Early indicators of high disease severity in imported falciparum malaria and their implications for supportive therapy.

BACKGROUND & OBJECTIVES: In imported falciparum malaria various life-threatening complications involving multiple organ systems can ensue rapidly and unpredictably. Early recognition of high disease severity is mandatory to provide optimal care, thereby reducing mortality. However, validated tools allowing precise assessment of disease severity are unavailable for imported malaria. This study aimed to identify indicators of high disease severity apparent on admission. METHODS: Fifty-four adult cases of severe imported falciparum malaria treated between 2001 and 2015 on various intensive care units of the Charité University Hospital, Berlin, were retrospectively grouped according to their admission coma-acidosis malaria (CAM) score. The association of sociodemographic and clinical parameters with disease severity was assessed by multivariable logistic regression. RESULTS: Nineteen female (35%) and 35 male (65%) patients (median age: 44 years) were enrolled. The admission CAM score was 0 in n=24, 1 in n=15, 2 in n=10, 3 in n=3, and 4 in n=2 subjects. Thus, 5 patients (9.3%) had a predicted mortality risk of >20%. Higher maximum heart rates (p=0.002), lower baseline haematocrit (p<0.001), increased oxygen demand (p<0.001), and infiltrates on the admission chest X-ray (p=0.019) were independently associated with higher disease severity in multivariable analysis. INTERPRETATION & CONCLUSION: In addition to the prognostic key parameters metabolic acidosis and impaired consciousness reflected by the CAM score, symptoms of respiratory distress and shock as well as profound anaemia help identify patients with highest disease severity. These indicators may guide clinicians to prompt targeted interventions at the earliest possible stage and may thus help improving survival.

Hypertension is associated with an increased risk for severe imported falciparum malaria: a tertiary care hospital based observational study from Berlin, Germany.

BACKGROUND: Increasing numbers of aging individuals with chronic co-morbidities travel to regions where falciparum malaria is endemic. Non-communicable diseases are now leading risk factors for death in such countries. Thus, the influence of chronic diseases on the outcome of falciparum malaria is an issue of major importance. Aim of the present study was to assess whether non-communicable diseases increase the risk for severe imported falciparum malaria. METHODS: A retrospective observational study of all adult cases with imported falciparum malaria hospitalized between 2001 and 2015 in the tertiary care Charité University Hospital, Berlin, was performed. RESULTS: A total of 536 adult patients (median age 37 years; 31.3% female) were enrolled. Of these, 329 (61.4%) originated from endemic countries, 207 patients (38.6%) from non-endemic regions. Criteria for severe malaria were fulfilled in 68 (12.7%) cases. With older age, lack of previous malaria episodes, being a tourist, and delayed presentation, well-characterized risk factors were associated with severe malaria in univariate analysis. After adjustment for these potential confounders hypertension (adjusted odds ratio aOR, 3.06 95% confidence interval, CI 1.34-7.02), cardiovascular diseases (aOR, 8.20 95% CI 2.30-29.22), and dyslipidaemia (aOR, 6.08 95% CI 1.13-32.88) were individual diseases associated with severe disease in multivariable logistic regression. Hypertension proved an independent risk factor among individuals of endemic (aOR, 4.83, 95% CI 1.44-16.22) as well as of non-endemic origin (aOR, 3.60 95% CI 1.05-12.35). CONCLUSIONS: In imported falciparum malaria hypertension and its related diseases are risk factors for severe disease.

Classification of common variable immunodeficiencies using flow cytometry and a memory B-cell functionality assay.

