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Highlights • Calciphylaxis may cause severe soft tissue complications after total joint arthroplasty. • Caliphylaxis is a potential differential diagnosis to surgical site infection in patients with chronic kidney disease. • Skin biopsy should be taken in case of suspected calciphylaxis to confirm the diagnosis., Background context Calciphylaxis is a rare complication of secondary hyperparathyroidism caused by calcifications of small blood vessels in the skin and soft tissue. The disease occurs almost exclusively in patients with chronic kidney disease and has an incidence of approximately 50 cases per year in Germany [1]. Purpose We present a case of a 61-year-old woman with calciphylaxis in connection with a primary knee endoprosthesis implantation. Study design Case report. Methods A review of the medical records since the time of initial hospital admission throughout the entire hospitalization until the death of the patient was performed. Results Calciphylaxis caused severe soft tissue complications after total joint arthroplasty. Despite interdisciplinary therapy, including revision and plastic surgery as well as intensive care, the patient died 4 months after primary total knee arthroplasty due to septic multi-organ failure. Conclusion Calciphylaxis may cause severe soft tissue complications after total joint arthroplasty and should be considered as potential differential diagnosis to surgical site infection. This is the first case report on calciphylaxis as direct complication of total joint replacement surgery.

Aktualisierung der 2010 publizierten evidenzbasierten S3-Leitlinie zu Epidemiologie, Diagnostik, Therapie und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen (HWI) bei erwachsenen Patienten. Die aktualisierte S3-Leitlinie behandelt jetzt auch die Prophylaxe rezidivierender unkomplizierter Harnwegsinfektionen. Die Leitlinie beinhaltet die aktuelle Evidenz zum rationalen Einsatz antimikrobieller Substanzen zur Reduktion eines unangemessenen Einsatzes bestimmter Antibiotikaklassen und zur Vermeidung der Entwicklung von Resistenzen. Die Aktualisierung der S3-Leitlinie erfolgte unter Federfuhrung der Deutschen Gesellschaft fur Urologie (DGU). Eine systematische Literaturrecherche wurde fur den Zeitraum 01.01.2008–31.12.2015 durchgefuhrt. Internationale Leitlinien wurden mitberucksichtigt. Evidenzgrad und Biasrisiko wurden zur Qualitatsprufung herangezogen. Aktualisierte Informationen zu Erregerempfindlichkeit, Erfolgsraten, Kollateralschaden und Sicherheit von Antibiotika der ersten und zweiten Wahl wurden neu gelistet. Fur die Therapie der unkomplizierten Zystitis sind in erster Linie Fosfomycin-Trometamol, Nitrofurantoin, Nitroxolin, Pivmecillinam oder Trimethoprim (unter Beachtung der ortlichen Resistenzsituation) zu empfehlen. Fluorchinolone und Cephalosporine sollen hier nicht als Antibiotika der ersten Wahl eingesetzt werden. Bei einer unkomplizierten Pyelonephritis mit leichten bis moderaten Verlaufsformen sollen vorzugsweise Cefpodoxim, Ceftibuten, Ciprofloxacin oder Levofloxacin als orale Antibiotika eingesetzt werden. Die aktualisierte deutsche S3-Leitlinie stellt eine umfassende Sammlung evidenz- und konsensbasierter Empfehlungen zur Epidemiologie, Diagnostik, Therapie, Pravention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten dar. Antibiotic Stewardship-Aspekte haben wesentlich die therapeutischen Empfehlungen gepragt. Eine breite Implementierung in alle behandelnden Fachgruppen ist notwendig, um eine vorausschauende Antibiotikapolitik zu gewahrleisten und damit eine Versorgungsverbesserung zu erzielen.

