Anatomically Integrated In-Place Visualization of Patient Data for Cooperative Tasks with a Case Study on a Neurosurgical Ward.

The workflow in modern hospitals entails that the medical treatment of a patient is distributed between several physicians and nurses. This leads to intensive cooperation, which takes place under particular time pressure and requires efficient conveyance of relevant patient-related medical data to colleagues. This requirement is difficult to achieve with traditional data representation approaches. In this paper, we introduce a novel concept of anatomically integrated in-place visualization designed to engage with cooperative tasks on a neurosurgical ward by using a virtual patient's body as spatial representation of visually encoded abstract medical data. Based on the findings of our field studies, we provide a set of formal requirements and procedures for this kind of visual encoding. Moreover, we implemented a prototype on a mobile device that supports the diagnosis of spinal disc herniation and has been evaluated by 10 neurosurgeons. The physicians have assessed the proposed concept as beneficial, especially emphasizing the advantages of the anatomical integration such as intuitiveness and a better data availability due to providing all information at a glance. Particularly, four of nine respondents have stressed solely benefits of the concept, other four have mentioned benefits with some limitations and only one person has seen no benefits.

Distally Based Peroneus Brevis Muscle Flap for Lower Extremity Defect Reconstruction in Severely Ill Multimorbid Patients. / Die distal gestielte Musculus-peroneus-brevis-Lappenplastik zur Defektdeckung an der unteren Extremität bei multimorbiden, schwer kranken Patienten.

BACKGROUND: Reconstruction of lower extremity soft tissue defects is an exceptional surgical challenge, especially in multimorbid, elderly and severely ill patients with their thin and tense local soft-tissue conditions and increased perioperative risk. The distally based peroneus brevis muscle flap (DPBM), a local flap based on the muscular branches of the fibular artery, could pose a pragmatic solution. The objective of this study was to evaluate and quantify DPBM defect reconstruction in the lower leg, especially in elderly, multimorbid and severely ill patients. MATERIAL AND METHODS: The DPBM as a surgical option in defect reconstruction in multimorbid, elderly, severely ill patients (inclusion criteria: at least 3 pre-existing comorbidities, patient age: at least 55 years, ASA status: at least III) was evaluated in a retrospective single-centre study from 01 April 2014 to 31 December 2019. The electronic SAP health records (EHR) were analysed according to 18 criteria, including patient details, extent of multimorbidity, defect characteristics, clinical outcome, and complications. OUTCOME: Ten patients with a mean age of 72.6 years, a mean number of 8.5 pre-existing comorbidities and a mean ASA status of 3.1 met the inclusion criteria. The leading causes of defects, each with exposed tendons, bones, joint capsule, or joint, were chronic ulcers (n = 5) and soft tissue defects resulting from fractures (n = 3). In case of DMPB the success rate was 100% (no partial or total loss) with a short operating time (mean: 103 min) and a brief postoperative length of stay (mean: 11 d). In 2 patients (20%), DPBM surgery had to be discontinued intraoperatively and an alternative technique of defect reconstruction had to be adopted. The reasons included impaired muscle perfusion and fatty degeneration of the peroneus brevis muscle. CONCLUSION: The DPBM flap allows straightforward, fast and safe defect reconstruction in the lower extremity, particularly in elderly, multimorbid and severely ill patients at risk. In patients with inadequate peroneal brevis muscle, however, DMPB surgery should be discontinued intraoperatively and the defect reconstructed using alternative techniques.

[Are autonomous departments better research institutions? Influence of independence on publication performance and study-types in academic Plastic Surgery]. / Sind autonome Kliniken die besseren Forschungsstandorte? Einfluss von Eigenständigkeit auf Publikationsleistung und Studientypen in der akademischen Plastischen Chirurgie.

INTRODUCTION: Despite its increasing acceptance as an autonomous specialty the field of plastic surgery remains underrepresented in terms of independent departments with a dedicated research infrastructure. The objective of this study was to analyze the current quantitative and qualitative publication performance of academic plastic surgery in Germany in order to compare independent departments and subordinate organizational structures regarding their scientific efficiency. MATERIAL AND METHODS: Via a pubmed analysis the publication performance between 2014 and 2015 was analyzed. In a publication content analysis potential differences in the publications' quality were assessed. RESULTS: The majority of publications (81 %) and of the cumulative impact factor (87 %) were created within the independent departments. Top-publications with an impact factor > 5 were published in departments only. The qualitative content analysis displayed a varying research-focus in the different organizational structures. Whereas in departments 50 % of publications were experimental, clinical-experimental or clinical, in subordinate organizational structures a major focus lay on retrospective-statistical work with 24 % in contrast to 10 % in independent departments. SUMMARY: This study demonstrates that the type of organizational structure could be a major influencing factor on the publication performance in German academic plastic surgery. An increased autonomy of an academic plastic surgery unit will most likely improve the publication performance and quality and could lead to a more complex study design.

