Whipple's procedure plus intraoperative pancreatic duct occlusion for severe chronic pancreatitis: clinical, exocrine, and endocrine consequences during a 3-year follow-up.

The present investigation provides follow-up data (up to 36 months) of exocrine and endocrine pancreatic function, inflammatory activity, pain, and body weight in 23 chronic pancreatitis patients submitted to Whipple's procedure plus intraoperative Ethibloc occlusion of the remaining pancreatic duct system between January 1983 and February 1984. Clinically, Whipple's procedure plus intraoperative pancreatic duct occlusion resulted in almost complete and continuous cessation of pain as well as significant (p less than 0.05) increase in body weight. With regard to exocrine pancreatic function (Secretin-Pancreozymin test, plasma amino acid consumption test, Pankreolauryl test, fecal chymotrypsin determination), intraoperative pancreatic duct occlusion was shown to induce high-grade insufficiency and thus exocrine parenchymal atrophy in all patients. Simultaneously, the inflammatory process (represented by serum levels of trypsin, lipase, and pancreatic isoamylase) was terminated in all 23 patients. Endocrine pancreatic function, evaluated by serum levels of insulin and C-peptide measured under fasting conditions and subsequent maximal combined beta-cell stimulation as well as corresponding integrated hormone releases, was reduced by partial pancreas resection by about 50%, while there was no further impairment during the 36-month follow-up period in consequence of additional intraoperative pancreatic duct occlusion. Altogether, Whipple's procedure plus intraoperative Ethibloc occlusion of the residual pancreatic duct system seems suitable for termination of the inflammatory process and thus preservation of residual endocrine pancreatic function in chronic pancreatitis.

[Providing practice-oriented social medicine in medical education--a lecture concept]. / Vermittlung praxisorientierter Sozialmedizin im Medizinstudium--ein Vorlesungskonzept.

This article outlines the concept on which lectures in Social Medicine offered at the Institute for Occupational, Social and Environmental Medicine of the University of Erlangen-Nuremberg for the past three years are based. In addition to the fundamentals of Social Medicine, in our lectures we impart practical and career-oriented knowledge of the social security system and socio-medical diagnostics and how to compile medical assessments. We thus try to make it easier for the prospective physicians to later give help and advice to their patients about gaining social welfare benefits. Additionally we instruct the students in the basics of preventive medicine and the economics of medical activity. Consequently they recognise the importance of these topics for their later work in a clinic or as general practitioners. Our concept is in accordance with the intended modification of the German legislation governing the permission of doctors to practise medicine. Improvements are planned which will gear medical training better with the requirements of a medical practitioner as well as offering more intensive instruction in preventive medicine and the economy aspects of health care.

[Social medicine for general practice--initial evaluation of a practice relevant teaching concept]. / Sozialmedizin für den ärztlichen Alltag--erste Evaluation eines praxisbezogenen Lehrkonzeptes.

The form and contents of lectures in social medicine as part of medical studies have caused controversy for some time. In the winter term of 1992/93 a new concept of main lectures in social medicine oriented to medical practice was introduced at the Friedrich-Alexander University of Erlangen-Nuremberg. In particular, these lectures deal with primary medical topics relevant to social medicine, interspersed with case examples, visits to patients and excursions. As a means for students to express critism of the lectures offered, at the end of the summer term of 1994 an evaluation of university tuition was first carried out using an anonymous, standardised questionnaire. Fifty-five of the 179 students registered for the lecture, studying in terms 7 to 12, took part in the survey. Among the regular lecture-goers there was a high acceptance of the concept and presentation of the lecture contents in 75% of those asked. This was not found to be dependent on sex or on how far the students had progressed in their studies. Despite interest in social medicine in 80% of cases, for the vast majority of those asked the subject does not yet play any role as a future field of research or occupation. While 60% of the participants in the questionnaire accorded sociomedical topics an important rank in the study of human medicine, 35% regarded an independent chair for social medicine, against the background of over-full timetables, as unnecessary. On the other hand, the practical relevance and usefulness of what is taught was regarded by 72% as high. Despite a general lack of enthusiasm for lectures the practically-oriented approach has obviously succeeded in making clear to the students the importance of sociomedical topics in routine medical practice.

