Interdisziplinäre Behandlung der Weichgewebesarkome der Extremitäten

Soft tissue sarcomas are a rare and heterogeneous group of tumors. Surgery clearly remains the standard therapy of non-metastatic soft tissue sarcoma. A pretreatment biopsy is necessary to determine the histology and grade of soft tissue sarcomas and to diagnose entities that can be treated by targeted therapies, such as dermatofibrosarcoma protuberans or alveolar soft tissue sarcoma once they are in a metastatic stage. Nevertheless, locally advanced disease requires multimodal treatment and interdisciplinary treatment decisions. Limb sarcoma of borderline resectability (encasement of vessels, invasion of joints or close proximity to motor nerves) may profit from isolated limb perfusion with recombinant tumor necrosis factor and melphalan. Preoperative chemotherapy may be applied in locally advanced high grade tumors when clear resection margins are difficult to achieve. Deep wave hyperthermia has proven to be a useful addition to systemic chemotherapy in such a neoadjuvant setting. Also preoperative radiation therapy has proven to be effective in controlling locally advanced sarcoma despite higher perioperative morbidity which pays off in the long run by better limb function. Postoperative adjuvant external beam irradiation therapy with the best available technique is recommended for any tumor larger than 5 cm with (FNLCC) grades 2 and 3 (American Joint Committee on Cancer stage IIb/III). Given all these therapeutic options, it is absolutely crucial that interdisciplinary decision-making starts early in the therapeutic process. Patients are often seen first by the surgeon. For an optimal treatment surgeons need to know the efficacy and toxicity of the multimodal treatment options described.     

Pioniere der Extremitätenverlängerung

Successful lengthening of the extremities was first published at the beginning of the twentieth century. Those reports in which methods such as the distraction of fragments, callus or epiphysis were mentioned for the first time are reviewed. Lengthening of the extremities by epiphyseal distraction was first mentioned by Bernhard v. Langenbeck in 1869 in an animal experiment. The publications of Codivilla, who introduced lengthening by fragment distraction, Kirschner, Bier and others are cited and analyzed critically. Thus, the historical development of the lengthening of the extremities is reported from 1869 to the middle of the twentieth century.     

Zur Mechanik der Ringbrüche der Schädelbasis und der Verletzungen der oberen Halswirbelsäule

Zusammenfassung Bei Ringbrüchen der Schädelbasis kann es sich um Impressions- oder Traktionsfrakturen handeln. Impressionsfrakturen können beim Fall aus der Höhe und Aufschlag auf die Beine oder das Gesäß, Gewalteinwirkungen gegen die Scheitelgegend aber auch bei solchen gegen die Schädelbasis eintreten. Traktionsfrakturen sind die Folge einer Schleuderung des Kopfes nach hinten oben (Beugung und Zerrung) und können bei Gewalteinwirkungen gegen das Gesicht oder gegen den Rumpf, hier besonders gegen den Rücken, auftreten. Die Unterscheidung, ob eine Impressions- oder eine Traktionsfraktur vorliegt, wird nach dem Verhalten der Bruchkanten (Knochenquerschnitt) getroffen. Nach Gewalteinwirkungen gegen den Rücken, aber auch von der Seite gegen den Rumpf kann es zu einem Abriß des Bandapparates zwischen Hinterhaupt und den oberen Halswirbeln kommen, ohne daß Frakturen an der Insertionsstelle der Bänder aufzutreten brauchen. Abrisse des Dens epistrophei als indirekte Verletzungen treten vorzugsweise bei seitlich oder von hinten seitlich gegen den Körper ansetzenden Traumata auf. Rupturen der basalen Hirnarterien brauchen sich nicht in der Umgebung des Skeletschadens zu finden, sondern können durch Fortleitung der Zugwirkung auch an anderen Stellen hervorgerufen werden. Ein Locus minoris resistentiae gegenüber kräftigen Zerrungen ist der Übergang von der Pons zur Medulla oblongata.Mit 7 Textabbildungen (13 Einzelbilder)     

Regionalanästhesie in der Orthopädie

Regional anesthesia has its place in the perioperative pain management of orthopedic patients. A reduction in postoperative mortality and morbidity with regional anesthesia is acknowledged for subsets of patient populations. Single shot and continuous applications are techniques for providing regional analgesia. Continuous infusion of local anesthetics with catheter techniques provides for uninterrupted postoperative analgesia. The combination of regional and general anesthesia reduces the consumption of systemic anesthetics. The side effects of opioid therapy are thereby reduced. The inhibition of intraoperative stress reaction, especially with epidural anesthesia, helps to prevent or lower unwanted metabolic changes. Patient contentment with analgesic quality differs with the technique with which the regional anesthesia is applied (PDA, PCEA, IVRA, peripheral block, i.a. injection), and the medication (LA, opioid) used.     

Berufliche Belastungsschäden der Wirbelsäule

Ohne ZusammenfassungMit 7 TextabbildungenNach einem auf der Arbeitstagung über degenerative Wirbelsäulenerkrankungen in Leipzig (Juni 1955) gehaltenen Referat.     

