Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients

This review was prompted by continued public and professional interest of necrotizing fasciitis as well as worldwide increases in the incidence of streptococcal invasive infections. Our objective was to outline the clinical course of necrotizing fasciitis and delineate factors relating to mortality among 163 diagnosed patients. Over 14 years patients diagnosed with necrotizing fasciitis were reviewed for patient history, comorbid conditions, and progression of clinical course. A logistic regression model was used to identify factors increasing mortality risk among necrotizing fasciitis patients. Nearly 17 per cent of the patients showed no identifiable antecedent trauma. Seventy-one per cent of tissue culture-positive patients (145) had multibacterial infections. Although no streptococcal species were recovered from one-third of these culture-positive patients there was an increase in mortality noted with beta-Streptococcus infections. Ninety-six per cent of the patient deaths were correlated with variables organized into the following categories: 1) patient history (intravenous drug use and age <1 or >60 years), 2) comorbid conditions (cancer, renal disease, and congestive heart failure), 3) characteristics of clinical course (trunk involvement, positive blood cultures, peripheral vascular disease, and positive cultures for beta-streptococcus or anaerobic bacteria), and 4) quantitative timeline of clinical course (time: injury to diagnosis, diagnosis to treatment). Mortality is correlated to patient history, comorbid conditions, and progression of clinical course. Necrotizing fasciitis can occur idiopathically and is generally a polymicrobial infection that sometimes occurs in the absence of streptococci. Clearly the mortality and morbidity associated with necrotizing fasciitis can be decreased with clinical awareness, early diagnosis, adequate surgical debridement, and intensive supportive care.     

Obstruction respiratoire au cours de l''anesthésie chez des enfants ayant un lymphome malin médiastinal

In children with a malignant mediastinal lymphoma, acute respiratory occlusion can be a life-threatening complication during general anaesthesia. 26 cases have been reported since 1973, with five deaths. There were 23 boys for 3 girls, aged between 13 months and 18 years. The hazards of anaesthesia in these children are described. The risk of airway obstruction should be assessed preoperatively. General anaesthesia, carried out with the patient half-sitting, should be aimed at maintaining spontaneous breathing, and therefore muscle relaxants should be avoided. The anaesthetist should also be prepared to change the patient rapidly to a lateral or prone position; a rigid bronchoscope should always be at hand. Preoperative awareness of the risk of respiratory occlusion in these patients is essential so that the correct anaesthetic technique can be chosen and the postoperative course prepared.     

Zertifizierungssysteme in der urologischen Versorgung

There have been function and organ-related certification systems in urology for a long time. The aim of such certificates is the optimization of patient care above the defined minimum standards and intensification of interdisciplinary cooperation. Whether such certificates have led to better patient care has not been proven. The obligatory documentation in epidemiological cancer registries, which has been taken up by legislature, will in future lead to so-called clinical cancer registries in which the complete course of treatment must be entered. With these registries the quality of healthcare can be compared between individual institutions. Until now, quality of care data outside oncology are lacking. Urology would also benefit from a registry with quality of care data for these patients.     

Patient monitoring techniques

The requirement for patient monitoring is an essential standard engrained into the modern practice of medicine. Accurate and contemporaneous monitoring to observe physiological parameters allows for timely interventions to guide patient care. Monitoring, whilst potentially complex in terms of technical specifications or its desired target for observation, in its simplest form can be divided into either; (a) a ‘snapshot’ clinical review or (b) a review of progressive changes in observed trends over the course of time. This can help optimize a patient's care and accordingly, guide the trajectory of their hospital admission. This article describes the modalities of basic and specialty-specific advanced monitoring and details the mechanism by which these monitors operate. Specific advantages and disadvantages of particular types of monitoring are described.     

Compressive neuropathies of the upper extremity

Although any peripheral nerve may be compressed anywhere along its course, nerve compression syndromes typically occur at predictable sites with predictable clinical presentations. A detailed history and physical examination can establish a diagnosis, and electrodiagnostic studies and at times imaging can confirm it. Physicians should adopt a systematic approach of diagnosing and treating these types of nerve lesions. The physician and the patient can be rewarded with favorable outcomes.     

