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The aim of this study was to evaluate the effectiveness of initially conservative therapy compared to immediate appendectomy for acute appendicitis with abscess in terms of medical and economic outcomes. Of all the patients treated for appendicitis from January 2009 to December 2017 in five German hospitals, 240 were included in the study. Fifty-three patients received conservative (CON) and 195 patients received surgical (SUR) therapy as initial treatment. Length of stay was similar (12.5 days in CON vs. 13.3 days in SUR, p = 0.530). Readmission rate was higher in the conservative group (54.7% vs. 6.2%, p

Recent advances in analytical chemistry have allowed a greater possibility of using quantitative approaches for measuring human exposure to chemicals. One of these approaches is biomonitoring (BM), which provides unequivocal evidence that both exposure and uptake of a chemical have taken place. BM has been a longstanding practice in occupational health for several reasons. BM integrates exposure from all routes. It can help identify unintentional and unexpected exposures and assess the effectiveness of existing risk-management measures. BM also provides relevant information to support policy development by delivering better evidence of workers' exposure to chemical substances, even within the framework of the present regulations. Thus, BM can allow for both the evaluation of the impact of regulation and identification of further needs for new or improved regulation. However, despite all these well-recognized advantages, BM is currently an underused exposure assessment tool. This paper provides an overview of the key aspects to be considered when using BM in the context of occupational health interventions. Additionally, this paper describes the potential of BM as an exposure assessment tool, distinguishing the role of BM in exposure assessment and health surveillance and clarifies ethical and communication aspects to guarantee that general data protection regulations are followed. In addition, actions and research needs are identified (particularly with reference to the European situation), which aim to encourage the increased use of BM as an exposure assessment tool. ispartof: INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH vol:17 issue:16 ispartof: location:Switzerland status: published

A method was developed and validated for multi-element analyses of human urine samples using inductively coupled plasma-tandem mass spectrometry. The combination of a simple sample preparation and the state-of-the-art technique allows high-throughput and lowest limits of quantification up to 1 ng/L. Thereby coefficients of variation ranges from 0.4% (V) to 3.7% (Be), and 0.9% (Cd) to 4.8% (Ni) for intraday and interday precision, respectively. The method's performance is demonstrated by successful participation in international interlaboratory comparison programs as external quality assurance. Moreover, the method was applied for the analysis of first-morning void urine samples of adults (N = 77) living in the German capital region. 15 metals and metalloids (Astotal, Be, Bi, Cd, Co, Cr, In, Mn, Mo, Ni, Pb, Sn, Tl, V, and Zn) were determined. With exception of indium, all elements were found in urine samples above the limit of quantification, demonstrating the suitability to measure the general population's exposure to these metals and metalloids. The method presented here shall be used for analysis of urine samples collected in the upcoming German Environmental Survey, GerES VI, a cross-sectional, population-representative study.

ZusammenfassungDer Nutzen von medizinischen Thromboseprophylaxestrümpfen (AES) als physikalisches Mittel zur Prävention von venösen Thrombosen der unteren Extremität wird im Zeitalter der evidenzbasierten Medizin infrage gestellt. Die aktuellen S3-Leitlinien schreiben sogar, dass ihre Nichtanwendung in den allermeisten Fällen explizit im Empfehlungskorridor dieser Leitlinie liegt. Die niedermolekularen Heparine (NMH) und die direkten oralen Antikoagulanzien (DOAK) haben über Studien zur Thromboseprophylaxe bei elektivem Knie- und Hüftgelenkersatz ihre Zulassung erhalten, allerdings ist zur Anwendung von AES in diesen Zulassungsstudien nichts bekannt. Nun wurden erstmals die Ergebnisse der zusätzlichen Wirkung der AES in den Zulassungsstudien von Edoxaban publiziert. Danach betrug die Inzidenz von venösen Thromboembolien 6,0%, wenn AES getragen wurden, und 13,0%, wenn keine AES getragen wurden. Da in den Zulassungsstudien von NMH und den DOAKs nicht die Anwendung von AES kontrolliert wurde, kann nicht gesagt werden, wie groß der Effekt der AES auf das Gesamtergebnis ist, und die Studienergebnisse gelten nur vor dem Hintergrund der allgemeinen Anwendung von AES.

Diese erste deutschsprachige S2k-Leitlinie zu bakteriellen Haut- und Weichgewebeinfektionen ist im Rahmen der „Empfehlungen zur kalkulierten parenteralen Initialtherapie bakterieller Erkrankungen“ unter Federfuhrung der Paul-Ehrlich-Gesellschaft fur Chemotherapie e.V. entstanden und wird in wichtigen Auszugen hier wiedergegeben. Voraussetzung fur gut kalkulierte Antibiotikatherapien ist eine genaue diagno­stische Zuordnung. So wird das Erysipel definiert als nichteitrige Infektion als deren Erreger β-­hamolysierende Streptokokken gelten, und das klinisch diagnostiziert wird aufgrund eines hellroten Erythems und initial auftretenden Fiebers oder Frostelns. Therapie der Wahl ist Penicillin. Begrenzte Phlegmonen dagegen werden meist durch Staphylococcus (S.) aureus verursacht, gehen haufig von Wunden aus, zeigen lividrote Erytheme und sind initial meist nicht von Fieber begleitet. Die Behandlung erfolgt mit einem Cephalosporin der Gruppe 1 oder 2 oder Flucloxacillin (parenteral). Schwere Phlegmonen sind eitrige, teilweise nekrotische, im Gewebe sich ausbreitende und bis an die Faszie reichende Infektionen, welche neben der Antibiotikabehandlung zusatzlich einer chirurgischen Versorgung bedurfen. Sie erfullen oft auch die Kriterien fur komplizierte Weichgewebeinfektionen, wie sie von der Food and Drug Administration fur klinische Studien definiert worden sind (u. a. Komorbiditaten wie schlecht eingestellter Diabetes mellitus, periphere arterielle Verschlusskrankheit, Neutropenie). Hierfur werden Antibiotika empfohlen, die neben S. aureus auch anaerobe Bakterien und/oder gramnegative Bakterien erfassen. Die sogenannten nekrotisierenden Weichgewebeinfektionen sind eigenstandige, rasch progrediente, akut lebensbedrohliche Infektionen infolge besonderer bakterieller Toxine, die zu ischamischen Nekrosen und Schock fuhren und ein schnelles radikales chirurgisches Debridement sowie entsprechende Anitbiotika erfordern. Abszesse mussen in erster Linie gut drainiert werden und erfordern nur unter bestimmten Umstanden zusatzlich Antibiotika (Lokalisation im Gesicht, Hand- oder Genitoanalbereich, schwieriger Drainage etc.). Die Leitlinie enthalt zusatzlich Konsensus-basierte Empfehlungen fur hohere als in Studien geprufte oder ublicherweise verabreichte Dosierungen. Ziel ist eine rationale Antibiotikatherapie, die wirksam und vertraglich ist und keinen unnotigen Selektionsdruck in Richtung (multi-)resistenter Erreger ausubt.

