[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]. / Auswirkungen der neuen Mindestmengen in der Viszeralchirurgie auf die Gesundheitsversorgung in Brandenburg aus der Perspektive der Versorger:innen.

BACKGROUND: The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement. OBJECTIVE: The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany. MATERIAL AND METHODS: In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis. RESULTS: Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted. CONCLUSION: The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

How can clinicians choose between conflicting and discordant systematic reviews? A replication study of the Jadad algorithm.

INTRODUCTION: The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results. METHODS: We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation. RESULTS: We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR. CONCLUSIONS: Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias.

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis.

PURPOSE: This systematic review and dose-response meta-analysis aimed to investigate the relationship between hospital volume and outcomes for total knee arthroplasty (TKA). METHODS: MEDLINE, Embase, CENTRAL and CINAHL were searched up to February 2020 for randomised controlled trials and cohort studies that reported TKA performed in hospitals with at least two different volumes and any associated patient-relevant outcomes. The adjusted effect estimates (odds ratios, OR) were pooled using a random-effects, linear dose-response meta-analysis. Heterogeneity was quantified using the I2-statistic. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively. RESULTS: A total of 68 cohort studies with data from 1985 to 2018 were included. The risk of bias for all outcomes ranged from moderate to critical. Higher hospital volume may be associated with a lower rate of early revision ≤ 12 months (narrative synthesis of k = 7 studies, n = 301,378 patients) and is likely associated with lower mortality ≤ 3 months (OR = 0.91 per additional 50 TKAs/year, 95% confidence interval [0.87-0.95], k = 9, n = 2,638,996, I2 = 51%) and readmissions ≤ 3 months (OR = 0.98 [0.97-0.99], k = 3, n = 830,381, I2 = 44%). Hospital volume may not be associated with the rates of deep infections within 1-4 years, late revision (1-10 years) or adverse events ≤ 3 months. The confidence in the cumulative evidence was moderate for mortality and readmission rates; low for early revision rates; and very low for deep infection, late revision and adverse event rates. CONCLUSION: An inverse volume-outcome relationship probably exists for some TKA outcomes, including mortality and readmissions, and may exist for early revisions. Small reductions in unfavourable outcomes may be clinically relevant at the population level, supporting centralisation of TKA to high-volume hospitals. LEVEL OF EVIDENCE: III. REGISTRATION NUMBER: The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019131209 available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131209 ).

An algal enzyme required for biosynthesis of the most abundant marine carotenoids.

Fucoxanthin and its derivatives are the main light-harvesting pigments in the photosynthetic apparatus of many chromalveolate algae and represent the most abundant carotenoids in the world's oceans, thus being major facilitators of marine primary production. A central step in fucoxanthin biosynthesis that has been elusive so far is the conversion of violaxanthin to neoxanthin. Here, we show that in chromalveolates, this reaction is catalyzed by violaxanthin de-epoxidase-like (VDL) proteins and that VDL is also involved in the formation of other light-harvesting carotenoids such as peridinin or vaucheriaxanthin. VDL is closely related to the photoprotective enzyme violaxanthin de-epoxidase that operates in plants and most algae, revealing that in major phyla of marine algae, an ancient gene duplication triggered the evolution of carotenoid functions beyond photoprotection toward light harvesting.

[Intestinal microbiota in individualized therapies]. / Die intestinale Mikrobiota als Ansatz für individuelle Therapien.

During recent years, the analysis of the human microbiota has been receiving more and more scientific focus. Deep sequencing analysis enables characterization of microbial communities in different environments without the need of culture-based methods. Hereby, information about microbial communities is increasing enormously. Numerous studies in humans and animal models revealed the important role of the microbiome in emergence and natural course of diseases such as autoimmune diseases and metabolic disorders, e. g., the metabolic syndrome. The identification of causalities between the intestinal microbiota composition and function, and diseases in humans and animal models can help to develop individualized therapies targeting the microbiome and its modification. Nowadays, it is established that several factors influence the composition of the microbiota. Diet it is one of the major factors shaping the microbiota and the use of pro- and prebiotica may induce changes in the microbial community. Fecal microbiome transfer is the first approach targeting the intestinal microbiota which is implemented in the clinical routine for patients with therapy-refractory infections with Clostridium difficile. Herewith, the recipient's microbiota can be changed permanently and the patient can be cured from the infection.

