Ist das Magnesium als Naht-und Schienungsmaterial für Knochenoperationen geeignet?

Ohne Zusammenfassung     

Institut für das Entgeltsystem im Krankenhaus

The Institute for the Remuneration System in Hospitals (InEK) was founded in 2001 following the introduction of the flat rate remuneration system for general full and partial inpatient somatic hospital services in Germany by the partners of the joint self-administration. It undertakes the administration and further development of the German diagnosis-related groups system (G-DRG). This includes the definitions and maintenance of the G?DRG considering the comorbidities and complexities, processing and updating of the German coding guidelines. It also includes calculation of the assessment relations of the G?DRG with appropriate supplementary and deduction charges from real costs data of hospitals. With the processing of the procedure for new investigation and treatment methods the InEK plays a decisive role in the integration of new innovative treatment methods and medications in the G?DRG system. The calculation of assessment relations to investment cost financing of hospitals is also a task of the InEK. In addition to these functions the InEK developed the flat rate remuneration system for psychiatry and psychosomatics (PEPP) and in cooperation with other states supported the implementation of flat rate remuneration systems in healthcare services.     

Indikationsstellung und Indikationen für eine Lebertransplantation

Liver transplantation represents an established component of the therapeutic repertoire for irreversible chronic liver diseases. Liver transplantation is confronted by a shortage of donor allografts as well as by an increasing overall number of potentially useful indications, which leads to a rationing of this therapeutic option. Since December 2006 the priority for liver transplantation is determined by the model for end-stage liver disease (MELD) and not by the length of waiting time. The evaluation of indications which are prioritized according to laboratory values (serum creatine, serum bilirubin and coagulation) and the so-called standard exception categories which have to fulfil specific criteria place increased demands on the interdisciplinary transplantation team, on the evaluation for liver transplantation and the prediction of the success of transplantation required by the Transplantation Act. The establishment and implementation of robust, objective and transparent systems to assess not only preoperative priorities but also postoperative benefits represents a major challenge for transplantation medicine.     

Moderate Hypothermie in der Aortenbogenchirurgie: eine Gefahr für das Rückenmark?

Surgery of the transverse arch still is one of the most challenging procedures in cardiovascular surgery associated with significant (neurologic) morbidity and mortality. In the past, selective cerebral perfusion (SCP) in combination with deep hypothermia gained widespread acceptance as the standard approach in aortic arch surgery. In recent years, SCP in combination with moderate hypothermia of up to 28°C, more recently even up to 32°C was introduced to avoid deep hypothermia-associated complications. However, this new perfusion strategy may lead to prolonged distal ischemia during mild hypothermia (or even normothermia), and therefore, bares an underestimated risk for the viscerals and the spinal cord. This article illustrates the development of various neuroprotective perfusion strategies utilized in modern aortic surgery focussing in particular on the core temperature managment during the currently most widely adopted technique ?C antegrade SCP ?C and discusses the pros and cons of the current trend towards normothermic core temperature management by critically reviewing the contemporary experimental and clinical literature.     

Krankenhausalarm- und Einsatzplanung – Empfehlung für eine modulare Materialvorhaltung für den Massenanfall von Verletzten

Notfall + Rettungsmedizin - Die Anforderungen an Krankenhäuser und medizinische Versorgungseinrichtungen im Rahmen der Krankenhausalarm- und Einsatzplanung steigen stetig, zum einen durch...     

Gibt es eine Evidenz für medizinische Aussichtslosigkeit?

Background

In the age of evidence-based medicine, therapeutic decisions should invariably be based on the best available evidence.

Aim

Are there defined clinical scenarios with sufficient evidence for futility of an otherwise successful treatment?

Materials and methods

Literature-based meta-analysis of studies claiming or rejecting futility in cardiac arrest or otherwise critically ill patients.

Results

The studies differ substantially in their definition of futility and in their statistical methodology. The studies are generally too small, there are large grey zones with ambiguous results, and the quality of the predictions is poor. The methodological problems resulting from framing and context effects, timing, and self-fulfilling prophecies are insufficiently addressed and possibly intrinsic. These can, however, be overcome with substantial methodological efforts.

Conclusion

There is no reliable evidence for or against the futility of medical interventions in end-of-life care. Instead of relying on scientific results, the time to abandon life-saving care has to be chosen following a patient’s will according to humanitarian considerations.     

Was bedeutet eine Virusinfektion für einen Herzchirurgen?

