Diagnostic and differential-diagnostic considerations regarding the assessment of children's reactions within the scope of psychosocial care in paediatric oncology and haematology

Oncological diseases in children and adolescents represent a considerable burden for the children themselves and for their families. In order to position such concomitants of a life-threatening disease appropriately among the diagnostic options of psychosocial cancer care one is repeatedly confronted with the issue of giving a diagnosis from the area of reactions to burdens and adaptive disturbances (ICD 10: F: 43 ff). This touches the question of whether or not confronting a life-threatening disease in and by itself suffices to fully justify establishing one of the psychiatric diagnoses mentioned, which would imply that the intensity of the burden experienced justified the assumption of a psychiatric disturbance in the person affected. Whereas considerable effort is regularly spent on taking action and giving support and care, and reactions occasionally exceed the appropriate degree, a fair majority show no pathological processes that would justify determining a psychiatric diagnosis as a rule. Ultimately, one would arrive at a false interpretation of actually altogether adequate reactions of the patient to the burden. The ICD and DSM classification systems, however, do not provide for diagnoses other than those allocated disease status; it must therefore be considered whether it may be better in these cases to speak not of a reaction to a burden or an adaptive disturbance in the sense of the ICD 10, Section F, but rather of a sustained reaction to a burden. This opinion is increasingly gaining acceptance in pediatric oncology.     

Tumors of the foot: diagnostics and therapy

Despite the compact anatomy with thin soft tissue coverage, diagnosis of both benign and malignant tumors of the foot is often delayed. Diagnostic errors are more common than in other body regions, as neoplasias are rarely considered. Barring a few exceptions the foot is not a typical predilection site for malignant musculoskeletal tumors, although, basically any tumor entity of the musculoskeletal system can affect the foot. Delays in specific diagnostic and therapeutic procedures of these lesions can entail serious consequences for patients as tumor size is a major prognostic factor for recurrence-free survival. In cases of an indistinct persistent swelling or bone lesion a tumorous process should always be considered to ensure early diagnosis and therapy of foot tumors.     

Gelenkerhaltende Hüftchirurgie im Erwachsenenalter

Deformity and malposition of the acetabulum can occur during the development of the hip. Developmental hip dysplasia and acetabular retroversion are possible causes of osteoarthritis in the young adult. Surgical management with reorientation of the acetabulum allows causal therapy of the deformity and preservation of the native hip joint. Established techniques are the Bernese periacetabular osteotomy (PAO) and the T?nnis and Kalchschmidt triple osteotomy of the pelvis. Both techniques permit three-dimensional correction of the position of the acetabulum. Advantages and disadvantages of each technique must be considered and are summarized in the present paper. If performed early (osteoarthritis grade T?nnis 0 and 1) with correct indication and proper technique, good results can be expected.     

Cholesterol and cholesterol sulphate concentration in the cell membrane complex of human scalp hair - A biomarker of aging?

Cell to cell cohesion in fully keratinized hair is mediated by a cell membrane complex which contains covalently bound (integral) hair lipids. The influence of aging on concentrations of integral cholesterol sulphate (CHSU) and cholesterol (CH) in human scalp hair shafts, and the relationship between hair and plasma lipids were examined in 50 subjects, aged 18 to 87 years, and in one case of Werner's syndrome. Hair CHSU concentrations were distributed normally and were significantly higher in male subjects with elevated plasma CH levels (>5.17 mmol/l) than in those with normal plasma CH levels (806+/-134 versus 624+/-155 nmol/g hair, p<0.001). Female subjects with elevated plasma CH levels had even lower hair CHSU, values (515+/-167 nmol/g hair, p<0.05) than men with normal plasma CH. The almost white hairs of the Werner's syndrome patient displayed low levels of CHSU, possibly indicating a precarious hair stability. A small but statistically significant linear correlation between donor age and integral CH in hair (n=51; y=97.7+0.9x; cc=0.32; p<0.05) was detected. No correlation between hair CHSU and age could be demonstrated. Since internal hair lipid concentrations do not correlate with plasma lipids, the age associated increase of hair CH as well as the observed gender differences in hair CHSU concentration may be related to alterations in the process of keratinization. Hair CH analysis seems to be of little significance in the clinical diagnosis of hypercholesterolemia.     

