„Intermediate-risk-“ und „High-risk-Prostatakarzinompatienten“

Introduction

We examined the quantity and localization of pelvic lymph node (LN) metastases in patients undergoing extended pelvic lymphadenectomy (ePLND).

Materials and methods

A total of 174 patients with intermediate and high-risk prostate cancer underwent radical prostatectomy (RP) and ePLND. We analyzed the relationship between the number of LNs removed and the number, frequency and topography of LN metastases.

Results

In group 1 (intermediate risk patients, n=115) the average number of LNs removed was 20.5, LN metastases were found in 15 patients (13 %) and the localizations were in the external iliac artery 19 %, the internal iliac artery 32 %, the obturator foramen 36 %, the common iliac artery 7 %, Marcille’s triangle 3 % and sacral regions 3 %. In group 2 (high-risk patients, n=59) the average number of LNs removed was 23.9, LN metastases were found in 19 patients (32 %) and the localizations were the external iliac artery 15 %, the internal iliac artery 26 %, the obturator foramen 19 %, the common iliac artery 29 %, Marcille’s triangle 6 % and sacral regions 5 %. The full number of metastases was detected only if more than 15 LNs were removed in group 1 and 18 LNs in group 2.

Conclusions

At least 15 LNs in the intermediate risk group and at least 18 LNs in high risk group should be removed. The ePLND should include the common iliac artery, the internal iliac artery, Marcille’s triangle and sacral regions.     

„Fast-track-Kolonchirurgie“

OBJECT: The aim of multimodal perioperative treatment concepts is to lower the extent of general complications after elective colonic resection and "traditional" perioperative therapy and to allow hospital discharge only a few days following the operation. MATERIALS AND METHODS: In this prospective study, we examined a new perioperative treatment plan for accelerating postoperative recovery and evaluated the results. This so-called "fast-track" program employs combined thoracal peridural analgesia, forced mobilization, and rapid renourishment within the clinic. RESULTS: Sixty-four consecutive patients with benign or malignant disease of the large intestine aged an average of 66 years (range 54-71) were operated on. Thirty received conventional resection and 34 were operated on laparoscopically and treated perioperatively using the fast-track program. The hospital diet was given in all cases on the 1st postoperative day, and the first bowel movement occurred on the 2nd day (range 2-3). The patients could be released on the 4th postresection day (range 4-5). General and local postoperative complications were observed in five patients each (8%), including two cases of anastomotic insufficiency. CONCLUSION: In colonic surgery, the "fast-track" method accelerated convalescence, lowered the number of general complications, and reduced the duration of hospital stay. Therefore, evaluation of "fast-track" concepts is warranted in other types of elective abdominal surgery.     

„Zweitmeinungszentren“

According to estimations of the German Cancer Research Center in Heidelberg, the management of germ cell tumors in Germany is characterized by a marked difference between the actual mortality and the mortality to be expected with adequate implementation of the therapy standard. Our aim is to reduce the mortality rate by introducing a treatment procedure supported by a second opinion center.     

„Human factors“ und „crisis resource management“

A continuing high number of patients suffer harm from medical treatment. In 60-70% of the cases the sources of harm can be attributed to the field of human factors (HFs) and teamwork; nevertheless, those topics are still neither part of medical education nor of basic and advanced training even though it has been known for many years and it has meanwhile also been demonstrated for surgical specialties that training in human factors and teamwork considerably reduces surgical mortality. Besides the medical field, the concept of crisis resource management (CRM) has already proven its worth in many other industries by improving teamwork and reducing errors in the domain of human factors. One of the best ways to learn about CRM and HFs is realistic simulation team training with well-trained instructors in CRM and HF. The educational concept of the HOTT (hand over team training) courses for trauma room training offered by the DGU integrates these elements based on the current state of science. It is time to establish such training for all medical teams in emergency medicine and operative care. Accompanying safety measures, such as the development of a positive culture of safety in every department and the use of effective critical incident reporting systems (CIRs) should be pursued.     

Simulationstraining zwischen „human factors“ und „technical skills“

Background

Complexity in clinical medicine has induced a higher consciousness for patient safety and clinical risk management. Technical progress has enabled transposition of learning progress towards a low-risk simulation-based environment. This has changed the former strategy in acquiring clinical abilities away from “see one, do one, teach one”.

Objective

Hereby, mobile full-scale simulators are able not only to provide an opportunity in training technical clinical skills but more often display whole chains of medical care, complex scenarios and clinical team trainings. Due to the technical advances, there is a shift in simulation-based trainings from technical to non-technical skills. Especially in the area of simulator-based team training, there is a broad heterogeneity, causing difficulties to acquire scientific evidence for their effectiveness.

Future

Essential for the establishment and the sustainable effect of simulator-based training is routine obligatory clinical training, participation of scientific associations, and integration into a clinical risk management system. Predefinition of learning targets and the selective, outcome driven use of simulation-based training are of importance.     

„Shoulder stiffness“

Die Unfallchirurgie -     

Simulationsbasiertes „Anaesthesia-Crisis-Resource-Management-Training“

Background

Up to as many as 38,000 people die in German hospitals each year as a result of preventable medical errors. Anesthetic procedures are generally safer than internal medical procedures and the mortality associated with anesthesia is estimated to be 3.3-5 cases per million. However, this is still 10 times higher than the risk associated with civilian aviation for example. Up to 80% of mistakes are attributable to inadequate execution of non-technical skills (NTS) such as communication, teamwork and organization of the working environment. Training in non-technical skills through Anesthesia Crisis Resource Management (ACRM) is an integral part of the Berlin Simulation Training (BeST) curriculum. The aim of this study was to describe the subjective evaluation of change in routine clinical behavior as a result of simulator training using latent outcome variables such as “subjective evaluation of learning outcome”, with special emphasis on communication.

