Less surgical site infections in neurosurgery during COVID-19 times-one potential benefit of the pandemic?

Hygiene measures were intensified when the COVID-19 pandemic began. Patient contacts were limited to a minimum. Visitors were either not allowed for a certain period or limited for the rest of the time. The hospital staff began to wear masks and gloves continuously. Clinical examinations and routine wound controls were also performed under intensified hygiene standards. These circumstances result in a limitation of direct physical interactions between the nursing staff, the physicians and the patients. We analyzed to what extent the intensification of hygiene measures affects the rate of surgical site infections (SSI) after neurosurgical procedures. The rate of SSI during the 6-month interval after the beginning of COVID-19 measures was compared with the SSI rate before. The numbers of the period before COVID-19 were analyzed as mean values resulting from the analysis of two separate time periods each consisting of 6 months. The spectrum of surgical procedures was compared. Patient-related risk factors for SSIs were noted. Microorganisms were analyzed. We focused on SSIs occurring at a maximum of 60 days after the primary surgery. Overall, in the two respective 6-month periods before COVID-19, a mean of 1379 patients was surgically treated in our institution. After the beginning of COVID-19 (starting from 04/2020) our surgical numbers dropped by 101, resulting in a total number of 1278 patients being operated after 03/2020 until 09/2020. The SSI rate was 3.6% (03/2019-09/2019, 50 SSIs) and 2.2% (09/2019-03/2020, 29 SSIs), resulting in a mean of 2.9% before COVID-19 began. After the beginning of COVID-19 hygiene measures, this rate dropped to 1.4% (16 SSIs) resembling a significant reduction (p=0.003). Risk factors for the development of SSI were present in 81.3% of all patients. Pre- and post-COVID-19 patient groups had similar baseline characteristics. The same holds true when comparing the percentage of cranial and spinal procedures pre- and post-COVID-19 (p=0.91). Comparing the numbers (p=0.28) and the species (p=0.85) of microorganisms (MO) causing SSI, we found a similar distribution. Despite equal demographics and characteristics of SSI, the rate of SSI dropped substantially. This argues for an effective reduction of postoperative SSI resulting from the implementation of strict hygiene measures being established after the beginning of the COVID-19 pandemic. We therefore advocate continuing with strict and intensive hygiene measures in the future.

In vitro performance of combinations of anti-siphon devices with differential pressure valves in relation to the spatial position.

BACKGROUND: Programmable differential pressure (DP) valves combined with an anti-siphon device (ASD) represent the current standard of care in preemtping overdrainage associated with ventriculoperitoneal shunting for hydrocephalus. OBJECTIVE: We aimed to provide comparative data of four combinations of two ASDs of different working principles in combination with two DP valves in an in vitro model in order to achieve a better understanding of the flow characteristics and potential clinical application. METHODS: We analyzed the flow performance of four possible combinations of two DP valves (CHPV [HM]; proGAV 2.0[PG]) in combination with either a gravity-regulated (Shuntassistant [SA]) or a flow-regulated (SiphonGuard [SG]) ASD in an in vitro setup. A DP between 4 and 60 cmH2O was generated, and the specific flow characteristics were measured. In addition, the two combinations with gravity-regulated ASDs were measured in defined spatial positions. RESULTS: Flow characteristics of the SA combinations corresponded to the DP in linear fashion and to the spatial position. Flow characteristics of the SG combinations were dependent upon the DP in a non-linear fashion and independent of the spatial position. Highest mean flow rate of the PG-SG- (HM-SG-) combination was 1.41 ± 0.24 ml/min (1.16 ± 0.06 ml/min). The mean flow rates sharply decreased with increasing inflow pressure and subsequently increased slowly up to 0.82 ± 0.26 ml/min (0.77 ± 0.08 ml/min). CONCLUSION: All tested device combinations were able to control hydrostatic effect and prevent consecutive excessive flow, to varying degrees. However, significant differences in flow characteristics can be seen, which might be relevant for their clinical application.

Prophylactic enlargement of the thecal sac volume by spinal expansion duroplasty in patients with unresectable malignant intramedullary tumors and metastases prior to radiotherapy.