[Limited Data for Second Opinion Programs: a Systematic Review]. / Kaum aktuelle Daten zu Zweitmeinungsverfahren vorhanden ­ eine systematische Übersichtsarbeit.

Objective: According to a new legislation that will be set up in 2016, patients with an indication for elective surgery have the right to obtain a second opinion. The Federal Joint Committee has to provide a list of indications where this legislation will come into effect. The aim of this systematic review is to summarize available data on second opinion programs and to analyze the indications that should be covered by the new legislation. Methods: Medline, Embase, Proquest and Google scholar were searched for relevant studies in March 2015. To be included, primary studies had to deal with a surgical, orthopedic or gynecological elective procedure, and report agreement between first and second opinion. Study selection and critical appraisal were carried out by 2 reviewers independently. Disagreements were resolved by discussion. Data were extracted and analyzed. Results: In total, 17 studies fulfilled all inclusion criteria. All but one study were from the United States and only 3 studies have been published since 2000. The majority of studies were published in the 70 s and 80 s. Overall, agreement rates varied substantially from 43.0% to 95.5%. Most studies dealt with hysterectomy (n=6), cholecystectomy (n=5) and knee surgery (n=5). Median agreement rates for these procedures were 77.9% (range: 72.7-92.0%), 92.0% (88.2-95.5%) and 85.6% (76.1-93.5%), respectively, in obligatory second opinion programs and 63.0% (58.0-66.7%) and 87.0% (78.0-87.9%) in voluntary second opinion programs. Not enough data were available for knee surgery. Conclusions: Current data on second opinion programs is very limited. There is no data for Germany. Following this, it remains unclear which data or evidence will be used by the Federal Joint Committee to set up the new legislation. However, the findings suggest a potential for second opinion programs. They should be investigated in controlled trials in future.

In vitro colonisation of the distal colon by Akkermansia muciniphila is largely mucin and pH dependent.

Host mucin is the main constituent of the mucus layer that covers the gut epithelium of the host, and an important source of glycans for the bacteria colonising the intestine. Akkermansia muciniphila is a mucin-degrading bacterium, abundant in the human gut, that is able to produce acetate and propionate during this degradation process. A. muciniphila has been correlated with human health in previous studies, but a mechanistic explanation is lacking. In this study, the main site of colonisation was characterised alongside additional conditions, such as differences in colon pH, prebiotic supplementation and variable mucin supply. To overcome the limitations of in vivo studies concerning variations in mucin availability and difficult access to proximal regions of the colon, a dynamic in vitro gut model (SHIME) was used. In this model, A. muciniphila was found to colonise the distal colon compartment more abundantly than the proximal colon ((±8 log copies/ml compared to ±4 log copies/ml) and the preference for the distal compartment was found to be pH-dependent. The addition of mucin caused a specific increase of A. muciniphila (±4.5 log increase over two days), far exceeding the response of other bacteria present, together with an increase in propionate. These findings suggest that colonisation and mucin degradation by A. muciniphila is dependent on pH and the concentration of mucin. Our results revealed the preference of A. muciniphila for the distal colon environment due to its higher pH and uncovered the quick and stable response of A. muciniphila to mucin supplementation.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]. / Sigmadivertikulitis : Behandlungsmodalitäten 2011 bis 2013.

INTRODUCTION: Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist. METHODS: Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics. RESULTS: Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible. CONCLUSION: To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

Microbial Toluene Removal in Hypoxic Model Constructed Wetlands Occurs Predominantly via the Ring Monooxygenation Pathway.

In the present study, microbial toluene degradation in controlled constructed wetland model systems, planted fixed-bed reactors (PFRs), was queried with DNA-based methods in combination with stable isotope fractionation analysis and characterization of toluene-degrading microbial isolates. Two PFR replicates were operated with toluene as the sole external carbon and electron source for 2 years. The bulk redox conditions in these systems were hypoxic to anoxic. The autochthonous bacterial communities, as analyzed by Illumina sequencing of 16S rRNA gene amplicons, were mainly comprised of the families Xanthomonadaceae, Comamonadaceae, and Burkholderiaceae, plus Rhodospirillaceae in one of the PFR replicates. DNA microarray analyses of the catabolic potentials for aromatic compound degradation suggested the presence of the ring monooxygenation pathway in both systems, as well as the anaerobic toluene pathway in the PFR replicate with a high abundance of Rhodospirillaceae. The presence of catabolic genes encoding the ring monooxygenation pathway was verified by quantitative PCR analysis, utilizing the obtained toluene-degrading isolates as references. Stable isotope fractionation analysis showed low-level of carbon fractionation and only minimal hydrogen fractionation in both PFRs, which matches the fractionation signatures of monooxygenation and dioxygenation. In combination with the results of the DNA-based analyses, this suggests that toluene degradation occurs predominantly via ring monooxygenation in the PFRs.

