Mimicry of surgical site infection - Case report.

BACKGROUND CONTEXT: Calciphylaxis is a rare complication of secondary hyperparathyroidism caused by calcifications of small blood vessels in the skin and soft tissue. The disease occurs almost exclusively in patients with chronic kidney disease and has an incidence of approximately 50 cases per year in Germany [1]. PURPOSE: We present a case of a 61-year-old woman with calciphylaxis in connection with a primary knee endoprosthesis implantation. STUDY DESIGN: Case report. METHODS: A review of the medical records since the time of initial hospital admission throughout the entire hospitalization until the death of the patient was performed. RESULTS: Calciphylaxis caused severe soft tissue complications after total joint arthroplasty. Despite interdisciplinary therapy, including revision and plastic surgery as well as intensive care, the patient died 4 months after primary total knee arthroplasty due to septic multi-organ failure. CONCLUSION: Calciphylaxis may cause severe soft tissue complications after total joint arthroplasty and should be considered as potential differential diagnosis to surgical site infection. This is the first case report on calciphylaxis as direct complication of total joint replacement surgery.

[Epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients : Update 2017 of the interdisciplinary AWMF S3 guideline]. / Epidemiologie, Diagnostik, Therapie, Prävention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten : Aktualisierung 2017 der interdisziplinären AWMF S3­Leitlinie.

BACKGROUND: Update of the 2010 published evidence-based S3 guideline on epidemiology, diagnostics, therapy and management of uncomplicated, bacterial, outpatient-acquired urinary tract infections in adult patients. The guideline contains current evidence for the rational use of antimicrobial substances, avoidance of inappropriate use of certain antibiotic classes and development of resistance. METHODOLOGY: The update was created under the leadership of the German Association of Urology (DGU). A systematic literature search was conducted for the period 01 January 2008 to 31 December 2015. International guidelines have also been taken into account. Evidence level and risk of bias were used for quality review. RESULTS: Updated information on bacterial susceptibility, success, collateral damage and safety of first- and second-line antibiotics was given. For the treatment of uncomplicated cystitis the first line antibiotics are fosfomycin trometamol, nitrofurantoin, nitroxoline, pivmecillinam, trimethoprim (with consideration of the local resistance rates). Fluoroquinolones and cephalosporins should not be used as first choice antibiotics. In the case of uncomplicated pyelonephritis of mild to moderate forms, preferably cefpodoxime, ceftibuten, ciprofloxacin or levofloxacin should be used as oral antibiotics. CONCLUSION: The updated German S3 guideline provides comprehensive evidence- and consensus-based recommendations on epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients. Antibiotic stewardship aspects have significantly influenced the therapeutic recommendations. A broad implementation in all clinical practice settings is necessary to ensure a foresighted antibiotic policy and thus t improve clinical care.

[Hearing preservation: Better hearing with advanced technology]. / Hörerhaltende Cochlea-Implantation: Besser Hören mit neuer Technik.

Preservation of residual hearing after cochlear implantation allows patients the synergetic use of electric and acoustic stimulation (EAS). The application of specific surgical and therapeutic techniques enables the reduction of inner ear trauma, which leads otherwise to complete hearing loss. Due to simultaneous electric and acoustic stimulation, speech understanding is improved especially in noise. EAS is a well-accepted therapeutic treatment for subjects with profound hearing loss in the higher frequencies and no or mild hearing loss in the low frequencies. Several Manufacturers offer individual soft electrodes specially designed for hearing preservation as well as combined electric-acoustic audio processors.

Calcium-binding protein expression in peritoneal endometriosis-associated nerve fibres.