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10 ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study

Aim

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development after ICH.

Background and purpose

Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain.

Methods

We retrospectively included patients with spontaneous ICH treated in our hospital in 2006–2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation.

Results

Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7 months after ICH (range 1–132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14–2.37]; p = 0.008), ICH volume > 10 ml (multivariable HR 1.91 [95% CI 1.33–2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20–2.75]; p = 0.005). Patients with cortical ICH > 10 ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08–0.84]; p = 0.025).

Conclusions

Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.     

Extrakorporale Stoßwellentherapie bei Knochenheilungsstörungen

Extracorporeal shock wave therapy (ESWT) is applied increasingly in the treatment of bone and soft tissue pathologies. Animal studies have yielded a broad scientific basis supporting the efficacy of ESWT in bone stimulation and also demonstrated its osteogenic potency. Discussion of molecular mechanisms of action has concentrated mainly on cell membrane hyperpolarization and radical production, followed by stimulation of osteoprogenitor cells and expression of growth factors. Clinical studies also indicate that ESWT is effective in the treatment of non-union and healing rates of 41–89% have been observed, but only on the basis of level IV evidence derived from uncontrolled studies. Among 601 patients prospectively treated for non-union, we achieved a consolidation rate of 83%. However, real evidence of its efficacy is still lacking. Until a randomized controlled study provides this ESWT must be recommended on the basis of the best available evidence – not least because of its low-level risks and side effects and positive cost-benefit ratio. More scientific data is available on ESWT than on most other conservative and operative treatment options for patients with bony non-union.     

Antibacterial effects of extracorporeal shock waves

Despite considerable knowledge about effects of extracorporeal shock-wave therapy (ESWT) on eukaryotic tissues, only little data are available concerning their effect on prokaryotic microorganisms. The objective of the present study was to determine the bactericidal activity as a function of energy flux density and shock-wave impulse number. Standardised suspensions of Staphylococcus aureus ATCC 25923 were exposed to different impulse numbers of shock waves with an energy flux density (ED) up to 0.96 mJ mm(-2) (2 Hz). Subsequently, viable bacteria were quantified by culture and compared with an untreated control. After applying 4000 impulses, a significant bactericidal effect was observed with a threshold ED of 0.59 mJ mm(-2) (p < 0.05). A threshold impulse number of more than 1000 impulses was necessary to reduce bacterial growth (p < 0.05). Further elevation of energy and impulse number exponentially increased bacterial killing. ESWT proved to exert significant antibacterial effect in an energy-dependent manner. Certain types of difficult-to-treat infections could offer new applications for ESWT.     

Proximaler Tibiaersatz und alloplastische Rekonstruktion des Streckapparats nach Resektion kniegelenksnaher Tumoren

Objective

The goal of the operation is limb-sparing resection of tumors arising from the proximal tibia with adequate surgical margins and local tumor control. Implantation of a constrained tumor prosthesis with an alloplastic reconstruction of the extensor mechanism to restore painless joint function and loading capacity of the extremity.

Indications

Primary bone and soft tissue sarcomas. Benign or semimalignant aggressive lesions. Metastatic disease (radiation resistance and/or good prognosis).

Contraindications

Poor physical status. Extensive metastatic disease with life expectancy <6?months. Tumor penetration through the skin. Local infection or recalcitrant osteomyelitis. Poor therapeutic compliance. Large popliteal extraosseous tumor masses with infiltration of neurovascular structures.