[Current status of total hip and knee replacements in Germany - results of a nation-wide survey]. / Aktueller Status der Hüft- und Knieendoprothetik in Deutschland - Ergebnisse einer bundesweiten Umfrage.

BACKGROUND: Total hip and knee replacements are very frequently performed operative procedures in German hospitals. Despite the high number of cases, only few data on treatment procedures of the clinical routine and their impact on postoperative length of stay and clinical outcome are available. The aim of our survey was to gain detailed insights of the treatment procedures in patients scheduled for elective hip or knee replacement in order to extract recommendations for improving patient care. METHODS: In a nation-wide survey, we asked leading physicians of 694 trauma surgery and orthopaedic surgery departments and their corresponding colleagues in the departments of anaesthesia for treatment procedures including the process of patient admission, surgical techniques, postoperative analgesia, discharge management and follow-up. We used a multiple linear regression for analysing variables impacting on the postoperative length of stay. RESULTS: Altogether, 303 replies representing 31.8 % of the contacted hospitals could be evaluated. For hip arthroplasty, the anterolateral approach was most commonly chosen. For knee arthroplasty, the parapatellar approach was most frequently used. Tourniquet and wound drainage (mostly removed on the second postoperative day) were widely used with more than 90 %. The avoidance of wound drainage was associated with a lower postoperative length of stay for patients following total hip or knee replacement. Only 70 % of the German departments followed up their patients after discharge checking especially the range of motion of the artificial joint replacement. CONCLUSION: The treatment procedures for elective hip and knee replacement are very heterogeneous in German hospitals. The quality of the clinical outcome cannot be related to a single procedure; in fact the choice and complementary interaction of interventions are essential for improving patient care. These results provide first important evidence to which extent organisational structures and treatment procedures affect patient care and length of stay. Therefore, the analyses show relevant indications for an optimised standard in patient care.

Quantitative response of nitrifying and denitrifying communities to environmental variables in a full-scale membrane bioreactor.

The abundance and transcription levels of specific gene markers of total bacteria, ammonia-oxidizing Betaproteobacteria, nitrite-oxidizing bacteria (Nitrospira-like) and denitrifiers (N2O-reducers) were analyzed using quantitative PCR (qPCR) and reverse-transcription qPCR during 9 months in a full-scale membrane bioreactor treating urban wastewater. A stable community of N-removal key players was developed; however, the abundance of active populations experienced sharper shifts, demonstrating their fast adaptation to changing conditions. Despite constituting a small percentage of the total bacterial community, the larger abundances of active populations of nitrifiers explained the high N-removal accomplished by the MBR. Multivariate analyses revealed that temperature, accumulation of volatile suspended solids in the sludge, BOD5, NH4(+) concentration and C/N ratio of the wastewater contributed significantly (23-38%) to explain changes in the abundance of nitrifiers and denitrifiers. However, each targeted group showed different responses to shifts in these parameters, evidencing the complexity of the balance among them for successful biological N-removal.

[Differences in the use of health care services--is everything unethical?]. / Unterschiede in der Häufigkeit von Gesundheitsleistungen--ist alles unethisch?

BACKGROUND: Regional differences in the use of health services have been known for several decades. This variability is often overall regarded as undesirable in discussions and ethical-moral argumentation takes place. The description and analysis of this variability and the underlying causes are the subject of numerous investigations in various health care systems. RESEARCH QUESTION: The purpose of this research was to determine which causes can the current health care situation be attributed to and which approaches exist to counteract undesirable variability. MATERIAL AND METHODS: On the basis of a selective literature search, an overview on the identification of variations in surgical care as well as a presentation of possible causes and solution approaches were created. RESULTS: Numerous factors influencing the decision-making process regarding surgical interventions could be identified. These can be patient-related, disease-/intervention-related, physician-related, or system-related and are partially linked with each other. The optimal strategies to minimize variability in health care are still unclear. Scientific evidence to assess the benefit and risk of an intervention, physician's attitudes and preferences as well as the involvement of patients in the decision-making process, however, seem to be important starting points. CONCLUSION: The description of regional differences is an important step toward provision of evidence-based and tailored health care. Differences in health care provision and especially regionally varying high intervention rates are not per se problematic. Whether a patient receives an intervention or not should, however, not depend any more on where he or she lives and which physician is being consulted, but on his or her individual medical condition or preferences. Target group-oriented evidence-based information can help to minimize undesirable variability.

