We report on the isolation of Actinobacillus equuli ssp. haemolyticus from wound smears of a 2-year-old girl who was admitted to the hospital due to partial amputation of the distal phalanx of her right middle finger caused by a horse bite. A. equuli typically causes diseases in horses and only very few reports describing human infections (mostly associated with wounds) are available in the literature. Interestingly, although the bacteria could be found in consecutive samples taken at different points in time, there were no signs of advancing infection or inflammation. Moreover, the fingertip regenerated after 74 days under semi-occlusive dressings with very pleasant results. For strain identification two automated systems were employed producing discrepant results: VITEK 2 described the pathogens as Pasteurella pneumotropica while MALDI-TOF MS analysis revealed A. equuli. Sequence analysis of 16S rDNA gene finally confirmed A. equuli ssp. haemolyticus as the isolated strain. The antimicrobial susceptibility testing was performed according to the CLSI criteria for Pasteurella spp. Additionally we conducted a test according to the EUCAST criteria.
Actinobacillus equuli; Pasteurella; MALDI-TOF MS; VITEK 2; semi-occlusive dressing; finger amputation
We analysed the typical features of primary small cell carcinoma of the esophagus (SCCE) with emphasis on occurrence, behaviour, outcome and treatment options. This metaanalysis was aimed at collecting and analyzing information from international studies about handling this disease. This seems necessary due to the rarity of this disease. Studies were acquired from electronic databases and reference lists. We finally analysed 313 patient cases from the literature with oesophageal SCC. A data extraction was accomplished referring to 13 evaluable features that are described in the “methods”, whereof 7 were analyzed with univariate and multivariate tests. Three hundred thirteen cases were analyzed, 109 patients (35%) had limited stage (LS), whereas 167 (54%) had extensive stage (ES). There is no information about the remaining 35 patients concerning the stage. Univariate and multivariate analysis showed only age (<50 years vs. >50 years, HR 1.024; 95% CI 1.000–1.041, P<0.0001) and disease stage (LS vs. ES, HR 4.884; 95% CI 2.572–9.27, P<0.0001) as significant prognostic factors. There also was a statistically significant difference in survival between those patients who received therapy compared to those who only received best supportive care (11.6 months vs. 0.8 months, HR 0.093, CI 95% 0.053–0.16, P<0.001). In this first multivariate analysis for SCCE we show that SCCE is an aggressive type of tumour with a shorter survival rate compared to its counterpart from the lung. It is demonstrated that only disease stage (limited vs. extensive stage), age (<50 years vs. >50 years) and therapy are independent significant predictors of prognosis.
small cell carcinoma; esophagus; oesophagus; metaanalysis
Background: Surgical procedures advocated for management of residual hepatic hydatid cyst cavity have been a subject of controversy. The aim of this study was to compare omentoplasty (OP) and external tube drainage (ETD).
Material and methods: This was a prospective randomized controlled study conducted on radiologically documented cases of hepatic hydatidosis (n=50) in a tertiary care hospital of Kashmir. Patients were divided into two groups; in one group ETD was performed and in another OP was done.
Results: Twenty-eight patients were offered ETD and 22 OP. There was no statistically significant difference in mean operative time. The overall complication rate was higher in ETD (42.86%) as compared to OP (22.73%). In ETD group two patients had bile leak and infection of residual cavity each; whereas no such complication was seen in OP. The mean pain scores were elevated in ETD (p<0.0016).The mean hospital stay was more in ETD as compared to OP (p<0.0031). Also time for resumption of activities of daily life was more in ETD (p<0.0026). The recurrence of disease was seen in three patients in ETD as compared to none in OP.
Conclusion: Omentoplasty offers a number of advantages over external tube drainage and should remain the preferred option whenever possible.
hydatid cyst; omentoplasty; external tube drainage; laparoscopy; liver
Objective: Newer non-benzodiazepines zolpidem and zopiclone (“Z-drugs”) are often prescribed instead of benzodiazepine hypnotics, although there is no evidence of differences in effectiveness and safety. Aim was to compare perceptions on benefits and harms of benzodiazepines and Z-drugs between general practitioners (GPs) and community pharmacists (CPs).
Methods: A questionnaire was mailed to a random sample of 1,350 GPs and 600 CPs in 2012. They were asked to rate perceptions on a five-point Likert scale used for both benzodiazepines and Z-drugs. Wilcoxon signed rank test was performed for the comparison of perceptions between GPs and CPs. Due to multiple testing, only p-values ≤0.01 were considered statistically significant.