BACKGROUND: The population of patients with common variable immunodeficiency (CVID) comprises a heterogeneous group of patients with different causes of hypogammaglobulinemia predisposing to recurrent infections, higher incidence of autoimmunity, and malignancy. Although memory B cells (memBcs) are key players in humoral defense and their numbers are commonly reduced in these patients, their functionality is not part of any current classification. OBJECTIVE: We established and validated a memBc enzyme-linked immunosorbent spot (ELISpot) assay that reveals the capacity of memBcs to develop into antibody-secreting cells and present an idea for a new classification based on this functional capacity. METHODS: The memBc ELISpot assay, combined with flow cytometry, was applied to patients with confirmed CVID in comparison with age-matched healthy control subjects. RESULTS: Ex vivo frequency of IgG-, IgM-, and IgA-secreting plasmablasts was significantly diminished by 27.2-, 2.4-, and 23.3-fold, respectively, compared with that seen in healthy control subjects. Moreover, in vitro differentiation of memBcs into antibody-secreting cells was 6.1-, 2.6-, and 3.7-fold significantly reduced for IgG-, IgM-, and IgA-secreting cells, respectively. Proliferation of memBcs correlates inversely to immunoglobulin-secreting capacity, suggesting compensatory hyperproliferation. Furthermore, patients with no serum IgA can still have a detectable IgA ELISpot assay result in vitro. Most importantly, the large heterogeneity of memBc function in patients with CVID homogenously grouped by means of fluorescence-activated cell sorting allowed additional subclassification based on memBc/plasmablast function. CONCLUSION: These data suggest almost normal memBc/immunoglobulin-secreting plasmablast functionality in some patients if sufficient stimulatory signals are delivered, which might open up opportunities for new therapeutic approaches.

Patient-Specific Implant in Prosthetic Craniofacial Reconstruction: First Report of a Novel Technique With Far-Reaching Perspective.

BACKGROUND: Application of endosseous implants in prosthetic craniofacial reconstruction represents a secure and reliable method and is a well-established surgical procedure. In areas of low bone presentation, standardized plate-like titanium implants are available. For allowing a congruent fitting to the recipient site, these contemporary implants have to be manually adapted--implicating drawbacks in terms of time consumption, technical complexity, and insufficient functional outcome. Owing to these limitations, a custom-made patient-specific implant is introduced based on Digital Imaging and Communications in Medicine (DICOM) data and designed for optimal prosthetic reconstruction. METHODS: For the first time, the application of a prefabricated patient-specific implant for retaining a craniofacial prosthesis is described. In a 64-year-old man with partial nasal defect standardized plate-like implants failed because of compromised bone quality due to Osler disease. To realize an implant-retained prosthetic reconstruction, a patient-specific implant was fabricated based on computer-aided design and computer-aided manufacturing (CAD/CAM) technology. This technique allows for considering the implant's ideal geometry as well as its correct placement of the required magnetic abutments. Furthermore, the surface of the implant can be designed for optimal hygienic conditions. RESULTS: The patient-specific implant was successfully inserted in a time effective operating procedure. Follow-up at 6 months showed an excellent functional and aesthetic outcome. CONCLUSIONS: Application of prefabricated patient-specific implants offers prospectively an ideal tool for retaining craniofacial prostheses and should be considered a viable option in standard cases, but obligatory in anatomically demanding defects.

Respiratory Distress Complicating Falciparum Malaria Imported to Berlin, Germany: Incidence, Burden, and Risk Factors.

While European healthcare systems face resource shortages as a consequence of the coronavirus pandemic, numbers of imported falciparum malaria cases increased again with re-intensifying international travel. The aim of the study was to identify malaria-specific complications associated with a prolonged intensive care unit (ICU) length of stay (ICU-LOS) in the pre-COVID-19 era and to determine targets for their prevention. This retrospective observational investigation included all the cases treated from 2001 to 2015 at the Charité University Hospital, Berlin. The association of malaria-specific complications with the ICU-LOS was assessed using a multivariate Cox proportional hazard regression. The risk factors for the individual complications were determined using a multivariate Bayesian logistic regression. Among the 536 included cases, 68 (12.7%) required intensive care and 55 (10.3%) suffered from severe malaria (SM). The median ICU-LOS was 61 h (IQR 38-91 h). Respiratory distress, which occurred in 11 individuals (2.1% of the total cases, 16.2% of the ICU patients, and 20% of the SM cases), was the only complication independently associated with ICU-LOS (adjusted hazard ratio for ICU discharge by 61 h 0.24, 95% confidence interval, 95%CI, 0.08-0.75). Shock (adjusted odds ratio, aOR, 11.5; 95%CI, 1.5-113.3), co-infections (aOR 7.5, 95%CI 1.2-62.8), and each mL/kg/h fluid intake in the first 24 treatment hours (aOR 2.2, 95%CI 1.1-5.1) were the independent risk factors for its development. Respiratory distress is not rare in severe imported falciparum malaria, and it is associated with a substantial burden. Cautious fluid management, including in shocked individuals, and the control of co-infections may help prevent its development and thereby reduce the ICU-LOS.