[Minimum thresholds under scrutiny]. / Mindestmengen auf dem Prüfstand.

Minimum volume thresholds for specific medical treatments have been implemented in Germany since 2004. In the last 9 years the catalogue of procedures, which is determined by the Federal Joint Committee, has changed continuously and currently consists of 8 procedures. In this article the basis of decision making for the enrolment in the catalogue of procedures and the determination of minimum volume thresholds are examined. An overview of systematic reviews was published in 2012 outlining the correlation between the volume components and medical outcome. The body of evidence identified is compared to the current regulatory conditions of the Federal Joint Committee.

[Patient safety in health service research]. / Patientensicherheit in der Versorgungsforschung.

Patient safety is an essential quality criterion for good medical care. A main aim of patient safety interventions is the prevention and/or reduction of adverse events. Various approaches are available for this. The multidisciplinarity in health services research as well as the wide range of methods and topics leads to the fact that health services research is predestined to deal with many of the resulting research questions and with respect to the complexity.

Adherence-enhancing interventions for highly active antiretroviral therapy in HIV-infected patients - a systematic review.

OBJECTIVES: The objective of this systematic review was to evaluate the effectiveness of adherence-enhancing interventions for highly active antiretroviral therapy (HAART) in HIV-infected patients in developed countries. METHODS: A systematic literature search was performed (January 2001 to May 2012) in EMBASE, including MEDLINE records, CENTRAL and PsycInfo. Trials meeting the following predefined inclusion criteria were included: adult patients with an HIV infection treated with HAART, an intervention to enhance patient adherence, adherence as the outcome, clinical outcomes, randomized controlled trial (RCT), article written in English or German, patient enrolment after 2001, and trial conducted in World Health Organization (WHO) stratum A. Selection was performed by two reviewers independently. All relevant data on patient characteristics, interventions, adherence measures and results were extracted in standardized tables. The methodological trial quality was evaluated by two reviewers independently. All discrepancies were discussed until a consensus was reached. A meta-analysis could not be performed because of the heterogeneity of trials. RESULTS: In total, 21 trials fulfilled all inclusion criteria. Of 21 trials, only one that examined motivational interviewing for alcohol-dependent patients showed statistically significant results for adherence rates and viral load in favour of the intervention. One trial showed a statistically significant clinical effect of the intervention; however, inconsistent results were presented for adherence depending on the underlying adherence definition. The results of the remaining 19 trials were not statistically significant or were conflicting for adherence and/or clinical outcomes. However, the methodological trial quality was low. CONCLUSIONS: It is not possible to definitively assess the effectiveness of adherence-enhancing interventions. However, it appears that most adherence interventions have no effect.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS: A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS: A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS: Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Prevalence and molecular epidemiology of meticillin-resistant Staphylococcus aureus in nursing home residents in northern Germany.

Nursing home residents are a population at risk for carrying meticillin-resistant Staphylococcus aureus (MRSA). To better guide infection control and healthcare network initiatives, we investigated the point prevalence and molecular epidemiology of MRSA colonisation among nursing home residents in Brunswick, northern Germany. Among the 32 participating nursing homes of the available 34 in the region, 68% of residents (1827 of 2688) were screened for nasal and/or wound colonisation. A total of 139 residents (7.6%; 95% confidence interval: 6.4-8.8%) were identified as MRSA positive, almost six-fold more than the 24 MRSA carriers (0.9%) expected according to the nursing homes' pre-test information. Although known risk factors including urinary tract catheters, wounds, preceding hospital admission, and high grade resident care were confirmed, none was sensitive enough to be considered as the sole determinant of MRSA carriage. spa typing revealed that more than 70% of isolates belonged to the Barnim strain (ST-22, EMRSA-15, CC22) typical for hospital-acquired MRSA in northern Germany. There was no evidence for the presence of community-acquired or livestock-associated S. aureus strains. These data show that in northern Germany MRSA has spread from the hospital environment to other healthcare institutions, which must now be regarded as important reservoirs for MRSA transmission.