These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for "calculated initial parenteral treatment of bacterial infections" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for "complicated soft tissue infections", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.

Background Peritonitis is responsible for thousands of deaths annually in Germany alone. Even source control (SC) and antibiotic treatment often fail to prevent severe sepsis or septic shock, and this situation has hardly improved in the past two decades. Most experimental immunomodulatory therapeutics for sepsis have been aimed at blocking or dampening a specific pro-inflammatory immunological mediator. However, the patient collective is large and heterogeneous. There are therefore grounds for investigating the possibility of developing personalized therapies by classifying patients into groups according to biomarkers. This study aims to combine an assessment of the efficacy of treatment with a preparation of human immunoglobulins G, A, and M (IgGAM) with individual status of various biomarkers (immunoglobulin level, procalcitonin, interleukin 6, antigen D-related human leucocyte antigen (HLA-DR), transcription factor NF-κB1, adrenomedullin, and pathogen spectrum). Methods/design A total of 200 patients with sepsis or septic shock will receive standard-of-care treatment (SoC). Of these, 133 patients (selected by 1:2 randomization) will in addition receive infusions of IgGAM for 5 days. All patients will be followed for approximately 90 days and assessed by the multiple-organ failure (MOF) score, by the EQ QLQ 5D quality-of-life scale, and by measurement of vital signs, biomarkers (as above), and survival. Discussion This study is intended to provide further information on the efficacy and safety of treatment with IgGAM and to offer the possibility of correlating these with the biomarkers to be studied. Specifically, it will test (at a descriptive level) the hypothesis that patients receiving IgGAM who have higher inflammation status (IL-6) and poorer immune status (low HLA-DR, low immunoglobulin levels) have a better outcome than patients who do not receive IgGAM. It is expected to provide information that will help to close the knowledge gap concerning the association between the effect of IgGAM and the presence of various biomarkers, thus possibly opening the way to a personalized medicine. Trial registration EudraCT, 2016–001788-34; ClinicalTrials.gov, NCT03334006. Registered on 17 Nov 2017. Trial sponsor: RWTH Aachen University, represented by the Center for Translational & Clinical Research Aachen (contact Dr. S. Isfort). Electronic supplementary material The online version of this article (10.1186/s13063-019-3244-4) contains supplementary material, which is available to authorized users.

Einfuhrung: Lungensequester sind seltene pulmonale Malformationen. Die komplexe Pathogenese ist nicht vollstandig geklart. Extralobare Sequester sind immer kongenital und werden im Kindesalter diagnostiziert. Demgegenuber scheinen bei Erwachsenen ein Teil der intralobaren Sequester erworben zu sein. Die unspezifische Klinik bedingt eine protrahierte Diagnose. In der Behandlung ist die Resektion weiterhin der Goldstandard. Trotz der geringen Inzidenz haben auch hier die technischen Entwicklungen der letzten Jahrzehnte, wie praoperative angiologische Interventionen und videoassistierte thorakoskopische Resektionen zu Veranderungen im Management der Erkrankung gefuhrt. Methode: Die prospektiv erfassten Daten von erwachsenen Patienten, die aufgrund eines Lungensequesters im Zeitraum von 23 Jahren in 4 verschiedenen Kliniken operiert wurden, wurden retrospektiv analysiert. Ergebnisse: Insgesamt wurden 14 Falle mit intralobaren Sequestern (n = 11, 79 % linker Unterlappen) beobachtet. Das mittlere Alter betrug 50 Jahre (27–76 Jahre). Das mannliche Geschlecht war haufiger betroffen (8/6). In der Symptomatik war die unspezifische pulmonale Infektsituation (n = 6, 42 %) fuhrend. Bei 2 Patienten bestanden Hamoptysen. Drei Patienten waren symptomlos. Die Diagnostik (CT-Thorax, n = 14) wurde in 7 Fallen durch ein CT-Abdomen sowie bei 10 Patienten durch eine Angiografie erganzt. Eine praoperative Embolisation wurde bei 5 dieser Patienten (2× Aste der abdominellen und 2× Aste der thorakalen Aorta und 1× Aste von beiden) durchgefuhrt. Die Resektion erfolgte zumeist offen-chirurgisch (n = 12, 86 %). Insgesamt uberwogen die nicht anatomischen Resektionen (n = 8, 57 %). Die Mikrobiologie zeigte in 7 Fallen eine bakterielle Superinfektion, gehauft mit Streptococcus pneumoniae. In einem Fall bestand der Nachweis einer Pilzinfektion mit Candida albicans. Schlussfolgerung: Bei unklaren pulmonalen Befunden, insbesondere im Bereich des Unterlappens, sollten Lungensequester auch im hoheren Alter differenzialdiagnostisch berucksichtigt werden. Die operative Entfernung wird bei fehlenden Kontraindikationen grundsatzlich empfohlen und kann in ausgewahlten Fallen minimalinvasiv erfolgen. Eine praoperative Abklarung der arteriellen Versorgung (Aste aus der Aorta thoracica, Aorta abdominalis oder aus beiden) kann die Planung der Resektion erleichtern. Bei Hamoptysen oder Versorgung aus der Aorta abdominalis ist die praoperative interventionell-radiologische Embolisation indiziert.