Spätresultate der hochdiaphysären Osteotomie in der Behandlung der irreponiblen Luxatio coxae congenita

Ohne ZusammenfassungMit 6 Textabbildungen     

Zur Frage der Entstehung der Gelenkmäuse

Ohne Zusammenfassung     

Qualitätsmanagement aus der Sicht der Krankenhausleitung

Background

Within the framework of patient care quality assurance and therefore quality management are of decisive significance. In this context it is questionable whether quality management has the same importance for all players.

Quality management

In contrast to medical and nursing personnel who are more concerned with the perspective of the discipline with the aim of therapeutic validation with full responsibility for quality, the perspective of the hospital management is more comprehensive and includes the complete hospital, the system. The management perspective is therefore correspondingly different.

Problem

The different perspectives often lead to misunderstandings, for example between department heads and hospital management. The frequently observed lack of willingness to accept change also leads to tension between system (hospital management) and faculty management (medical and nursing personnel) and reduces performance, even for the quality management.

Conclusion

By the implementation of integratively effective multiprofessional hospital performance management (HPM) the quality management can be improved. Medical and nursing personnel should also be actively involved in the optimization as this problem can only be solved in an interdisciplinary and multiprofessional manner and also results in changes in internal behavior which in turn have an effect on the quality of results in hospitals.     

Veränderungen der Muskarinrezeptoren der alternden Harnblase

The prevalence of the overactive bladder syndrome (OAB) increases with age. Unfortunately, treatment of the condition is still unsatisfactory. Since muscarinic receptor antagonists are the only effective drug treatment to date, it is logical to assume that muscarinic receptors play an important role in the pathogenesis of OAB. Muscarinic receptors are involved in both the normal and overactive detrusor contraction, and age-dependent changes in muscarinic receptor functions have been found in both animals and human detrusors. In animals as well as humans, two components of detrusor contraction have been demonstrated, the dominating one mediated by muscarinic receptors and the other by ATP (atropine-resistant component). The muscarinic receptor-mediated component decreases with age, and the ATP (purinergic) part increases. However, the clinical consequence of this is unclear, since no major age-dependent changes in the efficacy of antimuscarinic agents in the treatment of OAB have been demonstrated.     

Präklinische Immobilisation der Wirbelsäule

Background and objectives

The question about the need of spinal immobilization of trauma patients in general, and the various ways to do it in particular are nowadays increasingly discussed in scientific literature. Furthermore, daily practice of spinal immobilization routines also reflects a huge heterogeneity. The aim of this article is to give an overview about exemplarily selected literature on the subject of spinal immobilization of trauma patients. Thus, possible recommendations concerning spinal immobilization could be derived by the reader.

Spinal immobilization of trauma patients

The general lack of evidence towards spinal immobilization is well known. In the current scientific literature increasing hints can be found that the sole application of a cervical collar does not ensure a sufficient immobilization of the cervical spine. Thus, total spine immobilization, meaning fixation of the entire body of the trauma patient is recommended. However, total spine immobilization is also said to be associated with significant complications such as aggravated airway management or reduced lung function due to restrictions. Furthermore, the application of a cervical collar can lead to increased intracranial pressure. Thus, the indication for spinal immobilization should be sophisticated on behalf of immobilization decision tools such as the Canadian C-spine rule. In patients with acute life threatening conditions such as Hemorrhagic shock, it must be decided whether the immediate transport can be delayed by immobilization procedures. In the case of a trauma patient suffering from severe traumatic brain injury, one should consider whether the application of a cervical collar is mandatory or if alternative ways of immobilization could be carried out. Hence, the vacuum mattress offers better stability and greater comfort during total spinal immobilization compared to the spine board.

     

Qualitätsmanagement in der Anästhesie

Quality of care and costs are getting closer together. Whereas costs and quality management did not play a substantial role 30 years ago, the consumption of resources nowadays is part of the outcome of quality of care. The definition of quality must be seen in the dimensions of structure, process and result. Resulting from newly developed clinical practice, guidelines are planned as instruments for cost containment in near future. Those guidelines may end up in a quality management system. The most wellknown european basic of such a quality management system are the DIN EN ISO 9000 f and the EFQM. The ISO 9001 and the European Quality Award became the most common base of evaluation for certification of quality management systems in Organisations European wide. Whereas the ISO 9001 does not give any information about the real achieved quality, the European Quality Award reflects the process.Guidelines are necessary to prove the cost effectiveness of measures of quality control and quality assurance since too much quality control and assurance may result in increased overall consumption of resources, leading to a reduction in the quality of care when ensuring that the overall budget is covered.     

Qualität der BQS-Dokumentation

Background

The BQS is a nationwide quality assurance program in Germany. The aim was to evaluate the data quality on intra-operative and postoperative complications for cholecystectomy submitted to the BQS.