Elevated admission C-reactive protein to albumin ratios are associated with disease severity and respiratory complications in adults with imported falciparum malaria.

BACKGROUND: In imported falciparum malaria, systemic inflammation with increased capillary permeability can cause life-threatening complications, such as acute pulmonary edema (APO) or adult respiratory distress syndrome (ARDS). This observational study assessed the association of the admission serum albumin level (ALB) and C-reactive protein to albumin ratio (CRP/ALB) with disease severity and these respiratory complications. METHODS: All adult cases hospitalized during 2001-2015 in the Charité University Hospital, Berlin, with ALB and CRP values measured upon admission, were retrospectively analysed. RESULTS: Seventy-six patients were enrolled (26 female, median age: 37 y), 60 with uncomplicated malaria and 16 with severe malaria (SM). SM was associated with lower ALB (p<0.0001) and higher CRP/ALB (p<0.0001) values; the areas under the receiver operator curves (AUROCs) were 0.85 (95% CI 0.74 to 0.96) for ALB and 0.88 (95% CI 0.80 to 0.97) for CRP/ALB. Radiologic changes consistent with APO/ARDS were detectable in 5 of 45 admission chest X-rays performed (11.1%); the AUROCs were 0.86 (95% CI 0.74 to 0.99) for ALB and 0.91 (95% CI 0.82 to 0.99) for CRP/ALB. CONCLUSIONS: Diminished admission ALB levels and elevated CRP/ALB ratios are associated with disease severity and respiratory complications in imported falciparum malaria. These readily and ubiquitously available markers may facilitate early identification of at-risk patients.

Protection from cytomegalovirus after transplantation is correlated with immediate early 1-specific CD8 T cells.

T cells are crucial for the control of cytomegalovirus (CMV) in infected individuals. Although CMV-specific T cells can be quantified by various methods, clear correlates of protection from CMV disease have not been defined. However, responses to the pp65 protein are believed to play an important role. Here, the proportions of interferon gamma-producing T cells following ex vivo activation with pools of overlapping peptides representing the pp65 and immediate early (IE)-1 proteins were determined at multiple time points and related to the development of CMV disease in 27 heart and lung transplant recipients. Frequencies of IE-1-specific CD8 T cells above 0.2 and 0.4% at day 0 and 2 wk, respectively, or 0.4% at any time during the first months discriminated patients who did not develop CMV disease from patients at risk, 50-60% of whom developed CMV disease. No similar distinction between risk groups was possible based on pp65-specific CD8 or CD4 T cell responses. Remarkably, CMV disease developed exclusively in patients with a dominant pp65-specific CD8 T cell response. In conclusion, high frequencies of IE-1 but not pp65-specific CD8 T cells correlate with protection from CMV disease. These results have important implications for monitoring T cell responses, adoptive cell therapy, and vaccine design.

Asymmetric, disproportionate craniofacial hyperostoses of mosaic pattern in a patient not meeting Proteus syndrome criteria.

A 34-year-old patient with asymmetric hyperostosis of the craniofacial skeleton much more pronounced on the right side is presented. A long-term follow-up of 16 years showed progression of overgrowth even after skeletal maturity and despite repeated surgical corrections focusing on regional reduction of the hyperostoses. Clinical situation during infancy, adolescence, and adulthood is documented. Although the craniofacial hyperostosis in the patient was indicative of the Proteus syndrome, the applicable criteria were not met. Proportionate mild hemihypertrophia/hyperplasia of the patient's right extremities also exclude an oligosymptomatic variant of the Proteus syndrome limited to the skull. Both surgical strategies and difficulty of a diagnostic classification are discussed.

Dentoalveolar injury related to general anaesthesia: a 14 years review and a statement from the surgical point of view based on a retrospective analysis of the documentation of a university hospital.

