Comparison of Arterial and Venous Interposition Grafting for Arterial Defects in a Rat Model.

BACKGROUND: Interposition microvascular grafting may be required to bridge arterial defects during digital replantation or revascularization and has traditionally been performed utilizing a venous autograft. Arterial interposition grafting has been shown to be superior in maintaining patency in large vessel surgery; there are case reports of its use in microsurgery. METHODS: Six fellowship-trained hand and microsurgeons performed arterial and venous interposition grafts on the femoral arteries of 40 Wistar rats. After sectioning one femoral artery a segment of the contralateral femoral artery or vein was obtained. The time was recorded per graft and patency tested 10 minutes following grafting by an independent assessor. Each surgeon also completed a questionnaire detailing regular microsurgical volume, technical ease, and conceptual preference for either graft. RESULTS: Time for arterial interposition (median time 51.7 minutes) was longer than venous grafting (median time 45.9 minutes, p = 0.075). Arterial grafts were more likely to be patent or questionably patent (odds ratio [OR] = 6.77, p = 0.031). All surgeons found arterial interposition grafting technically easier and preferred it conceptually. Improvements were noted in patency rates (OR = 11.29, p = 0.018) and avoidance of anastomotic leak (OR = 0.19, p = 0.029) when surgeons performed moderate levels or greater of microsurgery within their regular practice. CONCLUSION: Greater immediate patency was noted with arterial interposition grafting in a rodent model when compared to venous grafting, although procedural time was greater. All surgeons found arterial grafting technically easier. Arterial microvascular grafting may be useful in the setting of digital replantation or revascularization with an arterial defect.

[Potential effect of the stimulus threshold level of the nociceptive flexion reflex (NFRT) on mortality and delirium incidence in the critically ill patient: a retrospective cohort analysis]. / Potenzieller Einfluss der Reizschwellenhöhe des nozizeptiven Flexorenreflex (NFRT) auf die Mortalitäts- und Delirinzidenz beim kritisch kranken Patienten: eine retrospektive Kohortenanalyse.

BACKGROUND: Mortality and delirium in critically ill patients are affected by the provided analgesics and sedatives. The deeper the sedation and the higher the dose of analgesics applied, the more difficult it is to assess pain and the depth of sedation. Therefore, instrumental measurement methods, such as the measurement of the stimulus threshold of the nociceptive flexion reflex (NFRT), are becoming increasingly more important. OBJECTIVE: The aim of the present study is to investigate a potential association between the level of the nociceptive flexion reflex, mortality, and the occurrence of delirium. MATERIAL AND METHODS: By retrospectively analyzing a pilot data set of 57 ICU patients from the interdisciplinary surgical ICU of Ulm University Hospital surveyed between 11/2018 and 03/2020, a possible association between the NFRT, mortality, and the occurrence of delirium was calculated in an adjusted logistic regression model. Depending on the cut-off value, the stimulus threshold corridors result in the following comparison pairs: < 20 mA vs. 20-40 mA/20-50 mA/20-60 mA, > 40 mA vs. 20-40 mA, > 50 mA vs. 20-50 mA and > 60 mA vs. 20-60 mA. Results are presented as odds ratios (OR) adjusted for age, sex, height, TISS-28, SAPS II, RASS, BPS, and applied analgesics. Pain assessment was performed, in addition to the Behavioral Pain scale, ≥ 3 times daily by measuring NFRT. RESULTS: A statistically nonsignificant tendency for an increase in mortality incidence occurred with an NFRT > 50 mA, versus a stimulus threshold corridor of 20-50 mA (OR 3.3, CI: 0.89-12.43, p = 0.07). A trend toward a reduction in delirium incidence occurred at an NFRT < 20 mA, versus a stimulus threshold corridor of 20-40 mA (OR 0.40, CI: 0.18-0.92, p = 0.03). CONCLUSION: Based on the level of the NFRT, no recommendation can be made at this point to adjust the analgesic regimen of critically ill patients, who are unable to communicate. The observation of a tendency towards an increase in mortality at high stimulus thresholds or a reduction in the occurrence of delirium at low stimulus thresholds of the NFRT must be verified in standardized studies.

