[Methods for organisational health services research]. / Methoden für die organisationsbezogene Versorgungsforschung.

On 1 July 2009, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned below and published in this journal (Gesundheitswesen 2009; 71: 505-510). The focus of this part of the Memorandum III "Methods for health services research" is on the questions and methods of organisational health services research. In a first step, we describe the central questions which are at the core of organisational health services research. In a second step, we describe the methodological standards and requirements with regard to a) sampling, b) measurement and c) research design. We present a phase model for complex intervention trials. This model allows to conduct high quality organisational health services research, to integrate different methods of social research and to show in which phase they are of special importance.

Gastric cancer after laparoscopic adjustable gastric banding.

A 63-year-old woman with BMI 46 underwent laparoscopic gastric banding. In the standardized follow-up after 14 and 24 months, the GI series and gastroscopy showed no pathological signs. The patient had hematemesis 32 months after gastric banding, followed by symptoms of obstruction, for which a laparotomy was performed. At operation, peritoneal carcinomatosis due to gastric cancer was found. Symptoms after bariatric procedures can be similar to symptoms of gastric or esophageal cancer. We believe that yearly postoperative gastroscopy is indicated to exclude pathological changes.

[Quality certificate "Geriatrie" from the care scientist's perspective]. / Qualitätssiegel Geriatrie aus pflegewissenschaftlicher Perspektive.

The current version of the quality certificate "Geriatrie" pretends to describe the specific content of high quality care in geriatric clinics. Besides methodological deficits, it also has deficits in the systematic choice of the quality items, including a lack of the perspectives of patients and their relatives. Thus, the certificate is actually an additional piece of paper with legitimatory function than an instrument to give quality orientation to older patients and their relatives or to insurance companies which pay for the care. Further development and the clarification of its aims are suggested.

Epiphrenic esophageal diverticulum after laparoscopic placement of an adjustable gastric band.

A morbidly obese woman (BMI 56 kg/m2) in 1998 underwent laparoscopic placement of an adjustable gastric band by the perigastric approach. 5 years later, she complained of reflux and weight regain. X-ray with contrast revealed pouch dilatation. She subsequently underwent a laparoscopic revision including retrocardia band replacement using the pars flaccida technique. During the further course, an epiphrenic diverticulum was diagnosed. Because of danger of perforation of the large thin-walled diverticulum and the esophageal motility disorder, the band was laparoscopically removed and the diverticulum was resected via a transhiatal approach. This case presents a very rare complication after placement of a gastric band and its successful management.

Rhabdomyolysis after biliopancreatic diversion with duodenal switch.

Rhabdomyolysis is an uncommon event in bariatric surgery. It can be caused by ischemia, crush injury, alcohol ingestion and drug intake, and as a consequence renal failure can develop. A few reports indicate that patients undergoing bariatric surgical intervention are at risk for rhabdomyolysis. A super-obese male (BMI 52 kg/m2) is reported, who underwent laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS). Operative time was 265 minutes, and the BPD/DS operation was uneventful. Post-operatively, the patient complained of pain in both hips and the left shoulder, and suffered oliguria. He was treated with fluids (isotonic saline), bicarbonate, and mannitol. Despite this, he developed renal failure, which subsequently required hemodialysis. The patient died from arrhythmia and cardiac arrest on the 8th postoperative day. Obese patients undergoing bariatric surgery are at risk of rhabdomyolysis. Prolonged compression of the muscles during the surgical intervention, in long laparoscopic procedures, predisposes to this complication.

[Band migration. A late complication of gastric banding]. / Bandmigration. Eine Spätkomplikation nach "Gastric Banding".

BACKGROUND: Adjustable silicone gastric banding is an effective and safe treatment for morbid obesity. Migration of the band through the stomach wall is a long-term complication. The causes, clinical symptoms, timing, and incidence of band migration have not yet been investigated. METHODS: We report our experience over 9 years. Between February 1995 and February 2004, we performed adjustable silicone gastric banding in 161 patients, with follow-up of about 90.5% of cases. Mean follow-up time was 60.4 months. Cases of erosion were studied retrospectively. RESULTS: Eight patients (4.9%) developed band migration. In seven, the migration occurred between 30 and 86 months after band implantation. In one case, the migration occurred 10 months after laparoscopic repositioning of the band to avoid pouch dilatation. In all cases, the bands were removed. CONCLUSION: Band migration is a late complication after gastric banding that requires band removal. Various symptoms and complications of band migration influence the kind of band removal. The causes of band migration and its treatment are discussed.

Ultrastructural analysis of chromatin in meiosis I + II of rye (Secale cereale L.).

