Introducing an innovative surgical technique: gluteal turnover flap for posterior vaginal wall reconstruction: a case series.

Four patients with rectal cancer required reconstruction of a defect of the posterior vaginal wall. All patients received neoadjuvant (chemo)radiotherapy, followed by an en bloc (abdomino)perineal resection of the rectum and posterior vaginal wall. The extent of the vaginal defect necessitated closure using a tissue flap with skin island. The gluteal turnover flap was used for this purpose as an alternative to conventional more invasive myocutaneous flaps (gracilis, gluteus, or rectus abdominis). The gluteal turnover flap was created through a curved incision at a maximum width of 2.5 cm from the edge of the perineal wound, thereby creating a half-moon shape skin island. The subcutaneous fat was dissected toward the gluteal muscle, and the gluteal fascia was incised. Thereafter, the flap was rotated into the defect and the skin island was sutured into the vaginal wall defect. The contralateral subcutaneous fat was mobilized for perineal closure in the midline, after which no donor site was visible.The duration of surgery varied from 77 to 392 min, and the hospital stay ranged between 3 and 16 days. A perineal wound dehiscence occurred in two patients, requiring an additional VY gluteal plasty in one patient. Complete vaginal and perineal wound healing was achieved in all patients. The gluteal turnover flap is a promising least invasive technique to reconstruct posterior vaginal wall defects after abdominoperineal resection for rectal cancer.

Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital - cross-sectional results of the intersec-CM study.

BACKGROUND: Cognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care. METHODS: The analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs. RESULTS: The sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment. CONCLUSIONS: Descriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care. TRIAL REGISTRATION: The intersec-CM trial is registered at ClinicalTrials.gov ( NCT03359408 ).

[Potentials and limits of aging cohort studies for geriatric psychiatry]. / Potenziale und Grenzen von Alternskohortenstudien für die Gerontopsychiatrie.

The sizeable number of population-based cohort studies of aging in Germany have provided highly valuable contributions for the specification of risk factors and predictors for frequent mental disorders in old age, especially dementia and depression. The results from these cohort studies enable the specification of mechanisms for the development of and preventative interventions for common mental disorders in old age. On the other hand, there is a significant paucity of clinical cohort studies investigating disease trajectories and possible markers for specific individualized interventions of frequent mental disorders in old age. In this article, we report selected key findings from cohort studies of aging and discuss novel approaches for the integration and harmonization of population-based and clinical cohort studies.

[Discharge management in German hospitals for cognitively impaired, older people-a scoping review]. / Das Entlassmanagement deutscher Krankenhäuser für kognitiv beeinträchtigte, ältere Menschen ­ ein Scoping Review.

BACKGROUND: In German hospitals approximately 40% of all patients over the age of 65 years are cognitively impaired (MmkB). After discharge from hospital it is particularly important for MmkB that the transition to domestic life is organized as seamlessly and as well-coordinated as possible. OBJECTIVE: The aim of the study was to determine the existing evidence on discharge management (EM) in MmkB and people with dementia (MmD). Furthermore, the study examined the necessity of an intersectoral concept for MmkB. MATERIAL AND METHODS: Based on a scoping review a total of 102 publications were identified, of which 6 articles were finally used for the evaluation. RESULTS: The article provides an overview of the current care of MmkB in acute care hospitals in Germany. General information on EM in hospitals was given in three of the six publications included. Information on special discharge and care management for MmkB and MmD was contained in five out of six papers. DISCUSSION: The article illustrates significant gaps in the hospital care for older MmkB, in particular at the interface of discharge management and demonstrates the need for new care models. To what extent these new care models can be structurally, procedurally and systemically embedded in the standard care and financed, is an open and unexplored question.

Consensus and variations in opinions on delirium care: a survey of European delirium specialists.

BACKGROUND: There are still substantial uncertainties over best practice in delirium care. The European Delirium Association (EDA) conducted a survey of its members and other interested parties on various aspects of delirium care. METHODS: The invitation to participate in the online survey was distributed among the EDA membership. The survey covered assessment, treatment of hyperactive and hypoactive delirium, and organizational management. RESULTS: A total of 200 responses were collected (United Kingdom 28.6%, Netherlands 25.3%, Italy 15%, Switzerland 9.7%, Germany 7.1%, Spain 3.8%, Portugal 2.5%, Ireland 2.5%, Sweden 0.6%, Denmark 0.6%, Austria 0.6%, and others 3.2%). Most of the responders were doctors (80%), working in geriatrics (45%) or internal medicine (14%). Ninety-two per cent of the responders assessed patients for delirium daily. The most commonly used assessment tools were the Confusion Assessment Method (52%) and the Delirium Observation Screening Scale (30%). The first-line choice in the management of hyperactive delirium was a combination of non-pharmacological and pharmacological approaches (61%). Conversely, non-pharmacological management was the first-line choice in hypoactive delirium (67%). Delirium awareness (34%), knowledge (33%), and lack of education (13%) were the most commonly reported barriers to improving the detection of delirium. Interestingly, 63% of the responders referred patients after an episode of delirium to a follow-up clinic. CONCLUSIONS: This is the first systematic survey involving an international group of specialists in delirium. Several areas of lack of consensus were found. These results emphasise the importance of further research to improve care of this major unmet medical need.

Effect of combined ultrasound and microbubbles treatment in an experimental model of cerebral ischemia.

Combined 2-MHz ultrasound (US) and second-generation, sulfur hexafluoride microbubbles (MB) treatment (US+MB) was performed in a permanent middle cerebral artery (MCA) occlusion model in rats to evaluate possible effects on the ischemic cascade. We used 16 Wistar rats and the MCA occlusion model for stroke induction. Glutamate, pyruvate, lactate and glycerol levels were measured by intracerebral microdialysis before and after stroke induction and after US+MB application (n = 8) for 20 h. After 24 h, brain infarct volume, apoptosis and IL-6 and TNF-alpha levels were evaluated. The infarct volume was significantly reduced (p < 0.05) in the US+MB-treated group compared with control animals. In additional, glutamate levels were significantly lower in US+MB-treated animals, and these animals showed a higher rate of apoptotic cell death in the infarcted area. The levels of IL-6 and TNF-alpha concentrations were not different in both groups, and there was no apoptotic cell death outside the infarction in animals treated with US+MB. The results demonstrate that US+MB with second generation microbubbles does not have a harmful effect on ischemic stroke in an MCA occlusion model of the rat.

Inflammatory cytokines in subarachnoid haemorrhage: association with abnormal blood flow velocities in basal cerebral arteries.

Subarachnoidal release of inflammatory cytokines (interleukin (IL)-1beta, IL-6, and tumour necrosis factor (TNF)-alpha) was characterised in 35 patients with subarachnoid haemorrhage (SAH) and control subjects and compared with development of complicating haemodynamic abnormalities in basal cerebral arteries and clinical outcome. Serial analysis allowed the observation of a subacute response profile of these key mediators of inflammation in the subarachnoidal space. This compartmentalised inflammatory host response was closely associated in time and extent with development of increased blood flow velocities in the basal cerebral vessels as recorded by transcranial Doppler sonography. Moreover, intrathecal secretion of inflammatory cytokines was significantly increased in patients with poor clinical outcome. Together, these findings suggest a role of excessive compartmentalised inflammatory host response in pathogenesis of cerebrovascular complications after SAH.