[Current diagnostic imaging and treatment planning for laryngeal cancer]. / Aktuelle Bildgebung bei Diagnostik und Therapieplanung des Larynxkarzinoms.

CLINICAL/METHODICAL ISSUE: Laryngeal cancer is the third most common malignancy in the head and neck region. Endoscopic laryngoscopy with assessment of vocal fold function, microlaryngoscopy with biopsy and computed tomography (CT)/magnetic resonance imaging (MRI) remain the cornerstones of diagnostic workup. Thus, in the context of therapy planning, consideration of individual functional and socioeconomic aspects is of major importance. STANDARD RADIOLOGICAL METHODS: Due to the short acquisition time and the possibility to perform functional maneuvers, CT is the tool of choice. MRI allows better soft tissue differentiation, but is more susceptible to movement artifacts and is complicated by disease-specific symptoms. The choice of examination method therefore depends on the patient's physical resilience. PERFORMANCE: Depending on the study, the information on the sensitivity of CT with regard to the question of cartilage infiltration varies between 62 and 87% with a specificity between 75 and 98%. For MRI, sensitivity between 64 and 95% and specificity between 56 and 88% are stated. ACHIEVEMENTS: The synthesis of the findings from endoscopy, biopsy and imaging is prerequisite for initiation of stage-appropriate treatment. For image interpretation, knowledge of the anatomical landmarks is essential. However, the assessment of posttherapeutic changes also poses a challenge for the radiologist. PRACTICAL RECOMMENDATIONS: Regular interdisciplinary dialogue between radiologists, otorhinolaryngologists and radiotherapists in the context of primary diagnostics, therapy planning and aftercare is essential.

[Work in progress: adaptation of electronic medical records to the requirements of a university eye clinic : Individual extensions of the software "FIDUS" at the Department of Ophthalmology of the Saarland University Medical Center UKS]. / Work in Progress: Anpassung der elektronischen Patientenakte an die Anforderungen einer Universitätsaugenklinik : Individuelle Erweiterungen der Software "FIDUS" an der Klinik für Augenheilkunde am Universitätsklinikum des Saarlandes UKS.

BACKGROUND: The implementation of electronic medical records (EMR) in the Department of Ophthalmology at the Saarland University Medical Center (UKS) in January 2016 was a timely response to growing documentation requirements and rapidly increasing electronic diagnostic data. The software system was primarily developed for private practices and cannot therefore meet the different requirements of various clinics out of the box. The purpose of this study was to identify features of the EMR beyond purely paper replacement that can assist in the clinical workflow and whether these features can be implemented in a running system. METHODS: The EMR was specifically individualized with respect to the work processes and documentation requirements of the Department of Ophthalmology at the UKS. In addition to a seamless integration into the hospital information system (HIS) the modifications included changes in the structure and visual presentation of the EMR as well as functional extensions. An internet-based platform was set up to enable a direct exchange of appointments and patient data with specialist practices. RESULTS: Due to the introduction of a so-called ghost list the position of patients within the hospital who are allocated to a physician, e.g. for diagnostics, can be reconstructed at any point in time. The logging of the individual treatment times enables tracking of patient flow within the clinic and a reduction of waiting times. Existing paper documents particularly for the graphic recording of findings, such as sketches, are digitalized eliminating the need to scan documents. The UKS.AUGEN.NETZ is an internet-based portal to facilitate direct organization of appointments with specialist practitioners and for the exchange of digital examination data and medical correspondence. CONCLUSION: The permanent close cooperation between employees of the Department of Ophthalmology at the UKS and the manufacturer of the software enables a continuous optimization of the EMR in a fully operational clinical workflow. In addition, the web-based interface improves the cooperation between the hospital and private practices.