Material and methods

In total 235 doctors with varying levels of professional experience received BeST training between 2001 and 2004. An anonymous postal questionnaire was sent to 228 of these participants and the response rate was 64% The questionnaire contained 13 questions covering evaluation of the workshop and learning outcome with respect to communication in the operating room (OR), teamwork in the OR and medical knowledge. Following factor analysis 3 latent outcome variables (subjective evaluation of the learning outcome, workshop-related change in perception of the value of communication and general value and relevance) were generated. Logistic regression was used to determine whether there was any relationship between the latent outcome variables and a number of independent factors.

Results

It was not possible to demonstrate any relationship between the level of professional training, age or date of the workshop and the variables selected to describe subjective evaluation of behavioral change as a result of the workshop. How realistic the candidates perceived the training scenarios to be (p<0.01) and the sex of the candidates (p=0.03) were both significantly related to evaluation and female candidates were more likely to positively evaluate the simulator training. From the candidates’ perspective the training significantly altered their perception of the value of NTSs, and in particular communication, during the management of critical incidents in the OR.

Conclusion

Well-staged and realistic simulation is associated with better learning outcomes. It may be important to take gender aspects into account in ACRM training.     

„Antibiotic Stewardship“

Antibiotic stewardship (ABS) comprises a bundle of different interventions to improve anti-infective treatment in a hospital setting. An important component of ABS interventions is the interdisciplinary approach to infection management. Besides improving infrastructural aspects on a hospital level, including surveillance of the use of anti-infective agents and nosocomial infections, collation and interpretation of statistics on resistance and formulation of local treatment guidelines, ABS teams go to the wards and advise treating physicians on antibiotic therapy. Frequent approaches for optimization are selection of substances, administration route, dosing of medication and duration of treatment. An important overall objective of ABS is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. A number of studies have shown that this goal can be achieved in different clinical settings without negatively affecting patient outcome. The strategies of ABS can also be applied with no problems to critically ill patients on the intensive care unit.     

„Energy-based devices“

Journal für Ästhetische Chirurgie -     

„Herztamponade.“

Ohne Zusammenfassung Im Auszuge vorgetragen in der Sitzung der Gesellschaft der Charitéarzte in Berlin am s. October 1883.     

„Soft skills“

Leading positions not only require excellent professional expertise but also strong soft skills in order to be successful. Factors such as personality traits, communication and management style are important for self-achievement or employee job satisfaction. The article reviews the definition of soft skills, the instruments for measuring such skills and furthermore possibilities for development in the medical context.     

„Target-controlled infusion“

Since its commercial introduction in 1996, target-controlled infusion (TCI) has become an established technique for administration of intravenous anaesthetics. Modern TCI systems, however, are characterized by an increasing number of additional options and features, such as the choice between different pharmacokinetic models and modes of application, which may confuse the less experienced user. This review describes the differences between pharmacokinetic models, modes of application and the effect of covariates as well as the consequences for dosing. The aim is to explicate for the user of modern TCI systems the underlying scientific concepts and the relevance for clinical practice.     

„Ventricular-assist-device“-Koordination

Background

An optimal patient care before and after ventricular assist device (VAD) operations, during the rehabilitation phase and after clinic discharge usually leads to earlier detection or even avoidance of complications and improvement of survival rates.

Material and methods

Patient management and coordination are discussed based on a long experience in multidisciplinary teamwork at the Herz- und Diabeteszentrum (HDZ) NRW (Heart and Diabetes Center NRW).

Results

In the multidisciplinary team VAD coordinators play a central role. Besides the coordinator team many other disciplines are necessary for a successful and appropriate patient-centered care. Increasing support times on devices are accompanied by growing requirements for optimal quality of care. Intensified endeavors are indispensable not only in the acute situation (preoperatively, intraoperatively and early postoperatively) but also in convalescence and rehabilitation. The focus in these periods is on surveillance and avoidance of complications. This includes the arrangement of an emergency system for out-of-hospital patients by integrating relatives and local physicians after adequate training.

Discussion

In summary the requirements for professionalism, motivation and ability to interact in the care for VAD patients are high. Optimal interdisciplinary support guarantees a high level of patient safety and improves the results in a sustainable manner. By connection to the team contact persons an additional safety option for the patient is ensured which facilitates the transfer to homecare out of hospital.     

„Fast-track“-Chirurgie

Zusammenfassung Die fast-track-Chirurgie ist ein multimodales Behandlungskonzept zur Beeinflussung pathophysiologischer funktioneller Veränderungen nach elektiven Eingriffen mit dem Resultat der verminderten Morbidität und beschleunigten Rekonvaleszenz. Erreicht wird dies durch eine optimierte interdisziplinäre (Chirurg, Anästhesist, Pflegepersonal, Physiotherapeut) und perioperative Fürsorge, welche zu einer verminderten operativen Stressreaktion des Patienten führt. Hierdurch konnten z. B. nach elektiven Kolonresektionen die Rate allgemeiner postoperativer Komplikationen und die Krankenhausliegezeiten deutlich gesenkt werden. Voraussetzung bei der Einführung der fast-track-Chirurgie ist der Wille der verantwortlichen Chirurgen zur Veränderung konventioneller Konzepte. Das Grundprinzip des fast-track-Managements wird zunehmend mit Erfolg auch auf andere abdominalchirurgische Operationen und andere operative Fächer wie z. B. die Urologie ausgeweitet.