BACKGROUND: Recent studies demonstrated the potential involvement of nerve fibres in the chronic inflammatory process of endometriosis. We aimed to characterize nerve fibres in the proximal and distal areas of the peritoneal endometriotic lesions in order to understand the chronic inflammatory process in endometriosis. METHODS: Peritoneal endometriotic lesions (proximal area) (n = 17), the matching unaffected peritoneum (distal area) and healthy peritoneum of patients without endometriosis (n = 15) were analysed with the neuronal markers PGP 9.5, calbindin, calretinin and parvalbumin. Peritoneal fluids of women with and without endometriosis were used for Western blot analysis and for the neuronal growth assay. The protein expression of neuronal PC-12 cells incubated with peritoneal fluids was analysed. RESULTS: The overall nerve fibre density was significantly reduced in the distal area of the lesion when compared with the proximal area or with healthy peritoneum. The density of calbindin-, calretinin- and parvalbumin-positive nerve fibres was significantly increased in the endometriosis group. Calretinin expression was elevated in the peritoneal fluid of women with symptomatic endometriosis when compared with women with asymptomatic endometriosis. Furthermore, PC-12 cells incubated with peritoneal fluid of women with endometriosis showed a higher proliferation rate and a stronger neurite outgrowth than the control group. PC-12 cells incubated in peritoneal fluids of women with endometriosis expressed less calretinin but more calbindin than the control group. CONCLUSIONS: Calcium-binding proteins seem to be increased in endometriosis-associated nerve fibres and might play an important role in the chronic inflammatory condition and the pain pathogenesis of endometriosis.

Diagnosis and inflammatory response of patients with candiduria.

Candiduria is common in hospitalised patients, but the clinical relevance is still unclear. This study was done to further our knowledge on detection of and host responses to candiduria. Urines and clinical data from 136 patients in whom presence of yeast was diagnosed by microscopic urinalysis were collected. Diagnosis by standard urine culture methods on blood and MacConkey agar as well as on fungal culture medium (Sabouraud dextrose agar) was compared. Inflammatory parameters (IL-6 and IL-17, Ig) were quantified in the urine and compared with levels in control patients without candiduria. Standard urine culture methods detected only 37% of Candida spp. in urine. Sensitivity was especially low (23%) for C. glabrata and was independent of fungal burden. Candida specific IgG but not IgA was significantly elevated when compared with control patients (P < 0.0001 and 0.07 respectively). In addition, urine levels of IL-6 and IL-17 were significantly higher in candiduric patients when compared with control patients (P < 0.001). Multivariate analysis documented an independent association between an increased IgG (odds ratio (OR) 136.0, 95% confidence interval (CI) 25.7-719.2; P < 0.0001), an increased IL-17 (OR 17.4, 95% CI 5.3-57.0; P < 0.0001) and an increased IL-6 level (OR 4.9, 95% CI 1.9-12.4; P = 0.001) and candiduria. In summary, our data indicate that clinical studies on candiduria should include fungal urine culture and that inflammatory parameters may be helpful to identify patients with clinically relevant candiduria.

[Cochlear implantation: a changing indication]. / Cochleaimplantatversorgung: Indikation im Wandel.

In recent years the indication criteria for cochlear implantation (CI) have changed. To gain optimal benefits, early implantation in prelingually deaf children is necessary. Even additional disabilities are no longer contraindications for CI. Nowadays the criteria for implantation not only include deafness but also residual hearing. Combined electric-acoustic stimulation has been established as a treatment option in patients with hearing still functioning in the low frequencies. Due to the benefits of binaural hearing, bilateral CI has become standard over the last decade. Recent experience has shown the benefits of CI in unilateral deafness and in cases of severe tinnitus. The actual benefit of CI shows great inter-individual differences. We usually expect (re-)habilitation of language communication skills with implantation.

Music perception in electric acoustic stimulation users as assessed by the Mu.S.I.C. test.

AIMS: This study compared the music perception abilities of 13 electric acoustic stimulation (EAS) users with two control groups: unilateral cochlear implant (CI) users and normal-hearing (NH) listeners. METHODS: Groups were matched according to age and musical experience before hearing loss (HL) and tested using the Musical Sounds in Cochlear Implants (Mu.S.I.C.) test. RESULTS: No difference was found on rhythm perception, chord discrimination, dissonance rating, and emotion rating subtest performance between groups. Mean frequency discrimination scores were significantly better in EAS participants than in CI participants and not significantly worse than in NH participants. However, the EAS and CI groups scored similarly (significantly worse than NH participants) on both instrument detection and identification. Results for EAS participants were not significantly worse when the hearing aid component was removed. Frequency of listening to music before HL was negatively correlated with EAS participants' frequency discrimination scores, though singing and playing an instrument appeared to have no effect. EAS participants who indicated many reasons for listening to music and who listen to many genres after implantation scored higher on instrument detection and instrument identification. Better results on these two subtests were correlated with EAS participants' better postoperative auditory thresholds at 250 and 500 Hz. CONCLUSIONS: Though EAS participants performed better on music perception testing (though not timbre-based tasks) than CI participants, their scores did not reach the level of NH participants. This indicates that acoustic hearing in the low frequencies is helpful for music perception, though not the only important factor.

