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Metsemakers WJ, Moriarty TF, Morgenstern M, Marais L, Onsea J, O'Toole RV, Depypere M, Obremskey WT, Verhofstad MHJ, McNally M, Morshed S, Wouthuyzen-Bakker M, Zalavras C. The global burden of fracture-related infection: can we do better? THE LANCET. INFECTIOUS DISEASES 2024; 24:e386-e393. [PMID: 38042164 DOI: 10.1016/s1473-3099(23)00503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 12/04/2023]
Abstract
Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland; Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford, UK
| | - Saam Morshed
- Department of Orthopaedic Surgery and Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Scotcher M, Uren N, Qureshi A, Hancock N, Round J. Fracture-related infection in revision proximal femoral intramedullary nails. Injury 2024; 55:111338. [PMID: 38281349 DOI: 10.1016/j.injury.2024.111338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND The proximal femoral nail is a commonly used fixation device for extra-capsular neck of femur fractures at our UK NHS Trust. Fracture-related infection (FRI) is a catastrophic complication that can be associated with internal fixation. FRI is often diagnosed late, and causes significant impact on the patient and healthcare system, leading to extended hospital stays, reduced quality of life, high healthcare costs and increased mortality and morbidity. AIM This study aims to evaluate whether failed proximal femoral nails treated at a major trauma centre in the United Kingdom are undergoing routine intraoperative microbiology sampling, as outlined by the FRI Consensus Group in 2020, and also to establish how often fracture-related infection is present in failed proximal femoral nails. METHOD Electronic patient record systems were reviewed over a 4-year period between 2018-2022 to identify patients who had a proximal femoral nailing, and those who required revision surgery. From this cohort, we then identified whether sampling had taken place during revision surgery, and the number of samples taken. RESULTS 1041 proximal femoral nails were performed at our trust during the 4-year period. 60 of these implants failed, with 52 of these undergoing revision surgery at our hospital. Only 56% cases had intra-operative samples taken for microbiology testing, with an average of 9 samples sent per case. Intra-operative sampling confirmed infection in 25% of cases with samples sent. Of the cases requiring ≥ 3 operations, 75% of cases had confirmed infection. DISCUSSION The data shows that more can be done to ensure earlier diagnosis of fracture-related infection in failed proximal femoral nails. We should have a high suspicion of FRI in this cohort of patients. This study highlights the importance of a standardised protocol to ensure routine intra-operative sampling during proximal femoral nail revision surgery.
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Affiliation(s)
- Megan Scotcher
- Department of Trauma & Orthopaedics, University Hospitals Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK.
| | - Nicholas Uren
- Department of Trauma & Orthopaedics, University Hospitals Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK
| | - Amir Qureshi
- Department of Trauma & Orthopaedics, University Hospitals Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK
| | - Nick Hancock
- Department of Trauma & Orthopaedics, University Hospitals Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK
| | - Joanne Round
- Department of Trauma & Orthopaedics, University Hospitals Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK
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Tsang STJ, Epstein GZ, Ferreira N. Critical Bone Defect Affecting the Outcome of Management in Anatomical Type IV Chronic Osteomyelitis. Strategies Trauma Limb Reconstr 2024; 19:26-31. [PMID: 38752191 PMCID: PMC11091896 DOI: 10.5005/jp-journals-10080-1610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/29/2024] [Indexed: 05/18/2024] Open
Abstract
Background The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regard to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. Methods A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Results Risk factors for the presence of a critical bone defect were female patients [OR 3.1 (95% CI, 1.08-8.92)] and requirement for soft tissue reconstruction [OR 3.35 (95% CI, 1.35-8.31)]; osteomyelitis of the femur was negatively associated with the presence of a critical bone defect [OR 0.13 (95% CI, 0.03-0.66)]. There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to the bone union was ten months (95% CI, 7.9-12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect [12.0 months (95% CI, 10.2-13.7 months)] and those without [6.0 months (95% CI, 4.8-7.1 months)]. Conclusion This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time. How to cite this article Tsang STJ, Epstein GZ, Ferreira N. Critical Bone Defect Affecting the Outcome of Management in Anatomical Type IV Chronic Osteomyelitis. Strategies Trauma Limb Reconstr 2024;19(1):26-31.