Some cardiac surgeons will have noticed an article in Deutsches ?rzteblatt originating from an HIV-infected surgeon [1]. This may have prompted the question, what the consequences of such an infection may be for a cardiac surgeon. The authors try to elucidate these questions in view of the legal background. These aspects are included: Human immunodeficiency virus, acquired immune deficiency syndrome, hepatitis C, hepatitis B, chronic virus infection, acute virus infection, prohibition of employment, employers executive prerogative, employers duty of care, duty of confidentiality, company medical officer, pre-employment medical checkup.     

Erlaubt die neue UICC-Klassifikation eine bessere Prognoseabschätzung für das duktale Pankreascarcinom?

INTRODUCTION: To compare treatment results an international established classification is necessary. In 1997 the TNM classification of 1992 was modified. METHODS: Between 1983 and 1997, 159 patients with a ductal carcinoma of the pancreas underwent resection. All data of the resected specimens were documented in standardized manner prospectively in a protocol that offered ready transfer of the collected data to a new classification. The TNM categories and stage groupings were transferred to the new UICC classification of 1997 and analyzed in comparison to the classification of 1992. RESULTS: The inclusion of a pT4 category equivalent to the other GI tumors made a new stage grouping necessary. Also division into pN1 a and pN1 b was established. According to the clinical experience only few tumors in early stages (pT1/2 and stage I) were observed in the new classification. There was a significant improval in the patient's distribution to the new stage grouping because of the homogeneous groups. In comparison to the 1992 classification the new stage II shows a relevant prognostic value and a significant difference to stage III. CONCLUSION: We conclude that the new UICC classification relates to prognosis better than the old classification.     

Ist die intraoperative Ulnarisluxation ein Kriterium für die Vorverlagerung?

Background

The relevance of subcutaneous transposition of the ulnar nerve in the therapy of cubital tunnel syndrome is still under debate. The aim of this study was to compare the results after decompression to additional transposition in cases of intraoperative luxation.

Methods

A total of 54 cases after surgery of cubital tunnel syndrome between 2000 and 2006 were analyzed. Nerve transposition was performed in cases of intraoperatively apparent nerve luxation.

Results

Of the patients 12 were treated by decompression alone and 42 by additional subcutaneous transposition. There was no significant difference concerning symptom amelioration, usage properties of the hand, sensation impairment and duration of disability. Force measurements of grip strength and pinch strength revealed no significant differences between either hand in both groups. The 2-point discrimination ability of the 8th to 10th finger nerves was not significantly different between the groups either.

Conclusion

Nerve transposition revealed no benefits in the treatment of cubital tunnel syndrome when performed in cases of intraoperative nerve luxation.     

Verbindliche Dosisempfehlungen für Sufentanil und Fentanyl?

Ohne Zusammenfassung     

Der Suizidversuch — eine Herausforderung für den Unfallchirurgen?

Zusammenfassung Die Daten von 767 Patienten wurden nach einem Suizidversuch oder Suizid retrospektiv analysiert. Bei 52% der Patienten lagen Skelettschäden vor; sie stellten bei Aufschlüsselung der Verletzungsmuster zugleich den größten Anteil dar. Es folgten Schäden des Zentralnervensystems (26,6%), und an dritter Stelle der Häufigkeit standen Verletzungen parenchymatöser Organe (20,1%). Weichteilschäden größeren Ausmaßes wurden bei 18,1% und relevante Gefäßverletzungen bei 16% der Suizidenten diagnostiziert. Der hohe Anteil polytraumatisierter Patienten (22,9%) dokumentiert hierbei zugleich die Schwere und den Umfang erlittener Verletzungen bei Anwendung sogenannter harter Methoden. Es zeigt sich, daß die Verletzungen von Suizidenten bei entsprechender Gewalteinwirkung oftmals denen schwerer Straßenverkehrsunfälle gleichen und die Verletzungsmuster polytraumatisierter Patienten im Gegensatz zum. unselektionierten Patientengut vor allem durch Sprünge aus großer Höhe und Bahnüberfahrungen bestimmt wurden. Bei Vorliegen ungewöhnlicher Selbsttötungstechniken kann die Erfahrung des Chirurgen aber schnell ihre Grenzen erreichen, so daß nach unseren Kenntnissen traumatologische Fachabteilungen die besten Voraussetzungen für die Diagnostik und Notfallversorgung dieser Patienten bieten, sofern es sich nicht um reine Bagatellverlerletzungen handelt.     