Introduction: Almost all studies on diabetic foot syndrome focused on prevention of amputation and did not investigate long-term prognosis and survival of patients as a primary outcome parameter. Methods: We did a retrospective cohort study including 314 patients who had diabetic foot syndrome and underwent amputation between December 1995 and January 2001. Results: A total of 48% of patients received minor amputation (group I), 15% only major amputation (group II) and 36% initially underwent a minor amputation that was followed by a major amputation (group III). Statistically significant differences were observed in comparison of the median survival of group I to group II (51 vs 40 months; p = 0.016) and of group II to group III (40 vs 55 months; p = 0.003). Discussion: The prognosis of patients with major amputation due to diabetic foot syndrome is comparable to patients with malignant diseases. Vascular interventions did not improve the individual prognosis of patients.

Background: In contrast to laparoscopic left pancreatic resection, laparoscopic total duodenopancreatectomy is a procedure that has not been standardized until now. It is not only the complexity that limits such a procedure but also its rare indication. The following article demonstrates the technical aspects of laparoscopic pylorus- and spleen-preserving duodenopancreatectomy. Case Report: The indication for intervention in the underlying case was a patient diagnosed with a multiple endocrine neoplasia (MEN) I syndrome and a multifocal neuroendocrine tumor (NET) infiltrating the duodenum and the pancreas. The patient was post median laparotomy which was necessary after jejunal perforation due to a peptic ulcer. The resection was carried out entirely laparoscopically, and the reconstruction, which included a biliodigestive anastomosis and a gastroenterostomy, was carried out by means of a median upper abdomen laparotomy of 7 cm in length through which the resected specimen was also removed. The total operative time was 391 min. The blood loss accounted for 250 ml. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day. Conclusion: Laparoscopic pancreatectomy is a treatment option in carefully selected indications. The complexity of the operation demands a high level of expertise in the surgical team.

In this age of evidence-based medicine, the use of medical thrombosis prophylaxis stockings (AES) as a physical strategy for the prevention of lower limb venous thrombosis has been questioned. The current German S3 guidelines even state that their non-application is, in the vast majority of cases, explicitly covered by the recommendations of this guideline. Low molecular weight heparins (NMH) and direct oral anticoagulants (DOAK) have received approval for thrombosis prophylaxis in elective knee and hip joint replacement, but the use of AES is absent from these approval studies. The results of the additional effects of the AES in the approval studies of Edoxaban were published for the first time. According to these results, the incidence of venous thromboembolism was 6.0% when AES were worn and 13.0% when AES were not worn. Since the approval studies of NMH and the DOAKs did not control for the use of AES, the impact of AES on the overall results remains unclear. Therefore the study results are only valid in the context of the general application of AES. Guidelines commissions should take this into account in their recommendations.Der Nutzen von medizinischen Thromboseprophylaxestrümpfen (AES) als physikalisches Mittel zur Prävention von venösen Thrombosen der unteren Extremität wird im Zeitalter der evidenzbasierten Medizin infrage gestellt. Die aktuellen S3-Leitlinien schreiben sogar, dass ihre Nichtanwendung in den allermeisten Fällen explizit im Empfehlungskorridor dieser Leitlinie liegt. Die niedermolekularen Heparine (NMH) und die direkten oralen Antikoagulanzien (DOAK) haben über Studien zur Thromboseprophylaxe bei elektivem Knie- und Hüftgelenkersatz ihre Zulassung erhalten, allerdings ist zur Anwendung von AES in diesen Zulassungsstudien nichts bekannt. Nun wurden erstmals die Ergebnisse der zusätzlichen Wirkung der AES in den Zulassungsstudien von Edoxaban publiziert. Danach betrug die Inzidenz von venösen Thromboembolien 6,0%, wenn AES getragen wurden, und 13,0%, wenn keine AES getragen wurden. Da in den Zulassungsstudien von NMH und den DOAKs nicht die Anwendung von AES kontrolliert wurde, kann nicht gesagt werden, wie groß der Effekt der AES auf das Gesamtergebnis ist, und die Studienergebnisse gelten nur vor dem Hintergrund der allgemeinen Anwendung von AES.

within community care. These studies have identified the cultural anthropological dimension of uncertainty avoidance (UA) as being particularly relevant in explaining why doctors in some European countries have a greater propensity to prescribe antibiotics for predominantly viral conditions, such as colds, flu, and sore throat, in the face of clear scientific evidence. UA is described in the Geert Hofstede model of cultural dimension as a construct estimating the extent to which a society tolerates uncertainty and ambiguity. Such cultures often try to counteract the unease created by situations of uncertainty through the adoption of dogmatic and excessive measure, even when there is no evidence of cost-effectiveness or risk attenuation. There is no evidence to support postoperative prophylaxis.

The aim of the study was to evaluate potential differences between patients with spontaneous and non-spontaneous bleeding episodes during treatment with vitamin K antagonists which mainly resulted in compartment syndromes.The population in this study comprised 116 patients who suffered at least one bleeding complication which required surgical treatment during therapy with an oral vitamin K antagonist. The patients were treated between September 2001 and July 2008.Significant differences were observed between the two patient groups with regard to the presence of renal failure, arterial hypertension, and diabetes mellitus, which occurred more frequently in patients with spontaneous bleeding. Also, significantly more patients with spontaneous bleedings developed compartment syndrome that needed emergency operation. Overall mortality was 9.6 %, was associated with multiorgan failure in all patients, and was not different between the two patient groups.The identification of high-risk patients before treatment with an oral vitamin K antagonist is of major importance. The existence of over-anticoagulation syndrome and compartment syndrome is associated with significant mortality and morbidity and should not be underestimated.

Weltweit nimmt die Bedeutung chronischer Erkrankungen zu; sie sind bereits heute verantwortlich fur 63 % aller Todesfalle. Auch die Zahl der Menschen, die von Nierenerkrankungen betroffen sind, vergrosert sich jahrlich. Bereits 2 Millionen Menschen werden weltweit mit einer Nierenersatztherapie behandelt. Die Chance einer solchen Therapie erhalten vor allem jedoch Nierenkranke in der westlichen Welt. Wie sieht die Situation von nierenkranken Menschen in Bangladesch, einem der armsten Lander der Welt, aus? Werden die Patienten mit Nierenerkrankungen uberhaupt entdeckt? Sind technische und logistische Voraussetzungen gegeben? Fur wen sind sie verfugbar? Wer wird gerettet und wer muss sterben? Uber 5 Jahre konnten wir auf verschiedenen Reisen, unterstutzt von 2 Lubecker Vereinen und Kliniken, die Situation nierenkranker Menschen in Bangladesch erfahren, eines der grosten Praventionsprogramme vor Ort realisieren und technischen sowie finanziellen Support fur lokale Organisationen geben. In unserem Beitrag stellen wir Bangladesch und seine Menschen vor, beleuchten, was es bedeutet, in diesem Land eine Nierenerkrankung zu haben, und erklaren die Bedeutung von Praventionsprogrammen zu chronischen Erkrankungen.

