„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.     

„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.     

„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.     

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.     

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.     

„Bionische“ Armprothesen

Background

A new generation of arm prostheses is being developed worldwide. These so-called bionic prostheses are intended to offer additional functions, such as sensory feedback, extended range of possible movement, intuitive movement control as far as possible, and a more natural cosmetic appearance.

State of the art in research and development

In recent years, prosthetic components with much enhanced performance have been developed for use at various levels of the upper limb. Artificial hands that allow for additional grips are are being tested in clinical settings. Innovative methods of signal acquisition and communication with the patient are being intensively researched.

Conclusion

Several patients have been provided with prototypes of new arm prostheses. At the moment, the results are limited by the restricted communication between patient and prosthesis. However, we can expect the options for prosthesis control to be extended in the near future.     

„Bedside“-Thrombelastographie

BACKGROUND: Demographic changes and aggressive medication with platelet aggregation inhibitors have resulted in a marked increase in blood and coagulation product expenditure and costs in cardiac surgery. We analyzed the bedside coagulation test (ROTEM) in order to verify clot forming quality and to find a cost-effective treatment algorithm. PATIENTS AND METHODS: Annual treatment costs of all cardiosurgical patients were retrospectively analyzed before (729 patients) and after (693 patients) implementation of the bedside ROTEM test. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and the coagulation factors prothrombin complex concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. The number of rethoracotomies and early mortality were assessed and compared in both periods. RESULTS: After ROTEM implementation cumulative RBC expenditure showed a 25% decrease and PltC a 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa was entirely omitted. Fibrinogen, however, showed a two-fold increase. Cumulative average monthly costs of all blood products decreased from 66,000 EUR to 45,000 EUR (-32%). Coagulation factor average monthly costs decreased from 60,000 EUR to 30,000 EUR (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1,580 EUR. The total number of rethoracotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. CONCLUSIONS: Cumulative costs for treatment of perioperative coagulation disorders were reduced by bedside ROTEM analysis to achieve a selective substitution management. Saved costs for blood and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.     

„Transversus-abdominis-plane“-Blockade

The transversus abdominis plane (TAP) block is a well known method for postoperative pain control after abdominal surgery. From an anatomical and physiological point of view it should be possible to perform abdominal wall surgery, e.g. wound debridement, using a TAP block only. To the authors knowledge no studies have been published with respect to the use of TAP only. This article presents a case report demonstrating that it is possible to perform three consecutive operation procedures within 7 days using only a bilateral TAP catheter technique. The TAP block without any co-medication provides high patient comfort and should be recognized as a good alternative for abdominal wall surgery.     

„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.     

Zusatzweiterbildung „Andrologie“

Andrology as a research topic has been well established for a long time – but andrological medical care has developed only recently. Medical doctors and scientists founded the German Society of Andrology (DGA) 35 years ago with the intention of promoting this field of medicine. Andrological skills are well established in the educational programme for residents in urology. The new regulations established in 2003 for residents in urology and certified urologists offer the chance to subspecialise in andrology. This specialisation constitutes progress, as patients now have a much better opportunity for identifying the andrologist as a competent partner for problems with fertility, hypogonadism and erectile dysfunction. Andrology comprises more than infertility – it covers the whole field of reproductive health in a broader sense: hypogonadism including genetic disorders, ejaculation disorders, erectile dysfunction, family planning and late-onset hypogonadism are included in the subspecialisation. There are minimum prerequisites concerning knowledge and skills that have to be fulfilled by urologists, dermatologists or endocrinologists. Surgical andrological procedures are better established in European than in German educational programmes. The educational programme has to be performed within 18 months; 6 of these months can be completed during residency training in urology. The importance of andrologists particularly in the setting of reproductive medicine is more than obvious: the Federal Medical Council clearly defines that an andrologist has to be involved in fertility centres performing assisted reproduction. According to the data compiled by Jens Jacobeit, responsible member for medical training of the DGA, 929 andrologists had achieved their certification in Germany at the end of the year 2009. The qualifying andrological postgraduate training is a duty and at the same time a chance for the urological community to professionally cover this field of subspecialisation in the future.     

„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.     

„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.     

„Shoulder stiffness“

Die Unfallchirurgie -     

Der „Pisse-Prophet“ oder „der englische Wahrsager aus dem Urin“

In the middle ages, uroscopy was the main nosological principle in medicine. It lead to quackery. One of the critics of uroscopy, who demanded a medicine mainly oriented on the patient, was Thomas Brian in 1637.     

„Resurfacing“ des Humeruskopfes

Surface replacement arthroplasty of the shoulder offers the ability to restore anatomy and biomechanics of the glenohumeral joint, if sufficient humeral bone stock of at least 60% of the humeral head is preserved and no severe deformity is present. The implantation following the individual anatomy helps to avoid complications such as prosthetic malpositioning and periprosthetic fractures. While the use of a glenoid component is technically demanding, revision to a stem prosthesis is relatively easy because of bone stock preservation.Indications for humeral head resurfacing are osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis stages 2-4, and stable forms of cuff tear arthropathy (CTA). Published results for OA and RA are comparable to those obtained with modern modular stem prostheses; the use in CTA appears promising under "limited goals criteria."     

Das „Forum Proteomics“

Ohne Zusammenfassung     

Nationaler Datensatz „Notaufnahme“

Background

The Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin (DIVI) is divided into sections one of which is the “Sektion Notaufnahmeprotokoll” (emergency department protocol section) founded in 2007. The main task was to create a national data set for the documentation of patients in emergency departments (ED).

Material and methods

In order to create such a data set a careful look was taken at the current state of documentation in many different hospitals throughout Germany. In addition, existing registries and international requirements were also taken into consideration. The content of the dataset “ED documentation” was developed in interdisciplinary and interprofessional expert rounds.

Results

The dataset “ED documentation” forms the first basis for documentation in German EDs. The modular data set contains 676 fields and covers all relevant information of the whole clinical process in the ED. Legal issues as well as several aspects for internal and external quality management are also included. For this reason the data of several German quality registries (e.g. TraumaRegister DGU® of the German Society of Trauma Surgery) are part of the data set. Furthermore, the data set forms the basis for several financial and billing aspects. A set of six forms was created in accordance with the developed modular data set. In 2010 the data set was approved by the executive committee of the DIVI. Several German medical associations (e.g. German Association for Emergency Medicine/Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin, DGINA) recommend its use. Currently 80 hospitals are using the data set.

Conclusion

Beside the ability to exchange information the presented data set is the basis for internal and external quality assessment in the ED even if most of the available scoring and benchmarking tools are not validated for the German medical system. Implementing an ED register in Germany which is planned in the future, could close this gap.