Patients and methods

For 205 patients who underwent cholecystectomy in 2007 complications were retrospectively evaluated and compared with those documented in the BQS database. Additionally the risk factors for complications were documented.

Results

A total of 205 patients were included in the study. In 88% of patients the operations were initiated as laparoscopy and the conversion rate was 8.3%. Of the patients 28 suffered from intra-operative or postoperative complications. There were no injuries to the ductus hepatocholedochus (DHC). The most common operation-specific complications were disorders in wound healing (n=7). Multivariate analyses resulted in significant increases in complication rates for ASA status (Odds ratio 3.29, 95% confidence interval 2.12–5.10, p<0.01) and acute cholecystitis (odds ratio 7.71, 9% confidence interval 2.96–20.08, p<0.01). Only 13 patients out of 28 were correctly documented in the BQS database (p<0.01). Sensitivity and specificity for complications were 46 and 98%, respectively.

Conclusions

Less than half of all cases were correctly documented in the BQS database. If documentation inthe BQS database was equally poor for all German surgical departments, neither benchmarking nor general conclusions on quality of surgical care could be drawn from the BQS data.     

Frakturen der Halswirbelsäule

Due to the high incidence of concomitant neurological lesions, standardized clinical and radiologic diagnostic procedures in cervical spine injuries are mandatory. Magnetic resonance imaging or a stress X-ray should be performed when discoligamentous injuries are suspected. The three most important pillars in the treatment of cervical spine injuries are the surgical indication, the surgical approach and the choice of implant. However, despite prompt and appropriate therapy many of these injuries lead to permanent functional impairment depending on the type of fracture. This article summarizes the most frequent fracture types of the cervical spine, as well as the corresponding therapeutic options and outcome.     

Verletzungen der Ringbänder

Trend sports have lead to an increase in annular ligament injuries in recent years. Careful clinical examination and ultrasound diagnosis determine the therapy options.     

Epidemiologie der Extremitätenfrakturen

To analyze age- and sex-specific frequencies of peripheral fractures, we used data from the third MONICA-Augsburg Survey (1994/95). The study comprises 2404 male and 2450 female participants (age 25 to 74 years) who were questioned regarding fracture history. We investigated fracture prevalence, age-specific incidence rates, and the circumstances under which the fractures occurred. The age-standardized, cumulative fracture prevalence among men (m) 25 to 74 years of age was 45% and among women (w) of the same age 31%. Fracture prevalence among women was more than 10% lower than among men in the younger age groups (age 25 to 64 years), but after an significant increase in the 65 to 74-year-olds the fracture prevalence corresponded to that of men (m: 42%, w: 40%). A peak of incidence rates was found among men at age 15-24 (overall incidence rate: 2017 fractures/100,000 person-years) and at age 45-54 (overall incidence rate: 1640 fractures/100,000 PY), respectively, and among women at age 65-74 (overall incidence rate: 3214 fractures/100,000 PY). The prevalence of self-reported osteoporosis (age 25 to 74 years) was higher in women (7%) than in men (1%). Falls caused 43% (w: 59%, m: 33%) of all fractures, external violence 40% (m: 47%, w: 29%), and sports activities 15% (m: 18%, w: 10%). Further investigation of risk factors related to fractures can contribute to the development of specific preventive measures in that field. In the future, the prevention and efficient treatment of an existing or an often undiagnosed osteoporosis and also the prevention of falls in elderly persons should be an important public health concern.     

Weichteilsarkome der Extremitäten

Whereas amputation was regularly carried out as a curative treatment strategy for soft tissue sarcomas of the extremities three decades ago, limb salvage procedures are nowadays preferred. In combination with adjuvant irradiation these procedures do not lead to higher recurrence rates.Limb salvage procedures are only considered if tumor-free resection margins and superior function can be achieved by extremity preservation compared with amputation. The modularity is a specific feature of tumor prostheses and forms the basis for the extensive flexibility of the surgeon and comprehensive possibilities for bone and joint reconstruction. The success of the development of modular tumor prostheses must be considered against the background of high rates of complications and revision.Studies of megaprostheses of the lower extremities show an implant survival of 77–100% after 10 years and a failure rate of 22% over 10 years. Due to a lower mechanical stress the results are better for the upper extremities. Infection rates for proximal humeral replacement are low. In contrast infection rates after proximal or distal femoral or proximal tibial replacement can be as high as 20–25%. After bone and joint replacement of the lower extremities and in particular after proximal tibial replacement, significant functional deficits are to be expected. Better results are reported after proximal femoral replacement and reconstructive procedures of the upper extremities.Studies on the quality of life after extremity preservation by means of tumor prostheses should include evaluation of complication and revision rates and aspects of postoperative function. An overall analysis of these factors is required for conclusive statements about amputation vs. reconstruction in individual cases.     

Neurobiologie der Opioidabhängigkeit

Die Anaesthesiologie - Die Opioidabhängigkeit ist eine chronisch verlaufende Erkrankung mit multifaktorieller Ätiologie. Neurobiologische Aspekte betreffen insbesondere die Manipulation...