MRSA: Resistenzmechanismen,Epidemiologie, Risikofaktoren,Prophylaxe, Therapie

Zusammenfassung Methicillin-resistente Staphylococcus aureus-Stämme (MRSA) sind inzwischen in vielen Ländern verbreitete Erreger, denen eine besondere Aufmerksamkeit geschenkt wird. In der vorliegenden Übersichtsarbeit werden der Resistenzmechanismus, die Epidemiologie der Verbreitung im Krankenhaus (H-MRSA) bzw. in Einrichtungen des Gesundheitswesens (HCA-MRSA) und außerhalb des Krankenhauses (C-MRSA), Ursachen der Zunahme des Nachweises, Besiedlungsdynamik, Erkrankungsrisiko und Letalität, das Vorgehen bei MRSA-Nachweis, Methoden zur Dekolonisierung, Überwachungskulturen sowie therapeutische Optionen diskutiert.     

Author Index EPOS, 2016, Rome,Italy

Purpose

In 1992, Georges Charpak invented a new type of X-ray detector, which in turn led to the development of the EOS^® 2D/3D imaging system. This system takes simultaneous anteroposterior and lateral 2D images of the whole body and can be utilized to perform 3D reconstruction based on statistical models. The purpose of this review is to present the state of the art for this EOS^® imaging technique, to report recent developments and advances in the technique, and to stress its benefits while also noting its limitations.

Methods

The review was based on a thorough literature search on the subject as well as personal experience gained from many years of using the EOS^® system.

Results

While EOS^® imaging could be proposed for many applications, it is most useful in relation to scoliosis and sagittal balance, due to its ability to take simultaneous orthogonal images while the patient is standing, to perform 3D reconstruction, and to determine various relationships among adjacent segments (cervical spine, pelvis, and lower limbs). The technique has also been validated for the study of pelvic and lower-limb deformity and pathology in adult and pediatric populations; in such a study it has the advantage of allowing the measurement of torsional deformity, which classically requires a CT scan.

Conclusions

The major advantages of EOS^® are the relatively low dose of radiation (50–80 % less than conventional X-rays) that the patient receives and the possibility of obtaining a 3D reconstruction of the bones. However, this 3D reconstruction is not created automatically; a well-trained operator is required to generate it. The EOS^® imaging technique has proven itself to be a very useful research and diagnostic tool.

     

Nephrology, Hypertension, Dialysis, Transplantation

Th. Andreoli, E. Ritz and L. Rosivall, Hungarian Kidney Foundation,Budapest, 2006. Total pages: 655. This monograph is a compilation of lectures given in recentcourses of the Budapest Nephrology School, a yearly educationalprogramme organized under     

Congenital,multiple, bilateral,trigger digits in a child

Summary Congenital triggering of a digit other than the thumb is a rare. A nine year old boy has been treated for congenital, multiple trigger digits in addition to the thumb. The operative findings were only slight thickening of the flexor pulley and noticeable fusiform swelling of the flexor tendons.

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Résumé Un garçon de 9 ans présentait des doigts à ressaut congénitaux. Ceux-ci ont été traités chirurgicalement. Cette anomalie est rare, sauf en ce qui concerne le pouce. Le ressaut semble être la conséquence d'un renflement fusiforme des tendons fléchisseurs.

     

Abdominal surgery, morbid obesity, age, dexamethasone, diabetes mellitus and glucose metabolism

Editor—We read, with interest, the paper by Hans and colleagues¹showing moderately increased capillary blood glucose concentrationsduring and after abdominal surgery in type 2 diabetic morbidlyobese patients when compared with a younger group of non-diabeticobese patients. All patients in this protocol had received abolus of 10 mg of dexamethasone for the prophylaxis of postoperativenausea and vomiting at the induction of general anaesthesia.The peak mean glucose concentration, 2 h after the administrationof dexamethasone, was 8.7 mmol litre^–1 in the diabeticand 7.5 mmol litre^–1 in the non-diabetic group. Theseare slightly higher     

Cholinergic stimulation of pancreatic polypeptide release by a meal,bombesin, neurotensin,tetragastrin, cholecystokinin,and cerulein

