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.     

Netzgestützte Operationstechniken in der Urogynäkologie

The vaginal and abdominal operation strategies with autologous tissue established for decades show acceptable results with moderate side effects but an up to 30 % relapse due to the existing connective tissue insufficiency. In recent years established methods employing alloplastic and biological meshes have in particular significantly increased the anatomical success rate. However, in addition to only moderate subjective improvements, new and sometimes serious side effects, such as mesh arrosion up to 20 %, pain syndromes, dyspareunia, infections, obstructions and urinary urgency syndrome can occur. Current guidelines confirm the use of meshes in relapse situations and in individual exceptional primary cases; however, there is no scientifically-based evidence for a general application in primary prolapse situations. Improved training of surgeons, refined diagnostics and individual comprehensive informed consent on the planned operation and possible alternatives as well as testing materials in randomized studies before becoming commercially available, all make valuable contributions to an improvement in postoperative results and a reduction of complications and side effects.     

Herz und Diabetes

Antidiabetic therapies have to prove cardiovascular safety and efficacy in addition to blood glucose lowering potential. In recent studies metformin administration and dipeptidyl peptidase-4 (DPP-4) inhibition both reduced hypoglycemic and cardiovascular events in comparison to sulfonylurea. High-density lipoprotein (HDL) cholesterol has recently received much attention as a modulator of cardiovascular risk; however, drug-induced increase of HDL cholesterol was unable to reduce cardiovascular events in patients on optimal statin therapy. Therefore, HDL cholesterol levels remain an important risk predictor without being a therapeutic target. In the field of interventional cardiology the FREEDOM trial demonstrated bypass operations to be superior to drug-eluting stent implantation in patients with diabetes and advanced coronary heart disease.