Scar tissue at the recipient site reduces the sensory recovery in myocutaneous flaps

In 1993 it was reported that sensory nerve axons enter myocutaneous flaps from all sides of the wound bed through empty perineural tubes, suggesting that small flaps (because less tissue must be reinnervated) and old flaps (because the regenerating process should be completed) would have the best sensation. However, sensory recovery is correlated with neither the flap size nor their age. Since all 16 flaps in this study were placed on significantly traumatized limbs, scar formation should hinder sprouting axons from entering the flap; the present study was performed to test this hypothesis. The sensation of 16 myocutaneous flaps (group A) placed in a nontraumatized wound bed was compared to that of patients in a previous study (group B). All 32 flaps were tested for pin-prick, hot, cold, 30-Hz, 256-Hz vibration, constant touch, moving two-point discrimination, and static two-point discrimination. The results were rated as follows: 2 points for a modality being present all over the flap, 1 for its partial or dull presence, and 0 for no sensation. The elapsed time following surgery was 1.10 –5.40 years in group A and 1.50–8.20 years in group B. Patients in group A scored a mean score of 8.0±2.1 points (4–11) and those in group one of B 5.9± 4.8 (0–13). There was a significant correlation between score and flap age in group A but not in group B; there was no correlation in either group between score and the flap size. Our findings suggest that scar formation is detrimental to the capacity for sensory recovery in myocutaneous flaps. Maximum scar tissue excision is recommended, especially since sensory recovery is not less than in large flaps.     

Push‐out bond strength of two root‐end filling materials in root‐end cavities prepared by Er,Cr:YSGG laser or ultrasonic technique

This study compared the push‐out bond strength of mineral trioxide aggregate (MTA) and a new endodontic cement (NEC) as root‐end filling materials in root‐end cavities prepared by ultrasonic technique (US) or Er,Cr:YSGG laser (L). Eighty single‐rooted extracted human teeth were endodontically treated, apicectomised and randomly divided into four following groups (n = 20): US/MTA, US/NEC, L/MTA and L/NEC. In US/MTA and US/NEC groups, root‐end cavities were prepared with ultrasonic retrotip and filled with MTA and NEC, respectively. In L/MTA and L/NEC groups, root‐end cavities were prepared using Er,Cr:YSGG laser and filled with MTA and NEC, respectively. Each root was cut apically to create a 2 mm‐thick root slice for measurement of bond strength using a universal testing machine. Then, all slices were examined to determine the mode of bond failure. Data were analysed using two‐way anova . Root‐end filling materials showed significantly higher bond strength in root‐end cavities prepared using ultrasonic technique (US/MTA and US/NEC) (P < 0.001). The bond strengths of MTA and NEC did not differ significantly. The failure modes were mainly adhesive for MTA, but cohesive for NEC. In conclusion, bond strengths of MTA and NEC to root‐end cavities were comparable and higher in ultrasonically prepared cavities.     

Gefäßchirurgische Ausbildung in Österreich: Gegenwart, Ziele, Visionen

Lengthy training, detouring via general surgical training, the only EU-wide status as an additive subspecialty without international recognition and hitherto inferior training in endovascular techniques all make it difficult to train qualified vascular surgeons in Austria. By developing a curriculum closely based on the European Board of Vascular Surgery (EBVS) standards, the Austrian Society for Vascular Surgery (ÖGG) tries to internationalize training and to include the teaching of endovascular techniques. The large variety in content and trainers necessitates more structuring and better regulation of vascular surgical training to achieve comparable standards. Thorough documentation of all training steps will make these transparent also in later medical practice. Lengthy training and lack of international recognition can only be overcome by creating a separate specialty of vascular surgery. Instituting a medical specialty of vascular medicine, which would combine all competences of angiology, endovascular procedures and vascular surgery, might be a further point for discussion.     

Fatal Mycoplasma pneumoniae pneumonia in a previously healthy 18-year-old girl

A case of fatal Mycoplasma pneumoniae pneumonia in a previously healthy 18-year-old girl is reported. On hospital day 9, the antibody titer to M. pneumoniae was 1:512 in the complement fixation test and 1:5120 in the microparticle agglutination assay. After five weeks in the intensive care unit, the patient died from necrotizing hemorrhagic pneumonia with multi-organ failure. No significant superinfections occurred during ICU treatment. Corticosteroids (hospital day 8 onward) did not influence the course of the disease. It is noteworthy that, as in some previously reported cases, the clinical state deteriorated during presumably adequate antibiotic treatment (2 days before admission onward), and despite documented eradication of the pathogen from the respiratory tract (PCR from bronchoalveolar fluid on hospital day 22 was negative). However, the illness had lasted for several days before admission to the hospital, therefore the potentially beneficial effect of antibiotic treatment at an early stage of the disease cannot be assessed. Clearly, in default of other treatment options, correct diagnosis and early treatment of mycoplasma community-acquired pneumonia seems mandatory. This is the third case of fatal mycoplasma pneumonia reported from Austria in recent years, making this topic worthy of further scientific attention.     