Candiduria is common in hospitalised patients, but the clinical relevance is still unclear. This study was done to further our knowledge on detection of and host responses to candiduria. Urines and clinical data from 136 patients in whom presence of yeast was diagnosed by microscopic urinalysis were collected. Diagnosis by standard urine culture methods on blood and MacConkey agar as well as on fungal culture medium (Sabouraud dextrose agar) was compared. Inflammatory parameters (IL-6 and IL-17, Ig) were quantified in the urine and compared with levels in control patients without candiduria. Standard urine culture methods detected only 37% of Candida spp. in urine. Sensitivity was especially low (23%) for C. glabrata and was independent of fungal burden. Candida specific IgG but not IgA was significantly elevated when compared with control patients (P < 0.0001 and 0.07 respectively). In addition, urine levels of IL-6 and IL-17 were significantly higher in candiduric patients when compared with control patients (P < 0.001). Multivariate analysis documented an independent association between an increased IgG (odds ratio (OR) 136.0, 95% confidence interval (CI) 25.7-719.2; P < 0.0001), an increased IL-17 (OR 17.4, 95% CI 5.3-57.0; P < 0.0001) and an increased IL-6 level (OR 4.9, 95% CI 1.9-12.4; P = 0.001) and candiduria. In summary, our data indicate that clinical studies on candiduria should include fungal urine culture and that inflammatory parameters may be helpful to identify patients with clinically relevant candiduria.

Die Indikationskriterien zur Cochleaimplantat-(CI-)Versorgung haben sich im Lauf der letzten Jahre verandert. In der Versorgung pralingual ertaubter Kinder ist eine fruhe Implantation anzustreben, um optimale Ergebnisse im Sprachverstandnis zu erzielen. Zusatzliche Behinderungen stellen heute per se keine Kontraindikation mehr dar. Das Indikationsspektrum hat sich von der Taubheit hin zur Resthorigkeit ausgedehnt. Besteht ein verwertbares Horvermogen im Tieftonbereich, hat sich die kombinierte elektrisch-akustische Stimulation als Behandlungsmoglichkeit etabliert. Die bilaterale CI-Versorgung ist aufgrund der Vorteile binauralen Horens inzwischen zur Regel geworden. Jungste Erfahrungen zeigen den Nutzen der CI-Versorgung bei einseitiger Ertaubung und einen positiven Effekt auf einen stark beeintrachtigenden Tinnitus. Der tatsachliche Nutzen eines CI weist grose interindividuelle Unterschiede auf. Zumeist wird von einer CI-Versorgung eine Horverbesserung und damit die (Wieder)herstellung der lautsprachlichen Kommunikationsfahigkeit erwartet.

The use of conventional CT- or MRI-based navigation systems for head and neck surgery is unsatisfactory due to tissue shift. Moreover, changes occurring during surgical procedures cannot be visualized. To overcome these drawbacks, we developed a novel ultrasound-guided navigation system for head and neck surgery. A comprehensive error analysis was undertaken to determine the accuracy of this new system.The evaluation of the system accuracy was essentially based on the method of error definition for well-established fiducial marker registration methods (point-pair matching) as used in, for example, CT- or MRI-based navigation. This method was modified in accordance with the specific requirements of ultrasound-guided navigation. The Fiducial Localization Error (FLE), Fiducial Registration Error (FRE) and Target Registration Error (TRE) were determined.In our navigation system, the real error (the TRE actually measured) did not exceed a volume of 1.58 mm(3) with a probability of 0.9. A mean value of 0.8 mm (standard deviation: 0.25 mm) was found for the FRE. The quality of the coordinate tracking system (Polaris localizer) could be defined with an FLE of 0.4 +/- 0.11 mm (mean +/- standard deviation). The quality of the coordinates of the crosshairs of the phantom was determined with a deviation of 0.5 mm (standard deviation: 0.07 mm).The results demonstrate that our newly developed ultrasound-guided navigation system shows only very small system deviations and therefore provides very accurate data for practical applications.

Preservation of residual hearing after cochlear implantation allows patients the synergetic use of electric and acoustic stimulation (EAS). The application of specific surgical and therapeutic techniques enables the reduction of inner ear trauma, which leads otherwise to complete hearing loss. Due to simultaneous electric and acoustic stimulation, speech understanding is improved especially in noise. EAS is a well-accepted therapeutic treatment for subjects with profound hearing loss in the higher frequencies and no or mild hearing loss in the low frequencies. Several Manufacturers offer individual soft electrodes specially designed for hearing preservation as well as combined electric-acoustic audio processors.

We consider parametric semi-infinite optimization problems without the usual asssumptions on the continuity of the involved mappings and on the compactness of the index set counting the inequalities. We establish a characterization of those optimization problems which have a unique or strongly unique solution and which are stable under small pertubations. This result generalizes a well-known theorem of Nurnberger. The crucial roles in our investigations are a new concept of active constraints, a generalized Slater's condition, and a Kuhn—Tucker-type theorem. Finally, we give some applications in vector optimization, for approximation problems in normed spaces, and in the stability of the minimal value.