[Colour duplex sonography and "Power-Duplex" in Perforator Surgery - Improvement of patients safety by efficient planning]. / Farbkodierte Duplexsonographie und "Power-Doppler" in der Perforatorchirurgie ­ Erhöhung der Patientensicherheit durch effiziente Planung.

INTRODUCTION: There are many techniques to identify vessels in perforator surgery, each with specific disadvantages. Handheld Dopplers are easy to use, but inaccurate with respect to the exact localisation of the perforator. Angio-CT is invasive, time consuming, and expensive. In contrast, duplex sonography is a reliable, easy-to-use and availabe alternative for pre-, intra-, and postoperative visualisation of vessels. Power Doppler further increases sensitivity and allows visualisation of vessels smaller than 0.5 mm in diameter. MATERIAL AND METHODS: The use of duplex sonography and power Doppler in preoperative planning is illustrated in photographs that show how to identify the course of the septal vessel in free ALT flaps, to ensure that there are competent recipient vessels and to plan pedicled perforator flaps. In all 33 free flaps (21 ALT, 5 DIEAP, 4 FCI, 2 MSAP, 1 tib. post. perf. flap) for lower leg and breast reconstruction and 19 pedicled perforator flaps at the trunk and the extremities were harvested with this technique and used to cover post traumatic and tumour defects. RESULTS: The detection accuracy of duplex sonography was 100 % with reference to the perforator being found within 0.5 cm of the duplexed point and the correct detection of the vessel course (septal vs. intramuscular). No flap loss was observed in this series. This is a non-invasive, reliable, and inexpensive, but time consuming and investigator-dependent technique. DISCUSSION: By direct visualisation of the arteries and veins, the exact localisation of fascia penetration can be detected and flaps can then be better designed. Perforators can be centred in the flaps. The course of perforators can be visualised - especially in ALT flaps - and time consuming dissections through muscle can be avoided.

Elective hand surgery after axillary lymph node dissection for cancer.

After axillary lymph node dissection (ALND), patients are cautioned against ipsilateral interventional procedures to avoid the theoretical increased risk of postoperative complications, particularly lymphedema. The authors' goal was to evaluate the complications of elective hand surgery after ALND. The authors reviewed patients presenting to their hand clinic from 1998 to 2011, selecting those with a diagnosis of breast cancer or melanoma and a history of previous ALND; the authors excluded those treated nonoperatively and those treated with elective surgery in the contralateral hand. Average age of the 22 patients meeting the criteria (20 with a history of breast cancer, 6 with preexisting lymphedema) was 53.9 years (range, 26.7 to 73.6 years) at the time of ALND and 63.1 years (range, 31.7 to 83.5 years) at the time of hand surgery. Average interval between surgeries was 9.2 years (range, 8 days to 37.3 years). Follow-up averaged 9.2 months (range, 8 days to 41.7 months). Fifteen patients were surveyed for long-term postoperative results (average surgery-to-survey interval, 4.3 years [range, 1 to 11.9 years]). Fifteen patients had uneventful postoperative recoveries, 4 had peri-incisional erythema requiring oral antibiotics, 1 had incisional pain and scarring, 1 had chronic wound-healing issues, and 1 had a dehiscence requiring a return to the operating room. In the 15 patients who completed the follow-up survey, there was no disease exacerbation in the 3 patients with preexisting lymphedema, and there were no new cases of lymphedema. Routine minor hand surgery did not result in lymphedema and did not increase existing lymphedema in these patients with previous ipsilateral ALND, but almost one-third of them had short-term complications in the postoperative recovery period.

Extensor tendon repair and reconstruction.

Extensor tendon reconstruction requires various complex hand surgery techniques, including direct tendon repair, tendon grafting transfer, and soft tissue reconstruction with local and free flaps. Choosing the best individual reconstruction plan for the individual patient with an individual defect is crucial.

CASE REPORT Rotational Vascularized Tibiaplasty After Oncologic Resection and Major Wound Healing Problems: A Novel Technique.