It has been demonstrated that pancreatic polypeptide (PP) release can be markedly impaired by vagotomy or anticholinergic drugs. The current studies examine the role of cholinomimetic stimulation on PP release in dogs. Eight conscious animals underwent a series of tests: (1) a test meal (10 g/kg Alpo); (2) tetragastrin infusion (4 μg/kg/hr); (3) bombesin infusion (1.0 μg/kg/hr); (4) cerulein infusion (100 ng/kg/hr); (5) cholecystokinin octapeptide (CCK-OP) infusion (100 ng/kg/hr); (6) neurotensin infusion (3 ng/kg/hr). All the studies were repeated individually with intravenous bethanecol (100 μg/ kg/hr) as the background stimulant. The mean increment of PP released by a meal (160 ± 32 fmol/ ml) was significantly increased by bethanecol infusion (316 ± 49 fmol/ml) (P < 0.05). Each individual peptide released a significant amount of PP; tetragastrin: 53 ± 11; neurotensin: 58 ± 14; CCK-OP: 42 ± 9; cerulein: 42 ± 12; bombesin: 118 ± 24 (P < 0.05). Bethanecol did not significantly augment PP release by any of the individual peptides (P > 0.05). This study indicates that PP release by a meal is sensitive to cholinomimetic stimulation and that the peptide involved is neither gastrin, neurotensin, CCK, bombesin, nor cerulein. These data support the possibility of the existence of a cholinergic stimulatable mechanism, possibly a peptide responsible for the release of PP.     

3D打印联合肱骨远端截骨治疗儿童肘内翻畸形

目的:探讨采用3D打印技术联合肱骨远端截骨治疗儿童肘内翻畸形的临床疗效。方法:回顾性分析自2017年1月至2020年1月行肱骨远端截骨矫形手术治疗的肘内翻畸形患儿17例,其中男11例,女6例;年龄5~11(7.8±1.7)岁。术前通过3D打印技术制作患侧肘关节模型,在模型上进行预手术,术中利用3D模型指导进行肱骨远端截骨矫形术。比较术前、术后6个月肘关节提携角、肘关节屈曲伸直角度变化情况,采用Flynn分级评价标准评价其临床疗效。结果:17例患儿均获得随访,时间6~12(9.6±1.7)个月。1例患儿出现伤口感染,予换药后完全愈合。所有患儿无骨不愈合、内固定断裂及神经损伤等并发症发生。患肢提携角由术前的(-20.8±2.4)°改善至术后6个月的(7.2±2.3)°;肘关节伸直角度由术前的(-5.6±3.9)°改善至术后6个月的(-2.6±2.1)°,术后6个月肘关节屈曲角度与术前比较差异无统计学意义(P>0.05);术后6个月患侧肘关节功能与健侧比较差异无统计学意义(P>0.05)。根据Flynn分级评价标准,优13例,良4例。结论:采用3D打印联合肱骨远端截骨治疗儿童肘内翻畸形,能够获得满意的治疗效果,利用该技术可以更精确地完成畸形矫正,恢复肘关节生理结构及功能。     

Arthrodese,Arthroplastik, Arthrolyse

Zusammenfassung Biologische und funktionelle Vor- und Nachteile von Arthrodese und Arthroplastik werden herausgestellt und gegeneinander abgewogen. Beide Operationsverfahren ergeben funktionell oft sehr brauchbare Ergebnisse, aber doch in der Form von Defektheilungen. Bei der Arthrodese wird von seiten der Statik und Kinetik ein starkes Ausgleichsbemühen verlangt, bei der Arthroplastik vor allem eine erhebliche biologische Regenerationsleistung. Doch sind auch die technischgelenkmechanischen Schwächen der Arthroplastik nicht zu übersehen. Die anatomische und gelenkmechanische Sonderstellung des Hüftgelenks verlangen eine besondere Wertung von Arthrodese und Arthroplastik an diesem Gelenk. Dabei werden auch vor allem die Gegenindikationen der Arthrodese herausgestellt. Die erheblichen Nachteile und trotz allem auch vorhandenen Vorteile der Fremdmaterialplastik am Hüftgelenk werden ausgeführt. Die Arthrolyse, besonders des Kniegelenks, wird als Sonderfall einer plastischen Mobilisierungsoperation grundsätzlich von der Arthroplastik durch Konservierung der Gelenkflächen unterschieden, charakterisiert. Vor einer allzu großen Skepsis gegenüber der Arthroplastik wird gewarnt. Sie hat, wie die Arthrodese, ihren gesicherten Anwendungsbereich und ist bisweilen unentbehrlich.Mit 12 TextabbildungenHerrn Professor Dr. G. Hohmann zum 80. Geburtstag.     