Basierend auf dem begriff der Ausfallratefunktion wird der Vorschlag fur ein lokales, kumuliertes Schadensmas abgeleitet, das es ermoglicht das Versagensverhalten von Kompositen im inhomogenen spannungsfeld zu modellieren. Das Schadensmas berucksichtigt die Akkumulation innerer, stochastischer schaden und eine damit verbundene Lastumverteilung auf ungeschadigte, tragende Volumenelemente. Als ein Anwendungsfall wird das Versagensverhalten von Biegebalken untersucht. Zum anderen wird nachgewiesen, das lokale Schadigungen im Bereich der Rispitze zum Verschwinden singularer Spannungsfelder an der Risfront fuhren. Local cumulative damage measure-crack tips without singularity A pointwise probability density for failure initiation is proposed regarding the evaluation of damaged composite structures. The local cumulative damage measure accounts for both the accumulation of local stochastic microdamaging and the load redistribution to undestroyed subregions. It bases on the global failure rate of heterogenous composites. Firstly the damage behaviour of beams under load is studied. Secondly it is proved that stress redistribution by a crack tip damage zone yields to the disappearence of singularity dominated stress fields.

Background Recent studies demonstrated the potential involvement of nerve fibres in the chronic inflammatory process of endometriosis. We aimed to characterize nerve fibres in the proximal and distal areas of the peritoneal endometriotic lesions in order to understand the chronic inflammatory process in endometriosis. Methods Peritoneal endometriotic lesions (proximal area) (n = 17), the matching unaffected peritoneum (distal area) and healthy peritoneum of patients without endometriosis (n = 15) were analysed with the neuronal markers PGP 9.5, calbindin, calretinin and parvalbumin. Peritoneal fluids of women with and without endometriosis were used for Western blot analysis and for the neuronal growth assay. The protein expression of neuronal PC-12 cells incubated with peritoneal fluids was analysed. Results The overall nerve fibre density was significantly reduced in the distal area of the lesion when compared with the proximal area or with healthy peritoneum. The density of calbindin-, calretinin- and parvalbumin-positive nerve fibres was significantly increased in the endometriosis group. Calretinin expression was elevated in the peritoneal fluid of women with symptomatic endometriosis when compared with women with asymptomatic endometriosis. Furthermore, PC-12 cells incubated with peritoneal fluid of women with endometriosis showed a higher proliferation rate and a stronger neurite outgrowth than the control group. PC-12 cells incubated in peritoneal fluids of women with endometriosis expressed less calretinin but more calbindin than the control group. Conclusions Calcium-binding proteins seem to be increased in endometriosis-associated nerve fibres and might play an important role in the chronic inflammatory condition and the pain pathogenesis of endometriosis.

Recent studies demonstrated the potential involvement of nerve fibres in the chronic inflammatory process of endometriosis. We aimed to characterize nerve fibres in the proximal and distal areas of the peritoneal endometriotic lesions in order to understand the chronic inflammatory process in endometriosis.Peritoneal endometriotic lesions (proximal area) (n = 17), the matching unaffected peritoneum (distal area) and healthy peritoneum of patients without endometriosis (n = 15) were analysed with the neuronal markers PGP 9.5, calbindin, calretinin and parvalbumin. Peritoneal fluids of women with and without endometriosis were used for Western blot analysis and for the neuronal growth assay. The protein expression of neuronal PC-12 cells incubated with peritoneal fluids was analysed.The overall nerve fibre density was significantly reduced in the distal area of the lesion when compared with the proximal area or with healthy peritoneum. The density of calbindin-, calretinin- and parvalbumin-positive nerve fibres was significantly increased in the endometriosis group. Calretinin expression was elevated in the peritoneal fluid of women with symptomatic endometriosis when compared with women with asymptomatic endometriosis. Furthermore, PC-12 cells incubated with peritoneal fluid of women with endometriosis showed a higher proliferation rate and a stronger neurite outgrowth than the control group. PC-12 cells incubated in peritoneal fluids of women with endometriosis expressed less calretinin but more calbindin than the control group.Calcium-binding proteins seem to be increased in endometriosis-associated nerve fibres and might play an important role in the chronic inflammatory condition and the pain pathogenesis of endometriosis.

