Was muss ich praktisch bei der Umsetzung einer Chemotherapie beachten?

The patient stands at the center of a chemotherapy. The aim of the curative or palliative treatment is not only the death of the tumor cells, but also the maintenance or improvement of the patient’s physical condition, especially the improvement of quality of life. Before starting the therapy, it is necessary to determine, for example, the patient’s general condition and motivation, and to carry out a consultation. Examinations, for example, blood tests, audiograms, renal function and lung function should also be made. Thus, the patient’s tolerance for even the most onerous chemotherapy can be investigated and patients can be individually prepared for the treatment.     

伯基特淋巴瘤化疗后合并巨细胞病毒视网膜炎一例

目的提高对伯基特淋巴瘤化疗后合并巨细胞病毒视网膜炎的认知。 方法分析1例58岁伯基特淋巴瘤化疗后合并巨细胞病毒视网膜炎患者的诊治过程,并结合相关文献进行复习。 结果该例伯基特淋巴瘤患者多疗程化疗后病情缓解,缓解后出现长期营养不良,抵抗力低下,免疫重建受损,诱发巨细胞病毒感染并引起巨细胞病毒视网膜炎,经更昔洛韦注射液抗病毒治疗后巨细胞病毒DNA低于检测下限,视力逐渐改善。 结论及时确诊及规范治疗是控制免疫化疗后合并巨细胞病毒视网膜炎病情及改善预后的关键。     

Improvement in physician pain perception with using pain scales

Background and aims

Acute pain is the most common reason for visits to the emergency department (ED). The underuse of analgesics occurs in a large proportion of ED patients. The physician’s accurate assessment of patients’ pain is a key element to improved pain management. The purpose of this study was to assess if physicians’ perception of pain can improve with looking at the pain score of the patient marked on VAS.

Study design

This was a single-center, cross-sectional prospective observational study, that took place in an academic ED.

Methods

All adult ED patients presenting with a painful condition were enrolled to the study. In the first phase of the study, the physician rated his/her opinion about the patient’s pain on a 100 mm VAS, in a blinded fashion to the patient’s pain score. In the second phase, the physician rated his/her opinion after looking at the pain scale marked by patient.

Results

587 patients (295, in first and 292, in second phase) were enrolled. The groups were not statistically different for demographic data. The physician’s perception of pain was lower than the patient’s pain score at both phases of the study. Insight of the patient’s pain score on VAS increased the physician’s pain perception significantly (p?=?0.03). During the second phase, physicians ordered significantly more analgesic medications to the patients (p?=?0.03).

Conclusion

The physicians’ perception of the patients’ pain differs significantly from the pain that the patient is experiencing. VAS helps to bring the physicians impression of pain perception to the level of pain that the patient is actually experiencing and resulted in ordering more analgesics to the patients. Implementation of a pain assessment tool can raise the physician’s perception of the pain and may improve pain management practices and patient satisfaction.

     

Anatomical measurements of the gastric cardia in obese patients

Background

Currently, surgeons implant a variety of laparoscopic adjustable gastric bands. However, there is little data to guide the selection process. This study aims to determine the relationship between a patient’s body mass index (BMI), height, and weight and the anatomical measurements of the gastric cardia in morbidly obese patients undergoing laparoscopic adjustable gastric band (LAGB) surgery.

Methods

A total of 67 morbidly obese patients undergoing LAGB surgery were studied. Intraoperative measurements of the gastric cardia were obtained. The relative circumference and posterior diameter of the gastric cardia were measured along with the patient’s height, weight, and BMI. Pearson’s correlation coefficient was used to measure the relationship between the circumference and posterior diameter of the gastric cardia and the BMI, height, and weight. A p < 0.05 was considered significant.

Results

No correlation exists between a patient’s BMI or weight and the circumference or diameter of the gastric cardia. A correlation exists between a patient’s height and the posterior diameter of the gastric cardia (p = 0.02). Of note, there is a correlation between the relative circumference and the posterior diameter of the gastric cardia for each patient (p = 0.05).

Conclusion

Our unique data show no significant correlation between a patient’s BMI and weight and the measurements of the gastric cardia. There was a correlation between a patient’s height and the posterior diameter of the gastric cardia. These intraoperative measurements may help surgeons objectively select the appropriate band for each respective patient undergoing LAGB surgery. This may potentially decrease postoperative dysphagia.     