[Sonographic analysis of swallowing in the cervical section of the esophagus]. / Sonographische Analyse des Schluckakts im zervikalen Ösophagusabschnitt.

BACKGROUND: Dysphagia is a common symptom reported by patients in various medical fields, raising the question of diagnosis. In addition to otorhinolaryngologic examination with a mirror, the current gold standards videofluoroscopy and fiber optic endoscopic evaluation of swallowing (FEES) are available. Ultrasound is frequently used in everyday clinical practice, although its application for swallowing diagnostics needs addressing. MATERIALS AND METHODS: Between April 2012 and February 2014, 81 subjects (age 19-66 years) with no indication of a swallowing disorder were sonographically examined. The anatomic representation of swallowing structures was evaluated and videos of the cervical part of the esophagus during swallowing of different consistencies (saliva, water, jelly) were recorded and analyzed. In a pilot study, the examination was tested on 3 dysphagia patients. RESULTS: The base of the tongue, the intralaryngeal structures, the cervical spine, and the thyroid glands were well visualized. Sonographic representation of the cervical esophagus section was particularly successful. Its length could be detected at 5.78 ± 1.66 cm, the diameter measured at 0.88 ± 0.10 cm. Sonographic inspection of the sinus piriformis was most difficult; it could not be seen in 39.5% of cases. Visualization of the sinus piriformis was better in cases of normal weight and age <25 years (odds ratios 5.6 and 11.3, respectively). In the examination of patients with a swallowing disorder, three different pathologies (Forestier's disease, esophageal stenosis, and motor neuron disease) were identified as the cause of complaints. CONCLUSION: Sonography enables very good visualization of swallowing and evaluation of the cervical esophagus. Where available, the otorhinolaryngologist should consider ultrasound as a diagnostic option, as it enables repeated evaluation of swallowing and can complement previously available diagnostic tools.

Flea market finds and global exports: Four multistate outbreaks of human Salmonella infections linked to small turtles, United States-2015.

Zoonotic transmission of Salmonella infections causes an estimated 11% of salmonellosis annually in the United States. This report describes the epidemiologic, traceback and laboratory investigations conducted in the United States as part of four multistate outbreaks of Salmonella infections linked to small turtles. Salmonella isolates indistinguishable from the outbreak strains were isolated from a total of 143 ill people in the United States, pet turtles, and pond water samples collected from turtle farm A, as well as ill people from Chile and Luxembourg. Almost half (45%) of infections occurred in children aged <5 years, underscoring the importance of the Centers for Disease Control and Prevention recommendation to keep pet turtles and other reptiles out of homes and childcare settings with young children. Although only 43% of the ill people who reported turtle exposure provided purchase information, most small turtles were purchased from flea markets or street vendors, which made it difficult to locate the vendor, trace the turtles to a farm of origin, provide education and enforce the United States federal ban on the sale and distribution of small turtles. These outbreaks highlight the importance of improving public awareness and education about the risk of Salmonella from small turtles not only in the United States but also worldwide.

[Infantile hemangiopericytoma of the nasal cavity]. / Infantiles Hämangioperizytom der Nasenhaupthöhle.

An infantile sinunasal hemangiopericytoma as a variant of infantile myofibroma is a rare finding. The observation of a sinunasal, infantile hemangiopericytoma affecting the anterior skull base and ethmoid bone in a female infant is presented. Chromosomal gains (6q14q16.2 und 18q22qter) as well as chromosomal losses (5q33.3q35.2, 10p11.2p12.2, 10q24.3q26.1, 15q23q25, 17p12pter and 22q11.2q13.2) were present. Endonasal tumor resection was achieved.

[Influence of external and endogenous factors on cervical lymph nodes : Sonographic study of size and morphology]. / Einfluss externer und endogener Faktoren auf Halslymphknoten : Sonographische Untersuchung der Größe und Morphologie.