Scanning electron microscopy (SEM) proves to be an appropriate technique for imaging chromatin organization in meiosis I and II of rye (Secale cereale) down to a resolution of a few nanometers. It could be shown for the first time that organization of basic structural elements (coiled and parallel fibers, chromomeres) changes dramatically during the progression to metaphase I and II. Controlled loosening with proteinase K (after fixation with glutaraldehyde) provides an enhanced insight into chromosome architecture even of highly condensed stages of meiosis. By selective staining with platinum blue, DNA content and distribution can be visualized within compact chromosomes as well as in a complex arrangement of fibers. Chromatin interconnecting threads, which are typically observed in prophase I between homologous and non-homologous chromosomes, stain clearly for DNA. In zygotene transversion of chromatid strands to their homologous counterparts becomes evident. In pachytene segments of synapsed and non-synapsed homologs alternate. At synapsed regions pairing is so intimate that homologous chromosomes form one filament of structural entity. Chiasmata are characterized by chromatid strands which traverse from one homolog to its counterpart. Bivalents are characteristically fused at their telomeric regions. In metaphase I and II there is no structural evidence for primary and secondary constrictions.

[Acute cholecystitis--primary laparoscopic procedure]. / Akute Cholecystitis--primär laparoskopisches Vorgehen.

The role of laparoscopic cholecystectomy on patients with histologically confirmed acute cholecystitis is still controversial. From January 1992 to December 1996, 228 cholecystectomies were performed for acute cholecystitis and a total of 104 patients were operated on conventionally and 124 patients underwent laparoscopic surgery. In a prospective study we compared the conventional with the laparoscopic technique. The results indicated that in 19 patients (15.3%) treated initially with the laparoscopic technique, a switch to laparotomy was required. The operating duration was lower for conventional cholecystectomy (75 min versus 95 min). However, surgical and nonsurgical complication rates were similar in both groups. The period of hospitalization was shorter in laparoscopic operations. According to these results we believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure. The patients will benefit from the advantages of laparoscopic surgery without increased morbidity.

[Strategies for coping with complex problems. Importance of an integrated practice to the quality of life in patient care]. / Strategien zur Bewältigung komplexer Problemlagen. Zur Bedeutung einer integrierten Versorgungspraxis für die Betreuungsqualität pflegebedürftiger Patienten.

Due to the demographic shift, increasing care needs of elderly and chronically ill people have growing impact on the health care services. With complex needs to meet, the quality of life of patients depends on multiple factors, of which the continuity of care plays an important role. Integrated care requires the exchange of information and close coordination on the concept of care between all participants in the care process. Yet, collaborative care is often seriously jeopardized by lack of knowledge about the concepts, scope of action and requests of the involved health professionals and services. Information on the past and present health state and on self care resources are prerequisites for adequate rehabilitation efforts that are patient-oriented and of high quality. To make sure that interventions promote or stabilize the quality of life, the participation of the client is inevitable in all stages of the process of care planning and coordination. The results of a research project concerning cooperative quality improvement carried out at the Agnes Karll Institute for Nursing Research stress these assumptions.

[Music therapy and internal medicine]. / Musiktherapie und innere Medizin.

Since December 1988 the district hospital of the Oberwallis hosts the 4 year project "Music-Therapy in Internal Medicine" under the scientific guidance of Dr. H. H. Decker-Voigt, director of the Institute of music therapy of the musical academy Hamburg. This therapy can be described as a form of psychotherapy which uses the medium music with its particularities as an adjunct for treatment. The different levels of action of music, a functional and a regressive one and their respective importance for music therapy are described first. An introduction to the two forms of music therapy, the receptive and the active with their respective particularities follows. Indications for music therapy are by large not disease-specific but depend on the assessment of the importance of psychic components in somatic disease. Coping with disease, psychosocial integration and promotion of positive resources or self-healing potential are regarded as indications for music therapy. Music therapy is not indicated when the patient is not motivated or his stay at the hospital is shorter than 2 weeks. We offer a music therapy to all patients in whose illness, according to our evaluation, emotional and psychic factors play an important role and to those patients with functional disorders on whom we would like to learn more by the psychoanalytic possibilities of music therapy. According to our experience music therapy is well suited as an adjunct in many diseases in internal medicine and represents an enrichment of our therapeutic possibilities.

[The concern with nursing research of future graduate nurses]. / Der Umgang mit Pflegeforschung in den zukünftigen Berufsfeldern der Absolventlnnen der Pflegestudiengänge.

The concern with nursing research in the future work of nurse graduates. Expectations from the viewpoint of the nurse researcher. Keeping in mind the concerns which occupy nurse researchers now and in the future, expectations are raised of the graduates of degree programmes in nursing science which are now also being established in the Federal Republic of Germany. This takes into account the structurally determined areas of self determined action in new fields of professional practice. Nurse graduates will be seen as "change agents" in their future areas of work and will have three essential aspects of involvement with nursing research: 1. they themselves will conduct research 2. they will receive, put into practice and transmit results of nursing research 3. they will initiate and commission nursing research projects. According to the broad topics of nursing research, requirements for nurses to act as professionals in their new working fields are formulated referring to the given structural conditions in Germany.