Pancreas transplant and incidental Meckel's diverticulum: not always a straightforward decision

Abstract: Introduction: Unexpected intraoperative findings are not rare in surgical practice. Meckel’s diverticulum with a mass is one such example. There are only two previously reported cases of Meckel’s in transplantation, and neither involved pancreas transplant. Results and discussion: We present a case report of novel surgical technique using a Meckel’s diverticulectomy site for the duodeno‐enterostomy to managing the exocrine secretions of the transplanted pancreas. We also discuss management of Meckel’s diverticulum. The patient tolerated the procedure without complication, and continues to have normal renal and pancreatic function without any gastrointestinal (GI) complaints. The excised Meckel’s diverticulum contained both gastric and pancreatic tissue. Conclusion: Although uncertainty about the best management practices exists in the general surgery patient population, given the potential complications that may arise from Meckel’s diverticulum, in transplant patients the Meckel’s should be removed when encountered. The point of excision can safely be incorporated into other intestinal anastomoses.     

Datenschutz in der gesetzlichen Unfallversicherung aus der Sicht der für die Unfallversicherungsträger tätigen Ärzte

The physician’s duty of professional discretion is one of the basic tenets at the heart of the doctor’s profession. It is laid down in the physicians’ professional code and determined ultimately by the patient’s right to self-determination, which is regulated in §203 of the German Criminal Code. It is established in the ordinance governing physicians’ work and has its origin in the patient’s right of self-determination. It is also regulated in §203 of the German Criminal Code. An exception can be made to the duty of professional secrecy if a patient gives express permission for this or if it is allowed or required by law. Some such exceptions are also specified in the German Social Code, although the physician’s duty of disclosure is then always precisely stated, particularly when medical data in the strictest sense of the phrase are concerned. Borderline cases are described to illustrate how the rules of professional medical discretion are breached in the course of day-to-day business transacted between the statutory accident insurance firms and the physicians under contract to them, and some hints are given on how this can be avoided.     

Custom‐made Prosthesis for Reconstruction after Radical Resection for Chondrosarcoma of Manubrium

The clinical incidence of tumors in the manubrium is not high. Regardless of whether the tumor is primary or metastatic, the tumor should be completely removed as long as the patient is able to tolerate the surgery. This procedure can lead to sternal defects. Deciding on the method of defect reconstruction is a critical problem that clinicians face. In this , to reduce the limitations of the patient’s upper body movement after surgery due to the inflexibility in the connections of the sternal prosthesis, we created a prosthesis using a computer‐assisted design method and a 3‐D technique, to completely preserve the agility of the sternum and maximize the patient’s post‐operational movement. The method used in the present study takes into consideration the individual’s chest anatomy, sternum stress, and many other biological characteristics. Care is taken to measure the sternum size accurately, to provide personalized treatment, to accomplish precise results, and to reduce potential future damage. The patient’s shoulder function was improved following the procedure.     

Wirbelsäulendeformitäten bei Parkinson

Spinal deformities in Parkinson’s disease are difficult to treat but with good indications, spinal surgery is a better treatment option taking into account all factors that accompany Parkinson’s disease. Despite greater operational time and cost expenditure with a long rehabilitation period, long stretch segmental fusion is preferable to short stretch segment fusion due to the lower revision rate. An adequate postoperative rehabilitation and good patient care is essential for success. This case illustrates successful treatment of a patient with Parkinson’s disease and camptocormia by long stretch segmental fusion.     

Chirurgische Therapie der Anorexia nervosa

The case of a female patient with rapid weight loss of unknown cause is reported. Numerous diagnostic procedures revealed no plausible cause for the patient’s cachexia. An occult malignant tumor was assumed. Psychiatric evaluation confirmed the diagnosis of a neurotic disease. A review of the patient’s angiogram showed occlusive disease of all mesenteric arteries. This was followed by mesenteric revascularisation. Rapid weight gain was paralleled by the disappearance of the neurotic symptoms. Ten years later, the patient continues to enjoy good health.     