Item does not contain fulltext OBJECTIVE: The aim was to compare the efficacy and safety of two antibiotic regimens in patients with diabetic foot infections (DFIs). METHODS: Data of a subset of patients enrolled in the RELIEF trial with DFIs requiring surgery and antibiotics were evaluated retrospectively. DFI was diagnosed on the basis of the modified Wagner, University of Texas, and PEDIS classification systems. Patients were randomized to receive either intravenous/oral moxifloxacin (MXF, N = 110) 400 mg q.d. or intravenous piperacillin/tazobactam 4.0/0.5 g t.d.s. followed by oral amoxicillin/clavulanate 875/125 mg b.d. (PIP/TAZ-AMC, N = 96), for 7-21 days until the end of treatment (EOT). The primary endpoint was clinical cure rates in the per-protocol (PP) population at the test-of-cure visit (TOC, 14-28 days after EOT). RESULTS: There were no significant differences between the demographic characteristics of PP patients in either treatment group. At TOC, MXF and PIP/TAZ-AMC had similar efficacy in both the PP and intent-to-treat (ITT) populations: MXF: 76.4 % versus PIP/TAZ-AMC: 78.1 %; 95 % confidence interval (CI) -14.5 %, 9.0 % in the PP population; MXF: 69.9 % versus PIP/TAZ-AMC: 69.1 %; 95 % CI -12.4 %, 12.1 % in the ITT population. The overall bacteriological success rates were similar in both treatment groups (MXF: 71.7 % versus PIP/TAZ-AMC: 71.8 %; 95 % CI -16.9 %, 10.7 %). A similar proportion of patients (ITT population) experienced any adverse events in both treatment groups (MXF: 30.9 % versus PIP/TAZ-AMC: 31.8 %, respectively). Death occurred in three MXF-treated patients and one PIP/TAZ-AMC-treated patient; these were unrelated to the study drugs. CONCLUSION: Moxifloxacin has shown favorable safety and efficacy profiles in DFI patients and could be an alternative antibiotic therapy in the management of DFI. Clinical trial: NCT00402727.

Haut- und Weichgewebsinfektionen gehoren zu den haufigsten Erkrankungen im chirurgischen Krankengut. Sie zeigen eine Variationsbreite vom banalen Furunkel bis zur schweren nekrotisierenden Infektion mit todlichem Verlauf. Die Abgrenzung der nekrotisierenden Infektionen ist mitunter schwierig und lasst sich oft nur durch den Verlauf bestimmen. Eine rechtzeitige Diagnose und eine fruhzeitige chirurgische Therapie sind ausschlaggebend fur die Prognose. Erganzend zur chirurgischen Therapie sind ebenfalls eine fruhzeitige antibiotische Behandlung und eine intensivmedizinische Therapie notwendig.

Das angloamerikanische Schrifttum benennt lebensbedrohliche Infektionen im Beckenbereich mit dem Schlagwort »Pelvic Sepsis«. Darunter sind schwere Krankheits bilder zu verstehen, die sich im gesamten Beckenbereich ausbreiten konnen. Lipsky hat versucht, die Gesamtgruppe der lebensbedrohlichen nekrotisierenden Infek tionen unter der Benennung »necrotizing soft tissue in fections« (NSTI) zusammenzufassen (DiNubile u. Lipsky 2004). Da bei diesen Erkrankungen mehrere Organsysteme in komplexer Form einbezogen werden, erklart sich der ebenfalls gebrauchliche Ausdruck »Complex Wounds« oder spanisch »Feridas Complexas «, die als Synonyme verwendet werden (Ferreira et al. 2006). Die dramatischen, nekrotisierenden Infektionen sowohl des Urogenital- sowie des Anorektalbereiches (Pelvic Sepsis) konnen diesen Begriffen zugeordnet werden.

The regular colonisation of the oesophagus with a Candida species can, after oesophageal perforation, result in a contamination of the mediastinum and the pleura with a Candida species. A patient cohort of 80 patients with oesophageal perforation between 1986 and 2010 was analysed retrospectively. The most common sources with positive results for Candida were mediastinal biopsies and broncho-alveolar secretions. Candida species were detected in 30% of the patients. The mortality rate was 41% in patients with positive microbiology results for Candida, whereas it was 23% in the remaining patient cohort. This difference did not reach statistical significance (P = 0.124). Mortality associated with oesophageal perforation was attributed mainly to septic complications, such as mediastinitis and severe pneumonia. During the study period we observed a shift towards non-albicans species that were less susceptible or resistant to fluconazole. In selected patients with risk factors as immunosuppression, granulocytopenia and long-term intensive-care treatment together with the finding of Candida, an antimycotic therapy should be started. A surgical approach offers the possibility to obtain deep tissue biopsies. The antimycotic therapy should start with an echinocandin, as the resistance to fluconazole is growing and to cover non-albicans Candida species, too.

Entgegen fruherer Auffassung hat sich seit einiger Zeit die Bewertung der Untersuchungsanlasse fur Pflichtuntersuchungen bei Tatigkeiten mit einigen im Anhang der Verordnung zur Arbeitsmedizinischen Vorsorge (ArbMedVV) genannten Stoffe geandert. Bei Tatigkeiten mit Stoffen dieser Liste, fur die es keine Arbeitsplatzgrenzwerte (AGW) gibt, sind nach neuerer Interpretation die rechtlichen Voraus Setzungen fur Pflichtuntersuchungen nicht mehr durch inhalative Exposition erfullbar. Damitist die Intention der Verordnung, bei besonders gefahrdenden Tatigkeiten, fur die ein Untersuchungsanlass arbeitsmedizinisch begrundet ist, Pflichtuntersuchungen vorzuschreiben, nicht mehr ausreichend umgesetzt. Aus diesem Grund wird im Ausschuss fur Arbeitsmedizin (AfAMed) beim BMAS diskutiert, ob ein neues Instrument — die Pflichtberatung — die Lucke, die die nicht mehr durchzufuhrenden Pflichtuntersuchungen hinterlassen haben, auffullen konnte.