Unresectable malignant intramedullary tumors and metastases usually require radiotherapy which intensifies spinal cord edema and might result in neurological decline. Spinal expansion duroplasty before radiotherapy enlarges the intrathecal volume and might thus prevent neurological deficits. The study aims to evaluate the clinical course of patients undergoing expansion duroplasty. This retrospective analysis (2007-2016) included all patients with unresectable intramedullary tumors who underwent spinal expansion duroplasty. To assess the degree of preoperative cord enlargement, we calculated the "diameter ratio": diameter of the spinal cord below and above the tumor / diameter of the tumor × 2. The presence of perimedullary cerebrospinal fluid (CSF) at the affected levels was analyzed on the preoperative magnetic resonance imaging (MRI). We recorded the occurrence of neurological deficits, wound breakdown, and CSF fistula. We screened 985 patients, 11 of which were included. Eight patients had an intramedullary metastasis, three patients a spinal malignant glioma. A diameter ratio ≤ 0.8 representing a significant preoperative intramedullary enlargement was seen in 10 cases (90.9%). Postoperative imaging was available in 9 patients, demonstrating successful decompression in 8 of the 9 patients (88.9%). The postoperative course was uneventful in 9 patients (81.8%). Mean overall survival was 13.4 (SD 16.2) months. Spinal expansion duroplasty prior to radiotherapy is a previously undescribed concept. Despite neoadjuvant radiation, no wound breakdown or CSF fistula occurred. In unresectable intramedullary tumors and metastases, spinal expansion duroplasty seems to be a safe procedure with the potential to prevent neurological decline due to radiation-induced cord swelling.

Multilevel Spinal Combined Subdural/Subarachnoid Hemorrhage Resulting in Paraplegia: An Unusual Complication of Kyphoplasty.

BACKGROUND: Paraplegia due to spinal combined subdural/subarachnoid hemorrhage is an extremely rare complication following percutaneous spinal augmentation procedures. METHODS: A 63-year-old male patient presented with severe neurologic decline (paraplegia with sensory and autonomic dysfunction) resulting from a multilevel spinal subarachnoid hemorrhage shortly after bilateral kyphoplasty. RESULTS: Reduction of intrathecal pressure via multiple dural and arachnoidal incisions and removal of the hematoma resulted in a good neurologic recovery with surgical decompression even though evacuation was performed with a significant delay after the onset of neurologic worsening. CONCLUSION: Spinal augmentation procedures should only be performed in a setting where management of complications can also be diagnosed and performed. Robot-assisted or navigation-assisted pedicle perforation should be considered because complications can be reduced significantly.

Assessing health-related quality of life in urology - a survey of 4500 German urologists.

BACKGROUND: Urological diseases and their treatment may negatively influence continence, potency, and health-related quality of life (HRQOL). Although current guidelines recommend HRQOL assessment in clinical urology, specific guidance on how to assess HRQOL is frequently absent. We evaluated whether and how urologists assess HRQOL and how they determine its practicality. METHODS: A random sample of 4500 (from 5200 identified German urologists) was drawn and invited to participate in a postal survey (an initial letter followed by one reminder after six weeks). The questionnaire included questions on whether and how HRQOL is assessed, general attitudes towards the concept of HRQOL, and socio-demographics. Due to the exploratory character of the study we produced mainly descriptive statistics. Chi2-tests and logistic regression were used for subgroup-analysis. RESULTS: 1557 urologists (85% male, with a mean age of 49 yrs.) participated. Most of them (87%) considered HRQOL assessment as 'important' in daily work, while only 7% reported not assessing HRQOL. Patients with prostate carcinoma, incontinence, pain, and benign prostate hyperplasia were the main target groups for HRQOL assessment. The primary aim of HRQOL assessment was to support treatment decisions, monitor patients, and produce a 'baseline measurement'. Two-thirds of urologists used questionnaires and interviews to evaluate HRQOL and one-quarter assessed HRQOL by asking: 'How are you?'. The main barriers to HRQOL assessment were anticipated questionnaire costs (77%), extensive questionnaire length (52%), and complex analysis (51%). CONCLUSIONS: The majority of German urologists assess HRQOL as part of their clinical routine. However, knowledge of HRQOL assessment, analysis, and interpretation seems to be limited in this group. Therefore, urologists may benefit from a targeted education program. TRIAL REGISTRATION: The clinical trial was registered with the code VfD_13_003629 at the German Healthcare Research Registry ( www.versorgungsforschung-deutschland.de ).

Posterior reversible encephalopathy syndrome presenting in the anterior circulation with malignant intracranial hypertension requiring surgical decompression: a case report and literature review.