OBJECTIVE: To describe a novel method to reconstruct, with a vascularized rotational tibiaplasty, a complex femoral defect in an adolescent. METHODS: After a femoral osteosarcoma resection, allograft reconstruction, and chemotherapy, an 11-year-old girl developed recurrent thigh wound infections and femoral allograft osteomyelitis despite multiple operative interventions. At the age of 13, she presented to our center with a complex right thigh wound and an unstable lower extremity secondary to a segmental femoral loss. To reestablish thigh stability and function and to avoid amputation at the hip, the authors performed a rotational vascularized tibiaplasty. The tibia was rotated 180° with the pivot at the knee. The distal tibia was internally stabilized to the residual proximal femur. RESULTS: Ten years later, the patient had a stable thigh, a functional hip, no evidence of infection or sarcoma, and a Toronto Extremity Salvage Score of 92.5 (minimal disability). CONCLUSIONS: In this patient, the tibial rotationplasty provided a vascularized bone strut mimicking the resected femur; saved the hip; obviated an allograft bone; and created a functional, biologic, stable, and durable thigh that allowed full weight bearing on a prosthesis, with a low physical disability level. We conclude that, for patients with complex femoral defects, a vascularized rotational tibiaplasty should be considered a feasible option before amputation.

Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits.

BACKGROUND: Stenosing flexor tenosynovitis of the digital flexor tendon (trigger digit) is a common condition encountered by hand surgeons. Our purpose was to determine the efficacy of corticosteroid injections and review the demographic profile of patients with trigger digits. METHODS: We reviewed the records of 362 patients (577 trigger digits) treated with steroid injections (8 mg of triamcinolone acetonide in 1 % lidocaine) from 1998 through 2011. Follow-up (intervention to last visit) averaged 66.4 months. We assessed patient demographics (e.g., gender, age, diabetes mellitus, hand dominance, trigger digit distribution) and determined recurrence rate and injection duration of efficacy. If one injection failed, additional injections or surgical A1 pulley release were offered. Results were analyzed with Student's t test or Fisher's exact test (significance, p < 0.05). RESULTS: Women (258, 71.3 %) were affected significantly (p < 0.001) more frequently than men (104, 28.7 %) and at a significantly (p < 0.001) younger age (average, 58.3 versus 62.1 years, respectively). Eighty patients (22.1 %) were diabetic. We observed no correlation between trigger digit and hand dominance. The two most commonly affected digits were the right long finger (17.8 %) and right thumb (17.7 %). For 721 injections, the recurrence rate was 20.3 %; there were no major complications. For recurrences, the injection efficacy averaged 315 days. Surgery was required for 117 patients. CONCLUSIONS: Injection therapy is safe and highly effective (79.7 %). Women were affected by trigger digits more often than men and at a younger age. Surgical release provides a definitive therapeutic option if corticosteroid injection fails.

Making sure. A comparative micro-analysis of diagnostic instruments in medical practice.

This article conceptualises diagnosis as ongoing practical judgement in medical care. Based on pragmatist and phenomenological considerations of tools in use, it uses a comparative approach to analyse similarities and differences in the use of diagnostic technologies. In the first part of the paper, a historical perspective on the innovation of the stethoscope is used to highlight the transformations in diagnostic practices occasioned by novel diagnostic instruments. In the second part of the paper, ethnographic accounts of contemporary anaesthesia are presented in order to sketch out the manifold variations of using diagnostic instruments in daily practice. Both cases are analysed on a micro-analytical level, emphasising the interrelations of bodies, tools and knowledge in concrete situations. The analysis shows how diagnostic instruments become embodied in the perceptual habits of physicians and how diagnosing becomes an ongoing activity in the course of managing an illness trajectory.

Suppression of soft tissue sarcoma growth by a host defense-like lytic peptide.