Spinal angiolipoma: etiology,imaging findings,classification, treatment,and prognosis

Purpose

To summarise our experience treating patients with spinal angiolipomas (SAs) and to evaluate factors relating to its prognosis.

Methods

We retrospectively reviewed the records of patients diagnosed with SAs who received surgical treatment from January 2001 to February 2013.

Results

Twenty-one patients were described. We divide SAs into two types: “intraspinal” and “dumbbell-shaped”. The former were further subclassified as “with lipomatosis” and “without lipomatosis”. Overweight people are more likely to get the “with lipomatosis” type which needs different surgical strategy and/or a diet therapy to get better outcomes.

Conclusion

Diagnosis of SAs should be made with reference to clinical, radiological, and pathological findings. Application of different methods is needed to treat SAs.     

168. Die Kompressionsstenose der Arteria coeliaca,Ursache, Diagnostik,Klinik, Operationsergebnis

Zusammenfassung Die Kompression der Art. coeliaca (A. C.) — ein zunehmend häufiger werdendes Krankheitsbild — wird verursacht durch das Ligamentum arcuatum medianum oder neurofibromatöses Gangliongewebe. Patienten mit hochgradiger Stenose oder Verschluß der A. C. haben Oberbauchschmerzen (92%), abdominelles Gefäßgeräusch (87%), Gewichtsverlust (56%), Brechreiz und Erbrechen (52%). Angiographisch fällt der ausgeprägte kollaterale Blutzufluß aus der A. mesenterica superior auf. Nach der eigenen Erfahrung mit 32 Patienten, die eine Kompression der A. C. hatten, besteht eine Op.-Indikation nur bei hochgradiger Stenose oder Verschluß und gleichzeitig über längere Zeit objektivierbaren Oberbauchschmerzen.     

Percutaneous endoscopic gastrostomy: Indications,limitations, techniques,and results

Percutaneous endoscopic gastrostomy was introduced in 1980 as an alternative to traditional operative methods for the creation of a feeding gastrostomy. The indications for the procedure are essentially the same as those for traditional gastrostomy and include the inability to swallow secondary to neurological impairment, oropharyngeal neoplasms, and facial trauma. The method is contraindicated in the presence of massive ascites, total esophageal obstruction, coagulation disorders, and sepsis. Several variations on the original technique have been developed, and results with each are comparable. The morbidity and mortality with percutaneous methods has been at least as good as those reported for operative techniques while the cost has been lower and patient acceptance high. In spite of the ease with which gastrostomy may be performed by the percutaneous method, patient selection must be appropriate and details of technique closely followed if results are to remain acceptable.

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Resumen La gastrostomía percutánea endoscópica fue introducida en 1980 como alternativa de los métodos operatorios tradicionales para la creación de una gastrostomía para alimentación. Las indicaciones son esencialmente las mismas que para la gastrostomía tradicional e incluyen la incapacidad para deglutir debido a alteración neurológica, neoplasia orofaríngea, o trauma facial. El método está contraindicado en presencia de ascitis masiva, obstrucción esofágica total, desórdenes de la coagulación, y sepsis. Algunas variaciones de la técnica original han sido desarrolladas, y sus resultados son comparables. Las tasas de morbilidad y mortalidad de los métodos percutáneos han sido por lo menos tan buenas como las que se informan para las técnicas operatorias, en tanto que el costo ha sido menor y el grado de satisfacción de los pacientes muy alto. A pesar de la facilidad con la cual se puede realizar la gastrostomia por el método percutáneo, debe prestarse especial atención a la selección de los pacientes y a la cuidadosa observation de los detalles de la técnica quirúrgica para así lograr que los resultados sigan siendo aceptables.