Posterior reversible encephalopathy syndrome (PRES) is thought to result from endothelial dysfunction and breakdown of the blood-brain barrier with subsequent vasogenic edema. Abrupt hypertension has been identified as one of its risk factors. We present a rare case of PRES in the anterior circulation with sudden onset of left hemiparesis and rapid neurological deterioration on the basis of hypertensive crisis. Due to refractory intracranial hypertension, the patient required emergent right decompressive craniectomy. Further investigations, including a biopsy, revealed an atypical form of PRES. This case illustrates the importance of aggressive medical and early surgical management to prevent permanent neurological deficits.

Fast piezoelectric valve offering controlled gas injection in magnetically confined fusion plasmas for diagnostic and fuelling purposes.

In magnetically confined fusion plasmas controlled gas injection is crucial for plasma fuelling as well as for various diagnostic applications such as active spectroscopy. We present a new, versatile system for the injection of collimated thermal gas beams into a vacuum chamber. This system consists of a gas pressure chamber, sealed by a custom made piezo valve towards a small capillary for gas injection. The setup can directly be placed inside of the vacuum chamber of fusion devices as it is small and immune against high magnetic fields. This enables gas injection close to the plasma periphery with high duty cycles and fast switch on/off times ≲ 0.5 ms. In this work, we present the design details of this new injection system and a systematic characterization of the beam properties as well as the gas flowrates which can be accomplished. The thin and relatively short capillary yields a small divergence of the injected beam with a half opening angle of 20°. The gas box is designed for pre-fill pressures of 10 mbar up to 100 bars and makes a flowrate accessible from 1018 part/s up to 1023 part/s. It hence is a versatile system for both diagnostic as well as fuelling applications. The implementation of this system in ASDEX Upgrade will be described and its application for line ratio spectroscopy on helium will be demonstrated on a selected example.

Spring-driven high speed valve for massive gas injection in tokamaks.

A new high speed gas valve was developed for disruption mitigation studies in the tokamak ASDEX Upgrade. The valve was designed to operate inside the vacuum vessel to reduce the time of flight of the injected gas and to prevent dispersion of the gas cloud before the gas reaches the plasma. A spring-driven mechanism was chosen for the valve as it is robust against the high magnetic fields and electromagnetic disturbances inside the vessel. The internal gas reservoir (128 cm3) of the valve, which holds the mitigation gas, is opened within 1.5 ms, and the maximal stroke between the valve plate and nozzle (diameter 13 mm) is 4.5 mm. This allows a peak flow rate of 72 kPam3/s after 1 ms which was determined both analytically and numerically. The highest gas velocity (approximately 560 m/s) is reached 0.6 ms after the valve is opened. The gas cloud expands in a pear shape with an opening angle of 49°.

Efficacy and safety of durotomy after decompressive hemicraniectomy in traumatic brain injury.

Decompressive hemicraniectomy (DH) plus duroplasty was demonstrated to be effective for treating critically elevated intracranial pressure (ICP). In order to shorten operation time and to avoid the use of autologous or heterologous material, durotomy has been introduced as an alternative to duroplasty. Only limited data is available on the effect of DH and durotomy on the increased ICP in traumatic brain injury (TBI). Therefore, we collected consecutive intraoperative ICP readings during the different steps of DH and durotomy in TBI patients. Eighteen patients with TBI and uncontrollable ICP increase (measured by either an intraparenchymal or an intraventricular ICP probe) underwent DH and durotomy. ICP readings as well as mean arterial blood pressure (MAP) and arterial PCO2 were obtained during defined stages of the operation. Surgical complications of the durotomy itself and of cranioplasty after 3 months were recorded. The outcome was assessed prior to cranioplasty using the Glasgow Outcome Scale (GOS). ICP dropped significantly during surgery from a mean of 41 ( ± 16.2) mmHg at the beginning to a mean of 11.8 ( ± 7.5) mmHg at the end (p ≤ 0.001). A first significant ICP-decrease to a mean of 18 ( ± 10.8) mmHg (p ≤ 0.001) was detected after removal of the bone flap, and a second significant ICP-decrease to a mean of 10.6 ( ± 5.3) mmHg (p < 0.001) during durotomy. The mean operation time was 115.3 min ( ± 49.6). Five patients (28%) died; seven patients (39%) had a good outcome (GOS 5). There were no relevant complications associated to durotomy. Durotomy after DH is a safe and straightforward procedure, which significantly lowers critically increased ICP in patients with TBI. Although no graft is used, dural preparation for cranioplasty at 3 months is easily possible.