BACKGROUND: Soft tissue sarcoma (STS) is an anatomically and histologically heterogeneous neoplasia that shares a putative mesenchymal cell origin. The treatment with common chemotherapeutics is still unsatisfying because of association with poor response rates. Although evidence is accumulating for potent oncolytic activity of host defense peptides (HDPs), their potential therapeutic use is often limited by poor bioavailability and inactivation in serum. Therefore, we tested the designer host defense-like lytic D,L-amino acid peptide [D]-K3H3L9 on two STS cell lines in vitro and also in an athymic and syngeneic mouse model. In recent studies the peptide could show selectivity against prostate carcinoma cells and also an active state in serum. METHODS: In vitro the human synovial sarcoma cell line SW982, the murine fibrosarcoma cell line BFS-1 and primary human fibroblasts as a control were exposed to [D]-K3H3L9, a 15mer D,L-amino acid designer HDP. Cell vitality in physiological and acidic conditions (MTT-assay), cell growth (BrdU) and DNA-fragmentation (TUNEL) were investigated. Membrane damage at different time points could be analyzed with LDH assay. An antibody against the tested peptide and recordings using scanning electron microscopy could give an inside in the mode of action. In vivo [D]-K3H3L9 was administered intratumorally in an athymic and syngeneic (immunocompetent) mouse model with SW982 and BFS-1 cells, respectively. After three weeks tumor sections were histologically analyzed. RESULTS: The peptide exerts rapid and high significant cytotoxicity and antiproliferating activity against the malignant cell lines, apparently via a membrane disrupting mode of action. The local intratumoral administration of [D]-K3H3L9 in the athymic and syngeneic mice models significantly inhibited tumor progression. The histological analyses of the tumor sections revealed a significant antiproliferative, antiangiogenic activity of the treatment group. CONCLUSION: These findings demonstrate the in vitro and in vivo oncolytic activity of [D]-K3H3L9 in athymic and syngeneic mouse models.

Oncolytic designer host defense peptide suppresses growth of human liposarcoma.

Sarcomas display a rare and heterogeneous group of tumors. Treatment options are limited. Host defense peptides (HDPs), effector molecules of the innate immune system, might provide a more effective treatment option. The aim of our study was to analyze the oncolytic activity and mode of action of a designer HDP. In vitro, the human liposarcoma cell line SW-872 and primary human fibroblasts as a control were exposed to [D]-K(3)H(3)L(9), a 15-mer D,L-amino acid designer peptide. Cell growth (MTT assay), proliferation (BrdU assay) and genotoxicity (TUNEL assay) were analyzed. The mode of action was examined via fluorescence-activated cell sorter (FACS) analysis and confocal laser scanning microscopy. In vivo, [D]-K(3)H(3)L(9) (n = 7) was administered intratumorally in a SW-872 xenograft mouse model (Foxn1nu/nu). Phosphate buffered saline served as a control (n = 5). After 4 weeks, tumor sections were histologically analyzed with respect to proliferation, cytotoxicity, vessel density and signs of apoptosis and necrosis, respectively. In vitro, [D]-K(3)H(3)L(9) highly significantly (p < 0.01) inhibited cell metabolism and proliferation. TUNEL assay revealed corresponding genotoxicity. FACS analysis suggested induction of necrosis as a cause of cell death. The mean tumor volume of the control group exponentially increased sevenfold, whereas the mean tumor growth was negligible in the treatment group. Macroscopically, [D]-K(3)H(3)L(9) induced full tumor remission in 43% of treated animals and partial remission in 43%. Vessel density was significantly reduced by 52%. Morphological analyses supported the hypothesis of cancer cell killing by necrosis. In summary, [D]-K(3)H(3)L(9) exerts very promising oncolytic activity on liposarcoma cells. Our study demonstrates the potential of HDPs as a novel therapeutic option in future soft tissue sarcoma therapy.

Establishment of a primary human sarcoma model in athymic nude mice.

Improvement of soft tissue sarcoma patient outcome requires well-characterized animal models in which to evaluate novel therapeutic options. Xenograft sarcoma models are frequently used, but commonly with established cell lines rather than with primary human sarcoma cells. The objective of the present study was to establish a reproducible xenograft model of primary human soft tissue sarcoma in athymic nude mice. Primary soft tissue sarcoma cells from four resected human sarcomas were isolated, cultured until the third passage and injected subcutaneously into athymic nude mice. The sarcoma xenograft was further analyzed by histological and immunohistochemical staining. In two out of four sarcomas tumor growth could successfully be established leading to solid tumors of up to 540 mm(3) volume. Histological and immunohistochemical staining confirmed the mouse xenograft as identical sarcoma compared with the original patient's tissue. In the present study a reproducible xenograft model of primary human soft tissue sarcoma in athymic nude mice was established. This animal model is of great interest for the study of sarcomogenesis and therapy.

Brachial neuropathy 22 years after radiation therapy for fibrosarcoma: a case report.

This case report presents a 56-year-old man with right upper limb weakness which arose 22 years after initial local radiation treatment for a grade III fibrosarcoma. Nerve conduction studies revealed impairment of all three major upper limb nerves compared with the left, with particular impairment of the median and ulnar nerves in the most fibrotic area that had been irradiated. In addition, the patient received multiple courses of chemotherapy. The occurrence of radiation-induced brachial plexopathy should be considered in patients presenting with limb pain or weakness even many years after radiation therapy.