Using the concept for ∈-efficient solutions introduced in Refs. 1 and 2, we extend the Ekeland variational principle and another variational principle given in Ref. 3 to vector-valued objective functions. This enables us to establish a kind of well-posedness for the resulting perturbed vector optimization problems. Based on this definition of ∈-efficiency, we also formulate a concept for level sets and prove some results about the Kuratowski limits of level sets.

In recent years the indication criteria for cochlear implantation (CI) have changed. To gain optimal benefits, early implantation in prelingually deaf children is necessary. Even additional disabilities are no longer contraindications for CI. Nowadays the criteria for implantation not only include deafness but also residual hearing. Combined electric-acoustic stimulation has been established as a treatment option in patients with hearing still functioning in the low frequencies. Due to the benefits of binaural hearing, bilateral CI has become standard over the last decade. Recent experience has shown the benefits of CI in unilateral deafness and in cases of severe tinnitus. The actual benefit of CI shows great inter-individual differences. We usually expect (re-)habilitation of language communication skills with implantation.

Storungen in der Interaktion und Kommunikation mit anderen, sei es nun in privaten Bereichen wie in Partnerschaft und Erziehung oder im beruflichen Kontext, gehen haufig mit erheblichen Einschrankungen und Belastungen fur den Betroffenen einher. Sie stellen daruber hinaus einen unspezifischen Risikofaktor fur die Entstehung und Aufrechterhaltung einer Vielzahl von psychischen Storungen dar.

This study compared the music perception abilities of 13 electric acoustic stimulation (EAS) users with two control groups: unilateral cochlear implant (CI) users and normal-hearing (NH) listeners.Groups were matched according to age and musical experience before hearing loss (HL) and tested using the Musical Sounds in Cochlear Implants (Mu.S.I.C.) test.No difference was found on rhythm perception, chord discrimination, dissonance rating, and emotion rating subtest performance between groups. Mean frequency discrimination scores were significantly better in EAS participants than in CI participants and not significantly worse than in NH participants. However, the EAS and CI groups scored similarly (significantly worse than NH participants) on both instrument detection and identification. Results for EAS participants were not significantly worse when the hearing aid component was removed. Frequency of listening to music before HL was negatively correlated with EAS participants' frequency discrimination scores, though singing and playing an instrument appeared to have no effect. EAS participants who indicated many reasons for listening to music and who listen to many genres after implantation scored higher on instrument detection and instrument identification. Better results on these two subtests were correlated with EAS participants' better postoperative auditory thresholds at 250 and 500 Hz.Though EAS participants performed better on music perception testing (though not timbre-based tasks) than CI participants, their scores did not reach the level of NH participants. This indicates that acoustic hearing in the low frequencies is helpful for music perception, though not the only important factor.

After cochlear implantation, individuals with sufficient residual hearing in the lower frequency region are able to successfully combine acoustic and electrical stimulation patterns to improve speech perception, especially in noise, and to improve music appraisal as well. These improvements occur through enhanced transmission of fine structure information by more accurate mapping of the fundamental frequency contour through acoustic hearing. In current cochlear implant systems, the transfer of frequency and melodic contour is very coarse, and the correct detection of pitch contour requires large frequency differences. It is assumed that the acoustically transferred part of the signal enables the cochlear implant recipient to better segregate between speech signals and interfering sounds. The detection and following of a speech signal emitted by a single talker in a multitalker babble situation is improved when fundamental frequencies as grouping cues are present. The preservation of hearing in the implanted ear must be considered a major surgical challenge. The development of very flexible and soft electrode carriers in combination with surgical approaches that minimally traumatize the inner ear enable hearing preservation in nearly all cases.