Results: 458 GPs and 202 CPs returned questionnaires (response 33.9% and 33.7%). Mean age of GPs was 53.3 years (40.6% female) and 48.8 years for CPs (59.2% females). Perceptions on benefits of benzodiazepines (and Z-drugs) between GPs and CPs were not different for 3 (and 2) of 5 items. Concerning side effects of benzodiazepines, there were no statistically significant differences for 3 of 5 comparisons. CPs perceived that 4 of 5 studied side effects of Z-drugs occur significantly more often than GPs (p=0.003 or less). For instance, whereas 45.2% of CPs answered that withdrawal effects on stopping happen often or very often/always on Z-drugs, these were only 28.3% of the GPs.
Conclusions: Although it is difficult to draw unambiguous conclusions from these findings, pharmacists might have a somewhat more critical view on Z-drugs, especially concerning side effects.
cross-sectional studies; Germany; hypnotics and sedatives; attitude of health personnel
Quality indicators are key elements of quality management. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2010 were recently evaluated when their validity time expired after two years. Overall one indicator was replaced and further three were in part changed. The former indicator I “elevation of head of bed” was replaced by the indicator “Daily multi-professional ward rounds with the documentation of daily therapy goals” and added to the indicator IV “Weaning and other measures to prevent ventilator associated pneumonias (short: Weaning/VAP Bundle)” (VAP = ventilator-associated pneumonia) which aims at the reduction of VAP incidence. The indicator VIII “Documentation of structured relative-/next-of-kin communication” was refined. The indicator X “Direction of the ICU by a specially trained certified intensivist with no other clinical duties in a department” was also updated according to recent study results. These updated quality indicators are part of the Peer Review in intensive care medicine. The next update of the quality indicators is due in 2016.
quality management; intensive care medicine; quality indicators; peer review
We describe diffuse colonic calcification detected on CT scan of the abdomen in a young female patient who presented to our clinic with vague intermittent abdominal pain of four weeks duration. Her investigative profile was normal and her colonoscopy did not reveal any mucosal changes. Colonic calcification has been known to occur mostly as a result of ischemic phenomenon but the index case had no such features or any other predisposing factor. The patient is currently symptom-free and is following our clinic for the last 8 months. After the review of literature and thorough investigations her colonic calcification remains unexplained.
abdominal CT scan; calcification; phlebosclerosis
Introduction: Postoperative neurological complications in pelvic and renal surgery are a well-known clinical problem and their morbidities are important. We designed this study to determine prevalence and risk factors of such complications after percutaneous nephrolithotomy (PCNL) surgery.
Material and methods: A cross-sectional study was performed during February and July 2011 on 68 PCNL cases. Demographic data and surgery reports were gathered and comprehensive neurological physical examination carried out before and after surgery. Then, data was analyzed using software SPSS 18.
Results: The ultimate sample included 30 (46.2%) male and 35 (53.8%) female patients with a mean age of 47.9 ± 11.47 years. In intercostal and lumbosacral plexus area, sensory neurological complications occurred in 8 patients (12.31%), 4 men and 4 women. The most common involved dermatomes and nerves were T12 (8 cases). There was a significant correlation between prolonged duration of surgery and prevalence of sensory complications (p<0.010). The highest hemoglobin value drop after surgery occurred in patients with neurological complications (p<0.001). There were no correlations between age, tracts used, diabetes mellitus, BMI, hypertension, positioning of patients and side of surgery with incidence of sensory neurological complications. No motor neurological complications occurred.
Conclusion: Prolonged duration of PCNL and increased value of hemoglobin drop may lead to increased risk of neuropathy. Larger prospective studies with retroperitoneal imagings and patients’ follow up is suggested for better understanding of this complication.
percutaneous nephrollithotomy; neuropathy; complication
Anisospondyly (irregularly shaped vertebral bodies) and enchondroma-like lesions in the metaphyseal and diaphyseal portions of the long tubular bones are the characteristic features in patients with dysspondyloenchondromatosis (DSC). Thoraco-lumbar scoliosis and windswept deformity of the lower limbs were the major abnormalities encountered in this patient. To the best of our knowledge this is the first case report delineating the spine pathology via reformatted CT scan and the correction of a windswept deformity by means of temporary hemiepiphysiodesis in a patient with (DSC).
dysspondyloenchondromatosis; anisospondyly; windswept deformity; hemiepiphysiodesis
Introduction: Tamoxifen is associated with a twofold increased risk of thromboembolic events. Third generation aromatase inhibitors (AIs), such as letrozole, anastrozole, and exemestane have therefore replaced tamoxifen in the adjuvant therapy of hormone receptor-positive breast cancer. A retrospective review was performed in patients who underwent delayed microvascular breast reconstruction and received tamoxifen at the time of surgery in order to assess the risk of both minor and major flap complications including thromboembolic events.