INTRODUCTION: Damage to dentoalveolar structures related to general anaesthesia is a well-known complication and may represent a relevant morbidity for affected patients. Central documentation of perioperative dentoalveolar injuries was performed since 1990 in the Department of Anaesthesiology and Intensive Care Medicine in cooperation with the Department of Oral and Maxillofacial Surgery at the Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum. Documentation of perioperative dentoalveolar injury consisted of anaesthesia charts, reports of the anaesthesiologists and consultant maxillofacial surgeons. MATERIALS AND METHODS: Retrospective analysis of the data from 1990 to 2004 was performed according to this documentation with respect to incidence, matter, distribution of dental injury and therapeutic consequences. RESULTS: Within 14 years 82 'dental injuries' with 103 affected teeth were documented in calculated 375,000 general anaesthesias. Incidence of 0.02% was very constant with an average of 5.5 events/year. Eighty-nine percent of the documented injuries occurred during scheduled operative procedures. Only 32.9% of the injuries took place during endotracheal intubation. In about 50% the injury was not related to intubation or extubation but happened during general anaesthesia. In 80% the dental injury was estimated by the anaesthesiologist as 'not avoidable'. In 83% pre-existing affection or structural injury of intraoral tissues was documented, in 32.7% of the affections sufficient therapy could be provided already during inhospital stay. CONCLUSION: Perioperative dentoalveolar injury is surely an annoying complication of general anaesthesia. However incidence is rare and seems to be unavoidable. Pre-existing damage to dentoalveolar structures is the main risk for additional injuries related to general anaesthesia. Adequate therapy can be provided by interdisciplinary concepts. There should be a fair balance between the benefit of the surgical procedure and the risk of dental injury related to general anaesthesia. Awareness of the problem and proper documentation are important factors for adequate management in liability cases.

Factors Associated with Prolonged Hospital Length of Stay in Adults with Imported Falciparum Malaria-An Observational Study from a Tertiary Care University Hospital in Berlin, Germany.

Outcome of falciparum malaria is largely influenced by the standard of care provided, which in turn depends on the available medical resources. Worldwide, the COVID-19 pandemic has had a major impact on the availability of these resources, even in resource-rich healthcare systems such as Germany's. The present study aimed to determine the under-explored factors associated with hospital length of stay (LOS) in imported falciparum malaria to identify potential targets for improving management. This retrospective observational study used multivariate Cox proportional hazard regression with time to discharge as an endpoint for adults hospitalized between 2001 and 2015 with imported falciparum malaria in the Charité University Hospital, Berlin. The median LOS of the 535 cases enrolled was 3 days (inter-quartile range, IQR, 3-4 days). The likelihood of being discharged by day 3 strongly decreased with severe malaria (hazard ratio, HR, 0.274; 95% Confidence interval, 95%CI: 0.190-0.396) and by 40% with each additional presenting complication (HR, 0.595; 95%CI: 0.510-0.694). The 55 (10.3%) severe cases required a median LOS of 7 days (IQR, 5-12 days). In multivariate analysis, occurrence of shock (adjusted HR, aHR, 0.438; 95%CI 0.220-0.873), acute pulmonary oedema or acute respiratory distress syndrome (aHR, 0.450; 95%CI: 0.223-0.874), and the need for renal replacement therapy (aHR, 0.170; 95%CI: 0.063-0.461) were independently associated with LOS. All patients survived to discharge. This study illustrates that favourable outcomes can be achieved with high-standard care in imported falciparum malaria. Early recognition of disease severity together with targeted supportive care can lead to avoidance of manifest organ failure, thereby potentially decreasing LOS and alleviating pressure on bed capacities.

'Run them dry': a retrospective experience with a restrictive fluid management strategy in severe imported falciparum malaria from a tertiary care university hospital in Berlin, Germany.