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Affiliation(s)
- Shao-Ting J Tsang
- Department of Trauma and Orthopaedic Surgery, Oxford University Hospitals, Oxford, Oxfordshire, United Kingdom
| | - Gadi Z Epstein
- Department of Orthopaedic Surgery, Tygerberg Hospital, University of Stellenbosch, South Africa
| | - Nando Ferreira
- Department of Orthopaedic Surgery, Tygerberg Hospital, University of Stellenbosch, South Africa
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Chen B, Pu B, Li S, Gong Y, Dong H. The role of NSAID in mediating the effect of genetically predicted major depressive disorder on osteomyelitis: A Mendelian randomization study. J Affect Disord 2023; 341:62-66. [PMID: 37634817 DOI: 10.1016/j.jad.2023.08.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Osteomyelitis and major depressive disorder (MDD) are significant health concerns with potential interconnections. However, the underlying mechanisms linking these conditions remain unknown. This study aimed to investigate the potential mediating role of non-steroidal anti-inflammatory drug (NSAID) medication in the association between MDD and the risk of osteomyelitis. METHODS We utilized summary data from large-scale genome-wide association studies (GWAS) to perform Mendelian randomization (MR) mediation analysis. Instrumental variables were selected based on genome-wide significance, and instrumental strength was assessed using F-statistics. Univariable and multivariable MR analyses were conducted to estimate causal effects and proportions mediated by NSAID medication. RESULTS The univariable MR analysis revealed significant associations between MDD and osteomyelitis (odds ratio [OR] = 1.44, 95 % confidence interval [CI]: 1.18-1.874) and between MDD and NSAID medication (OR = 1.36, 95 % CI 1.24-1.49). In the multivariable MR analysis, the direct effect of MDD on osteomyelitis was OR 1.35 (95 % CI: 1.09, 1.67) after adjusting for NSAID medication. The proportion of mediation by NSAID medication was 23 % (95 % CI: 0.05 %, 38.6 %). CONCLUSION This MR study provides evidence for a genetically predicted causal association between MDD, NSAID medication, and osteomyelitis. The findings emphasize the need for a comprehensive approach in managing individuals with comorbid depression and osteomyelitis, considering the potential risks and benefits of NSAID medication. Future research should address limitations and explore additional mediators and confounding factors to enhance understanding of this complex relationship.
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Affiliation(s)
- Baixing Chen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Bin Pu
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China.
| | - Shaoshuo Li
- Wuxi Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Wuxi, China.
| | - Yu Gong
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Hang Dong
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China.
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Song CS, Zhang P, Lin QR, Hu YY, Pan CQ, Jiang N, Hu YJ. Nitric oxide synthase 2 genetic variation rs2297514 associates with a decreased susceptibility to extremity post-traumatic osteomyelitis in a Chinese Han population. Front Cell Infect Microbiol 2023; 13:1177830. [PMID: 37465758 PMCID: PMC10350522 DOI: 10.3389/fcimb.2023.1177830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Background Previous studies have indicated that nitric oxide synthase 2 (NOS2) genetic variations are involved in delayed fracture healing and fracture non-union. Whether these genetic variants associate with the development of osteomyelitis (OM) remains unclear. Here, we analyzed the potential relationships between NOS2 genetic variations and the risk of developing post-traumatic OM (PTOM) in a Chinese Han population. Methods Altogether 704 participants, including 336 PTOM patients and 368 healthy controls, were genotyped of rs2297514 and rs2248814 of the NOS2 gene using the SNaPshot genotyping method. Results Outcomes showed that the frequency of allele C of rs2297514 in the patient group was significantly lower than that in the control group (48.7% vs. 54.5%, P = 0.029, OR = 0.792, 95% CI 0.642 - 0.976). In addition, significant associations were found between rs2297514 and susceptibility to PTOM by the recessive model (P = 0.007, OR = 0.633, 95% CI 0.453 - 0.884), and the homozygous model (P = 0.039, OR = 0.648, 95% CI 0.429 - 0.979). Moreover, patients with the CC genotype of rs2297514 had lower inflammatory biomarkers levels than the TT genotype, especially for the C-reactive protein (CRP) level (median: 4.1 mg/L vs. 8.9 mg/L, P = 0.027). However, no significant relationship was noted between rs2248814 and the risk of developing PTOM. Conclusion In this Chinese cohort, rs2297514 is correlated with a decreased risk of PTOM development, with genotype CC as a protective factor.
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Affiliation(s)
- Chen-sheng Song
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ping Zhang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qing-rong Lin
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying-yu Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Hospital Management, Southern Medical University, Guangzhou, China
| | - Chun-qiu Pan
- Department of Emergency Trauma Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan-jun Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Moore AJ, Wylde V, Whitehouse MR, Beswick AD, Walsh NE, Jameson C, Blom AW. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open 2023; 4:226-233. [PMID: 37051823 PMCID: PMC10065846 DOI: 10.1302/2633-1462.44.bjo-2022-0155.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Aims Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233.
