Traumatische Apophysenl?sung des Trochanter minor

An avulsion fracture of the lesser trochanter is a very rare injury often misdiagnosed as a muscle lesion or hip distortion. This report concerns the avulsion fracture of the lesser trochanter of a 13-year-old boy, suffered on a runway preparing for a long jump. Conservative treatment without weight-bearing was indicated for 6 weeks. Twelve weeks after the injury the patient resumed his normal sport activities.     

Hüftgelenknahe Femurfrakturen im Qualitätssicherungsmodul 17/1

Background

For the quality indicator “preoperative stay” a part of the external quality assurance for proximal femoral fractures (module 17/1), a tolerance range for surgery within 48 h after admission of ≤15 % is given.

Materials and methods

Over a period of 5 years all cases were analyzed with respect to reasons for delayed surgery of more than 48 h after admission.

Results

A total of 165 patients (16%) out of 1,036 documented cases had surgery later than 48 h after admission. Reasons were pathological bleeding, preoperative poor general condition, lack of informed consent, intake of metformin and lacking initial radiological detection of fractures. Due to a lack of software-related specifications in ten patients a wrong preoperative length of stay was generated.

Conclusion

The significance of the quality indicator “preoperative stay” without division into whether this was administrative or patient-related must be considered critically. For fall-related fractures in hospital the time of the accident or diagnosis should be considered.     

Mortality after proximal femur fracture with a delay of surgery of more than 48 h

Purpose

For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay.

Methods

One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01–72 h (2–3 days), 72.01–120 h (3–5 days), 120.01–168 h (5–7 days), 168 h (>7 days).

Results

94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5–9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient’s age at the time of injury (p = 0.005).

Conclusions

In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.     

Die kindliche Nussknackerfraktur

Cuboid fractures in children are rare. Missed fractures of the cuboid may lead to severe alterations in foot mechanics and function. In the case described a 9-year-old girl suffered a compression fracture of the cuboid after falling from a tree. The rarity of this injury in children results in a lack of standardized procedures. If severe impaction is present bone grafting is recommended. Transarticular K-wires are usually used for transfixation of the calcaneocuboid joint after open reduction. Disadvantages are damage to the cartilage caused by transarticular transfixation and potential loss of anatomical reduction of the cuboid. Considering operative treatment in adults, we used a fixed-angle plate for internal fixation after open reduction to reduce these risks. Bone grafting was not necessary. Due to continuing growth the plate was removed 6 months after the operation. Physical and radiological examinations revealed an excellent result.     

Platelet C4d is highly specific for systemic lupus erythematosus

OBJECTIVE: Complement-activation product C4d is deposited on normal erythrocytes, while abnormal levels have been observed on the surface of erythrocytes of patients with systemic lupus erythematosus (SLE). This study examines whether C4d also deposits on human platelet surfaces, and whether platelet-bound C4d may provide a biomarker for SLE. METHODS: We conducted a cross-sectional study of 105 patients with SLE, 115 patients with other diseases, and 100 healthy controls. Levels of C4d on the surface of platelets were examined by flow cytometry and scanning confocal microscopy. Statistical analyses were performed to determine the clinical variables associated with platelet C4d. RESULTS: Abnormal levels of platelet C4d were found to be highly specific for SLE. Platelet C4d was detected in 18% of patients with SLE, being 100% specific for a diagnosis of SLE compared with healthy controls and 98% specific for SLE compared with patients with other diseases (P < 0.0001). In addition, platelet C4d was significantly associated with positivity for lupus anticoagulant (P < 0.0001) and anticardiolipin antibodies of the IgG (P = 0.035) or the IgM (P = 0.016) isotype. Platelet C4d was also significantly associated with SLE disease activity according to the SLE Disease Activity Index (P = 0.039), low serum C4 (P = 0.046), an elevated erythrocyte sedimentation rate (P = 0.006), and abnormal levels of C4d on erythrocytes (P < 0.0001). CONCLUSION: This observation suggests that platelet-bound C4d may be a useful biomarker for SLE and may be a clue to the pathogenic mechanisms responsible for the myriad thrombotic and vascular complications of lupus associated with antiphospholipid antibodies.     

DRGs as future reimbursement system for hospital services exemplified by multiple sclerosis

Introducing the Diagnosis Related Groups (DRG) system into the German public health sector will prompt important changes for in- and outpatient care. Especially admission to hospital, extent of diagnostic and therapeutic procedures, and duration of hospitalisation might be affected. Taking multiple sclerosis, the most frequent inflammatory disease of the nervous system for Europe, with yearly treatment costs of about 2.3 billion Euro in Germany as example, the effect on reimbursement of complete documentation of the medical output is illustrated. Extensive information on clinically relevant items is given. The possible role of the DRG system as a cost- and quality-controlling tool in the German public health system as well as its potential risks in the absence of broadly accepted treatment guidelines is discussed.     

Detecting Staphylococcus aureus Virulence and Resistance Genes: a Comparison of Whole-Genome Sequencing and DNA Microarray Technology

Staphylococcus aureus is a major bacterial pathogen causing a variety of diseases ranging from wound infections to severe bacteremia or intoxications. Besides host factors, the course and severity of disease is also widely dependent on the genotype of the bacterium. Whole-genome sequencing (WGS), followed by bioinformatic sequence analysis, is currently the most extensive genotyping method available. To identify clinically relevant staphylococcal virulence and resistance genes in WGS data, we developed an in silico typing scheme for the software SeqSphere⁺ (Ridom GmbH, Münster, Germany). The implemented target genes (n = 182) correspond to those queried by the Identibac S. aureus Genotyping DNA microarray (Alere Technologies, Jena, Germany). The in silico scheme was evaluated by comparing the typing results of microarray and of WGS for 154 human S. aureus isolates. A total of 96.8% (n = 27,119) of all typing results were equally identified with microarray and WGS (40.6% present and 56.2% absent). Discrepancies (3.2% in total) were caused by WGS errors (1.7%), microarray hybridization failures (1.3%), wrong prediction of ambiguous microarray results (0.1%), or unknown causes (0.1%). Superior to the microarray, WGS enabled the distinction of allelic variants, which may be essential for the prediction of bacterial virulence and resistance phenotypes. Multilocus sequence typing clonal complexes and staphylococcal cassette chromosome mec element types inferred from microarray hybridization patterns were equally determined by WGS. In conclusion, WGS may substitute array-based methods due to its universal methodology, open and expandable nature, and rapid parallel analysis capacity for different characteristics in once-generated sequences.