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Résumé La gastrostomie endoscopique percutanée réalisée dès 1980 remplace avantageusement la gastrostomie classique dans certaines circonstances. Les indications sont les mêmes que celles de la gastrostomie classique: incapacité d'avaler en rapport avec une maladie neurologique, un traumatisme facial ou un cancer oropharyngé. Cette méthode est contreindiquée en cas d'ascite, d'obstruction oesophagienne totale, de troubles de l'hémostase, et de septicémie. On a développé plusieurs variantes techniques; leurs résultats sont comparables. Les taux de morbidité et de mortalité des méthodes percutanées sont similaires à celles des méthodes traditionnelles; leur coût est inférieur et le patient les accepte mieux. Malgré la facilité avec laquelle se réalise la gastrostomie percutanée, il faut bien choisir les malades et les détails techniques si on veut de bons résultats.

     

SAPHO,autophagy, IL-1, FoxO1, and Propionibacterium (Cutibacterium) acnes

Overt infection by Propionibacterium acnes is lacking in many SAPHO syndromes, and antibiotics have only a transient and incomplete effect, either in SAPHO syndrome or acne. As several auto-inflammatory bone disorders sharing overproduction of IL-1β can mimic SAPHO, this syndrome could partly depend on genetically encoded overproduction of IL-1β. However, cyclic intracellular infections, mostly by P. acnes, can contribute to the enhanced IL-1β release by some skin cells, and probably by bone cells. P. acnes is indeed a powerful trigger of NLRP3-inflammasome activation and IL-1β, leading to osteitis and enhanced mesenchymal cells differentiation in osteoblasts. Recent advances in the understanding of acne suggest that first steps of this disorder are not driven by P. acnes, but by a relative deficiency of FoxO1 within the nucleus of sebaceous cells. A similar defect of FoXO1 in bone cells should also be sought in SAPHO, since repression of FoxO1 gene is found in lesional psoriasis skin, and is associated with an increased number of osteoblasts and high bone mass in mice. FoxO1 selectively promotes IL-1β production, so that its downregulation could help some P. acnes t escape innate immunity and persist in a latent state in bone cells, including mesenchymal stem cells. However, P. acnes itself possibly contributes to FoxO1 downregulation, like H. pylori infection which induces nuclear inactivation of FoxO1 in human gastric cells to slow down autophagic clearance. As bisphosphonates, which often improve SAPHO syndromes, enhance autophagy, it may be worth testing whether their combination with antibiotics is synergistic in SAPHO syndromes.     

Bewusstlosigeit, Koma, Somnolenz, Stupor und Sopor

Background

In German the terms unconsciousness, coma, somnolence, stupor and sopor are used to describe a state of impaired consciousness partly due to historical reasons. In parallel the Glasgow Coma Scale (GCS) introduced in 1974 provides a better definition for the state of consciousness.

Material and methods

In this study two different groups were evaluated: active emergency physicians and emergency medicine trainees. Using a questionnaire both groups were asked to describe the impaired consciousness terms and indicate a corresponding GCS value. In addition they were asked to define a predescribed state of consciousness justifying the need for intubation.

Results

The active emergency physicians assigned coma and unconsciousness median GCS levels of 7 (5–8, interquartile range, IQR) and 9 (7–10 IQR), respectively, whereas trainees assigned mean GCS levels of 6.5 (5–8 IQR) and 8 (8–10 IQR), respectively. Of the participants 60% assumed that an unconscious patient, in contrast to the definition, does not show any defence signs to pain. Somnolence was assigned higher GCS values (median 11, 10–13 IQR) and 12, 10–13.5 IQR). Stupor and sopor were assessed to having GCS scores covering almost the complete range of values.

Conclusions

The results showed that most participating physicians were not aware that coma and unconsciousness are synonyms. Moreover, this demonstrates that much uncertainty is associated with the terms somnolence, sopor and stupor. In order to describe altered levels of consciousness, particularly in trauma patients, restrictions should be placed on the terms impaired consciousness and unconsciousness with a parallel use of the numerical GCS scale.     

A 6-week,multicentre, randomised,double-blind,double-dummy,active-controlled,clinical safety study of lumiracoxib and rofecoxib in osteoarthritis patients

Background  

Lumiracoxib is a selective cyclooxygenase-2 inhibitor effective in the treatment of osteoarthritis (OA) with a superior gastrointestinal (GI) safety profile as compared to traditional non-steroidal anti-inflammatory drugs (NSAIDs, ibuprofen and naproxen). This safety study compared the GI tolerability, the blood pressure (BP) profile and the incidence of oedema with lumiracoxib and rofecoxib in the treatment of OA. Rofecoxib was withdrawn worldwide due to an associated increased risk of CV events and lumiracoxib has been withdrawn from Australia, Canada, Europe and a few other countries following reports of suspected adverse liver reactions.     