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Affiliation(s)
- Andrew J. Moore
- University of Bristol, Bristol, UK
- Correspondence should be sent to Andrew J. Moore. E-mail:
| | | | | | | | - Nicola E. Walsh
- HAS - Allied Health Professions, University of the West of England, Bristol, UK
| | | | - Ashley W. Blom
- University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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Walter N, Hinterberger T, Szymski D, Alt V, Rupp M. Psychological comorbidities in osteoarthritis in Germany. Sci Rep 2023; 13:2905. [PMID: 36806322 PMCID: PMC9938889 DOI: 10.1038/s41598-023-29867-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/11/2023] [Indexed: 02/20/2023] Open
Abstract
Osteoarthritis is a degenerative joint disease associated with pain, loss of function and reduced quality of life. Concomitant psychological disorders can significantly influence treatment outcomes. Therefore, we aimed to answer the following research questions: (1) How has the incidence of primary coxarthrosis and gonarthrosis developed over the last decade? (2) How high is the prevalence of osteoarthritis patients with concomitant psychological diagnoses? (3) Which psychological comorbidities are most prevalent in coxarthrosis and gonarthrosis patients, respectively? For this cross-sectional study, a dataset provided by the Federal Statistical Office (Destatis) consisting of annual, Germany-wide ICD-10 diagnosis codes from 2009 to 2019 was analysed. Incidences of the codes "M16.1" and "M17.1", unilateral primary coxarthrosis and unilateral primary gonarthrosis, were quantified. Prevalence rates of secondary diagnoses of the chapter F of the ICD-10 were determined. Incidences were 230.7/100,000 inhabitants for coxarthrosis and 224.2/100,000 inhabitants for gonarthrosis. Patients with psychological comorbidities constituted 9.0% of coxarthrosis cases and 8.9% of gonarthrosis cases, respectively. Between 2009 through 2019, the proportion of patients with a concomitant "F" diagnoses of the ICD-10 increased by + 37.8% for coxarthrosis and by 17.9% for gonarthrosis. The most prevalent secondary diagnoses were affective disorders (F3), whereby numbers increased over the years. Increasing psychological comorbidities advocate for the implementation of screening tools, prevention strategies, interdisciplinary approaches and psychological support in the treatment of osteoarthritis.
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Affiliation(s)
- Nike Walter
- grid.411941.80000 0000 9194 7179Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany ,grid.411941.80000 0000 9194 7179Department for Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Thilo Hinterberger
- grid.411941.80000 0000 9194 7179Department for Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Dominik Szymski
- grid.411941.80000 0000 9194 7179Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- grid.411941.80000 0000 9194 7179Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Rupp M, Walter N, Popp D, Hitzenbichler F, Heyd R, Geis S, Kandulski M, Thurn S, Betz T, Brochhausen C, Alt V. Multidisciplinary Treatment of Fracture-Related Infection Has a Positive Impact on Clinical Outcome-A Retrospective Case Control Study at a Tertiary Referral Center. Antibiotics (Basel) 2023; 12:antibiotics12020230. [PMID: 36830141 PMCID: PMC9952612 DOI: 10.3390/antibiotics12020230] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Fracture-related infection (FRI) is a major complication in orthopedic and trauma surgery. The management and choice of treatment can be difficult depending on multiple factors. Therefore, we implemented a weekly multidisciplinary team discussion to determine diagnostic and treatment strategies in FRI patients and aimed to analyze its effect on clinical outcomes. METHODS Clinical outcomes of FRI patients treated before and after implementation of a structured multidisciplinary treatment (MDT) approach with a weekly case discussion were compared at a follow-up of 12 months. RESULTS In total, n = 117 were eligible for enrolment, whereby n = 58 patients (72.4% male, mean age 56.7 ± 16.8 years) constituted the MDT group and n = 59 patients (72.9% male, mean age 55.0 ± 16.5 years) the control group. In the MDT group more cases were treated with local antibiotics (67.2% vs. 27.1%, p < 0.001) and significant less amputations (3.4% vs. 6.8%, p = 0.014), as well as less revision surgeries (1.5 ± 1.2 (0-5) vs. 2.2 ± 1.2 (0-7), p = 0.048) were performed. A trend towards less debridement, antibiotics and implant retention (DAIR) procedures, lower rates of recurrence of infection and less treatment failures in the MDT group was observable, even though not statistically significant. CONCLUSION An MDT approach providing a patient tailored treatment concept in the treatment of FRI patients appears to be beneficial for the affected patients. Quality and efficacy of implemented MDT meetings should further be evaluated to provide sufficient evidence to further implement this valuable tool in clinical practice and decision making.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Correspondence: (M.R.); (N.W.)
| | - Nike Walter
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department for Psychosomatic Medicine, University Hospital Regensburg, 93053 Regensburg, Germany
- Correspondence: (M.R.); (N.W.)
| | - Daniel Popp
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Robert Heyd
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Sebastian Geis
- Center of Plastic and Aesthetic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Melanie Kandulski
- Department of Internal Medicine I, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Sylvia Thurn
- Institute of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Thomas Betz
- Department of Vascular Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University Regensburg, 93053 Regensburg, Germany
- Institute of Pathology, University Medical Center, 68167 Mannheim, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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