Kann die Telemedizin in der Schlafmedizin die Akzeptanz der nCPAP-Therapie verbessern?

The obstructive sleep apnea syndrome has considerable consequences for morbidity and mortality in affected patients. The continuous positive airway pressure (CPAP) therapy can reliably prevent the nocturnal disordered breathing and minimize health implications (high efficacy). However, the effectiveness of this therapy is restricted due to reduced adherence in the daily routine. Practical methods are urgently needed to improve adherence. Special problem groups, such as post-stroke patients or those with poor sleep efficiency in the first therapy night have already been identified. Up to date information technology enables remote monitoring and control of therapy devices and a centralized evaluation of the data. Usage time, residual breathing disorders, high mask leakage or high therapy pressure in the home environment can promptly be determined to arrange remedies in a timely manner. Scientific evidence regarding the effects of telemedical care of CPAP patients is limited, but the results of available studies are promising. Many practical questions have still not been answered. Furthermore, the danger of using the new technologies only with the aim of short-term cost reduction must explicitly be emphasized. If such information would only be used to discontinue funding of an allegedly insufficient treatment, no additional benefits would be achieved from the patient point of view. The aim of telemedical concepts has to be the improvement of therapy acceptance especially in risk groups. From the perspective of sleep medicine a primacy of physicians is promoted in order to achieve a real improvement for the patient due to telemedicine. The findings obtained so far are promising.     

Rolle der Angiogenese und ihrer Inhibitoren in der Gynäkologie

Angiogenesis describes the neoformation of blood vessels which develop by budding and sprouting of the existing vessel system. Solid tumor growth is dependent on the surrounding growing capillary network providing the tumor with essential nutrients and oxygen. The pathophysiological role of angiogenesis could be shown for multiple benign (endometriosis, menorrhagia, leiomyomatosis, ovarian hyperstimulation syndrome, preeclampsia and placental hypoperfusion syndrome) and malignant (especially metastasized and therapy-refractory breast cancer, ovarian cancer, cancer of the fallopian tube and the primary peritoneal cancer) diseases. Diseases that are very much dependent on (neo) angiogenesis can be treated with various anti-angiogenic agents. Due to the broad spectrum of side effects of established angiogenesis inhibitors which are mostly given in combination with chemotherapeutic agents, this therapeutic approach is mostly limited to malignant diseases, such as breast cancer, ovarian cancer, cancer of the fallopian tube and primary peritoneal carcinoma. This review provides an overview of the current state of knowledge in the anti-angiogenic therapy of gynecological diseases and will give a perspective of potential future implications of new therapeutic agents.     

Rückblick auf 10 Jahre Infektionsschutzgesetz

In 2001, the German Protection against Infection Act came into force, implementing a variety of new regulations. For the first time, obligatory infection control visits of the public health departments in surgical ambulatory practices were implemented, as well as optional infection control visits in all medical, dental and paramedical practices using invasive methods. Based on the data of the public health department of the city of Frankfurt am Main, Germany, an evaluation of this new regulation is given in this paper. First, prioritization of these new tasks was mandatory. First priority was given to the obligatory visits in surgical practices, second priority to the hygiene visits in practices performing endoscopy in gastroenterology as well as in urology and in practices of traditional healers, and third priority was given to all other doctors’ practices. After receiving preliminary information and further training of the doctors etc., the control visits were performed by members of the public health department, using a checklist based on the guidelines of the German Commission on Hospital Infection Prevention (“Kommission für Krankenhaushygiene und Infektionsprävention”). Since 2001, more than 1100 infection control visits in medical practices in Frankfurt am Main were documented. Not only in surgical, but also in gastroenterological and urological practices great improvement could be achieved, regarding not only hand hygiene and reprocessing surface areas, but especially in reprocessing medical devices. In practices for internal medicine and those of general practitioners, errors in hand hygiene, skin antiseptic and surface disinfection also decreased. According to our results, especially regarding the improved quality of structure as well as quality of process and with regard to the public discussion on this hygiene topic, our evaluation is absolutely positive. The new regulation proved worthwhile.     

Schmerztherapeutische Möglichkeiten in der Unfallchirurgie

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.     

Skapulaosteotomie nach Benjamin bei liegender Humeruskopfprothese

In 1994 a 47-year-old female patient with primary osteoarthritis of the shoulder joint was implanted with a humeral head endoprosthesis. Secondary glenoid erosion developed 2.5 years later which was not treated by glenoid implantation but by means of scapular neck osteotomy according to Benjamin. After surgery the situation substantially improved and the patient is currently free of pain and exhibits a nearly free active and passive mobility. The patient returned to the clinic 18 years after the primary surgery and approximately 15 years following the scapular neck osteotomy to discuss the implantation of a total shoulder endoprosthesis on the opposite side. In view of this exceptionally favorable course this possibility should be considered in severe cases where secondary glenoid implantation is not possible for various reasons.     

Urinmarkersysteme zur Diagnostik des Urothelkarzinoms

Cystoscopy and urinary cytology are standard tools in the diagnostics of urothelial cancer of the urinary bladder; however, cystoscopy is invasive and urinary cytology lacks accuracy for the diagnosis of low grade tumors. More recently several alternative urinary test systems were developed with the aim to make the diagnostics of urothelial tumors more reliable; however, in general all protein-based point of care test systems have a high rate of false positive test results, especially in patients with benign disorders. Fluorescence in situ hybridization, which is highly sensitive and specific, may be a reasonable supplement to the diagnostic spectrum in patients after instillation therapy or bladder replacement. Additionally, there are several new test systems which still need to be tested in large clinical studies with respect to diagnostic accuracy.     

Ungeplante Zweiteingriffe nach Frakturen des oberen Sprunggelenks

The purpose of the present study was to analyze the risk factors associated with unexpected second procedures and strategies of revision surgery. Within a 5 year period 647 patients with closed ankle fractures AO type 44 were identified of which 77 (11.9%) needed revision surgery. Complications were addressed to 4 main groups: deep infections (IG) were seen in 29 patients (4.5%), problems with primary wound closure (WG) in 22 patients (3.4%), insufficient reduction (KG) in 22 patients (3.4%) and other causes (RG) included 4 patients (0.6%). Significant predictive factors for soft tissue complications were higher age, comorbidities with peripheral arteriosclerosis, high American Society of Anesthesiologists (ASA) score and diabetes mellitus. AO 44 type B2 and B3 fractures were often associated with soft tissue problems. The more complex fracture types AO 44 C1-C3 and A2-A3 were significantly associated with problems of insufficient congruency post-surgery. The distribution of the mean revision rate was significantly different (p<0.01) for all groups: IG 4.59, WG 3.5, KG 1.55, RG 1.25. In summary, we strongly recommend immediate reduction of displaced fractures and to consider a more detailed fracture classification. To reduce the amount of unexpected ankle procedures individual risk factors should be weighed against the advantages of optimal open reduction and internal fixation.