What Is Expected of the Facial Nerve in Michel Aplasia? Anatomic Variation

We sought better understanding about the facial nerve anatomy in the rare inner ear Michel anomaly to help better define this aplasia and prevent potential complications in surgery on these patients. The data from computed tomography scans and magnetic resonance images of six Michel aplastic ears (three patients) were evaluated for a facial nerve course. Facial nerve course and anatomic landmarks were noted. Based on data obtained from this group of very rare patients, three different facial nerve anatomies were encountered. The first patient had normal-looking mastoid cells, normal middle ear ossicles, and a completely formed facial nerve canal through the middle ear. The second patient had pneumatized mastoid air cells despite an anomalous ossicular chain. This patient also had a facial nerve canal but not through the middle ear. In the third patient, although mastoid cells were present, neither ossicles nor a definite facial nerve canal could be detected. With guidance provided by the anatomy of the other parts of the ear, such as air cells and the ossicular chain, the danger zones posing a high probability of facial nerve injury can be predicted. Although all Michel aplasias may have aplastic petrous bone in common, there are some degrees of variation.     

Foot manifestations in a patient with COVID-19 and Epstein-Barr virus: A case study

SARS-CoV-2 (COVID-19) is highly-contagious. It can lead to respiratory distress—and in some cases—death. Recent reports and observations have identified an association between COVID-19 and manifestations in the feet. However, there are very few reports that describe the course of these foot manifestations in any detail. The authors present a case study chronicling the progression of foot issues in a COVID-19 positive patient who also was positive for the Epstein-Barr virus.     

Three-dimensional computed tomography for lung cancer in a patient with three right vein ostia

Some variations in pulmonary vein anatomy can have serious consequences in patients undergoing lung surgery, but clinicians rarely encounter patients with these variations. We report here a thoracoscopic lobectomy for right lung cancer in a patient with three right vein ostia. Preoperative review of three-dimensional 64-row multidetector computed tomography (3D-MDCT) of the patient showed a variation that was not confirmed in transverse plane computed tomography films. However, the variant anomaly was confirmed during thoracoscopic right lower lobectomy. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Preoperative 3D-MDCT of the pulmonary vein produced a precise preoperative simulation for the surgeon and clearly showed the orientation of the patient’s vascular variant during surgery. This imaging technology contributes to safer thoracic surgery, especially thoracoscopic surgery.     

Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways

BACKGROUND: Although clinical pathways were developed to streamline patient care cost efficiently, few have been put to rigorous financial test. This is important today, because payors demand clear solutions to the cost-quality puzzle. We describe a novel, objective, and versatile model that can evaluate and link the clinical and economic impacts of clinical pathways. STUDY DESIGN: Outcomes for 209 consecutive patients undergoing high-acuity surgery (pancreaticoduodenectomy), before and after pathway implementation, were examined. Four grades of deviation (none to major) from the expected postoperative course were defined by merging length of stay with a validated classification scheme for complications. Deviation-based cost modeling (DBCM) links these deviations to actual total costs. RESULTS: Clinical outcomes compared favorably with benchmark standards for pancreaticoduodenectomy. Despite increasing patient acuity, this new pathway shortened length of stay, reduced resource use, and decreased hospital costs. DBCM indicated that fewer deviations from the expected course occurred after pathway implementation. The impacts of complications were less severe and translated to an overall cost savings of $5,542 per patient. DBCM also revealed that as more patients migrated to the expected course within our standardized care path, 50% of overall cost savings ($2,780) was attributable to the pathway alone, and improvements in care over time (secular trends) accounted for the remainder. CONCLUSIONS: DBCM accurately determined the incremental contribution of clinical pathway implementation to cost savings beyond that of secular trends alone. In addition, this versatile model can be customized to other systems' improvements to reveal their true clinical and economic impacts. This is valuable when choices linking quality with cost must be made.     