BACKGROUND: Sonographic evaluation of the dignity of cervical lymph nodes is essential for further diagnostics and treatment concepts in various diseases. The aim of this prospective monocenter study was to determine the sonomorphology and size of benign changes of lymph nodes in healthy subjects and patients who had undergone surgery, in order to examine the influence of various factors. MATERIALS AND METHODS: Data from 205 healthy subjects and 15 patients before and after surgery were analyzed. Sonographically representative lymph nodes were measured in diameter and volumes were calculated; margins, the recognizability of a hilus, and vascularization were documented. A detailed medical history was taken using a standardized questionnaire. RESULTS: In 20-39-year-olds, lymph node diameters were larger than in 40-59- and over 60-year-olds, and in 40-59-year-olds, the lymph nodes were larger than over 60-year-old subjects. Individuals with consumption of less than 10 and 10-20 cigarettes per day showed larger cervical lymph nodes compared to subjects with a consumption of more than 20 cigarettes per day. Smokers who additionally exercised routinely showed larger lymph nodes than those who never smoked or exercised. In addition, we observed that both the size and the number of cervical lymph nodes increased postoperatively compared to preoperative. CONCLUSION: The recorded lymph nodes corresponded to the established sonographic criteria of benign lymph nodes. Our results show that age, smoking intensity, combination of smoking with sporting activity, and surgery influence the size of sonographically measured cervical lymph nodes.

[Per aspera ad astra: implementation of electronic patient records in a university eye hospital : Experience with FIDUS in the Clinic for Ophthalmology at the Saarland University Medical Center UKS]. / Per aspera ad astra: Einführung einer elektronischen Patientenakte an einer Universitätsaugenklinik : Erfahrungen mit "FIDUS" in der Klinik für Augenheilkunde am Universitätsklinikum des Saarlandes UKS.

BACKGROUND: For more than 60 years patient records of the Department of Ophthalmology at the Saarland Medical Center in Homburg were documented on handwritten paper documents and filed in archives. Increasing requirements for medical documentation, exploding volumes of diagnostic data, overcrowded archives and unavailable files when needed, were the essential rationales for the implementation of an electronic patient archive (EPA). METHODS: The EPA has been specifically adapted to the requirements of the Department of Ophthalmology in order to guarantee a standardized unobstructed documentation and patient care across all sections of the department. Seamless integration into the clinic information system (KIS) and network-compatible diagnostic software were essential as well as a timely digitization of existing paper charts. Decisive factors for using FIDUS (Arztservice Wente GmbH, Darmstadt, Germany) as the EPA software were the visual layout of the EPA, user friendliness and reference installations of the software in other ophthalmology departments. RESULTS: After one and a half years of meticulous preparation with specific adaptations to the requirements of our department, the EPA was finally implemented in January 2016 and since then we have been working on improvements. The EPA software retrieves basic patient data from the KIS and diagnostic data from electronic devices via various interfaces. Expenses for printers could be reduced but computer workplaces had to be expanded or newly created. For previous patients paper files are digitized externally and stored in an electronic archive directly accessible from the EPA. DISCUSSION: Successful reorganization and implementation of electronic documentation during clinical routine is feasible with careful preparation and timely involvement of information technology experts, motivated physicians, nurses, research departments and the administration.

[Satisfaction of patients with tracheostomal epithesis]. / Die Tracheostomaepithese - eine Evaluation der Patientenzufriedenheit.