Protheseninfektionen im aortofemoralen Bereich und ihre Vermeidung

Vascular prosthesis infections are potentially severe adverse events following vascular reconstruction. They are often associated with a high morbidity and mortality, especially in the aortofemoral region. The present article outlines the diagnosis, prevention and treatment of vascular graft infections in a clinical setting. The clinical presentation, inflammatory markers, microbiological work-up and imaging studies can contribute to diagnosing a prosthesis infection. Regarding the bacterial spectrum involved in the etiology of prosthesis infections, single organism infections (monoinfections) have become less significant over the past years, whereas infections with multiple organisms now constitute the most abundant microbiological constellation. Also, infections with resistant bacterial strains have been increasing in number over the past years and deserve special consideration. It remains unclear whether both aspects are due to a true epidemiological change or are the result of advanced molecular microbiological diagnostic methods. While during the past decades perioperative antibiotic prophylaxis was regarded as the most important measure for preventing prosthesis infections in vascular surgery, other primary preventive hygiene strategies have been increasingly explored and grouped together in the sense of preventive bundles. In most cases of deep postoperative infections involving a prosthetic device in the aortofemoral region, explantation of the prosthesis will be required. In situ and extra-anatomical reconstructions are often performed in such cases and the decision process to develop an optimal treatment plan must consider several individual factors. In select patients, palliative preservation of the prosthesis despite surrounding infection (i.e. graft salvage) and best conservative management in combination with local surgical measures, such as incision and drainage and vacuum therapy, deserve consideration as a treatment option for patients with a high surgical risk.     

Long-term results of covered stent repair of internal carotid artery dissections

BACKGROUND: Traumatic and spontaneous dissections of internal carotid arteries (ICA) are rare conditions. So far, these pathologies are primarily treated conservatively, surgical revascularization being an option only after recurrent thromboembolic neurologic episodes or continuous aneurysm growth. Successful endovascular treatment strategies with covered stents have been reported in patients with ICA dissections. However, no long-term results are published so far. Herein, we report our experience of a combined conventional and endovascular repair of ICA dissections under reversed flow and their respective long-term results. METHODS: In a prospective evaluation of clinical and morphologic outcome of 6 patients with carotid artery dissections, 2 patients were treated for continuous aneurysm growth and 4 patients for high-grade ICA stenoses with recurrent thromboembolic episodes during a 6-month follow-up period. A 6-mm polytetrafluoroethylene Hemobahn endoprosthesis was inserted under reversed flow of the internal carotid artery. RESULTS: No perioperative strokes were observed; one TIA occurred, lasting less than 3 hours; no peripheral cranial nerve injuries or deaths were observed. No occlusions, hemodynamically significant stenosis, or recurrent neurologic symptoms were seen during follow-up, which ranged from 6 to 54 months (mean, 38.3 months). CONCLUSION: Open endovascular repair of the ICA of symptomatic patients with dissections with a 6-mm covered endoprosthesis is a safe alternative to conventional surgery, with excellent long-term patency.     

From antiseptics to antibiotics – and back?

There is no straight line to trace the trajectory of antiseptics; rather, this has been manifested more as a fluctuating line, a backwards and forwards movement, seen in the wake of major discoveries but of colossal mistakes too. While today no one would allow their prophylactic policies to be guided by miasma or contagia, there continues to be some uncertainly about how to manage anti-infectives effectively even today.When in 1941 the first human being was successfully treated with penicillin, interest in antiseptics gradually waned. From that time onwards, everything was treated with antibiotics, unleashing a race for the discovery of novel antibiotics, as witnessed decades earlier in the case of antiseptics. The significance of antiseptics declined to such an extent that among physicians they were associated merely with cleaning agents or sanitary disinfection. Today, at the beginning of the 21^st century we know that the euphoria generated by antibiotics was just another station along the pathway of discoveries. Bacterial infections and new, hitherto unknown infectious diseases continue to play a major role. Several viral infections continue to be refractory to successful treatment and bacterial antibiotic resistance has become a problem worldwide. The most effective countermeasures no longer entail only the development of new antibiotics but above all responsible management of antibiotics and strict observance of infection control measures in the hospital setting. Set against that background, interest in antiseptics has been rekindled. In that spirit we can look eagerly forward over the coming years to further developments in antisepsis.