Sowohl das stumpfe als auch das penetrierende Abdominaltrauma stellen nach wie vor eine Herausforderung im klinischen Alltag dar. Insbesondere die Verletzung groser Gefase oder parenchymatoser Organe kann durch Massenblutungen schnell zum hamodynamischen Schock und zur Verbrauchskoagulopathie fuhren. Das Zeitintervall zwischen Verletzung und Beginn chirurgischer Masnahmen bestimmt hier neben der Art der praklinischen Rettung und initialen Volumenersatztherapie entscheidend die Prognose des Patienten. Somit erfordert das Abdominaltrauma ein strukturiertes Management mit dem Ziel einer raschen Diagnostik und Therapie zur Senkung der Morbiditat und Letalitat. Entsprechende Behandlungsalgorithmen sollten daher an allen versorgenden Zentren implementiert sein. Bei Gefas-, Leber- und Milzverletzungen besteht die primare Herausforderung in der Beherrschung vital bedrohlicher Blutungen. Die Therapie von Hohlorgan- und Pankreasverletzungen zielt vor allem auf die Vermeidung septischer Komplikationen. Hierbei gilt es, die chirurgische Therapie dem Verletzungsmuster sowie der Allgemeinsituation des Patienten anzupassen. Ziel aller Behandlungsalgorithmen muss es sein, durch entsprechende klinische und bildgebende Untersuchungen, die Organverletzungen nachzuweisen oder auszuschliesen sowie Indikationen fur eine operative Therapie zu uberprufen. Gerade bei stumpfen Verletzungen konnen 60–80 % der Patienten konservativ therapiert werden, aber auch beim penetrierenden Trauma setzt sich zunehmend das selektive Management zur Vermeidung unnotiger Laparotomien durch. Dabei stellen bei hamodynamisch stabilen Patienten heute sowohl die Laparoskopie als auch interventionelle Verfahren wertvolle zusatzliche Therapieoptionen dar.

Ziel dieser aktuellen Studie ist die Bestimmung der prognostischen Faktoren fur das Langzeituberleben bei Patienten mit fortgeschrittenen kolorektalen Karzinomen in einer konsekutiven Kohorte. Zwischen 1. Januar 2002 und 31. Dezember 2008 wurden insgesamt 123 Patienten wegen eines kolorektalen T4-Karzinoms in der Chirurgischen Klinik UK-SH Campus Lubeck operiert. Insgesamt 78 Patienten hatten eine multiviszerale Resektion (MVR). Die postoperative Morbiditat war in der Patientengruppe mit MVR (34,6% vs. 26,7%) erhoht. Gleichwohl fanden wir bezuglich der 30-Tage-Mortalitat keine signifikanten Unterschiede (7,7% vs. 8,9%; p=0,815). Der hauptsachliche prognostische Faktor, der in der Multivarianzanalyse Signifikanz erreichte, war die Moglichkeit einer R0-Resektion (p

Diagnose ist die Zuordnung einer Krankheit zu den Beschwerden eines konkreten Patienten. Diagnostische Methoden sollen helfen, Merkmale der jeweiligen Krankheit am konkreten Fall festzustellen.

Invasive aspergillosis (IA), the most life-threatening form of aspergillosis, has become a major opportunistic fungal disease in immunocompromised patients. In high-risk patients with hematologic malignancies, IA appears to decline with the use of mold-active antifungal prophylaxis, but the situation is less clear in other patient groups at risk for IA, and precise epidemiologic data from patients treated in intensive care units (ICUs) are lacking. Most Aspergillus culture isolates from nonsterile body sites do not represent disease, but isolation of Aspergillus in critically ill patients is a marker of poor prognosis and is associated with high mortality regardless of invasion or colonization. This review presents current information on epidemiology, risk factors, and diagnosis, and discusses treatment options for patients with IA in the ICU.

A technique for the safe transfer of electric energy to the pulmonary surface for the potential evaporation of malignant tumours is non-existent to date. By conducting the current study, we wanted to generate data on the potential beneficiary effects and complications of using cold-plasma coagulation on the pulmonary surface. Cold-plasma coagulation was applied to the pulmonary surface in eight female mini-pigs via a thoracoscopic access. After 12 days, we performed a re-thoracoscopy on the contralateral side. After a further 12 days, we performed a median sternotomy and did cold-plasma coagulation on previously untreated areas of either lung. No pulmonary fistulas were detected. In two of the eight pigs, we found a localized chronic pneumonia. None of the pigs died during the course of the study. Morbidity was also low with two pigs refusing food intake, one pig with dyspnoea after difficult intubation and one pig coughing. All events were self-limited and occurred only on post-operative Day 1. The treatment effect was almost linear and correlated to the generator energy applied. The differences between the effects reached statistical significance (P

Ewing's sarcoma (ES) and primitive neuroectodermal tumor (PNET) are closely related malignant neoplasms, usually affecting the skeletal system. Extraosseous ES/PNETs are uncommon, with occasional reports of tumors affecting the genitourinary tract. Only few cases of primary vulvar Ewing's sarcoma/PNET have previously been reported.We present a patient with primary vulvar Ewing's sarcoma with pulmonary metastasis who presented at the Department of Gynecology and Obstetrics, University of Schleswig-Holstein, Campus Luebeck.The present report is the third case of a primary vulvar Ewing's sarcoma and the first constellation with pulmonary metastasis at diagnosis in the current literature. We present the diagnostic and therapeutic management including surgery, chemotherapy and radiation.The treatment of the Ewing's sarcomas and PNETs requires a multidisciplinary systemic approach. Despite its rarity, the differential diagnosis of vulvar sarcoma must be considered in young women.

Summary Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.