Es wird ein theoretisches Modell der Lastubertragung zwischen monoklin anisotroper Faser und dem umgebenden Matrixmaterial in uniaxial faserverstarkten verbunden nahe eines Matrixfehlers diskutiert welches eine-reibungsbehaftete Grenzflachenablosung zwischen beiden Materialkomponenten einbezieht. Die Zunahme der Bruchzahigkeit infolge Fasergleiten delaminierter Faserstucke wird untersucht. Dabei wird eine Weibullverteilung der Faserzugfestigkeiten vorausgesetzt. Die gesamte dissipative Arbeit kann als Gutezahl zur Bewertung der Schadenstoleranz verwendet werden. Es erfolgt eine kritische Bewertung von einigen aus der Literatur bekannten Modellansatzen zu lokalen Versagenswahrscheinlichkeiten Numerische Ergebnisse werden vorgestellt. Bedingungen fur einen optimierten C/Al Verbund werden genannt. Micromechanical stochastic failure model of uniaxial fibre-reinforced composites A theoretical model of stress transfer between a transversal isotropic fibre and the surrounding matrix material in a uniaxially fibre-reinforced composite near a single matrix flaw is discussed including friction controlled fibre-matrix interface debonding. The rise of fracture toughness due to frictional fibre sliding is studied accounting for Weibull strength distribution of fibres. The total dissipative work may be used as figure of merit regarding the damage tolerance. A critical evaluation is presented concerning some previous models of local failure probabilities. Numerical results are demonstrated. Conditions for an optimized C/Al-composite are presented.

In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized.A novel navigation device for sonography of soft tissues was developed. This consists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable.The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate.This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues.

In vector optimization, topological properties of the set of efficient and weakly efficient points are of interest. In this paper, we study the connectedness of the setE w of all weakly efficient points of a subsetZ of a locally convex spaceX with respect to a continuous mappingp:X ?Y,Y locally convex and partially ordered by a closed, convex cone with nonempty interior. Under the general assumptions thatZ is convex and closed and thatp is a pointwise quasiconvex mapping (i.e., a generalized quasiconvex concept), the setE w is connected, if the lower level sets ofp are compact. Furthermore, we show some connectedness results on the efficient points and the efficient and weakly efficient outcomes. The considerations of this paper extend the previous results of Refs. 1---3. Moreover, some examples in vector approximation are given.

The aim of this paper is to study the continuous dependence of the feasible set of a disjunctive semi-infinite linear optimization problem on all involved parameters (matrix and right-hand side). The feasible set of such an optimization problem is the union of (a. possible infinite number of) convex sets, which each is described by a finite or an infinite number of strict and non-strict linear inequalities. We derive necessary and sufficient conditions for the upper- and lower-semi-continuity, and the closedness of the feasible-set-mapping Z Especially, the compactness of the boundary of the feasible set and the closedness of Z are equivalent to the upper-semi-continuity of Zwhile the lower semi-continuity of Z is equivalent to a certain constraint qualification. This constraint qualification is a strengthened kind of Slater condition, rrom tuese investigations, we derive known results in parametric semi-infinite optimization and parametric integer programming.

In 2003, our department inaugurated a quality management system. The certification according to DIN EN ISO 9001:2000 as required by the hospital management was achieved in August 2005. The aims were optimization of internal operating schedules and standardization of procedures according to logistic interfaces with external structures.Since 2000, the implementation of an internal quality management system is required by German law and threatened by penalty in case of non-implementation. Beside a basic audit and optimization of all organizational procedures, all core processes were determined and the approvals checked. These aims involve both the quality of operational procedures, in and outpatient treatment, research, study and teaching and aspects of service such as quickness of scheduling and forwarding of reports as well as economic aspects and efficiency. The department of "quality management", whose main tasks are the professional guidance and the training of the quality management representatives, plays an important role.Realization of the new regulations and restructuring resulted in an increase in effectiveness and an improvement in operational procedures. In particular, patients and staff have benefited from the reorganized and modified sequence of operations.Implementation of a quality management system in different hospital departments is recommended.

The introduction of Diagnosis-Related Groups, which standardize payment for each clinical service, entails keeping the inpatient treatment as short as possible. Thus outpatient treatment is gaining in importance. To cope with this change, organizational and structural modifications of clinic routine are necessary.In the ear, nose, and throat outpatient clinic of Johann Wolfgang Goethe University in Frankfurt, Germany, a hotline was established that allows patients to make appointments and get advice based on quality management guidelines according to DIN EN ISO 9001:2000. The development of this project is described here step by step, from planning to inclusion in the daily clinic routine.Patient visits became more effective despite increasing demand. This resulted in high satisfaction of patients and clinic personnel alike.This model may contribute considerably to coping with the increasing demand for clinic appointments and to optimal use of a clinic's human resources.