Development and status of social medicine in Germany.

The current status of scientific social medicine in the Federal Republic of Germany is presented against the background of historical development. Ideas differ when it comes to identity, academic institutionalisation, the main emphasis of work, the syllabus and future tasks. The heterogenic diversity of the subject is emphasised by the lack of any generally accepted definition. There is a current tendency to regard social medicine exclusively as population medicine rather than more generally as the interaction between disease/health, general social system and the individual. Clinical practical social medicine, epidemiology, health system research/health economy, and public health can be distinguished as important occupational fields. Acquiring the additional title in social medicine is widely recognised as the necessary further training. However, the discussion about improving the training in social medicine at German universities is still causing much controversy. Secure anchoring within the canon of medical subjects is of particular importance regarding the totality of the subject and its future in medical faculties.

[Educational and occupational expectations of tomorrow's generation of physicians]. / Ausbildungs- und Berufserwartungen der Arztegeneration von morgen.

As a result of increased competition on the market for young doctors and the continuing debate on the kind and extent of reforms planned for university courses, it is becoming increasingly difficult for students of human medicine to plan their occupational future. Against this background, the aim of this study was to evaluate the expectations regarding training and occupation of students embarking on their course and to carry out extensive analysis of the results taking socio-demographic variables into consideration. The study was designed as a survey using standardised, anonymous questionnaires, which took place at the beginning of two terms (summer term 95 and winter term 95/96) and was carried out with students attending the lectures on "Occupational opportunities". Sociodemographic factors, the student's educational history, expectations of university training, estimation of occupational opportunities and the medical discipline the student hoped to work in, were all taken into consideration. 212 (female: 110/male: 102) (78%) of the 271 students registered for the course took part in the survey. All the students were in their first term. The median age was 20 (range 18-32). 55% of those taking part in the survey came from academic families, 15% with doctors in the family. On the average, 12 months had elapsed since leaving school and starting university. 21% had taken up another course of study before turning to medicine, 20% had already completed some other occupational training, in particular in non-medical health services. For the great majority (97%) the quality of the course is very important and great emphasis is laid on how knowledge is conveyed in lectures. Correspondingly, 86% regarded personal contact with the lecturers as important. Two-thirds of those taking part in the survey had heard of the concept "problem-oriented learning", 91% could imagine having part of their training abroad. Every second student regarded his own occupational changes skeptically, and 50% of first-term students could imagine their occupational futures outside the classical occupational fields in clinics and general practice. Qualified teaching with personal contact with the lecturers is regarded as particularly important despite the general complaint of mass teaching and anonymity. Bearing this in mind, future reforms should, in particular, aim at strengthening personnel and financial resources. With recognisable occupational flexibility already apparent at the beginning of medical studies, more information should be provided on training for alternative medical occupations.

[Ring trials in expert assessment--a practicable procedure for quality assurance?]. / Ringversuche in der Begutachtung--ein praktikables Verfahren zur Qualitätssicherung?

An intercomparison programme for expert assessment was carried out as part of quality assurance for the public health departments in Bavaria. A file documenting medical diagnoses and reports of a patient was presented to medical doctors in a district of Bavaria and in the Academy for Public Health Services in Munich for assessment. The participation was voluntary and anonymous. The case presented was an obese man who wanted to become a civil servant. The doctors were asked to give an expert assessment of his health. Four criteria were used to evaluate the assessments: the assessment, its conclusiveness, the documentation and the epicrisis. 54 out of 100 doctors asked participated. On average all criteria were adequately fulfilled. This paper discusses the advantages and disadvantages of an intercomparison programme for expert assessments in the field of social medicine. Our results show that an intercomparison programme for expert assessments could form part of quality assurance.

[Effectiveness and tolerance of genetically engineered vaccines for hepatitis B--a comparative study]. / Wirksamkeit und Verträglichkeit gentechnologisch hergestellter Impfstoffe gegen Hepatitis B--eine vergleichende Gegenüberstellung.