Reduced port laparoscopic surgery using umbilical zigzag incision for Meckel’s diverticulitis

IntroductionReduced port laparoscopic surgery using an umbilical zigzag incision is comparable to conventional multiport laparoscopic surgery. This method is associated with improved cosmesis and decreased wound pain.Presentation of caseA 67-year-old man visited our hospital. He presented emergency room with a chief complaint of right lower abdominal pain by walking. The patient was diagnosed Meckel’s diverticulitis by computed tomography (CT). At first, antibiotics therapy and fasting were performed. Three months later, the patient underwent resection of Meckel’ diverticulum with zigzag transumbilical laparoscopic surgery. The patient’s postoperative course was good, and he rarely felt wound pain. The patient started oral intake three days after surgery, and was discharged 10 days after surgery.DiscussionZigzag transumbilical laparoscopic surgery is very useful for resection of the small intestine. This method is associated with improved cosmesis and decreased wound pain. In the case of Meckel’s diverticulitis, we suggest that interval resection of Meckel’s diverticulum was very useful as it was an operation that could be performed easily.ConclusionReduced port laparoscopic surgery using an umbilical zigzag incision is considered to be an excellent technique in terms of operability and aesthetic outcomes.     

Robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus

We report the case of a morbidly obese patient with situs inversus who presented for robotic-assisted Roux-en-Y gastric bypass. To do the procedure, the ports were reversed and the first assistant stood on the opposite side of the table. With these minor modifications to technique, the surgery was successfully performed without confusion over the patient’s anatomy. There were no intraoperative complications. The patient’s postoperative course was uneventful and he was discharged on postoperative day 3. We believe this is the first reported robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus.     

A unique presentation of ectopic thyroid,a case report

IntroductionThis case presents a painful ectopic thyroid, an unusual presentation, in an atypical location. The patient’s history of an ingested fish bone, her acute presentation, and inconclusive imaging, made this case a diagnostic dilemma.Presentation of case61-year-old female presented with acutely worsening history of left throat pain and dysphagia after swallowing a fish bone. CT scan showed a foreign body in the anterior wall of the cervical esophagus. EGD studies were inconclusive. Surgical exploration identified and excised a multinodular cystic lesion without connection to esophageal lumen. Pathology described multinodular thyroid parenchyma with chronic inflammation and no evidence of malignancy. No foreign body was located.DiscussionBased on the patient’s history, imaging, and acute presentation, an esophageal perforation with abscess formation was the most likely diagnosis. Surgical exploration was the necessary intervention for this patient’s acute symptoms as both a diagnostic and therapeutic tool. The diagnosis of ectopic thyroid tissue from pathology of the excised cystic lesion was unexpected, as the location of tissue and the painful presentation are not typical characteristics of ectopic thyroid tissue. Management of the this case illustrates the dilemma faced in determining the appropriate work up for a patient, without compromising the patient’s safety.ConclusionThough painful presentation and this case’s location are rare, ectopic thyroid tissue should be included in the differential diagnosis of point tenderness with an associated lesion on imaging.     

Gallstone obstructing the duodenum. Report of two cases of Bouveret’s syndrome

Bouveret’s syndrome is the obstruction of the duodenum due to a gallstone. It is a rare condition, known for over a century that continues to confound emergency room physicians and surgeons to this day. We present two cases of Bouveret’s syndrome. The first is a 63-year-old female patient with a 4 cm gallstone obstructing the third part of the duodenum. The patient underwent prompt surgery and the gallstone was removed through the jejunum. The other patient’s course, an 88–year-old male, was more complicated. After fluid resuscitation and an attempt at endoscopic removal, a gallstone obstructing the first part of the duodenum was surgically removed through a gastrotomy. Both patients recovered fully and were discharged. Both cases presented many dilemmas and challenges from the diagnosis to the final management.     

Verbesserung der Behandlung von Patienten mit akutem Koronarsyndrom durch Aufbau einer Netzwerkstruktur im ländlichen Raum

Patient’s therapy with acute coronary syndromes (ACS) in rural areas should be improved in Germany. The emergency physician’s technical possibilities for diagnosis and therapy at patient’s bed side is often limited. For patients with ACS it is not possible to reach a cardiologic center for guideline therapy immediately because of missing infrastructure in rural areas. Therefore it is necessary to establish a network structure between emergency physicians and cardiologic centers to optimize patient’s treatment. We describe in this article the foundation of a network between emergency physicians and a cardiologic center in our community. We have documented the treatment results of 537 patients with ACS. The total mortality in patients with ACS, unstable angina, non ST-elevation myocardial infarction, and ST-elevation myocardial infarction, together was lower than 5%.     