Patients and methods: Twenty-nine patients who underwent delayed microsurgical breast reconstruction with autologous tissue between 2006 and 2012 were included in the study. The overall complication rates were compared between patients who did versus those who did not receive tamoxifen at the time of microsurgical breast reconstruction.
Results: Breast reconstruction was performed with a DIEP flap in 25 patients and with a TRAM flap in 4 patients. Overall, the complication rate was 37.9% (n=11) consisting of 5 major (including one total flap loss) and 6 minor complications. In patients receiving tamoxifen (n=5), we observed one minor complication and one major complication with a total flap loss due to thrombus formation at the anastomosis site. In one patient pulmonary embolism occurred without association to tamoxifen. The number of thromboembolic events was equivalent in both groups (p=0.642). No increase of major (p=0.858) or minor (p=0.967) complications in the tamoxifen group could be observed. Taking the overall complication rate into account there was no statistically difference between the two groups (p=0.917).
Conclusion: In our study we could not observe an increased risk for thromobembolic events in patients receiving tamoxifen while undergoing autologous microvascular breast reconstruction.
Tamoxifen; breast cancer; adjuvant therapy; microvascular breast reconstruction
Since several years risk-based monitoring is the new “magic bullet” for improvement in clinical research. Lots of authors in clinical research ranging from industry and academia to authorities are keen on demonstrating better monitoring-efficiency by reducing monitoring visits, monitoring time on site, monitoring costs and so on, always arguing with the use of risk-based monitoring principles. Mostly forgotten is the fact, that the use of risk-based monitoring is only adequate if all mandatory prerequisites at site and for the monitor and the sponsor are fulfilled.
Based on the relevant chapter in ICH GCP (International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use – Good Clinical Practice) this publication takes a holistic approach by identifying and describing the requirements for future monitoring and the use of risk-based monitoring. As the authors are operational managers as well as QA (Quality Assurance) experts, both aspects are represented to come up with efficient and qualitative ways of future monitoring according to ICH GCP.
monitoring; risk-based monitoring; quality management
Scope: To discuss the rationale behind informed consent in clinical trials focusing on vulnerable patients from a European and German viewpoint.
Methods: Scientific literature search via PubMed, Medline, Google.
Results: Voluntary informed consent is the cornerstone of policies regulating clinical trials. To enroll a patient into a clinical trial without having obtained written and signed consent is to be considered as a serious issue in the conduct of a clinical trial. Development of ethical guidance for physicians started before Christ Era with the Hippocratic Oath. Main function of consent, as articulated in all guidelines developed for clinical research, is to facilitate an individual’s freedom of choice, respect autonomy, and thus to ensure welfare of the participants in clinical trials. Minors are unable to provide legally binding informed consent, this issue is addressed through a combination of parental permission and minor’s assent. Illiteracy is a critical problem that affects all corners of our earth; it has no boundaries and exists among every race and ethnicity, age group, and economic class. New strategies to improve communication with patients including the use of videotapes or animated cartoon illustrations could be taught. Finally the time with the potential participant seems to be the best way to improve understanding.
Conclusion: Discovery of life saving and life enhancing new treatments requires partnership that is based on good communication and trust between patients and researchers, sponsors, ethics committees, authorities, lawyers and politicians so that vulnerable patients can benefit from the results of well controlled clinical trials.
informed consent; vulnerable patients; minors; illiteracy
Although endovascular transcatheter embolization of arteriovenous fistulas is minimally invasive, the torrential flow prevailing within a fistula implies the risk of migration of the deployed embolization devices into the downstream venous and pulmonary circulation. We present the endovascular treatment of a giant postnephrectomy arteriovenous fistula between the right renal pedicle and the residual renal vein in a 63-year-old man.
The purpose of this case report is to demonstrate that the Amplatzer vascular plug (AVP) can be safely positioned to embolize even relatively large arteriovenous fistulas (AVFs). Secondly, we illustrate that this occluder can even be introduced to the fistula via a transvenous catheter in cases where it is initially not possible to advance the deployment-catheter through a tortuous feeder artery. Migration of the vascular plug was ruled out at follow-up 4 months subsequently to the intervention.