Neue Materialien für eine bessere Patientenversorgung

Background

Novel biomaterials for orthopaedic applications are being investigated to improve patient care.

Permanent implants

The longevity of permanent implants depends on several factors, the dominant one being resistance to wear. To improve the longevity of these implants (e.g., knee prostheses) low-wear ceramic materials and novel device designs are under investigation. Ceramic prostheses have shown promising wear resistance compared to conventional prostheses.

Degradable implants

In specific cases, a mechanical function is to be performed for a limited time span. These implants gradually degrade in the body and eliminate the need for surgical removal of the implant. In recent years, several degradable magnesium alloys have been investigated regarding their mechanical properties and biocompatibility.     

Stelz-Kunstbein auch für Unterschenkelstümpfe,eine Ergänzung und Verbesserung

Ohne Zusammenfassung Aus der Orthop?dischen Versorgungsstelle Allenstein, Ostpreu?en. Mit 4 Abbildungen im Text.     

Simulationstraining für das Team im Rettungsdienst

Background

Simulator based training is extensively used in many non-medical high-risk industries. Critical scenarios and standard situations can be trained in complete safety.

Results and objectives

Situations which are regularly met in the field by the emergency team can be simulated. Careful planning and preparation of realistic scenarios is vital to ensure acceptance by the participants and a high rate of transfer of skills to the daily working environment. Only training which is carried out by all emergency medical personnel in the region can achieve a high level of effectiveness. The instructors of the simulation team at the Saint Josef Hospital in Freiburg developed a 1?day seminar with practical as well as theoretical contents. This was implemented over 1 year for more than 100 paramedics in the region. The concept focused on short lectures and intensive debriefings following scenarios in which the participants developed strategies for crew resource management, non technical skills and learned to put it into practice. The organizers wanted to demonstrate the practicability of a regionwide education concept in simulation and team training for the emergency medical service.

Conclusions

With the help of the carefully developed course concept an impressive training course was offered. The participants, when questioned directly after the course, were satisfied with the training and the results. In a further evaluation after some months the success and aftereffects of the project were confirmed.

     

Risikofaktoren für das Versagen von Osteosynthesen

Background

The increasing number of implantations of total knee endoprostheses shows a correlation with an increase in revision operations and periprosthetic fractures.

Objective

This article presents strategies for prevention of complications after open reduction internal fixation (ORIF) of periprosthetic fractures in addition to the classification of periprosthetic fractures of the knee joint.

Therapy strategies

Osteosynthetic treatment is only applicable in some of the cases. Although special periprosthetic, angle locking plates are available for osteosynthesis, treatment of periprosthetic fractures of the knee joint remains a challenge with a high complication rate. If the prosthesis becomes loosened, the prosthesis should be replaced and ORIF should not be performed.

Risk factors

The risk factors for failure of osteosynthesis include the prosthesis model and the associated reduction of residual bone and the mostly osteoporotic bone structures.     

Risikofaktoren für eine fehlgeschlagene Infektsanierung nach periprothetischer Hüftprothesensp?tinfektion

Background

Despite extensive cleansing concepts recurrent infections are relatively common especially for infections of hip prostheses. The aim of this retrospective study was to identify factors which hinder cleansing and facilitate recurrence.

Materials and methods

This study included 40?patients with periprosthetic delayed hip prosthesis infection who had been treated with the aim of infection cleansing between 2006 and 2008. Infection cleansing was carried out using a standardized treatment regimen with two and multiple phase reimplantation of the hip prosthesis following successful pathogen eradication. A clinical course follow-up was carried out after 2?years.

Results

Of the patients 18 (45%) were free of recurrence following successful eradication and reimplantation of the prosthesis and 5 (12.5%) suffered recurrence of infection after primarily successful revision prosthesis. In 17 patients (42.5%) treatment was switched to an alternative procedure primarily due to an uncleansable infection. In the group of patients with recurrent infections or untreatable infection, resistant pathogens could be detected significantly more often (p=0.001), in particular methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and highly resistant Pseudomonas. This group had a significantly worse American Society of Anesthesiologists (ASA) score (p?=?0.002). The number of surgical interventions in this group was significantly higher.

Conclusions

A poorer general physical condition and resistant infectious pathogens are the main risk factors for recurrent infections following prosthesis reimplantation. Therefore, a different treatment concept should be used for polymorbid patients with resistant pathogen infections.