Objectives Ceftaroline (active form of the prodrug ceftaroline fosamil) is a novel cephalosporin with activity against pathogens commonly associated with community-acquired pneumonia (CAP), including Streptococcus pneumoniae and Gram-negative pathogens. This randomized, double-blind, Phase III study evaluated the efficacy and safety of ceftaroline fosamil in treating patients with CAP. The primary objective was to determine non-inferiority [lower limit of 95% confidence interval (CI) ≥ -10%] of clinical cure rates achieved with ceftaroline fosamil compared with those achieved with ceftriaxone in the clinically evaluable (CE) and modified intent-to-treat efficacy (MITTE) populations. Methods Patients hospitalized in a non-intensive care unit setting with CAP of Pneumonia Outcomes Research Team (PORT) risk class III or IV requiring intravenous (iv) therapy were randomized (1:1) to receive 600 mg of ceftaroline fosamil iv every 12 h or 1 g of ceftriaxone iv every 24 h. Clinical cure, microbiological response, adverse events (AEs) and laboratory tests were assessed. FOCUS 2 registration number NCT00509106 (http://clinicaltrials.gov/ct2/show/NCT00509106). Results The study enrolled 627 patients, 315 of whom received ceftaroline fosamil and 307 of whom received ceftriaxone. Patients in both treatment groups had comparable baseline characteristics. Clinical cure rates were as follows: CE population, 82.1% (193/235) for ceftaroline fosamil and 77.2% (166/215) for ceftriaxone [difference (95% CI), 4.9% (-2.5, 12.5)]; and MITTE population, 81.3% (235/289) for ceftaroline fosamil and 75.5% (206/273) for ceftriaxone [difference (95% CI), 5.9% (-1.0, 12.7)]. Clinical cure rates for CAP caused by S. pneumoniae in the microbiological MITTE (mMITTE) population were 83.3% (35/42) and 70.0% (28/40) for ceftaroline fosamil and ceftriaxone, respectively. Ceftaroline fosamil and ceftriaxone were well tolerated, with similar rates of AEs, serious AEs, deaths and discontinuations due to an AE. The most common AEs for ceftaroline fosamil-treated patients were diarrhoea, headache, hypokalaemia, insomnia and phlebitis, and the most common AEs for ceftriaxone-treated patients were diarrhoea, insomnia, phlebitis and hypertension. Conclusions Ceftaroline fosamil achieved high clinical cure and microbiological response rates in patients hospitalized with CAP of PORT risk class III or IV. Ceftaroline fosamil was well tolerated, with a safety profile that is similar to that of ceftriaxone and other cephalosporins. Ceftaroline fosamil is a promising agent for the treatment of CAP.

Die perioperative Thromboseprophylaxe wird in Deutschland zumeist mit niedermolekularem Heparin (NMH) durchgefuhrt. Bei der Anwendung von NMH muss auf die Nierenfunktion geachtet werden und gegebenenfalls die Dosis bei eingeschrankter Nierenfunktion angepasst werden. Auch beim sog. Bridging, dem Unterbrechen einer Therapie mit Vitamin-K-Antagonisten, sollte bevorzugt NMH verwendet werden. Hierbei zeigen neueste Daten, dass bis dato wahrscheinlich viel zu hoch wahrend der Uberbruckungsphase antikoaguliert wurde. Bei niedrigem und mittlerem Risiko scheint eine Gabe der Thromboseprophylaxedosierung des NMH ausreichend zu sein, wenn die orale Antikoagulation zugig wieder aufgenommen wird. Bei der Pausierung einer dualen oder singularen antithrombozytaren Therapie muss ein besonderes Augenmerk auf stattgefundene Stentimplantationen oder ein akutes Koronarereignis gelegt werden. Das unkritische Pausieren der Thrombozytenaggregationshemmer kann deletare Folgen haben.

Item does not contain fulltext OBJECTIVES: The primary aim of the RELIEF study was to evaluate the efficacy and safety of two sequential intravenous (iv)/oral regimens: moxifloxacin iv/oral versus piperacillin/tazobactam (TZP) iv followed by oral amoxicillin/clavulanate (AMC). PATIENTS AND METHODS: The study had a prospective, randomized, double-dummy, double-blind, multicentre design. Patients >/=18 years were prospectively stratified according to complicated skin and skin structure infection (cSSSI) subtype/diagnosis (major abscess, diabetic foot infection, wound infection or infected ischaemic ulcer), surgical intervention and severity of illness. Diagnoses and disease severity were based on predetermined criteria, documented by repeated photographs, and confirmed by an independent data review committee. Patients were randomized to receive either 400 mg of moxifloxacin iv once daily followed by 400 mg of moxifloxacin orally once daily or 4.0/0.5 g of TZP iv thrice daily followed by 875/125 mg of AMC orally twice daily for 7-21 days. The primary efficacy variable was clinical response at test of cure (TOC) for the per-protocol (PP) population. Clinical efficacy was assessed by the data review committee based on repeated photographs and case descriptions. Clinical trials registry number: NCT 00402727. RESULTS: A total of 813 patients were randomized. Clinical success rates at TOC were similar for moxifloxacin and TZP-AMC in the PP [320/361 (88.6%) versus 275/307 (89.6%), respectively; P = 0.758] and intent-to-treat (ITT) [350/426 (82.2%) versus 305/377 (80.9%), respectively; P = 0.632] populations. Thus, moxifloxacin was non-inferior to TZP-AMC. Bacteriological success rates were high in both treatment arms [moxifloxacin: 432/497 (86.9%) versus TZP-AMC: 370/429 (86.2%), microbiologically valid (MBV) population]. Moxifloxacin was non-inferior to TZP-AMC at TOC in both the MBV and the ITT populations. Both treatments were well tolerated. CONCLUSIONS: Once-daily iv/oral moxifloxacin monotherapy was clinically and bacteriologically non-inferior to iv TZP thrice daily followed by oral AMC twice daily in patients with cSSSIs.

Adolescents with asthma or allergies do not consider their disease when making their career choice. Therefore the aim of this project was to sensitize secondary school students for occupational diseases before they start working. Four virtual patients for secondary school students were created. They present their experiences as apprentices. Occupational diseases as well as prevention methods are discussed. Evaluation and longterm knowledge was assessed. Furthermore, a webpage (http://www.volle-puste.de/en/) was created, where free access to the virtual patients can be ordered by teachers. Virtual patients are suitable for age 13-16. On a scale from 1 (very good) to 6 (insufficient) students rated the use of the virtual patients with an overall mean of 2.7 (Standard deviation: 1.15). Long-term gain in knowledge was shown. Using virtual patients in adolescents is useful to enhance knowledge about occupational risks. Whether this contributes to an informed job choice has to be shown in further studies.