BACKGROUND: Due to the unique pathophysiology with progressive mircocirculatory obstruction and simultaneously increased vascular permeability, overhydration can be rapidly harmful in patients with falciparum malaria. The outcome in all 558 cases hospitalised during 2001-2015 in the Charité University Hospital, Berlin, was favourable, independent of the antimalarial used. Here, the fluid management strategy in the most severely affected subgroup is examined. METHODS: All fluids in 32 patients requiring treatment on intensive care units (ICUs) for >48 h were retrospectively quantified. All malaria-specific complications were followed up over the whole ICU stay. RESULTS: Strong linear relationships between fluid intake and positive balances reflecting dehydration and increased vascular permeability were evident over the whole stay. With 2.2 (range: 0.7-6.9), 1.8 (0.6-6.1) and 1.3 (0.3-5.0) mL/kg/h on day 1, day 2 and over the remaining ICU stay, respectively, median fluid volumes remained below the actual WHO recommendations. No evidence for deterioration of any malaria-specific complication under such restrictive fluid management was found. The key prognostic parameter metabolic acidosis improved significantly over 48 h (p=0.02). All patients survived to discharge. CONCLUSIONS: These results suggest that in the face of markedly increased vascular permeability, a restrictive fluid management strategy is clinically safe in adults with severe imported falciparum malaria.

Malaria transmission in non-endemic areas: case report, review of the literature and implications for public health management.

In non-endemic areas, malaria is rare and locally acquired infections, particularly with Plasmodium falciparum, are exceptional events. The diagnosis is, therefore, likely to be delayed or missed in patients without a relevant travel history. This report describes a case of falciparum malaria in Berlin, Germany, in a patient who had not been to an endemic area for more than a decade. Potential routes of vector-related and direct transmission were evaluated, particularly with regard to a possible danger to the public. A review of the literature was conducted regarding possible routes of transmission and their probability assessed. Genotyping of parasite isolates of this and another patient with malaria admitted 16 days before revealed homology between the two strains. In a local entomological survey, anopheline vectors on the hospital grounds as well as in the residential area of both patients were found. Despite intensive investigations, the mode of transmission remained obscure. In this context, possible routes of vector-borne and direct occupational/accidental transmission in a major European city are reviewed and discussed, providing information and guidance in case other similar events occur elsewhere. Examples for investigations and measures to be taken in such a situation are provided. When local malaria transmission within a large non-immune population cannot be ruled out, genotyping of parasite isolates, local entomological surveys, preparedness for secondary cases, expert consultations in a multidisciplinary team and careful information management are essential. Malaria acquired in non-endemic areas remains an unlikely, but possible event for which awareness needs to be maintained.

Dissection of the CMV specific T-cell response is required for optimized cardiac transplant monitoring.

Despite the success of antivirals in preventing clinically overt CMV disease in cardiac allograft recipients, sub-clinical active CMV infection remains a major concern because of its association with allograft rejection and vasculopathy. The measurement of CMV specific T-cell responses is a promising approach to assessing this situation. For simplicity, class-I MHC/peptide-multimers staining CD8 T-cells directly are often used but this ignores a much wider range of responses including the whole CD4 T-cell compartment. CD4 T-cells, however, were recently shown to be critical to reducing CMV load early after transplantation. To determine how extensive T-cell responses to CMV are, the responses to two dominant CMV proteins, IE-1 and pp65, were dissected in detail accounting for T-cell lineage, frequencies, epitope recognition and changes over time in more than 25 heart transplant recipients. Cross-sectional results from over 30 healthy CMV-carriers were analyzed for comparison. Responses were unexpectedly complex, with considerable inter-individual variation in terms of dominance, breadth, and recognized epitopes. Whereas the use of MHC/peptide-multimers for clinical CD8 T-cell response monitoring alone can be justified in some situations, short term T-cell activation combined with intracellular cytokine staining was clearly found to be of more general usefulness. The performance of IFN-gamma, TNF-alpha, or IL-2 as single read-outs in identifying activated T-cells was examined and confirmed that the frequently used IFN-gamma was best suited. These results should be used to inform the design of clinically applicable and diagnostically useful approaches to monitoring CMV specific responses in heart transplant recipients.

Pyruvate kinase isoenzyme M2 is not of diagnostic relevance as a marker for oral cancer.

