-6 locus, where only five alleles were detected by the usual method. The results obtained suggest that habitat choice alone may not be a selective factor, but may be selective in combination with other environmental factors.

[Infections Associated with Treatment with Hirudo medicinalis - Report of Two Cases and Review of the Literature]. / Infektionen im Zusammenhang mit der Anwendung von Hirudo medicinalis - Zwei Fallberichte und Literaturübersicht.

Medicinal leeches are well-established for promoting venous drainage in transplants/flaps and analgesia in osteoarthritis. Although medicinal leeches are bred and kept under controlled conditions, they are colonised by a genuine species-specific bacterial flora. Therapeutic application of leeches implies skin penetration carrying an a priori risk of infection. We report 2 cases with different indications for medicinal leech therapy. In both cases wound infection occurred in close temporal and spatial correlation or with evidence of a leech-associated germ that could be treated successfully. An unclarified complication rate warrants strict indications for the application of medicinal leeches. Preventive measures are currently tested.

Forebrain and midbrain astrocytes promote neuritogenesis in cultured chromaffin cells.

Adrenal chromaffin cells from immature or adult rats were grown in one of the following 'in vitro' conditions: (1) on coverslips placed on top of confluent, fetal, regional glia cultures; (2) in conditioned media from similar confluent cultures; (3) after direct seeding on top of such confluent cultures. Astroglia was obtained from cerebral cortex, septum, striatum and ventral mesen-cephalon from El6-17 pregnant-dated rats. All regions succesfully generated conditions for the early (less than 24 h) expression of neuritogenesis in about 15% of cells, which was more apparent in immature adrenal cell dissociates than in adult ones. The former grew long neurites compared with their adult counterparts. In addition to the known effects of glioma conditioned medium and isolated trophic factors described by other authors, it is concluded that adrenal chromaffin cells are responsive to the neuritogenic activity of (central) astroglial diffusible factor(s) in non-supplemented, defined culture media conditioned by astrocytes from various brain regions. Additionally, evidence is offered that adult chromaffin cells show a reduced responsiveness towards such astroglial factor(s). Possible implications for cell trasplantation chimeras are discussed.

In vitro induction of radial-like cells by leptomeningeal and cortical astroglial conditioned media. Effect of protease inhibitors.

A population of subcultured astroglia from rat fetal cortex was transformed into radial-like cells after exposure to cerebral cortex astroglial conditioned medium in vitro. Such changes were also induced by basal medium modified by fetal leptomeningeal subcultures, but not by postnatal leptomeninges nor by fetal skin fibroblasts. The radializing effects of astroglial conditioned medium were inhibited by previous heat treatment. The addition of protease inhibitors to the basal medium did not cause spontaneous radialization of subcultured cortical astroglia, but increased the length of cell processes and incidence of radial-like forms when added to cortical astroglial conditioned medium. It is concluded that cortical astroglia and leptomeningeal cells share the capability of synthesizing and releasing diffusible molecules into the culture medium which act as morphogenetic inducers in vitro. Based on the present results, it is suggested that such effects would depend on the presence of instructive factor(s) in the conditioned medium which are able to induce rearrangement of the cytoskeleton, rather than on secreted molecules able to modify cell adhesion to the substrate.

Heterochronous maturation of regional brain astroglia: neuronal modulation of striatal glial cells differentiation ex vivo.