Thus, the Amplatzer vascular plug and the arteriovenous through-and-through guide wire access with subsequent transvenous deployment should be considered in similar cases.
arteriovenous fistula; AV-fistula; nephrectomy; embolisation; endovascular treatment; arteriovenous access; through-and-through; transvenous access; Amplatzer vascular plug
Aim of the study: To investigate the comorbidity of Alzheimer’s/dementia, epilepsy, multiple sclerosis and Parkinson’s with depression.
Methods: 42,914 patients who were newly diagnosed with the four comorbid diseases were included in the study. We analyzed how many of these patients developed depression within five years.
Results: Between 21% (males with epilepsy) and 39% (women with Parkinson’s)/44% (Alzheimer’s patients under 60 years) developed depression within five years.
Conclusion: We recommend routine checks for depression in patients diagnosed with one of these diseases, especially in the most comorbid ones.
comorbidity; depression; dementia; epilepsy; multiple sclerosis; Parkinson’s
Actinic keratosis is one of the most commonly treated skin conditions. A number of studies have recently been published on the treatment of this ailment using photodynamic therapy. The authors of this letter are concerned about the interpretation of some of these studies and would like to outline possible misinterpretations which may arise due to an incomplete analysis of the study reports available. Clearly, the “ideal” therapy for actinic keratosis should be a carefully chosen compromise between undesired side-effects and therapeutic efficacy and needs to be based on a consideration of all of the relevant clinical studies.
dermatology; actinic keratosis; 5-aminolaevulinic acid; methyl-5-aminolaevulinate; photodynamic therapy; light sources
The World Health Organization states that in a widespread report that “in developed countries, adherence among patients suffering chronic diseases averages only 50%”. We followed the quoted references to this statement. The data basis for this statement is one randomized controlled trial (RCT) on hypertensive steel workers in Canada published in 1975 and one study dealing with neurotic outpatients in Pennsylvania, USA published in 1965. Both studies are not suitable to assume such generalized adherence estimation and are not for different reasons transferable to today’s patient care.
patient compliance; medication adherence; chronic disease; evidence-based medicine; information science; behavior
Epiploic appendagitis is a rare cause of acute abdomen. Depending on the site of occurrence, it can mimic any cause of acute abdomen or disease of the colon and caecal appendix; making its preoperative diagnosis very difficult. We present here a case of a 7-year-old boy misdiagnosed preoperatively as acute appendicitis and later on, upon surgical exploration, found to have caecal appendagitis. The affected epiploic appendage was removed and the patient had an uneventful recovery. We also review the relevant literature and discuss the measures to overcome this diagnostic dilemma. General surgeons should be aware of this self-limiting disease and consider it as a differential diagnosis of acute abdomen.
caecal appendagitis; appendices epiploicae; torsion; acute appendicitis; epiploic appendagitis; acute abdomen
Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease.
Methods: A systematic review of the literature was undertaken.
Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction).
Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well.
Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient.
Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
rectovaginal fistula; surgery; incontinence; postpartal trauma; rectal cancer; German guideline
Background: Treatment of high anal fistulas may be associated with a high risk of continence disorders. Beside traditional procedure of flap-reconstruction the occlusion of the fistula tract using fistula-plugs offers a new sphincter-saving treatment option. In this study for the first time results from Germany are described.
Patients and method: 40 patients (30 male, 10 female, age 51±12 years) underwent closure of a high trans-sphincteric (n=28) or supra-sphincteric (n=12) fistula with Gore BioA Fistula Plug® in three surgical departments. The surgical procedures had been performed by five colorectal surgeons. Four patients had Crohn’s disease. Preoperatively 33 patients were completely continent; seven patients complained of minor continence disorders. Treatment of the patients was performed on a intent-to-treat basis and evaluation of the results was retrospective using pooled data from each center.
Results: Postoperatively one patient developed an abscess, which had to be managed surgically. In two patients the plug had fallen out within the first two weeks postoperatively. Six months after surgery the fistula has been healed in 20 patients (50.0%). Three additional fistulas healed after 7, 9 rsp. 12 months. The overall healing-rate was 57.5% (23/40). The healing rate differs considerably between the surgeons from 0 to 75% and depends on the number of previous interventions. In patients having only drainage of the abscess success occurred in 63.6% (14/22) whereas in patients after one or more flap fistula reconstruction the healing rate decreased slightly to 50% (9/18). No patient complained about any impairment of his preoperative continence status.