Incidental carcinoma of the prostate: an analysis of the predictors of progression

Incidentally discovered prostatic cancer can pursue a benign clinical course or it can rapidly progress. Differentiating those tumors with low biological potential from more aggressive lesions has been the focus of many reports. To define more completely the variables that can be used to predict those patients with low biological potential requiring limited treatment from those needing more extensive therapy, a retrospective study of 232 patients with incidentally discovered cancer was undertaken. Progressive disease was used as an endpoint for statistical analysis with the Kaplan-Meier technique and Cox's multiple hazard regression mode. This extensive analysis of multiple parameters demonstrated a significant advantage of survival free of disease for patients presenting with tumors manifesting a lower Gleason score and volume extent. Probability tables were constructed to allow for prediction of the probability of progression for a given patient with incidentally discovered prostate cancer directly related to patient age at diagnosis, Gleason score, and initial volume extent of the tumor. With these tables a logical therapeutic approach can be derived for each patient in an attempt to maximize survival free of disease with minimal intervention.     

Influence of hip flexion on the course of the ureter. Ureteroscopic implications

Early experience with the rigid ureteroscopy has identified two regions of the ureter that can be difficult to negotiate, the first at the vesicoureteric junction and the second anterior to the iliac bifurcation. Placing the patient in varying degrees of lithotomy has been proposed to overcome these problems. In this study the effects of these alterations of hip flexion on the course of the ureter have been studied by radiographs in patients undergoing ureteroscopy. The lower ureter was demonstrated to possess two curves, an upper curve at the iliac bifurcation which straightens with increasing degrees of lithotomy and a lower vesical curve in the pelvis which is unaltered by patient position. These findings and their clinical significance are described.     

Life saving abdominal decompression in a patient with severe acute pancreatitis

Severe acute pancreatitis can be complicated early in its course by life threatening conditions such as abdominal compartment syndrome. We report a patient who needed abdominal decompression three days after admission to the intensive care unit because of intra-abdominal hypertension and end stage organ dysfunction. The clinical course was protracted, but the patient survived and was discharged from the hospital.     

Life Saving Abdominal Decompression in a Patient with Severe Acute Pancreatitis

Severe acute pancreatitis can be complicated early in its course by life threatening conditions such as abdominal compartment syndrome. We report a patient who needed abdominal decompression three days after admission to the intensive care unit because of intra-abdominal hypertension and end stage organ dysfunction. The clinical course was protracted, but the patient survived and was discharged from the hospital.     

Bonner Schockraummanagement-Kurs®

Backround

Intrahospital acute care of the severely injured patient is guided by interprofessional and interdisciplinary procedures. A grade A recommendation by the current S3 guidelines for the management and treatment of severely injured patients requires that established teams – so-called emergency room teams – treat patients according to prestructured management plans and/or should undergo a specific training.

Methods

The University Hospital Bonn is a level I trauma center and has implemented these guidelines by establishing the Bonner Schockraummanagement course®. The following objectives should be accomplished for the interprofessional and interdisciplinary treatment and management of the severely injured patient adapted to realistic scenarios and conditions: integration of all trauma-involved professions including prehospital care units in a training according to S3 guidelines with best possible evidence, Human Factor Training and modern educational modalities and concepts integrated into clinical daily routine. The course was introduced as a blended learning concept which is facilitated by a student’s course manual based on the guidelines and training videos which can be used as home educational tools. Oral presentations during the course and full-scale simulator team training with real life scenarios build the core of the educational concept. Each scenario is followed by a debriefing focusing on the horizontal approach of trauma care and human factor training. Continuous scientific course evaluation provides a base for further improvements.

Conclusion

The Bonner Schockraummanagement course® represents a symbiosis of horizontal approach of trauma care and human factor training. Thus, acute care of the severely injured patient will improve by integrating all associated professions and disciplines in a focused team training.     