Principles of organizing a surgical list

The principles of organizing a theatre list are based on a multidisciplinary, safety-centred approach to patient care and require a surgeon to have good organizational, communication and leadership skills.It is important to understand the processes and protocols required to ensure patient safety and maintain theatre efficiency, as well as the various patient-specific and operation-specific factors that need to be considered when booking cases.This article aims to cover the various steps through a patient’s journey from the decision to treat through to aftercare, highlighting the factors that the surgeon should consider at each stage. They include the preoperative planning process from pre-assessment to booking cases, and embraces day-of-surgery issues from team briefing to the perioperative care of the patient’s co-morbidities.Preoperative planning is essential in the complexity of modern day surgery to ensure patient safety and maintain theatre efficiency. The contemporary surgeon should be prepared constantly to evolve processes and improve team skills to enhance their patient’s experiences and outcomes. A thorough grasp of the principles behind running an operating list is vital for the maintenance of good surgical practice.     

Abdominaltrauma

Abdominal trauma is still a challenge in clinical practice. A structured management routine is nescessary to ensure rapid diagnosis and treatment so as to reduce morbidity and mortality. Injuries to solid organs exert a particularly strong influence on the patient’s prognosis and clinical course. In the case of hepatobiliary and splenic trauma the main challenge lies in the need to control life-threatening bleeding, while in pancreatic injuries the primary goal is the avoidance of septic complications. It is essential to tailor operative treatment to the patient’s injuries and general hemodynamic situation.     

The head butler with design modification: a useful mountable shelf for the operating table in robotic surgery

The ‘head butler’ or ‘iron maiden’, as it is sometimes referred to, is a mountable shelf that is attached to the main operating room table using stirrup clamps or brackets. It provides an elevated flat surface, which protects the patient’s face and chest from inadvertent trauma of robotic arms, instruments and camera while also serving as a platform for placement of instrumentation that minimizes handoffs to improve workflow. Its canted design also prevents slippage of instruments off the operating field during steep Trendelenburg positioning. This operating room equipment was designed to improve efficiency in an operating room set-up while ensuring safety during patient positioning when performing robotic procedures. A modification of the original Head Butler^® (Tri-Medical Corporation, Portland, OR, USA) is presented here which improves upon the design by avoiding brachial plexus nerve injury to the patient due to pressure from the uprights pressing on the patient’s shoulders during use.     

Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons

Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients’ wishes, their surrogates’ wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon’s interest in gathering additional information on the patient’s social environment and supposed patient’s wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.     

Editorial Commentary: Preoperative Exercise,Workers’ Compensation,Diabetes, Lateral Extra-Articular Tenodesis,and Return to Sport Determine Patient Satisfaction After Anterior Cruciate Ligament Reconstruction

Patient-reported outcome measures (PROMs) have been developed and used as the primary determinant of successful patient-centered results. The patient acceptable symptomatic state delineates an absolute value for PROMs indicating that patients are satisfied with their outcome. When this metric is used for anterior cruciate ligament reconstruction, patients reach a satisfactory outcome at between 6 and 8 months postoperatively, and more than 90% reach a satisfactory outcome at 12 months. Preoperative variables such as preoperative exercise, Workers’ Compensation, and diabetes impact patient outcomes, whereas preoperative PROMs and use of the anteromedial portal technique for femoral tunnel drilling have a limited impact on satisfaction. Iliotibial band tenodesis shows a large impact on satisfactory outcomes; however, this result may be affected by patient demographic issues (selection bias). Ultimately, a “satisfactory” outcome is a very general term and may not necessarily apply to active athletes desiring a return to competitive sport. Thus, the patient acceptable symptomatic state should be interpreted in combination with a surgeon’s experience. Ultimately, the success of a surgical procedure could be determined, in large part, based on the patient’s individual preoperative expectations.     

乳腺癌孤立性局部区域复发的诊断和治疗

乳腺癌孤立性局部区域复发受多种危险因素影响,虽然预示着随后可能出现远处转移,然而经过规范的诊断和治疗,仍可获得较好的局部控制率和远期生存率。其复发具有较大的临床异质性,因而治疗也应根据不同的情况选择合理的局部治疗和全身治疗手段,达到改善患者生活质量和提高远期生存的目的。