Background Mucoceles of the appendix are rare. After appendectomy, mucoceles are detected with a frequency of 0.2 to 0.3 %. Both stenosing / obliterating processes and alterations of the epithelium (hyperplasia, mucinous cystadenoma, cystadenoma with uncertain malignant potential (UMP), mucinous cystadenocarcinoma lead to the occurrence of mucoceles. The perforation of a mucocele with possible spread of mucus and cells into the abdominal cavity constitutes a severe complication (pseudomyxoma peritonei). Surgical resection is the curative approach for mucoceles of the appendix. Materials and methods Data of patients who were treated for an appendiceal mucocele between 1995 and 2009 were analysed retrospectively with regard to clinical presentation, diagnostic measures, surgical procedure and histopathological result. Follow-up was evaluated in telephone interviews. Results We extracted 5 cases from our database. Clinical symptoms varied greatly among the individual patients, ranging from peracute abdominal pain in the right lower quadrant to chronic obstipation. Results from abdominal ultrasound and / or abdominal CT scans contributed to the indication for surgical intervention in all cases. In 2 patients surgery was stated as urgent whereas in 3 the operation was scheduled electively. In one patient the diagnosis of an appendiceal mucocele was stated preoperatively and in another intraoperatively. In 3 patients only the histopathological result revealed the underlying mucocele. We performed 1 open and 1 laparoscopic appendectomy, 1 open appendectomy with a partial resection of the coecum and 2 laparoscopic ileocoecal resections. One of the patients had a pseudomyxoma peritonei. The histopathological diagnoses ranged from mere epithelial hyperplasia to an adenoma with uncertain malignant potential and a mucinous cystadenocarcinoma. One patient's long-term follow-up could not be evaluated. All other patients had neither recurrence nor any complications after discharge. Conclusions Mucoceles of the appendix present with a wide spectrum of clinical symptoms and histopathological alterations. Only an accurate histological analysis reveals the underlying pathological lesion correctly. This study emphasises that a mucocele of the appendix constitutes an important differential diagnosis in patients presenting with pathologies in their right lower abdominal quadrant.

Als Standardverfahren zur praoperativen bildmorphologischen Diagnostik bei Patienten mit zentralen malignen Lungentumoren ist das axiale 2-D-Computertomogramm des Thorax akzeptiert und etabliert. Tumorausdehnung, Infiltration von zentralen Strukturen oder segmentaler Bezug sind entscheidende Parameter zur Abklarung der technischen Operabilitat und des Resektionsausmases. Durch computergestutzte Methoden der Segmentierung anatomischer Strukturen in CT-Daten (Fraunhofer MeVis, Bremen) ist erstmals eine selektive dreidimensionale Visualisierung moglich. Im Zeitraum zwischen 08/07 und 06/09 wurden 22 Patienten mit zentralem Lungentumor in der Thoraxchirurgischen Abteilung der Universitat Schleswig-Holstein, Campus Lubeck, behandelt. 15 Manner, 7 Frauen, mittleres Alter bei Diagnosestellung 60,2 Jahre (Spannweite 41–74 Jahre). Lediglich 4 von 22 Patienten waren Nichtraucher gewesen, die ubrigen 18 Patienten hatten eine zum Teil erhebliche Raucheranamnese. 20 Patienten hatten ein primares Bronchialkarzinom, je ein Patient hatte ein Lokalrezidiv nach Tumorlobektomie bzw. eine zentrale Lungenmetastase eines extrapulmonalen Primarius. In allen Fallen wurde praoperativ ein Dunnschicht-MSDCT (Multi-slice detector computer tomogramm) angefertigt. Die Daten wurden mittels computerassistierter Software dreidimensional rekonstruiert und visualisiert. Lungenfunktionstests, geschatzte postoperative Lungenrestfunktion, Bronchoskopiebefund, Allgemeinzustand des Patienten sowie die 3-D-rekonstruierten CT-Datensatze wurden zur individuellen praoperativen Risikoanalyse und Auswahl der Operationstaktik verwendet. Vierzehn der 22 Patienten wurden aufgrund der durchgefuhrten Risikoanalyse operiert, 7 Patienten wurden als funktionell inoperabel eingestuft, ein Patient war technisch inoperabel. Insgesamt wurden 5 Pneumonektomien, 4 Bi-/Lobektomien, 3 erweiterte Lobektomien und jeweils eine atypische Resektion und eine Manschettenresektion durchgefuhrt. 2 Patienten wurden im Stadium I operiert, 7 Patienten im Stadium II und 3 Patienten im Stadium IIIa. Der mediane stationare Aufenthalt betrug 8,5±33,0 Tage. Die Hospitalletalitat betrug bei 0%. Die 3-D-Visualisierung des Tumors sowie der anatomische Bezug zu Nachbarstrukturen waren in allen Fallen exakt moglich. Intraoperativ konnte die 3-D-Rekonstruktion zu 100% validiert werden. Die computerassistierte 3-D-Rekonstruktion eines Thorax-CT ist eine neuartige und vielversprechende Methode zur praoperativen Darstellung und Risikoanalyse von zentralen Lungentumoren. Die 3-D-Visualisierung des Tumors in Kombination mit farbkodierter Lappenzugehorigkeit, beweglich in allen Ebenen, ermoglicht dem Chirurgen eine differenzierte Strategieplanung bei zentralen Lungentumoren.

Deep fungal infection was diagnosed in 42 patients (a rate of four per 1000) treated during a one-year period between 1988 and 1989 at the Surgical Clinic in Wurzburg. Most occurred in association with damage to intra-abdominal hollow organs. Diagnosis of deep fungal infections is difficult and only histological identification provides definite proof. However, often the decision to treat has to be made on the basis of the clinical picture and the physician's subjective assessment. Combination treatment with amphotericin B and 5-fluorocytosine is still the current recommendation but the introduction of the azole antifungal agents appears likely to bring about a change. A trial of fluconazole showed it to have clear advantages over combination treatment, being effective, well tolerated and easily administered.