[Hearing with combined electric acoustic stimulation]. / Hören mit kombinierter elektrischer und akustischer Stimulation.

After cochlear implantation, individuals with sufficient residual hearing in the lower frequency region are able to successfully combine acoustic and electrical stimulation patterns to improve speech perception, especially in noise, and to improve music appraisal as well. These improvements occur through enhanced transmission of fine structure information by more accurate mapping of the fundamental frequency contour through acoustic hearing. In current cochlear implant systems, the transfer of frequency and melodic contour is very coarse, and the correct detection of pitch contour requires large frequency differences. It is assumed that the acoustically transferred part of the signal enables the cochlear implant recipient to better segregate between speech signals and interfering sounds. The detection and following of a speech signal emitted by a single talker in a multitalker babble situation is improved when fundamental frequencies as grouping cues are present. The preservation of hearing in the implanted ear must be considered a major surgical challenge. The development of very flexible and soft electrode carriers in combination with surgical approaches that minimally traumatize the inner ear enable hearing preservation in nearly all cases.

Error analysis for determination of accuracy of an ultrasound navigation system for head and neck surgery.

OBJECTIVE: The use of conventional CT- or MRI-based navigation systems for head and neck surgery is unsatisfactory due to tissue shift. Moreover, changes occurring during surgical procedures cannot be visualized. To overcome these drawbacks, we developed a novel ultrasound-guided navigation system for head and neck surgery. A comprehensive error analysis was undertaken to determine the accuracy of this new system. MATERIALS AND METHODS: The evaluation of the system accuracy was essentially based on the method of error definition for well-established fiducial marker registration methods (point-pair matching) as used in, for example, CT- or MRI-based navigation. This method was modified in accordance with the specific requirements of ultrasound-guided navigation. The Fiducial Localization Error (FLE), Fiducial Registration Error (FRE) and Target Registration Error (TRE) were determined. RESULTS: In our navigation system, the real error (the TRE actually measured) did not exceed a volume of 1.58 mm(3) with a probability of 0.9. A mean value of 0.8 mm (standard deviation: 0.25 mm) was found for the FRE. The quality of the coordinate tracking system (Polaris localizer) could be defined with an FLE of 0.4 +/- 0.11 mm (mean +/- standard deviation). The quality of the coordinates of the crosshairs of the phantom was determined with a deviation of 0.5 mm (standard deviation: 0.07 mm). CONCLUSION: The results demonstrate that our newly developed ultrasound-guided navigation system shows only very small system deviations and therefore provides very accurate data for practical applications.

[Navigation-assisted sonography for soft tissues in the head and neck region]. / Navigationsunterstützte Weichteilsonographie für den Kopf-Hals-Bereich.

BACKGROUND: In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized. METHODS: A novel navigation device for sonography of soft tissues was developed. This consists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable. RESULTS: The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate. CONCLUSION: This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues.

Navigation-supported and sonographically-controlled fine-needle puncture in soft tissues of the neck.

In surgery, sonography has been a well-accepted means of orientation for years. The immediate vicinity of many vital structures in the head and neck region calls for a very exact visualization of the surgical instrument in the 2-D ultrasonic picture. We report on the development of a new method for navigation-supported and sonographically-controlled fine-needle puncture in soft tissues of the neck. Our system comprises a navigated ultrasound probe, a navigated fine-puncture needle and a coordinate sensor. A personal computer with specially-developed software assists calibration and surgical application. The applicability test for the system is described. In vitro, a model lymph node of 9 mm in diameter had been hit. It is shown that the target structure can be aimed at very precisely by the navigated puncture needle. An accuracy of 97% and a specificity of 99% could be demonstrated. The development of a very precise and easy-to-handle method for navigation-supported fine-needle puncture in the neck region is presented. The outstanding advantage of this method is that no rigid reference gadget fixed to the patient's body is necessary. That makes this method very suitable for surgery in the neck region. Contrary to other sonographically-supported navigation methods in the head and neck region, preoperative imaging (CT or MRT) is dispensable.