The two hepatitis B vaccines produced by gene technology that are presently available in Germany, were compared in respect of efficacy and tolerance in 80 nurses (female and male) who were under training. Both vaccines proved to be highly effective and well tolerated. In respect of the achieved anti-HBs titer, however, the two vaccines differed significantly from each other. Using the 20 micrograms HBs antigen, the antibody titers obtained were higher by a factor of 1.8. The article gives update recommendations in respect of hepatitis B vaccination as a preventive measure in risk groups.

[Internal hazardous substance burden of persons from various regions of origin--studies of lead, mercury, arsenic and cadmium exposure]. / Innere Schadstoffbelastung von Personen aus verschiedenen Herkunftsregionen--Untersuchungen zur Blei-, Quecksilber-, Arsen- und Cadmiumexposition.

AIM OF THE STUDY: The aim of this study was to investigate the concentration of metals of environmental-medical relevance in biological materials in persons seeking asylum with regard to their country of origin. COLLECTIVE AND METHOD: During medical examination after entry into Germany of persons seeking asylum, samples were taken for determination of the following biological monitoring parameters: lead in blood, and arsenic, cadmium and mercury in urine. A total of 103 males were investigated (13 from former Yugoslavia, 29 from the former USSR, 33 Africans and 28 Asians) ranging from 16 to 53 years of age (median 27 years). 34 male Germans without occupational exposure to these substances and a similar age structure (age 25-36 years; median 26 years) served as a control group. RESULTS: The countries of origin had a significant influence on all the biological monitoring parameters investigated. The mean blood lead concentration in the Asians of 75.4 micrograms/L was the highest level found, while the lowest concentration of 38.0 micrograms/L was measured in the German controls. Also the level of arsenic excreted in the urine was on average much higher in the persons seeking asylum than in the German controls. In the Africans a mean level of 9.7 micrograms/g creatinine was reached. The Germans had the lowest arsenic concentrations in urine of 5.3 micrograms/g creatinine. There were, however, considerable interindividual fluctuations, which are probably due to oral uptake of arsenic compounds as a result of eating seafoods. The highest mean concentration of mercury excreted in urine was found in the German controls. Values of 0.9 microgram/g creatinine were determined. The men seeking asylum from former Yugoslavia had significantly higher values than other groups for cadmium excreted in urine. The median of 0.6 microgram/g creatinine was nearly three times as high as found in the Germans. CONCLUSIONS: For all parameters investigated, with the exception of mercury, higher internal exposure was found in the persons seeking asylum than in the German controls. This may be due to individual life style, dietary habits or environmental conditions in the country of origin. For clinical environmental medicine, the 95th percentile, as the upper limit of the reference range, can only be regarded as an orientation aid for classifying the exposure to hazardous substances of an individual compared to other persons from the same environment.

[Significance of social medicine in the medical contract office]. / Zur Bedeutung von Sozialmedizin in der vertragsärztlichen Praxis.