BACKGROUND: The utilization of craniofacial prosthesis has proven to be very successful for craniofacial defects. However, there is a lack of knowledge about the value of an epithesis for voice rehabilitation in patients with tracheostomy. The aim of this study was to describe application of the tracheostomy epithesis and to present a systematic analysis of the functional results of this prosthetic technique. MATERIALS AND METHODS: This retrospective analysis included 48 patients on follow-up being treated in three different centers after laryngectomy and/or tracheostomy between 2008 and 2014. Subjects were given a questionnaire with items such as speech quality, quality of life, free hand speech ability, respiratory quality and sufficient tracheostomal sealing comparing values before and after application of an individually custom-made tracheostomy epithesis. Twenty-eight answered the questionnaire and could be reported. RESULTS: Twenty-eight of 48 patients were consistently being included in follow-up. The statistical analysis revealed a significant improvement of tracheostoma occlusion (p < 0.05) and improvement in free hand speech ability (p < 0.05). A leakage of air during voice production could be prevented in 59.3% after application of an epithesis. Quality of life correlated directly with successful utilization of an epithesis. CONCLUSION: In the literature, different industrialized products are described to realize occlusion of the tracheostoma for sufficient speech production without using the hands. In numerous cases commercial solutions fail and the patients need individual modifications. Our study first describes the evaluation of custom-made tracheostomal epithesis. From our observed results we advocate the individual tracheostomal epithesis as a durable solution for voice rehabilitation.

[Cerebral venous thrombosis: Case report and clinical procedures]. / Zerebrale Venenthrombose: Fallbeschreibung und Vorgehen.

Cerebral venous and dural sinuses thrombosis (CVT) is a relatively rare but very serious disease, because of the risk of mortality. Cardinal symptoms are usually severe sudden-onset localized headaches, which may or not be accompanied by focal or generalized neurological deficits or seizures. It is particularly important to consider CVT in the presence of underlying prothrombotic conditions (genetically predisposed or acquired defects of the coagulation system) or well-known risk factors (hormonal contraception, pregnancy, puerperium, smoker status). Based on clinical findings, diagnosis is established using neuroimaging (MRI and MR venography, CT and CT venography) and D-dimer measurement. In the case of early diagnosis and onset of antithrombotic treatment, the prognosis is good. Otherwise there is a high risk of irreversible neurological deficits or even mortality. In daily clinical routine, where many patients present with similar or unspecific symptoms-most of which are harmless-it is thus particularly important that CVT be considered in the differential diagnosis.

[Epithetic replacement in otorhinolaryngology]. / Epithetische Versorgung in der HNO-Heilkunde.

The past century saw rapid development of craniofacial prostheses. Particularly the challenging issue of surgical fixation was the subject of intensive research and development. During the past three decades, the principle of osseointegration has proven to provide a reliable method for epithesis fixation. The continuous technical development of implant systems has led to almost minimally invasive surgical techniques, with ever increasing stability of the implants. Osseointegrated implants are a proven and durable solution in the rehabilitation of the patient with a defect in the craniofacial region. Overall complication rates are low. The design and mechanics of the implants, as well as the artificial body of the epithesis itself, are topics of current medical-technical research by anaplastologists and surgeons. Finally, functional prostheses, such as the tracheostomy epithesis, deserve particular attention.

[Today's importance of ultrasound in ENT]. / Importance de l'échographie en ORL à l'heure actuelle.

Since ultrasound has been established for diagnosis in ENT several new techniques have been introduced. But also ultrasonography has technically developed and thus has earned even more importance and indications. This was to be shown by this paper as well as the advantages and pitfalls. Ultrasound is quite useful in inflammatory, infectious and tumor pathology in order to make a better diagnosis or staging and to help the surgeon for punture or incision of a pathologic lesion (cytology, bacteriology, drainage). Especially in ENT oncology and post-treatment follow up ultrasound is a very precious technique. Ultrasound can be realized by the ENT specialist himself anywhere and at any time. It is a non aggressive, non invasive technique and its cost is relatively low. Unfortunately by itself it is not very performant to distinguish benign and malignant lesions. But its specificity can be considerably enhanced by combinating it with cytology (UGFNAB, ultrasound guided fine needle aspiration biopsy). Another important field of ultrasound is the examination of salivary glands.

Endonasal modification of the frontal sinus drainage type IIb according to Draf.