Bacteria,toxins, and the peritoneum

Intraperitoneal infections are caused by members of the gastrointestinal flora, mainlyEscherichia coli, enterococci, Klebsiella, Enterobacter, Proteus, Bacteroides, anaerobic cocci, Clostridia, and Fusobacteria. The Gram-negative aerobic bacteria exert their pathogenic potential mainly through endotoxin which acts by way of mediators, causing systemic septic response and, initially, the local response of the peritoneal cavity. The main virulence factors of anaerobic bacteria are exoenzymes and capsular polysaccharides. Peritoneal infections are truly synergistic infections. The most important synergistic mechanisms are protection against host defense and creation of a suitable environment by one member of the flora for another. Aside from bacteria, certain adjuvant substances, i.e., bile, gastric juice, blood, and necrotic tissue, play a role in the pathogenesis of peritonitis. The peritoneum deals with an infection in 3 ways: first, the direct absorption of bacteria into the lymphatics via the stomata of the diaphragmatic peritoneum; second, the local destruction of bacteria through phagocytosis by either resident macrophages or polymorphonuclear granulocytes attracted to the peritoneal cavity; and third, the localization of the infection in the form of an abscess.

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Resumen Las infecciones intraperitoneales son causadas por miembros de la flora gastrointestinal, principalmenteEscherichia coli, enterococos, Klebsiella, Enterobacter, Proteus, Bacteroides, cocos anaeróbicos, Clostridia, y Fusobacterias. Las bacterias aeróbicas Gram-negativas ejercen su potencial patogénico principalmente a través de la endotoxina que actúa por vía de mediadores, lo cual causa la respuesta séptica sistémica e inicialmente la respuesta local en la cavidad peritoneal. Los principales factores de virulencia de las bacterias anaeróbicas son las exoenzimas y los polisacáridos capsulares. Las infecciones peritoneales son realmente infecciones sinérgicas. Los más importantes mecanismos de sinergismo son la protección contra las defensas del huésped y la creación de un ambiente adecuado, por parte de un miembro de la flora en favor de otro. Además de las bacterias, ciertas sustancias adyuvantes, como bilis, jugo gástrico, sangre, y tejido necrótico desempeñan un papel importante en la patogenesis de la peritonitis. El peritoneo se enfrenta a la infección de 3 maneras. En primer lugar mediante la absorción directa de bacterias por los linfáticos vía los estomas del peritoneo diafragmático; en segundo, por la destrucción local de bacterias por fagocitosis por la macrófagos residentes o por los granulocitos polimorfonucleares atraídos por la cavidad peritoneal, y en tercero mediante la localización de la infección en forma de absceso.

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Résumé Les infections intrapéritonéales sont provoquées par les germes de la flore gastro-intestinale:Escherichia coli, enterococci, Klebsielles, Enterobacter, Proteus, Bactéroïdes, cocci anaérobiques, clostridias, et Fusobactéries. Les bactéries Gram-négatives aérobiques exercent leur potentiel pathogénique par l'intermédiaire d'une endotoxine qui, agissant sur les médiateurs, provoque une réponse locale péritonéale et systémique au sepsis initial. Les principaux facteurs de virulence des bactéries anaérobies sont dus à des exoenzymes et des polysaccharides capsulaires. Les infections péritonéales sont de véritables infections synergistiques. Les mécanismes synergistiques les plus importants sont la protection contre les moyens de défense de l'hôte et la création d'un environnement propice pour un autre par un germe de la flore. Outre les bactéries, certaines substances adjuvantes (bile, suc gastrique, sang, et tissus nécrotiques) jouent aussi un rôle dans la pathogenèse de la péritonite. Trois réactions péritonéales sont possibles: les bactéries sont captées et acheminées vers la grande circulation par les lymphatiques traversant le diaphragme; les microbes sont localement détruits par phagocytose des macrophages résidents ou des polynucléaires attirés vers la cavité péritonéale; et l'infection se localise sous forme d'abcès.