Subcultured astroglial cells from striatum, cerebral cortex and ventral mesencephalon obtained from primary cultures of fetal (E14, E17 and E21) or postnatal (days 5-6) rats showed different regional, age-dependent morphological response (stellation) to cyclic AMP. While most of the cerebral cortex and ventral mesencephalic astroglial cell population was responsive at all ages tested, striatal cells at E14 and E17 were not. At age E21 striatal astroglia showed a significant shift toward a mature-like type of response to cyclic AMP. Postnatal striatal astroglia responded to cyclic AMP as the cortical and ventral mesencephalic astroglia did, with generalized stellation. Prenatal striatal astroglia was characterized immunocytochemically as A2B5+, fibronectin+, vimentin+, S-100+ and GFAP-. Failure of early prenatal (E14, E17) striatal astroglia to differentiate in response to cyclic AMP, was overcome by previous (5-7 days) co-culture with primary cell dissociates from postnatal-, but not from prenatal donors, from all brain regions tested including a non-target region for striatal cells, such as septum. This effect was duplicated when striatal astroglia was co-cultured with cell populations enriched in neurons through Percoll gradients. Only cell-to-cell contact co-cultures were able to induce a change in the studied response. Dead neuron-enriched populations obtained following various types of physical treatments were also able to change significantly striatal cell response toward cyclic AMP. Enriched astroglial populations from postnatal donors did not change striatal astroglial response toward cyclic AMP, except for ventral mesencephalic astroglia which induced a comparatively reduced but significant increase in striatal cell responsiveness. It is concluded that astroglial maturation and potential for phenotype expression during brain development proceeds with regional heterochrony. Also, that maturation of prenatal striatal astroglia responsiveness toward cyclic AMP is inducible by non-diffusible factors, probably of neuronal origin, expressed in live or dead primary cultures from various, homotopic and heterotopic, postnatal brain regions. It is further suggested that striatal afferents and/or mature local striatal neurons express membrane associated molecules that regulate responsiveness for phenotype expression of striatal glial cells, thus reinforcing the concept of a highly interactive, continuous neuron-glial developmental process that takes place during brain organization.

Leptomeningeal and skin fibroblasts: two different cell types?

Leptomeningeal and skin fetal (E16-17) fibroblasts were subcultured in vitro either in DMEM/F12 basal medium (with or without 10% FCS) or in astroglial conditioned medium (ACM). Both populations were characteristically composed of flat, undifferentiated, fibronectin(+), GFAP(-)cells where cultured in fetal serum supplemented basal media. When exposed to ACM leptomeningeal cells developed a population of thin, elongated, fibronectin(+) cells with radial type long processes while skin fibroblasts did not show significant changes in their characteristic morphotype. Exposure to db cAMP in basal medium resulted within 3 hr in their transformation to an astrocytic-like morphotype characterized by a condensed soma and multiple, short processes. Twenty-four hours later skin fibroblasts had returned to their flat appearance while leptomeningeal ones showed elongated, radial-like forms. Results indicate the possible existence of different receptors (to ACM factors) and/or cytoskeletal properties, and suggest that ACM-reactive fibroblasts of leptomeningeal origin represent a different cell type from those of skin origin. The hypothetical role of leptomeningeal cells during brain development is considered.

Regional differences in in vitro growth of neural cell processes during development.

Primary cell cultures from cerebral cortex, striatum and ventral mesencephalon obtained from rat fetal (embryonic day 17, E17) or postnatal (day 2, PN2) donors were grown either in media conditioned by subcultured astroglia from the same regions, an artificial trophic medium, normal human amniotic fluid, or in normal human cerebrospinal fluid. To estimate the presence of neuronal-like and non-neuronal cells, cell morphology and immunocytochemistry against microtubule-associated proteins and beta-tubulin were taken into consideration. The percentage of emitting neural cells and length of cell processes were determined after 24 hr in culture. Growth of cell processes in neuronal and non-neuronal cells from prenatal striatum was minimal compared with that in cerebral cortex and ventral mesencephalon, regardless of the culture condition. Nerve growth factor, basic fibroblast growth factor or epidermal growth factor did not significantly modify cell growth in E17 cultures, except for epidermal growth factor, which reduced the number of emitting cells in striatal cultures and increased it in cerebral cortex ones. Cultures derived from postnatal striatum showed a significant increase in neurite length when grown in an astroglial conditioned medium as compared to cultures derived from prenatal (E17) striatum. Results suggest significant regional differences in the brain regarding growth of cell processes at age E17, and reversal of striatal ability to grow cell processes by postnatal day 2. Reduced growth of cell processes showed by E17 striatum cultures was rather independent of the culture media. This fact could suggest that such early regional differences would depend on characteristics of sublineages present at this developmental stage, which would modulate the organization of regional neuropils. The restricted growth of cell processes in cultures from E17 striatum, no longer present in postnatal striatum, suggests that inputs to the striatum may modify expression of cell lineages at later stages of development.

