[Spectrum of microbial colonisation and resistance of a surgical ICU in a systematic comparison of the 10-year time period 1996-2005 using routine microbiological testing]

INTRODUCTION

Knowledge on potentially pathogenic microbes including characteristics of their antibiotic resistance in septic patients as well as on the ward- and department-specific microbial spectrum can be considered essential for an efficient initiation of an adequate antimicrobial treatment, which turns out to become pivotal for patient outcome. Permanent changes in microbial patterns and antibiotic resistance can only be identified by a continuous investigation of various microbiological specimens.

AIM

Based on the retrospective evaluation of prospectively collected data on microbiological investigations of the surgical ICU in 1996, 2002, 2004 and 2005, the short- and long-term changes by trend of microbial spectrum and antibiotic resistance following reorganisation and restructuring of the University Hospital from the more traditional pavillon-based system to a multidisciplinary complex building in 2003 were investigated.

MATERIAL AND METHODS

Twice a week, routine microbiological testing of blood and urinary cultures as well as swabs from wound areas and endotracheal swabs were initiated in septic patients (suspect, manifestation) or in case of their clinical impairment. The microbial spectrum was sub-divided according to Gram-staining (Gram-positive/ -negative), various species and fungi with descriptive absolute and relative data values. -Various groups and time periods were statistically compared using χ² test as appropriate. P values < 0.05 were considered statistically significant.

RESULTS

In total (n (Total) = 4 899), microbiological testing resulted in the detection of microbes in 699 and 833 blood and urinary cultures (14.3 % and 17 %, respectively) as well as 1 232 wound swabs (25.1 %) together with 2 135 samples from the endotracheal sites (43.6 %). During the short- (2002 vs. 2004) and long-term analyses (1996 vs. 2005), the proportion of Gram-positive microbes increased. Al-though Gram-positive bacteria can be considered the most frequent microbes for bacteriemia, there was a shift onto urinary and wound infections as well as pneumonias through the observation period. Despite the decreasing incidence of Enterococcus and the consistent proportion of MRSA, the increase of resistant Enterococcus strains (0 % vs. 43.2 %; P < 0.05) is critical. However, in the Gram-negative microbial spectrum there was an increase of the bacteraemia rate but a fall of the detection rate in wound and endotracheal swabs. In parallel, an increase of the detection rate of E. coli in blood (6.5 % vs. 45.5 %; P < 0.05) and endotracheal swabs (9.2 % vs. 16.2 %; P < 0.05) is associated with an increase of multiresistant Enterobacteriaceae strains (0 % vs. 30.7 %; P < 0.05). The portion of multiresistant strains of Pseudomonas with 31 % stayed the same through the 10-year time period. While Candida-based colonisation showed a decreased incidence (25 % vs. 15 %; P < 0.05) during the whole investigation period, there was a relative rise in the frequency of candidemia.

CONCLUSION

ICU relocation from the pavillon-based system to a new complex clinic building was not associated with any significant alteration of the microbial spectrum on the surgical ICU. Increasing incidences of resistant Enterococcus and Gram-negative problematic microbes may indicate a general spread of multi-resistant microbes under the steady selecting pressure of a not always adequately initiated antibiotic / antimicrobial therapeutic regimen and underline the required but specific and selected microbiological screening.

[Malignant rhino- and otobasal mucosal melanomas--therapy and outcome]

BACKGROUND

Malignant melanoma of the rhinobasal mucosa is very rare and makes up less than one percent of all malignant melanomas. Symptoms are unspecific in most cases, and patients often present with large tumours. During the past two decades, a variety of therapeutic modalities has been proposed.

MATERIALS AND METHODS

In a retrospective quality assessment, we analysed the charts of fifteen consecutive patients suffering from malignant melanoma of the skull base who where treated in our department since 1993. The influence of specific surgical and adjuvant therapy on recurrence and outcome was evaluated.

RESULTS

Initial symptoms were unspecific in all patients. Thus, melanoma was an accidental finding of a biopsy or sinus surgery in most patients, including all cases with amelanotic melanoma. All patients underwent surgery as the initial treatment, in 8 cases followed by adjuvant therapy. In these patients the disease specific survival was slightly better than in patients treated with surgery only. When recurrence was treated by radical mutilating surgery, this did not influence the overall prognosis.

CONCLUSION

We conclude from our data and analysis of literature that the prognosis of MM has not developed favourably during the past two decades. Radiation therapy and adjuvant immuno- or chemotherapy seems to have a positive impact. Mutilating surgery is usually not indicated nor is it associated with an improvement of outcome.

Ethisorb®/Ethisorb Durapatch® bei der transnasalen Duraplastik

BACKGROUND

Defects of the dura in the rhinobasal area can be closed transnasally. Various procedures with autologous or alloplastic material can be chosen.