INTRODUCTION: Increased aerobic glycolysis is one of the most common abnormalities occurring in the metabolism of tumour cells with pyruvate kinase as one of the key glycolytic enzymes. The dimeric form of M2-pyruvate kinase, found predominantly in tumour cells, is designated as tumour M2-pyruvate kinase (TuM2-PK). The aim of the present, prospective study was to evaluate the diagnostic relevance of TuM2-PK in detecting oral squamous cell carcinoma (OSCC). MATERIAL AND METHODS: TuM2-PK concentration was analysed in ethylene diaminetetraacetic acid plasma of 80 untreated patients with histologically confirmed OSCC stages T3 and T4, whilst 90 patients with non-malignant diseases served as controls. The analysis was done using a sandwich enzyme-linked immunosorbent assay (ScheBo Biotech AG, Giessen, Germany). Immunohistochemical detection of TuM2-PK was performed by specific mouse monoclonal antibody DF-4. RESULTS: The median TuM2-PK concentration was 22.92U/ml in the tumour group and 10.00U/ml in the control group (p<0.001). Using 15U/ml as a cut-off yielded a sensitivity of 63% and a specificity of 59%. Moreover, the positive and negative predictive values were 57% and 64%, respectively. Immunohistochemical staining of tissue sections showed that TuM2-PK was not selectively expressed in tumour cells but also in non-malignant cells, particularly in more regenerative ones. CONCLUSION: Low sensitivity and specificity for stages T3 and T4 OSCC render the TuM2-PK test unsuitable as a tool for detecting OSCC, particularly in an early stage. Thus, routine clinical and radiological follow-up is indispensable after treatment of OSCC.

Current concepts in cleft care: A multicenter analysis.

The current surgical techniques used in cleft repair are well established, but different centers use different approaches. To determine the best treatment for patients, a multi-center comparative study is required. In this study, we surveyed all craniofacial departments registered with the German Society of Maxillofacial Surgery to determine which cleft repair techniques are currently in use. Our findings revealed much variation in cleft repair between different centers. Although most centers did use a two-stage approach, the operative techniques and timing of lip and palate closure were different in every center. This shows that a retrospective comparative analysis of patient outcome between the participating centers is not possible and illustrates the need for prospective comparative studies to establish the optimal technique for reconstructive cleft surgery.

Pathophysiology, risk factors and management of bisphosphonate-associated osteonecrosis of the jaw: Is there a diverse relationship of amino- and non-aminobisphosphonates?

Reports of osteonecrosis of the jaw (ONJ) in patients receiving long-term bisphosphonate therapy have appeared in the literature since 2003. This condition involves avascular necrotic bone in the area of maxilla or mandibula and there may be a secondary infection. Most cases of ONJ have been reported in cancer patients receiving the intravenous aminobisphosphonates zoledronic acid and pamidronate monthly or q 3 week; of note these are also the two most commonly used agents of this class. Risk factors for ONJ include a history of trauma, dental surgery or dental infection and intravenous bisphosphonate administration; in addition, the extent and duration of exposure to bisphosphonates also seem to correlate with the risk. Although a direct causal relationship with bisphosphonates cannot be assumed, these agents may possibly contribute to the development of ONJ by suppression of bone remodeling in the jaw which leads to increased rates of bone mineralisation and accumulation of microfractures. Clodronate, a non-aminobisphosphonate, appears to have a different mechanism of suppressing bone remodeling compared with aminobisphosphonates, and this may explain why few cases of ONJ have been reported with clodronate despite extensive use over the past 20 years; however, the potential of clodronate to reduce the risk of ONJ while providing equivalent clinical benefit to the aminobisphosphonates needs to be substantiated in controlled clinical trials. Use of bisphosphonate therapy should be carefully planned in patients with metastatic bone disease who have risk factors for ONJ, and appropriate preventive measures taken to avoid the development of this condition.

Cerebral toxocariasis after consumption of raw duck liver.

Human toxocariasis is usually contracted by exposure to contaminated soil. This disease is rarely transmitted by raw meat or giblets of paratenic animals, such as chickens, lambs, or cows. We present a case of isolated cerebral toxocariasis presumably caused by the consumption of raw duck liver. This 55-year-old woman had sudden-onset hemiparesis of the right leg, eosinophilia of 30%, and markedly elevated total serum IgE levels. Magnetic resonance imaging demonstrated multiple cerebral hyperintense lesions on T2-weighed images. Tests for antibodies to Toxocara in serum and cerebrospinal fluid yielded highly positive results. Repeated courses of albendazole and corticosteroids led to significant clinical improvement.