The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management.

Studies on immediate failed back surgery syndrome (iFBSS) following lumbar microdiscectomy are rare. Our aim is to describe the incidence and the causes of these immediate failures to define the value of radiological imaging for identification of the underlying pathology and to propose a management algorithm. We defined iFBSS as persistence, deterioration or recurrence (during hospital stay) of radicular pain and/or sensorimotor deficits and/or sphincter dysfunction after microdiscectomy, which was uneventful from the surgeon's perspective. The medical records of 1546 patients undergoing discectomy for mediolateral lumbar disc herniations were screened for iFBSS. The pre- and postoperative imaging, surgical records, therapy and outcome of patients with iFBSS were reviewed. Forty-four of 1546 patients (2.8%) with iFBSS were identified. All patients underwent reoperation. Overseen disc material/re-herniation (n = 22), epidural hematoma (n = 6), inadequate decompression of accompanying recessal stenosis (n = 2) and dural tear with fascicle herniation (n = 1) were found to be causative. In 13 patients, who revealed no clear pathology intraoperatively, we diagnosed a battered root syndrome (nerve root swelling due to excessive surgical manipulation). The correct diagnosis could be established by neuroradiological imaging in 25 of 43 radiologically investigated patients (57%). In our study, the radiological workup was of limited value for the correct differentiation of the various aetiologies of iFBSS. Therefore, the authors believe that the treatment strategy should strongly rely on the clinical presentation. To avoid unnecessary surgery in cases of battered root syndrome, we propose to proceed to reoperation only in patients with new or persistent radiculopathy despite adequate antiedematous medical therapy.

Immunohistochemical expression of receptor tyrosine kinase PDGFR-α, c-Met, and EGFR in skull base chordoma.

Chordomas are rare, locally aggressive malignancies that often exhibit an insidious natural history and are difficult to eradicate. Surgery and radiotherapy are the treatment mainstays of chordoma, but the chance of local recurrence remains high. Reports of receptor tyrosine kinase (RTK) expression in chordoma suggest that these tumors may respond to kinase inhibitor therapy. Currently, there are no effective chemotherapeutic protocols for chordoma. A tissue microarray containing 74 tumor specimens from primary chordoma patients and 71 from their recurrent tumors for a total of 145 tumor specimens was immunohistochemically analyzed for expression of a number of proteins involved in signal transduction from RTKs. Platelet-derived growth factor receptor-α (PDGFR-α), epidermal growth factor receptor (EGFR), c-Met, and CD-34 were detected in 100, 92, 100, and 59% of cases, respectively. PDGFR-α and c-Met staining was of moderate to strong intensity in all cases. In contrast, total EGFR staining was variable; weak staining was detected in 10 cases. Our results contribute to the understanding of the expression of RTKs in skull base chordomas and support the development of targeted therapies that inhibit RTKs, which may have a synergistic effect for chemotherapy in patients. There were statistically significant correlations between the expression of PDGFR-α, c-Met, and EGFR and disease-free survival. The results nonetheless suggest that chordomas may respond to RTK inhibitors or modulators of other downstream signaling.

The influence of skull base chordoma on lower urinary tract symptoms.

OBJECTIVE: To provide the first insights into the potential role of skull base chordoma, which causes brainstem compression in and around Barrington's nucleus and its effect on the micturition center. Chordoma is a rare malignant bone tumor that originates from the remnants of the embryonic notochord, which normally forms and dissolves during early fetal development. Although it is a slowly growing tumor, it displays local invasive growth. METHODS: Urodynamic testing of 22 symptomatic patients was performed. All women and men with skull base chordoma treated in 2 hospitals in Germany between 1986 and 2007 were studied. Follow-up periods ranged from 6 months to 10 years. Lower urinary tract symptoms were documented in patients with acute brainstem compression because of local chordoma growth. RESULTS: Of 74 patients treated, 22 (7 women, 15 men) with a median age of 37 years were evaluated with voiding diaries and computer urodynamic investigation. Urodynamic testing of 22 symptomatic patients revealed detrusor overactivity in 55%, low compliance bladder in 14%, detrusor-sphincter dyssynergia in 45%, and uninhibited sphincter relaxation in 27%. Despite the description of incomplete emptying and urgency, 4 patients had normal urodynamic findings (18%). Brain magnetic resonance images of the lesions of the symptomatic patients were obtained to determine the side of lesions. CONCLUSION: The dorsolateral pons, including pontine reticular nucleus and the reticular formation and the locus coeruleus, seems to be mainly responsible for lower urinary tract symptoms in our patients with skull base chordoma and brainstem compression.