A retrospective chart review was performed in 242 consecutive patients aged 65 years or older who were treated in an academic surgical centre between January 2004 and July 2007. A total of 249 thoracic procedures were performed in 242 patients, of whom 143 were men and 99 women with a mean age of 69.9 years (range 65-92). Overall operative mortality was 2.4%, rising to 26.4% in emergency patients. Negative predictors for perioperative mortality were: American Society of Anesthesiology (ASA) class 4, pre-existing kidney failure, leucocytosis, low haemoglobin, elevated C-reactive protein, diabetes mellitus and emergency surgery. In addition, the risk of major and minor complications resulting in a prolonged hospital stay was increased in emergency patients, patients with multiple co-morbidities and ASA class 3 or 4. Appropriate thoracic surgery can be offered to the elderly with an acceptable level of perioperative morbidity and mortality. Regardless of age, a high degree of co-morbidity or emergency surgery are the main risk factors for perioperative mortality and/or prolonged hospital stay.

To examine the treatment outcome for patients with acute bleeding from the lower gastrointestinal tract requiring transfusion and acute surgical care as a function of various risk factorsBetween 1999 and 2007, we collected data on 59 patients (39 male and 20 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion at our university clinic. Treatment complications and mortality were analyzed retrospectively.The average age of the patients in this study is 70.0 +/- 12.2 years (range, 39 to 97 years) with an overall mortality of 15.3%. Blood transfusions10 U (p = 0.031), postoperative need for ventilation (p = 0.004), necessary reoperations (p = 0.016), and an initial hemoglobin level80 g/L (p = 0.043) proved to be significant risk factors for death. Blood transfusions10 U (p = 0.028), necessary reoperations (p = 0.001), and an initial hemoglobin level80 g/L (p = 0.033) were found to be significant risk factors for postoperative complications. All other parameters have no significant impact.The decisive factors for the outcome of lower gastrointestinal hemorrhage requiring surgery are the severity of bleeding, beginning of treatment (initial hemoglobin level, need for packed red blood cells), and treatment efficiency (necessary reoperation).

In the past, women with Crohn’s disease (CD) as a risk factor in pregnancy were discouraged from becoming pregnant. Today, by contrast, gestation is medically acceptable in these patients despite several severe complications. We present the course of five female patients with CD requiring surgery during pregnancy and giving birth at our institution between 1998 and 2008. These cases as well as our treatment recommendations for patients wishing to have children and our approaches to the management of complications during pregnancy are discussed in the light of the literature. Three of five women had a preterm delivery (26 to 31 weeks’ gestation) with a decreased neonatal weight. Generally, the diagnosis of CD is often delayed and diagnostic errors (four of five women) are not uncommon. The symptoms vary widely and include those typical of pregnancy. Three patients had to have a cesarean and only two patients were able to deliver vaginally. Especially in pregnant patients, the course of the disease is highly variable and difficult to predict. Our experience suggests that patients should be advised to conceive during remission. Indications for surgery in pregnant patients are the same as for nonpregnant women and include perforation, obstruction, hemorrhage, and abscess. The advantages of endoscopic surgery also apply to pregnant patients with acute manifestations. A stoma is not a contraindication to vaginal delivery.

To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years. Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases. Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%. Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.

Background In spite of the important role of conservative treatment, up to 90 % of all patients with Crohn's disease will undergo an operation during the course of their illness. Up to 50 % even need a second operation or further surgical procedures - with an increasing risk for perioperative complications. This study was designed to identify the risk factors for recurrence in patients with Crohn's disease and the influence of the primary operation. Methods Between 1986 and 2004, 412 patients with Crohn's disease required operative treatment. 218 underwent a primary procedure and 194 needed a reoperation. In particular, the indications for surgical treatment, the surgical procedures and the perioperative complications were registered and evaluated in the context of a possible recurrence of Crohn's disease. In this study, "recurrence" is defined as a reoperation because of Crohn's disease after a primary operation. Results The most common indications for a surgical treatment were stenosis (58.4 %) and fistulas (38.5 %). As the most frequent procedures, the ileocoecal resection and the partial resection of the small bowel were performed. Altogether, the complication rate was 11.5 %. The primary procedures (6.52 %) had less complications than the operations for a recurrence of Crohn's disease (17.70 %). The rate for the recurrence of Crohn's disease was 17.4 % after 5 years, 36.7 % after 10 years and 52.8 % after 15 years. Patients with fistulas as the indication for primary operation had the highest rate of recurrence (45 %). Patients with an isolated Crohn's lesion of the small intestine had a significantly higher risk for recurrence (59.5 %) than patients with lesions in the ileocoecal region or the colon. The anastomosis region (73 %) was the most common localisation for recurrence. Conclusion On the basis of defined risk factors, patients with a high risk for recurrence can be identified. This is very important because of the higher risk for complications caused by reoperations compared to primary procedures. That is why interdisciplinary cooperation including postoperative care and optimal conservative treatment are absolutely essential.

Die antimikrobielle Chemotherapie ist essenzieller Bestandteil in der Behandlung intraabdomineller Infektionen. Die initiale Antibiotikatherapie sollte nach Sicherung der Diagnose fruhzeitig erfolgen. Die Auswahl des Antibiotikums muss sich am zu erwartenden Erregerspektrum im Sinne einer kalkulierten Therapie orientieren. Aufgrund der vorliegenden klinischen Studien ist eine generelle Empfehlung fur ein bestimmtes Antibiotikum bzw. einer Substanzgruppe nicht moglich, da methodisch immer auf „Nichtunterlegenheit“ zum Vergleichsantibiotikum gepruft wurde. Auf der Basis einer Vielzahl von Studien haben die Fachgesellschaften Empfehlungen erarbeitet. Die antibiotische Therapie der postoperativen Peritonitis sollte die besondere Risikokonstellation des Patienten wie antibiotische Vorbehandlung, das Auftreten multiresistenter Problemkeime und der hospitalen Epidemiologie Rechnung tragen. Das Auftreten peritonealer Mykosen ist selten. Die Therapie sollte nach mikrobiologischer Testung erfolgen.