In the German statutory social security system, the necessity of long-term care for chronically ill persons with multi-morbidity and reduced performance has made the socio-medical management of illness and its consequences an important characteristic of primary medical activity. In routine practice a discrepancy between the practical demands and social-medical insights has often been observed. With this in mind, the aim of our pilot study was to systematically collect data on the state of the art and attitudes towards the relevant spheres of work in a defined group of physicians and analyse this data. The study was carried out in the form of a voluntary questionnaire within the medical association (Arztlicher Kreisverband-AKV) in the area of Erlangen-Hochstadt. The database was a computer-processible, anonymous questionnaire with which first of all general socio-demographic and activity-related data was collected. The following 10 questions included, in addition to an estimation of the participants' own socio-medical knowledge, questions on the general status of socio-medical knowledge and how the individual gained this knowledge and the importance of socio-medical themes in routine practice. The data was evaluated using descriptive statistics in the form of exploratory data analysis. Of the 320 physicians registered at the time of the investigation (4/96), 89 (31 female doctors, 58 male doctors) sent back a questionnaire that proved useful (returns: approx. 28%). Significant sex-related or specialisation-related differences with regard to participation in the study were not observed. The ratio of female to male doctors and of general practitioners to specialists in the study collective corresponded more or less to the distribution in the total group. The participants had a median age of 41 years (minimum 31, maximum 71) and had been in practice for a median of 11 years (maximum 43 years, minimum 1 year). 36% were general practitioners, 64% specialists. 97% regarded sound knowledge in socio-medicine as essential for doctors wishing to set up practice. 70% regarded their own knowledge of socio-medicine as being in need of improvement. 85% regarded their knowledge as having been insufficient at the start of their medical careers. With regard to doctors gaining socio-medical competence, routine practice and their own autodidactic capabilities played an important role. 84% would like to see increased teaching of socio-medical themes during specialist training courses. For over 70% socio-medicine is a part of medical studies as a subject in its own right. The content and aims of New Public Health were known to 45%. Among the areas of socio-medical work the care of chronically ill persons was given highest priority. Preventive measures were also accorded high relevance by the participants, and they were particularly interested in preventive medicine. Taking into consideration conceptional problems (e.g. the size of the random sample/selection effects) it was found that: despite many years of practice in some cases, doctors feel there is a deficit in their socio-medical knowledge--prcctical knowledge is mainly gained autodidactically during routine practice ("learning by doing"). There is a clear wish for increased consideration of socio-medical themes in specialist training courses. The great importance of socio-medical tasks as part of medical practice is undeniable to the study collective. The results underline the necessity for improved communication and co-operation between doctors involved in primary medical activity and in socio-medicine.

Internal exposure to hazardous substances of persons from various continents: investigations on exposure to different organochlorine compounds.

UNLABELLED: The aim of the study was to investigate the concentration of organochlorine compounds of environmental-medical relevance in biological materials from refugees with regard to their countries of origin and to compare these concentrations with the internal exposure of the German general population. METHODS: During medical examination after entry to Germany specimens could be taken from the refugees to determine the following parameters of biological monitoring: 1,1-dichloro-2,2-bis(-chlorophenyl)-ethylene (DDE-P), polychlorinated biphenyls (PCB-P), pentachlorophenol (PCP-P) and the beta- and gamma-hexachlorocyclohexanes (beta-HCH-P, gamma-HCH-P) in plasma and the excretion of chlorophenols (4-MCP-U, 2,4-DCP-U, 2,5-DCP-U, 2,4,5-TCP-U, 2,4,6-TCP-U, 2,3,4,5-TeCP-U, 2,3,5,6-TeCP-U) in urine. One hundred and three men (13 from former Yugoslavia, 29 from the former USSR, 33 Africans and 28 Asians) ranging from 16 to 53 years of age (median 27 years) were investigated. Thirty four male Germans without occupational exposure to these substances and a similar age structure (age 25-36 years; median 26 years) served as a control group. RESULTS: A much higher level of internal exposure was found for the DDT metabolite, DDE, for those persons from Asia, the former USSR and Africa compared with the German controls (medians: 16.9 micrograms/l, 11.9 micrograms/l and 10.9 micrograms/l) and 1.1 micrograms/l). The levels of PCB in plasma were below the detection limit in the majority of refugees. In the control group, however, the PCB levels were higher (sigma PCB; median: 2.1 micrograms/l, maximum: 13.3 micrograms/l). The highest beta-HCH concentrations, up to a maximum of 15.5 micrograms/l, were detected in the persons from the former USSR and Asia. The five groups do not differ with regard to internal exposure to PCP and gamma-HCH. Renal excretion of 4-MCP, 2,4-DCP and TeCP did not differ between the five groups. The concentrations of 2,5-DCP in urine, however, were significantly lower in the Germans than the refugees from the four regions investigated. The median for the Germans was 3.0 micrograms/l and for the refugees between 10.8 and 14.7 micrograms/l. Also the levels of 2,4,5-TCP and 2,4,6-TCP in urine were lower in the German controls than in the men from the former USSR, Africa and Asia. CONCLUSIONS: Organochlorine compounds exist worldwide due to their extensive use. There are, however, regional differences for the various substance groups, which during biological monitoring are seen in the different background exposures of the general population. Particularly characteristic are markedly higher levels of DDE in plasma from the refugees compared with the German population.