Conclusion: By occlusion of high anal fistulas with a plug technique definitive healing could be achieved in nearly every second patients. Previous surgery seems to have a negative impact on success rate. We have not observed any negative impact on anal continence. From that point of view anal fistula plugs might be discussed as a treatment option for high anal fistulas, but further studies are needed to gain conclusive evidence.
complex fistula-in-ano; transsphincteric fistula; suprasphincteric fistula; surgical procedures; fecal incontinence; fistula plug
Inverted papilloma is an uncommon primary nasal tumor. Despite its benign nature, this tumor represents three typical characteristics: a high propensity of recurrence, local aggressiveness and association with malignancy. Inverted papilloma can reduce the patient’s quality of life due to compromised nasal function, extension to the orbit and brain. The authors reported the unusual case of a 72-year-old male patient with inverted papilloma, which fatally extended to the intracranial temporal fossa after multiple recurrences. To the authors’ knowledge, this is the twelfth case in the literature of inverted papilla extending into the temporal fossa. The current and pertinent literature in English, French and German was reviewed, and an algorithm for managing inverted papilloma was also proposed.
inverted papilloma; tumor extension; paranasal sinus tumor; intracranial involvement
The basis for the new procedure is the simultaneous transcutaneous measurement of the peri-ulceral oxygen partial pressure (tcPO2), using a minimum of 4 electrodes which are placed as close to the wound margin as possible, additionally, as a challenge the patient inhales pure oxygen for approximately 15 minutes.
In order to evaluate the measurement data and to characterise the wounds, two new oxygen parameters were defined: (1) the oxygen characteristic (K-PO2), and (2) the oxygen inhomogeneity (I-PO2) of a chronic wound. The first of these is the arithmetic mean of the two lowest tcPO2 measurement values, and the second is the variation coefficient of the four measurement values. Using the K-PO2 parameter, a grading of wound hypoxia can be obtained. To begin with, the physiologically regulated (and still compensated) hypoxia with K-PO2 values of between 35 and 40 mmHg is distinguished from the pathological decompensated hypoxia with K-PO2 values of between 0 and 35 mmHg; the first of these still stimulates self-healing (within the limits of the oxygen balance). The decompensated hypoxia can be (arbitrarily) divided into “simple” hypoxia (Grade I), intense hypoxia (Grade II) and extreme hypoxia (Grade III), with the possibility of intermediate grades (I/II and II/III).
Measurements were carried out using the new procedure on the skin of the right inner ankle of 21 healthy volunteers of various ages, and in 17 CVI (chronic venous insufficiency) wounds. Sixteen of the 17 CVI wounds (i.e., 94%) were found to be pathologically hypoxic, a state which was not found in any of the healthy volunteers. The oxygen inhomogeneity (I-PO2) of the individual chronic wounds increased exponentially as a function of the hypoxia grading (K-PO2), with a 10-fold increase with extreme hypoxia in contrast to a constant value of approximately 14% in the healthy volunteers. This pronounced oxygen inhomogeneity explains inhomogeneous wound healings, resulting in the so-called mosaic wounds. The hypoxia grades found in all of the chronic wounds was seen to be evenly distributed with values ranging from 0 to 40 mmHg, and therefore extremely inhomogeneous. In terms of oxygenation, chronic wounds are therefore inhomogeneous in two respects: (1) within the wound itself (intra-individual wound inhomogeneity) and (2) between different wounds (inter-individual wound inhomogeneity). Due to the extreme oxygen inhomogeneity, single measurements are not diagnostically useful.
In healthy individuals the oxygen inhalation challenge (see above) results in synchronised tcPO2 oscillations occurring at minute rhythms, which are not seen in CVI wounds. These oscillations can be interpreted as a sign of a functioning arterial vasomotor system.
The new procedure is suitable for the routine characterisation of chronic wounds in terms of their oxygen status, and correspondingly, their metabolically determining (and limiting) potential for healing and regeneration. The oxygen characteristic K-PO2 can furthermore be used as a warning of impending ulceration, since the oxygen provision worsens over time prior to the demise of the ulcerated tissue, thus making a controlled prophylaxis possible.