The description of different endonasal drainage options (type I, II and III according to Draf) and their successful use in numerous patients has reached a milestone in frontal sinus surgery. We herein describe a modification of an endonasal frontal sinus drainage type IIb with the additional removal of the lower part of the frontal sinus septum without opening the frontal recess of the other side and without resection of the nasal septum. The modified endonasal endoscopic frontal sinus drainage type IIb was performed on 9 patients at the Department of Otorhinolaryngology, University Medical Center, Homburg/Saar between 02/2011 and 6/2013 after having gained patients' consent. Follow-ups with endoscopic examination were performed after 6, 12 and 24 months (median follow-up: 14 months). Endonasal endoscopic opening of the frontal sinus was achieved in all patients. Endoscopic examination 6, 12 and 24 months after surgery revealed patent frontal sinus drainage in 8 patients. The frontal sinus drainage could not be visualized endoscopically in one patient who was free of symptoms for 24 months and where a ventilated frontal sinus was proven radiologically by computed tomography. The study demonstrates the option to additionally remove the lower part of the inter-frontal septum with a frontal sinus drainage type IIb. As the number of patients treated by this modified frontal sinus type IIb drainage is limited, further investigations are needed to define the value of a modified frontal sinus drainage type IIb.

[A new implant system for orbital prosthetic rehabilitation: "epiplating mono"]. / Ein neues Implantatsystem für die epithetische Orbitarehabilitation: "Epiplating Mono"

A New Implant System for Orbital Prosthetic Rehabilitation: "Epiplating Mono" Prosthetic or episthetic rehabilitation of ear, eye and nose are currently most common performed using magnetic fixation. While at the beginning single implants have been used, now-a-days a more extended approach with plate fixation are recommended to enhance the stability of the anchored magnets. A newly designed implant system epiplating mono is presented that combines the structure of a single implant with additional fixation elements. In a pilot study this new implant system was used in 4 patients for prosthetic orbital rehabilitation. Further experiences with this new implant system are required necessitating long-term experiences of implant stability to define the value of the presented epiplating mono system for prosthetic rehabilitation.

[Which colours can we hear?: light stimulation of the hearing system]. / Welche Farben könnten wir hören?: Lichtstimulation des Hörsystems.

The success of conventional hearing aids and electrical auditory prostheses for hearing impaired patients is still limited in noisy environments and for sounds more complex than speech (e. g. music). This is partially due to the difficulty of frequency-specific activation of the auditory system using these devices. Stimulation of the auditory system using light pulses represents an alternative to mechanical and electrical stimulation. Light is a source of energy that can be very exactly focused and applied with little scattering, thus offering perspectives for optimal activation of the auditory system. Studies investigating light stimulation of sectors along the auditory pathway have shown stimulation of the auditory system is possible using light pulses. However, further studies and developments are needed before a new generation of light stimulation-based auditory prostheses can be made available for clinical application.

[First experience in the thyroid and parathyroid surgery using the da Vinci® system]. / Erste Erfahrungen in der Schilddrüsen- und Nebenschilddrüsenchirurgie mit dem da Vinci®-System.

BACKGROUND: Endoscopic surgery for the treatment of thyroid and parathyroid pathologies is gaining increasing attention. The da Vinci® system has been already widely used in different fields of medicine including recently thyroid and parathyroid surgery. Herein we report our first experiences in endoscopic surgery of thyroid and parathyroid pathologies using the da Vinci® system. MATERIAL AND METHODS: 8 patients presenting with struma nodosa in 6 cases and parathyroid adenomas in 2 cases have been treated using the da Vinci® system at the ENT department of Homburg/Saar University. RESULTS: The skin incision to introduce the instruments with the da Vinci® system were axilar or at the lateral segment of the clavicle. The neurovascular structures like inferior laryngeal nerve as well as the pathologies were clearly 3-dimensional visualized in all 8 cases. No paralysis of the vocal cord was observed. All patients had in histological examination a benign pathology. CONCLUSIONS: The endoscopic surgery of the thyroid and parathyroid gland can be performed using the da Vinci® system and offers an excellent, intraoperative, 3-dimensional visualization of the neurovascular structures. Additionally the da Vinci® system enables skin incisions within considerable distance from the thyroid and parathyroid gland.