HLA-A, B, DR and Bf allotypes in patients with idiopathic membranous nephropathy (IMN)

Fifty-five adult biopsy-proven patients with idiopathic membranous nephropathy were examined for HLA-A, B and DR antigens, and for the Bf allotypes. The phenotype frequencies of HLA-DR3 (52 vs. 23%) and HLA-B8 (46 vs. 24%) showed a significant increase in the IMN patient group compared to those of controls from the same region. The supraphenotype in which the combination of DR3-B8 alleles in Bf SS homozygotes occurred was significantly more common in the patient group than in the controls. A subset of six individuals carrying antigens DR3, B8, and common Bf*S alleles was identified, and the clinical course of those patients was found to be significantly worse compared to the rest of the patients. The present results do not support the existing suggestion that the clinical course of these diseases in Caucasians is determined by antigens B18 and the rare Bf allele (Bf*F1). It seems likely that IMN is not a single disease but a renal lesion that can result from several combinations of genetic predisposition and environmental stimuli.     

Chronic illness and the psychology of erectile dysfunction.

The toll of chronic illness on the sexual functioning of the male patient can be devastating both physically and psychologically. The practitioner is encouraged to address the patient's sexual concerns early on in the course of treatment. The involvement of the patient's partner, if available, is strongly recommended to assist in their sexual adjustment and in their overall relationship. There is no uniform course in the deterioration in erectile function in the patient with chronic illness as is true of the illness, itself. This article presents a multistage progression of interventions by practitioner (and staff) that suggests a course of involvement for the practitioner, time, expertise, inclination, and reimbursement, allowing. It also encourages consultation with or referral to specialists, as appropriate.     

The role of the nephrologist in delivering the information about transplantation from a living-donor

Eight percent only of the renal transplantations performed each year in France are from a living-donor, to be compared with 30-50% in Northern Europe and the USA. From the experience of these countries, we understand that to be successful, the information has to be delivered early in the course of kidney failure. It means that informing the patient about living-donation should be the mission, not of the transplant team, but of the patient nephrologist. There are many other reasons to give him this initiating role: he has a general vision of the treatment of end stage renal disease for this patient as well as a better knowledge of his psychological, socioprofessionnal and familial situation and he can more easily meet patient's relatives to discuss kidney donation.     

Natural course of incisional hernia and indications for repair

BACKGROUND: Incisional hernias and incisional hernia repair can be a significant challenge for both surgeon and patient. Despite the growing amount of literature describing various methods of surgical techniques, little has been published the natural course of an incisional hernia and regarding indications for incisional hernia repair. METHODS: An internet database search was performed to identify articles describing symptoms presented by patients and indications for incisional hernia repair. RESULTS: Various symptoms and indications regarding incisional hernia repair and the natural course of an incisional hernia are mentioned in the literature. Nevertheless, published data accurately describing these symptoms and indications are rare. CONCLUSION: A prospective trial monitoring incisional hernias as well as comparing conservative treatment with repair should be performed.     

Phallic construction in a 65-year-old male pseudohermaphrodite.

The authors constructed a functional, sensate phallus for a 65-year-old male pseudohermaphrodite. Although their technique is employed frequently for gender reassignment and posttraumatic reconstruction, the opportunity to perform this procedure to aid an adult patient with ambiguous genitalia is unusual. Of course, having such a patient present for treatment in his seventh decade of life is also unique. After careful consideration of his history, previous failure of medical therapy, and overall excellent medical condition the authors determined that age alone should not be an impediment to phallic construction for this patient. Their decision not to construct a penile urethra, and therefore avoid potential urethral complications, helped to ensure an uneventful postoperative course. Their success in this case has clearly broadened the range of patients that can benefit from phallic construction.     

Anaesthesia and mitochondrial disease

Mitochondrial diseases, or encephalomyopathies, are an uncommon, heterogeneous group of disorders with variable clinical course and presentation. Many of these patients present for surgery, or undergo anaesthesia in the course of investigation of their illness. Unfortunately, little information exists on their management in anaesthetic texts and the literature. We report on the anaesthetic management of a paediatric patient with mitochondrial disease, and briefly discuss the pathophysiology and anaesthetic implications of these disorders.