[Electronic data processing in nursing: specific needs related to rostering programs in nursing]. / EDV in der Krankenpflege: Pflegespezifische Anforderungen an Dienstplanprogramme.

Electronic data processing is taking over in the nursing domain in German hospitals. This is due, not only to the fact that computer hard- and software are getting better and cheaper, but also due to the legal demands of the new health legislation. Neither nurse-managers nor the nurses themselves are adequately prepared for this technical innovation or its implications. The dominant influence of management-interests leads to the danger that criteria relevant to the content of nursing fail to be taken into account. Consequently the quality of care may suffer. The Ministry for environment, energy, youth, family and health has commissioned the Agnes Karll Institute for Nursing Research to identify software features specific for the requirement of nurses. The study focuses on rostering programs for nursing staff allocation, in relation to the workload and on conditions which have to be met to make software nurse-friendly. Selected, important results are reported.

[A new documentation system to simplify a patient-centered nursing process in ambulatory care and in long-term care in a nursing facility]. / Neues Dokumentationssystem zur vereinfachten patientenbezogenen Umsetzung des Pflegeprozesses in ambulanter und stationärer Langzeitpflege. Kurzbericht zu einem Forschungsprojekt.

In 1995/96, the new care insurance was introduced in Germany, regulating longterm nursing care in the community and in nursing homes. In order to implement the new legislative regulations the Federal Ministry of Labour and Social Affairs commissioned the AKI Institute to develop adequate patient centered quality standards for care planning and documentation. On the results of a multimethod survey a new documentation system was developed that enables a new patient centred approach, putting the client's habits and his or her view of health problems in the centre of nursing action. Traditional formats were altered to facilitate the documentation of the nursing process. The results show clearly that care is now more orientated towards a patient's autonomy and wishes. On the whole, the documentation is clearer and more systematic.

[Patient-oriented quality assurance. Information and cooperation of the health services as a condition for integrated care]. / Patientenorientierte Qualitätssicherung. Information und Kooperation der Gesundheitsdienste als Voraussetzung für eine integrierte Versorgungspraxis.

The increasing care needs of the elderly and chronically ill have a growing impact on health care services. With complex needs to meet, the patient's quality of life depends on multiple factors, of which the continuity of care plays an important role. Information on the past and present health state and on self care resources are prerequisites for adequate rehabilitation efforts that are patient-oriented and of high quality. Institutionally induced "cascade episodes of incompetence" (Ulmer & Saller, 1994) have to be avoided. To make sure that interventions promote or stabilize the quality of life, the participation of the client is crucial in all stages of the process of care planning and coordination. Integrated care requires the exchange of information and close coordination on the concept of care between all participants in the care process. Yet, collaborative care is often seriously jeopardized by lack of knowledge about the concepts, scope of action and requests of the involved health professionals and services. At the Agnes Karll Institute of Nursing Research an action research project aiming at cooperative quality assurance was carried out. It became obvious that there is a large amount of intersectoral knowledge necessarily needed by all professionals and services to ensure seamless professional care. But often they have no access to the information needed. Therefore a client's accompanying booklet was developed to pass on basic information. It is kept by the client and shall be used and filled out by them, their relatives and the different health professionals and health care services involved.

[Using interaction-intensive therapeutic nursing measures and "home remedies" in nursing care. An explorative study as a plea for integrated nursing practice]. / Der Einsatz von interaktionsintensiven pflegetherapeutischen Massnahmen und von "Hausmitteln" in der Pflege. Eine explorative Studie als Plädoyer für eine integrierte Pflegepraxis.

BACKGROUND: Until today there existed no major studies about the wide range of currently utilized methods or potential sociodemographic and institutional influences on utilization despite an immense interest among nurses in alternative nursing methods (in this study referred to as home remedies). METHODS: In this study, from standardized questionnaires with a convenience sample of three different settings of nursing practice, i.e. acute-care, nursing homes, and home health care were analyzed using the statistical program SPSS. RESULTS: Our analysis showed that a wide range of traditional home remedies is being utilized, e.g. application of heat and cold or herbal infusion (herbal teas). Furthermore, lay approaches such as aromatherapy were also commonly used. The statistical analysis revealed complex influences of age, duration of nursing practice and institutional setting in the utilization of home remedies. CONCLUSION: There is need for more systematic studies to further examine the alternative methods or home remedies so popular among nurses and their patients. Regarding a more consistent naming of the variety of different methods coming from naturopathy, folk and lay medicine, the authors suggest the term "integrative nursing care".