     

Transcapillary exchange and retention of fluoride,strontium, EDTA,sucrose, and antipyrine in bone

Summary The extractions of⁸⁵Sr²⁺,¹⁸F⁻, sucrose-¹⁴C, EDTA-⁵¹Cr, and antipyrine-¹⁴C in bone were determined by the multiple indicator-dilution method. Fluoride and strontium extractions were 18 to 70% during a single transcapillary passage, and those of EDTA and sucrose were from 11 to 59%, whereas extraction of antipyrine was 87%. Injections of⁸⁵Sr²⁺ and¹⁸F⁻ made when perfusion was done alternately with blood and plasma resulted in similar fractional extractions. When flow and extraction were measured simultaneously, extraction was related inversely to flow.     

201. Strumachirurgie,KlaBifikation, Therapie,ErgebniBe

ZusammenfaBung Von 1960-1976 wurden an der Chirurgischen Klinik der Universität München 2370 Patienten an der Schilddrüse operiert. Davon 2150 wegen einer benignen und 220 wegen einer malignen Struma. Der prozentuale Anteil der einzelnen Krankheitsbilder betrug: Blande Struma 58,2%; autonomes Adenom 19,4%, Hyperthyreose (Typ M. Basedow) 11,3%, Struma maligna 9,3 %, Thyreoiditis 1,8%. Zur präoperativen Diagnostik, Operationsindikation sowie zum operativen Vorgehen werden allgemeine Richtlinien gegeben. Besonders herausgestellt wird die Problematik der intraoperativen Schnellschnittdiagnostik bei Verdacht auf Struma maligna. Der Wert einer cyto-morphologischen Diagnose und die p. op. Nachsorge wird herausgestellt.     

Transatlantic registries of pancreatic surgery in the United States of America,Germany, the Netherlands,and Sweden: Comparing design,variables, patients,treatment strategies,and outcomes

BackgroundRegistries of pancreatic surgery have become increasingly popular as they facilitate both quality improvement and clinical research. We aimed to compare registries for design, variables collected, patient characteristics, treatment strategies, clinical outcomes, and pathology.MethodsRegistered variables and outcomes of pancreatoduodenectomy (2014–2017) in 4 nationwide or multicenter pancreatic surgery registries from the United States of America (American College of Surgeons National Surgical Quality Improvement Program), Germany (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie - Studien-, Dokumentations- und Qualitätszentrum), the Netherlands (Dutch Pancreatic Cancer Audit), and Sweden (Swedish National Pancreatic and Periampullary Cancer Registry) were compared. A core registry set of 55 parameters was identified and evaluated using relative and absolute largest differences between extremes (smallest versus largest).ResultsOverall, 22,983 pancreatoduodenectomies were included (15,224, 3,558, 2,795, and 1,406 in the United States of America, Germany, the Netherlands, and Sweden). Design of the registries varied because 20 out of 55 (36.4%) core parameters were not available in 1 or more registries. Preoperative chemotherapy in patients with pancreatic ductal adenocarcinoma was administered in 27.6%, 4.9%, 7.0%, and 3.4% (relative largest difference 8.1, absolute largest difference 24.2%, P < .001). Minimally invasive surgery was performed in 7.8%, 4.5%, 13.5%, and unknown (relative largest difference 3.0, absolute largest difference 9.0%, P < .001). Median length of stay was 8.0, 16.0, 12.0, and 11.0 days (relative largest difference 2.0, absolute largest difference 8.0, P < .001). Reoperation was performed in 5.7%, 17.1%, 8.7%, and 11.2% (relative largest difference 3.0, absolute largest difference 11.4%, P < .001). In-hospital mortality was 1.3%, 4.7%, 3.6%, and 2.7% (relative largest difference 3.6, absolute largest difference 3.4%, P < .001).ConclusionConsiderable differences exist in the design, variables, patients, treatment strategies, and outcomes in 4 Western registries of pancreatic surgery. The absolute largest differences of 24.3% for the use of preoperative chemotherapy, 9.0% for minimally invasive surgery, 11.4% for reoperation rate, and 3.4% for in-hospital mortality require further study and improvement. This analysis provides 55 core parameters for pancreatic surgery registries.