chronic wounds; mosaic wound; physiological hypoxia; decompensated hypoxia; chronic venous insufficiency (CVI); peri-ulceral oxygen partial pressure; simultaneous peri-ulceral tcPO2 measurement; oxygen topography; oxidation potential; hypoxia grading; haemoglobin; tissue PO2 (gPO2); arterial occlusion; synchronised tcPO2 oscillations; oxygen toxicity; skin pigmentation; white skin atrophy; controlled wound prophylaxis; controlled wound rehabilitation; oxygen characteristic (K-PO2); oxygen inhomogeneity (I-PO2) (simultaneously or sequentially determined); chronic wounds requiring oxygen; hyperoxic blood vessel constriction; biologically available oxygen
Biliary parasitosis is one of the important causes of biliary obstruction in endemic areas, however due to migration and travel the disease is known to occur in non endemic zones as well. The spectrum of biliary fascioliasis ranges from recurrent biliary colics to acute cholangitis. The long term complications are gall stones, sclerosing cholangitis and biliary cirrhosis. We describe fascioliasis as a cause of recurrent biliary colics in a young male necessitating multiple hospitalizations over a period of four years. Investigative profile had been non-contributory every time he was hospitalized for his abdominal pain prior to the current presentation. He never had cholangitis due to the worm in the common bile duct. It was only at endoscopic retrograde cholangiopancreatography (ERCP) biliary fascioliasis was discovered to be the cause of his recurrent biliary colics. After removal of the live Fasciola hepatica from the common bile duct he became symptom free and is attending our clinic for last 11 months now. Clinical spectrum of biliary fascioliasis is discussed in this report.
Pediatric wrist empyema are very rare, this is the first case report in the current literature describing a hematogenic spreading of bacteria from dental caries, leading to a severe wrist empyema.
wrist empyema; childhood; dental bacteremia
Diagnosis-Related Group (DRG) is a classification system, which groups patients according to their diagnosis and resource consumption. Common hand surgical diagnoses and procedures were processed using national DRG-groupers of six European countries.
The upper thresholds of length of stay (LoS) are indicated for every country with the exception of Spain. The mean value in the series was 9.9 days for Germany, 4.5 days for Austria, 10.7 days for Italy, 9.7 days for Sweden and 9.4 days for the United Kingdom (UK). Germany and Austria also have lower thresholds of LoS and the average LoS.
Multiple finger replantation presented the highest single case reimbursement in Germany, Austria and the UK (13,825 €, 10,576 € and 9,198 €). Scaphoid non-union had the highest single case reimbursement in Italy (2,676 €), flap coverage of wounds in Spain (5,506 €) and trapeziometacarpal arthritis in Sweden (5,350 €). The mean values for single case reimbursement were as follows: Germany 3,211 €, Austria 2,821 €, Italy 1,947 €, Spain 3,594 €, Sweden 2,403 € and the UK 3,253 €. Ten out of 19 cases showed the highest reimbursement in Spain, followed by the UK (5 cases), Sweden (2 cases), Germany and Austria (1 case each).
Applying the case numbers of our clinic to the reimbursement system of each country, total proceeds would be 2.25 million € in Spain, 1.79 million € in Germany as well as the UK, 1.75 million € in Austria, 1.63 million € in Sweden and 1.22 million € in Italy.
The consequences of international differences in efficiency and reimbursement are hard to assess as they are influenced by multiple factors that are seldom purely market-driven. However, the consideration of international data for benchmarking and refinement of national compensation systems should be a useful instrument.
Diagnosis-Related Groups; Hand Surgery; reimbursement; length of stay; Europe
Purpose: To date there are only a few studies published, dealing with delirium in critically ill patients. The problem with these studies is that prevalence rates of delirium could only be estimated because of the lack of validated delirium assessment tools for the paediatric intensive care unit (PICU). The paediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU) was specifically developed and validated for the detection of delirium in PICU patients. The purpose of this study was the translation of the English pCAM-ICU into German according to international validated guidelines.
Methods: The translation process was performed according to the principles of good practice for the translation and cultural adaptation process for patient reported outcomes measures: From three independently created German forward-translation versions one preliminary German version was developed, which was then retranslated to English by a certified, state-approved translator. The back-translated version was submitted to the original author for evaluation. The German translation was evaluated by clinicians and specialists anonymously (German grades) in regards to language and content of the translation.
Results: The results of the cognitive debriefing revealed good to very good results. After that the translation process was successfully completed and the final version of the German pCAM-ICU was adopted by the expert committee.
Conclusion: The German version of the pCAM-ICU is a result of a translation process in accordance with internationally acknowledged guidelines. Particularly, with respect to the excellent results of the cognitive debriefing, we could finalise the translation and cultural adaptation process for the German pCAM-ICU.
delirium; paediatric; pCAM-ICU; intensive care unit; translation