Surgical technique

A single incision is made from the anteromedial aspect of the distal femur to the distal one third of the medial lower leg. Preparation of large medial and lateral fasciocutaneous flaps. The popliteal vessels are explored through a medial approach by releasing the pes anserinus and semimembranosus tendon, mobilizing the medial gastrocnemius muscle and detaching the soleus muscle from the tibial margo medialis. The anterior tibial artery and vein are ligated. If the knee joint is free of tumor, circumferential dissection of the knee capsule is performed and the patellar ligament is dissected. An osteotomy of the tibia shaft is performed with safety margins according to preoperative planning. In order to obtain adequate surgical margins, in some cases an en?bloc resection of the tibiofibular joint becomes necessary. Therefore, the peroneal nerve is exposed. Parts of the M. tibialis anterior, a portion of the M. soleus and the entire M. popliteus are left on the resected tibial bone. After implantation of the prosthesis and coupling of the femoral and tibial component, the extensor mechanism is reconstructed using an alloplastic cord. It is passed transversely through the distal end of the quadriceps tendon looping the proximal margin of the patella. Both ends are passed distally through a subsynovial tunnel and are fixed under adequate pretension in a metal block of the tibial component. The detached hamstrings and remaining ligaments can be fixed on preformed eyes of the prosthesis. A medial gastrocnemius muscle flap is used to provide soft tissue coverage of the tibial component.

Postoperative management

Immobilization and elevation of the extremity for 5?days, then flap conditioning. Mobilization in a hinged knee brace locked in extension for 6?weeks without weight bearing. During this time active flexion with a stepwise progress, isometric quadriceps training. Then beginning of straight leg raising exercises, stepwise unlocking of the brace with 30° every 2?weeks. Weight-bearing is increased by 10?kg/week. Thrombosis prophylaxis until full weight-bearing. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination and radiographic studies.

Results

Between 1988 and 2009, endoprosthetic replacement and alloplastic reconstruction of the extensor mechanism after resection of tibial bone tumors was performed in 17?consecutive patients (9?females and 8?males) with a mean age of 31.1?years (range 11?C65?years). There were no local recurrences. Until now, 5?patients have died of tumor disease. One or more operative revisions were necessary in 53.9% of the patients. According to Kaplan?CMeier survival analysis, the implant survival at 5?years was 53.6% and 35.7% at 10?years, respectively. In 2?cases, a distal transfemoral amputation had to be performed due to deep infection. There were 3?cases of tibial stem revision due to implant failure and aseptic loosening, respectively. In 3?patients, the hinge of the prosthesis had to be revised. Impaired wound healing occurred in 2?cases. Peroneal nerve palsy was observed in 3?patients with recovery in only one. The mean Oxford knee score for 9?of the 12?living patients was 30.7?±?7.5 (24?C36). No patient had a clinically relevant extension lag. The mean range of motion at the last follow-up was 90.2°?±?26.7 (range 35?C130°). All patients were well satisfied with their postoperative outcomes.     

Total hip replacement in developmental dysplasia using an oval-shaped cementless press-fit cup

Purpose

Acetabular roof deficiency due to subluxation of the femoral head (Hartofilakidis type II) increases the complexity of total hip arthroplasty. In these cases some form of support is usually required, to reach stable fixation of the acetabular component. Pursuing this aim, the oval-shaped cementless cranial socket could be an alternative to conventional treatment options.

Methods

Between 1998 and 2008, 37 patients (40 hips) underwent primary total hip arthroplasty using the cranial socket (mean follow-up 5.6 years, range 26 to 133 months). In a retrospective study we compared these clinical and radiological results with the results of a matched control group consisting of 35 patients (40 hips) treated with a standard cementless hemispherical cup in combination with bulk femoral autografting (mean follow-up 6.9 years, range 30 to 151 months).

Results

There were no statistically significant differences in the HHS (p = 0.205) or the SF-36 (p = 0.26) between both groups. There was no prosthesis failure due to septic or aseptic loosening. Time of surgery was significantly shorter in the cranial socket group (p < 0.001). The acetabular component could be placed in the ideal rotational hip centre in 24 (60%) hips in the cranial socket group and 32 (80%) hips in the control group, respectively.

Conclusions

Our study indicates, that the cranial socket can be an alternative treatment option for the reconstruction of acetabular deficiency in osteoarthritis secondary to developmental dysplasia.