Expression of vascular endothelial growth factor receptor 2 (VEGFR-2), inducible nitric oxide synthase (iNOS), and Ki-M1P in skull base chordoma: a series of 145 tumors.

Chordomas are locally invasive tumors that have a tendency to relapse despite optimal treatment. Specific biological markers might be used to describe their behavior. There is currently no agreement regarding the best way to manage intracranial chordomas. We studied the expression of vascular endothelial growth factor receptor 2 (VEGFR-2), inducible nitric oxide synthase (iNOS), and Ki-M1P in 145 paraffin-embedded tumors. The purpose of our study was to determine: (a) the role of potent angiogenic factors VEGFR-2 and iNOS and their relationship to each other in skull base chordoma and (b) the role of monocytes/macrophages as a potential iNOS source in the angiogenic process. A series of 74 chordoma patients for a total of 145 lesions (including 71 recurrent lesions) and 10 specimens from embryonic notochord were investigated for the expression of iNOS, VEGFR-2, Ki-M1P, and CD-34 using immunohistochemistry. In the majority of the chordomas, correlations were found between iNOS and the immunoreactivity of Ki-M1P (r = 0.5303, P < 0.0001). Furthermore, the expressions of Ki-M1P was correlated with VEGFR-2 (r = 0.4181, P < 0.0001). Our results indicate that chordomas may respond to receptor tyrosine kinase inhibitors such as VEGFR-2 or modulators of other downstream signaling molecules. The future of VEGFR-2 and iNOS inhibitors as therapeutic agents in the treatment of chordoma will be clearer over the next years as results of the current clinical trials become available and as the factors regulating angiogenesis and the interactions between these factors are elucidated. However, appropriate functional experiments remain to be conducted to prove such a hypothesis.

Cervical spinal canal stenosis and central disc herniation c3/4 in a man with primary complaint of thigh pain.

Purpose The purpose of this report is to describe the clinical course of a patient who had a primary complaint of isolated right lateral thigh pain 3 years prior that was nonresponsive to conservative measures. Hypoesthesia in the lateral side of the right forearm, deltoid and biceps, as well as triceps paresis, was also diagnosed. Results Immediately after surgery, the patient reported substantial improvement in his right thigh symptoms. The signs and symptoms associated with the right C6 and C7 radiculopathy did improve. Conclusion Although the presentation described in this case is somewhat unique, the eventual myelopathic signs and symptoms were not. It was these myelopathic signs and symptoms that led to cervical magnetic resonance imaging, the diagnosis of cervical cord compressive myelopathy, and surgical management.

Neurosurgical strategies and operative results in the treatment of tumors of or extending to the petrous apex.

BACKGROUND: Tumors originating from or involving the petrous apex are considered to be an operative challenge due to their deep location and close relationship to critical neural and vascular structures. Extensive skull base approaches have been developed to deal with these lesions. The purpose of this study is to review an institutional series of 57 petrous apex tumors, to report our operative experiences and to address the usefulness and limits of standard approaches. MATERIAL AND METHODS: 57 patients (22 men, 35 women) with petrous apex tumors were treated microsurgically. We analyzed the type of surgical approach, histological diagnoses, pre- and postoperative clinical findings, diagnostic imaging and surgery-associated complications. RESULTS: According to the location and its predominant extension, a retromastoid approach (n=27), subtemporal approach (n=18), subtemporal/anterosigmoid approach (n=5), transnasal-transsphenoidal approach (n=2), pterional approach (n=2) or a subtemporal/retrosigmoid approach, biphasic approach (subtemporal and pterional), transmastoidal approach (n=1 each) was chosen. In the majority of cases, histological analysis revealed a meningeoma (n=31) or neurinoma (n=7). A total tumor resection was accomplished in 37 patients (64.9%). New permanent neurological deficits, mainly cranial nerve palsies, were found in 18 (31.6%), transient deficits in 5 patients (9.6%). Postoperative improvements of neurological deficits were observed in 17 patients (29.8%), and the neurological status remained unchanged in 17 patients (32.7%). CONCLUSION: Complete resection of petrous apex tumors using standard neurosurgical approaches without permanent surgery-associated neurological deficits is achievable in the majority of cases.

Implementation of a critical incident reporting system in a neurosurgical department.