Trophic influences of human and rat amniotic fluid on neural tube-derived rat fetal cells.

Normal human (week 17-20) and rat (E16-17) amniotic fluids were used as culture media for primary cultures of rat fetal (E 16) cortical, mesencephalic and striatal cell dissociates, or astroglial subcultures from the same brain regions. Phase-bright and dark cells were identified under phase contrast microscopy and their cell processes were measured utilizing semi-automated procedures. Subcultured astroglia were immuno-reacted against glial fibrillary acidic protein and fibronectin. Rat and human amniotic fluid allowed survival and growth of neuronal and non-neuronal cells. Human amniotic fluid samples were trophic in variable degrees. Cerebral cortex subcultured astroglia usually expressed a radial-like morphotype. Although charcoal-adsorbed human amniotic fluid was trophic for primary cultures, its ability to sustain neuritic growth depended on its degree of trophism before treatment. Growth of cell processes in neuronal- and glial-like cells in primary cultures was inhibited to different degrees by the addition of antisera towards nerve or epidermal growth factors. It is concluded that amniotic fluid constitutes a trophic medium for astroglia and neurons. Both, nerve and epidermal growth factors appear to be necessary for growth of cell processes in neuronal and glial primary cultures in amniotic fluid. Trophic effect of amniotic fluid on subcultured astroglia did not seem to be diminished by nerve growth factor antiserum. The role of amniotic fluid during the early phases of brain organogenesis is discussed.

Tissue printing of astroglial interlaminar processes from human and non-human primate cerebral cortex.

Astroglial interlaminar processes are unique features of the cerebral cortex of adult primates, including man. The functional role of these processes in the primate cerebral cortex is largely unknown. The development and standardization of procedures that could maximize the utilization of primate brain samples is required for the experimental analysis of the individual and collective dynamic properties of interlaminar glial processes. With this aim and in order to assess the relative stability of these glial processes in ex vivo conditions, "tissue printing" procedures were applied. "Tissue printing" allows for the acute transfer of cellular elements from fresh tissue onto an artificial substrate. Human, monkey (Cebus apella), and rat brain samples were subjected to "tissue printing" procedures followed by cell culture and immunohistochemistry. For the purpose of comparing the efficiency of this procedure on the transfer of other long glial processes, "tissue prints" of radial glial processes from neonatal rats and of Bergmann glia from cerebellar samples of adult rats were included. Nitrocellulose (with and without added fibronectin or laminin) produced the best attachment results. Interlaminar processes were not modified following 24-h incubation in a cell culture medium, with the addition of agents known to modify astroglial morphotypes in vitro (cyclic adenosine monophosphate, 40 mM K(+), or fetal calf serum). It is concluded that glia with interlaminar processes can be detached from fresh tissue using "tissue printing" procedures, can be maintained for at least 24 h in standard culture conditions, and showed a stable morphological phenotype.

"In vitro" effect of GM1 ganglioside on adrenal chromaffin cells.

Exposure of "in vitro" grown immature and adult adrenal chromaffin cells to concentrations of 10(-3) or 10(-5) M but not 10(-7) M GM1 ganglioside, resulted in significant increase in cell diameter, coupled with reduction of adhesion to substrate within 48 hrs of exposure. None of the GM1 concentrations, with or without serum supplementation, did significantly increase neuritogenesis in chromaffin cells. Immature chromaffin cells underwent neuritogenesis when grown in co-cultures with actively growing astroglia from striatum or cerebral cortex, an effect that was potentiated by NGF administration and blocked by anti-NGF. In neither of the former conditions did 10(-6) M GM1 prove to increase the number of neurite emitting cells nor their mean neuritic length further. It is speculated that GM1 does not perform the neuritogenic role described for central neurons in chromaffin cells, nor does it potentiate NGF effect on neuritogenesis observed in other peripheral neurons.