Contemporary Correction of Dentofacial Anomalies: A Clinical Assessment.

Contemporary computer-assisted technologies can support the surgical team in the treatment of patients affected by dentofacial deformities. Based on own experiences of 350 patients that received orthognathic surgery by the same team from 2007 to 2015, this clinical review is intended to give an overview of the results and risks related to the surgical correction of dentofacial anomalies. Different clinical and technological innovations that can contribute to improve the planning and transfer of corrective dentofacial surgery are discussed as well. However, despite the presence of modern technologies, a patient-specific approach and solid craftsmanship remain the key factors in this elective surgery.

The "tight orbit": Incidence and management of the orbital compartment syndrome.

PURPOSE: The orbital compartment syndrome (OCS) constitutes a severe emergency, requiring immediate clinical diagnosis and surgical decompression. The key symptom is progressive visual impairment caused by an increase in intraorbital pressure, impairing the perfusion of relevant neurovascular and neurosensory structures. Intraorbital bleeding due to trauma and surgical intervention is known to be the main etiological factor. MATERIAL AND METHODS: A retrospective analysis of all patients affected by an OCS between January 1, 2012, and May 31, 2015, was performed. Patients' records were reviewed with regard to etiology, initial ophthalmologic status, fracture pattern, concomitant medication, surgical management, and postoperative outcome. The incidence of OCS was calculated based on the total number of craniomaxillofacial (CMF) emergencies. RESULTS: Within 3.5 years, a total of 18,093 CMF emergencies were registered. In 16 patients, an OCS was documented, corresponding to an incidence of 0.088%. The mean patient age was 67.31 ± 23.86 years, ranging from 22 to 102 years. The etiology varied, but trauma with subsequent intraorbital bleeding was the main cause. The use of anticoagulative medication was documented in 50% of the cases. In 14 patients, immediate surgical orbital decompression was performed: in 10 patients, vision could be preserved; in three patients, blindness resulted; and one patient was lost to follow-up. Two patients were managed without surgery. CONCLUSION: With regard to the total number of CMF emergencies, OCS is a rare condition. Early clinical diagnosis and surgical decompression are required to prevent permanent vision impairment. Anticoagulative medication must be considered as a predisposing factor for an orbital compartment syndrome in patients affected by periorbital trauma.

Patient and treatment-related risk factors for osteoradionecrosis of the jaw in patients with head and neck cancer.

OBJECTIVE: The purpose of this study was to evaluate risk factors for and the incidence of osteoradionecrosis (ORN) of the jaw in patients with head and neck cancer. STUDY DESIGN: This study was a retrospective analysis of the risk for ORN and outcome for 149 of 540 patients with head and neck cancer of the oral cavity (65%), oropharynx (26%), or other head and neck sites (9%) treated with radiotherapy between 2004 and 2009. ORN was graded according to Late Effects of Normal Tissues/Somatic Objective Management Analytic Scale (LENT/SOMA) criteria. RESULTS: Within a median follow-up of 41 months (95% confidence interval: 27.4-54.6), 38 patients (25.5%) had developed ORN, 37 patients (25%) had a local recurrence, and 53 patients (36%) had died. The median time to diagnosis of ORN was 14.5 months (range: 3-80), and 79% were diagnosed within 2 years of RT. Eleven of these patients had undergone previous mandibular surgery. Univariate significant risk factors for ORN were any comorbidity, poor oral hygiene, pre-radiotherapy osteotomy, close tumor-to-bone proximity, post-radiotherapy dentoalveolar surgery (DAS), DAS without sufficient wound closure, alcohol consumption, and denture pressure sores. In multivariate analysis, comorbidities, pre-radiotherapy mandibular surgery, poor oral hygiene, and insufficient DAS remained significant. CONCLUSIONS: Reducing the risk of ORN calls for maintaining optimal oral hygiene, ensuring good denture fit, receiving proper training in DAS, and helping patients to stop drinking and smoking.