[Quality management: reduced waiting time and enhanced efficiency in a university ear, nose, and throat outpatient department]. / Qualitätsmanagement: Verkürzung von Wartezeiten und Effizienzsteigerung bei der Versorgung ambulanter Patienten an einer HNO-Universitätsklinik.

BACKGROUND: The introduction of Diagnosis-Related Groups, which standardize payment for each clinical service, entails keeping the inpatient treatment as short as possible. Thus outpatient treatment is gaining in importance. To cope with this change, organizational and structural modifications of clinic routine are necessary. METHODS: In the ear, nose, and throat outpatient clinic of Johann Wolfgang Goethe University in Frankfurt, Germany, a hotline was established that allows patients to make appointments and get advice based on quality management guidelines according to DIN EN ISO 9001:2000. The development of this project is described here step by step, from planning to inclusion in the daily clinic routine. RESULTS: Patient visits became more effective despite increasing demand. This resulted in high satisfaction of patients and clinic personnel alike. CONCLUSION: This model may contribute considerably to coping with the increasing demand for clinic appointments and to optimal use of a clinic's human resources.

[Quality assessment according to DIN EN ISO 9001:2000: certification in a university ENT department]. / Qualitätsmanagement nach DIN EN ISO 9001:2000: Zertifizierung einer HNO-Universitätsklinik.

BACKGROUND: In 2003, our department inaugurated a quality management system. The certification according to DIN EN ISO 9001:2000 as required by the hospital management was achieved in August 2005. The aims were optimization of internal operating schedules and standardization of procedures according to logistic interfaces with external structures. METHODS: Since 2000, the implementation of an internal quality management system is required by German law and threatened by penalty in case of non-implementation. Beside a basic audit and optimization of all organizational procedures, all core processes were determined and the approvals checked. These aims involve both the quality of operational procedures, in and outpatient treatment, research, study and teaching and aspects of service such as quickness of scheduling and forwarding of reports as well as economic aspects and efficiency. The department of "quality management", whose main tasks are the professional guidance and the training of the quality management representatives, plays an important role. RESULTS: Realization of the new regulations and restructuring resulted in an increase in effectiveness and an improvement in operational procedures. In particular, patients and staff have benefited from the reorganized and modified sequence of operations. CONCLUSION: Implementation of a quality management system in different hospital departments is recommended.

[Rare cause of long QT and resuscitation-requiring torsade de pointes tachycardia]. / Seltene Ursache einer Prolongierung der QT-Zeit und reanimationspflichtigen Torsade-de-pointes-Tachykardie.

A 62 year old patient underwent an intraoperative pancreas biopsy because of a pancreas head process. On 13(th) and 20(th) postoperative day a short syncope episode occurred. On that days calcium blood levels were 1,82 and 1,74 mmol/l, respectively. On 13(th) postoperative day QT(c) interval was 565 ms. On 26(th) postoperative day the patient was resuscitated because of torsade de pointes tachycardia. His actual calcium blood level was 1,47 mmol/l and QT(c) interval 627 ms. An extensive diagnostic work-up revealed no evidence of cardiac disease. After calcium substitution QT interval normalised. During a follow-up period of 16 months the patient remained without symptoms.

Radiofrequency energy modification of the atrioventricular junction in patients with atrial fibrillation: modes of ventricular response under autonomic blockade and long-term effect.

The short- and long-term effect of radiofrequency (RF) modification of the AV junction on ventricular rate and left ventricular function and the different types of ventricular response during energy application under autonomic nervous blockade were assessed in 28 patients with medically refractory atrial fibrillation. During the successful RF application, ventricular rate slowed progressively (type I response, ten patients) or accelerated at first and then slowed (type II response, 11 patients). Type II response was associated with a more anterior ablation site compared to Type I response. A primary successful outcome was achieved in 21 patients. Inadvertent complete AV block developed in three patients, while in four patients AV nodal ablation was performed after an unsuccessful modification attempt. During 6-month follow-up, the ventricular rate was adequately controlled in only four patients. Among the 16 patients with a recurrence of uncontrolled AF were all 10 patients with type I response and 6 of 11 patients with type II response. One patient died suddenly 10 weeks after the procedure.