METHOD

From 2001 to 2004, we closed a rhinobasal dura defect with Ethisorb or Ethisorb durapatch in sandwich technique in 8 patients. After smoothing the bone edges, Ethisorb is applied under microscopic or endoscopic view endocranially, extradurally as "underlay" to seal and absorb the liquor pressure pillar. Additionally, another Ethisorb implant as "underlay" is applied extracranially from endonasally as "underlay", and sealed with a further layer of nasal concha mucosa with fibrin glue.

RESULTS

All patients were successfully treated with this technique. There were no evidences for persisting rhinoliquorrhoe after the period of wound healing. For hemostasia, a nasal package was applied for compression at the donor site of the inferior nasal concha. The former dura defect was at all times freely accessible in order to be able to recognize a possible new rhinoliquorrhoea early and to prevent a possible congestive secretion with superinfection.

DISCUSSION

The material of Ethisorb and Ethisorb durapatch is stiff and can be easily modelled, so it is an alternative as an alloplastic material for endonasal closure of defined substantial defects of the dura with rhinoliquorrhoe.

Imiglucerase low-dose therapy for paediatric Gaucher disease--a long-term cohort study

BACKGROUND

Gaucher disease is the most common lysosomal storage disorder caused by the insufficiency of the lysosomal enzyme, glucocerebrosidase. This deficiency results in absent or inefficient conversion of glucocerebroside (a membrane lipid) to ceramide and glucose. Accumulation of glucocerebroside occurs primarily in macrophage lysosomes (i.e. monocytes and macrophages) during phagocytic degradation of red blood cells. Clinical symptoms arise due to the displacement of normal cells by lipid-engorged Gaucher cells. Enzyme replacement therapy (ERT) targets the macrophage system and has been shown to be successful in the treatment of type 1 Gaucher disease in adults and children. ERT (60 U/kg) every 2 weeks decreases and often reverses organomegaly and haematological complications and improves quality of life for patients with type 1 Gaucher disease. The present study describes the course of 9 paediatric patients followed up for 2 - 10 years receiving low-dose imiglucerase therapy (+/- 10 U/kg every 2 weeks) for moderate to severe type 1 Gaucher disease.

OBJECTIVES

To evaluate the efficacy of low-dose imiglucerase therapy in paediatric Gaucher disease.

SUBJECTS AND METHODS

Data were recorded at a single centre for 9 paediatric patients. Assessment of response included serial measurements of haemoglobin (Hb) concentrations, platelet count, angiotensin-converting enzyme (ACE) and total acid phosphatase (TAP) levels. Growth was assessed by serial determinations of body weight and height, plotted against standard growth charts. Organ size (liver and spleen) was measured clinically and also radiologically, where possible.

RESULTS

In this low-dose imiglucerase treatment group: (i) there was a significant increase in Hb over time--normal Hb levels were achieved in 7 of the 9 patients after a mean of 3.7 years; (ii) platelet counts increased over time, reaching normal levels in 7 patients; (iii) there was a significant decrease in both ACE and TAP over time; (iv) heights and weights of the subjects increased significantly over time with treatment, normalising to the expected growth percentiles; and (v) organ size (liver and spleen) reduced with therapy in all patients measured.

CONCLUSION

ERT with low-dose imiglucerase (+/- 10 U/kg/fortnight) ameliorates Gaucher disease-associated anaemia and thrombocytopenia. Low-dose ERT is effective and may be considered in resource-poor clinical situations when other alternatives are not available.

[Paralyzed face. Ansa-cervicalis-nervi-hypoglossi]

INTRODUCTION

For 100 years hypoglossal-facial nerve anastomosis (HFA) has been a common surgical procedure for reanimation of paralyzed mimic muscles of the face after axotomy of the facial nerve. However, the denervation and subsequent scarred degeneration of the target muscles of the hypoglossal nerve often results in unfavorable late effects for speech and swallowing. Therefore, the ansa cervicalis nervi hypoglossi-facial nerve anastomosis (ACHFA) can be an alternative to avoid such late effects. As a branch of the hypoglossal nerve the ansa cervicalis innervates the infrahyoidal muscles. Neck dissection surgery proved that resection of the ansa cervicalis causes no side effects for swallowing because of several nerve anastomoses to the cervical plexus.

PATIENTS AND METHOD

We compared our clinical results of eight cases following a delayed ACHFA with our own experiences after HFA and results from the literature.

RESULTS

We found a reanimation rate lower than usually seen after HFA only in the target muscles of the forehead. This may be caused by a reduced neuronal plasticity of the ansa cervicalis. However, in the target muscles of the other two facial nerve branches we observed the same good results one would expect after HFA. There were no late side effects for swallowing and speech though.