BACKGROUND: Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies. METHODS: All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety. RESULTS: Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09). CONCLUSIONS: Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments.

Paraganglioma of the filum terminale: review and report of the first case analyzed by CGH.

OBJECTIVE: As a rare tumor paraganglioma of the filum terminale is of diagnostic challenge. A thorough review of all published cases most often reveals a benign course if complete surgically resection is achieved. We report on the first molecular cytogenetic analyses performed on filum termiale paragangliomas. CLINICAL PRESENTATION: A 52-year-old man suffered from low back pain for many years that gradually worsened and was aggravated by sitting and bending. The pain radiated dorsally into both legs. Magnetic resonance imaging (MRI) with and without Gd-DTPA revealed a 12 mm sized, intradural oval mass at the level of L3 with slightly increased T2-signal and a rim of low signal on T2-weighted sequences. The tumor enhanced remarkably after Gd-DTPA. INTERVENTION: The patient underwent a left sided hemilaminectomy of L3. Durotomy revealed a well-delineated, firm and highly vascularized reddish tumor. The proximal terminal filum entered the tumor at the proximal pole and exited its distal pole. Coagulation and dissection of the terminal filum allowed in toto removal of the tumor. DNA was isolated from the formalin-fixed and paraffin-embedded specimen. The tumor was analyzed by comparative genomic hybridization, providing a normal DNA profile without any chromosomal copy number changes. CONCLUSION: The origin of paragangliomas of the CNS and especially of the filum terminale is still unclear. If no complete surgical resection can be achieved, molecular cytogenetic analysis is of additional value to prognostification of paragangliomas of the filum terminale.

Risk management in the treatment of malignant gliomas with BCNU wafer implants.

Implantation of BCNU wafers (Gliadel®) into the resection cavity has demonstrated a survival benefit for patients with newly diagnosed malignant gliomas. The follow-up of two phase III trails has further shown that the number of long-term survivors was significantly increased by BCNU wafer treatment. BCNU wafer implantation may be integrated into current multimodal first line strategies. In the setting of recurrent disease BCNU wafer implantation has also shown a survival benefit and now extends the treatment options in a patient population that typically has undergone extensive pretreatment. An analysis of the literature has helped to clearly identify the risks associated with topic BCNU treatment. Here we summarize the incidence and time course of adverse events associated with local chemotherapy and propose solutions. The growing body of experience with BCNU wafer implantation may serve as a basis to develop adequate risk management strategies with regard to patient selection, surgical techniques, and follow-up schedules.

Decrease in prostate cancer incidence and mortality in Germany - effects of opportunistic PSA screening or more?

BACKGROUND: An increasing incidence and controversial interpretations about the valuation of improved survival rates are the main subjects of the discussion dealing with the epidemiology of the prostate carcinoma. In this study the most recent data of the Cancer Registry Schleswig-Holstein (the northernmost state of Germany) are introduced. MATERIALS AND METHODS: Data from the population-based cancer registry covering a population of 2.8 million inhabitants were evaluated descriptively for the years 1999-2005. RESULTS: The frequency of more prognostic favourable diagnosis rose in the analyzed period. In 2000-2001, 62.9% of the patients were diagnosed with stage I/II and in 2004-2005 the percentage rose to 67.9%. From 1999 to 2003 the age-adjusted incidence increased by 30% and declined to the level of 1999 within 2 years. Mortality decreased continuously and from 1999 to 2005 it dropped by 20%. CONCLUSION: We assume that a selected group of men in Schleswig-Holstein has been screened regularly by PSA testing. The rise of incidence could be interpreted as a typical effect of a screening prevalence round. Thereafter the incidence declined because of the initial screening effect. However, it is not yet evident whether the PSA tests will have further effects on mortality rates.

Frontal sinus osteoma complicated by extended intracranial mucocele and cerebral abscess: neurosurgical strategy of a rare clinical entity.

The combination of paranasal sinus osteoma, mucocele and brain abscess is rare. Only one other case has been reported so far, where the cerebral abscess was diagnosed intraoperatively. We report here on a second patient with combined frontal sinus osteoma, intracerebral mucocele as well as cerebral abscess. However, in our case, the diagnosis of cerebral abscess was reached prior to surgery, which allowed for a tailored treatment strategy with abscess puncture under neuronavigational guidance and, after 3 weeks of antibiotic therapy with documented abscess shrinkage, osteoma and mucocele resection as well as reconstruction of the eroded dura.