[Certification of a University Department of Otolaryngology according to DIN EN ISO 9001:2008]. / Zertifizierung einer Universitäts-Hals-Nasen-Ohren-Klinik nach DIN EN ISO 9001:2008.

INTRODUCTION: Quality management (QM) is a control tool for the implementation of a wide range of organizational measures aimed at achieving process orientation and process optimization. The organizational framework for these measures can be structured to fulfill the requirements of certification to the DIN EN ISO 9001 standard. The objective was to implement this tool within a university otorhinolaryngology department. MATERIAL AND METHOD: After drawing up a project plan, the measures required to fulfill the audit requirements were put into practice by a QM core team, which included employees from four areas: healthcare, research, nursing and teaching. RESULTS: The measures carried out resulted in the achievement of certification, provided that annual surveillance audits are performed. DISCUSSION: The attainment of the certificate requires continuous fulfillment of the required standards. Future requirements, such as the demands placed on knowledge management, necessitate further appropriate measures.

[Tumor of the mesosalpinx with unclear differentiation]. / Tumor der Mesosalpinx mit unklarer Differenzierung.

Female adnexal tumors of probable Wolffian origin (FATWO) are rare tumors, which are mostly localized in the broad ligament or the mesosalpinx. They show high intratumor and intertumor variability of histological patterns (e.g. solid, tubular, cribriform and cystic) with usually unremarkable cellular and nuclear morphology and a lower mitotic rate. In general, they behave in a benign fashion but there are rare cases with malignant transformation, so that careful examination and surveillance are necessary. Differential diagnoses include Sertoli-Leydig cell tumors, metastasized endometrioid carcinoma and the FATWO-like variant of the endometrioid carcinoma of the fallopian tubes. The FATWOs express pancytokeratin, CD10, vimentin, calretinin and inhibin A. Estrogen and progesterone receptors are expressed in a minority of cases, whereas epithelial membrane antigen (EMA) is not detectable.

A nationwide survey on bariatric surgery in Germany--results 2005-2007.

BACKGROUND: Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated. RESULTS: During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall). CONCLUSION: As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

Results of sleeve gastrectomy-data from a nationwide survey on bariatric surgery in Germany.

BACKGROUND: Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at the Otto-von-Guericke-University Magdeburg. The objective of this study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. METHODS: Data collection occurred prospectively in an online data bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy procedure were evaluated with a focus on operative details and complication rates. RESULTS: The total study cohort contains 3,122 patients. From January 2006 to December 2007, 144 sleeve gastrectomy procedures were performed in the 17 hospitals participating in the study. The mean body mass index (BMI) of all patients was 48.8 kg/m(2). The BMI of patients undergoing SG was 54.5 kg/m(2). In total, 73.8% of the patients were female and 26.2% of the patients were male. There were no significant differences between patients undergoing SG. The general complication rate after SG was 14.1%, and the surgical complication rate was 9.4%. The postoperative mortality rate was 1.4%. CONCLUSIONS: The complication rate during the first 2 years after SG in Germany is similar to that published in the literature. In order to improve the quality of bariatric surgery, an evaluation of data from a German multicenter trial is necessary to evaluate the position of SG in the bariatric algorithm.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature.

BACKGROUND: Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI). RESULTS: Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day. CONCLUSION: In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

The influence of diffuse pollution on groundwater content patterns for the groundwater bodies of Germany.

Commissioned by Germany's Working Group of the Federal States on Water Problems (LAWA) the authors developed a procedure to define natural groundwater conditions from groundwater monitoring data. The distribution pattern of a specific groundwater parameter observed by a number of groundwater monitoring stations within a petrographically comparable groundwater typology is reproduced by two statistical distribution functions, representing the "natural" and "influenced" component. The range of natural groundwater concentrations is characterized by confidence intervals of the distribution function of the natural component. The applicability of the approach was established for 17 hydrochemical different groundwater typologies occurring throughout Germany. Based on groundwater monitoring data from ca. 26,000 groundwater-monitoring stations, 40 different hydrochemical parameters were evaluated for each groundwater typology. For all investigated parameters the range of natural groundwater concentrations has been identified. According to the requirements of the EC Water Framework Directive (article 17) (WFD) this study is a basis for the German position to propose criteria for assessing a reference state for a "good groundwater chemical status".

Determination of exposure due to mobile phone base stations in an epidemiological study.

To investigate a supposed relationship between exposure by mobile phone base stations and wellbeing, an epidemiological cross sectional study is carried out within the German Mobile Telecommunication Research Program. In a parallel project, a method for the classification of electromagnetic exposure due to mobile phone base stations has been developed. This is based on the results of measurements of high frequency immissions in the interior of more than 1100 rooms and at outdoor locations, the calculation of the emissions of mobile phone antennas under free space propagation conditions and empirically determined transmission factors for the propagation of electromagnetic waves in different types of residential areas for passage of walls and windows. Standard tests (correlation-test, kappa-test, Bland-Altman-Plot, analysis of sensitivity and specificity) show that the method for computational exposure assessment developed in this project is applicable for a first classification of exposures due to mobile phone base stations in epidemiological studies.

Some physico-chemical parameters that influence proteinase K resistance and the infectivity of PrPSc after high pressure treatment.

Crude brain homogenates of terminally diseased hamsters infected with the 263 K strain of scrapie (PrP Sc) were heated and/or pressurized at 800 MPa at 60 degrees C for different times (a few seconds or 5, 30, 120 min) in phosphate-buffered saline (PBS) of different pH and concentration. Prion proteins were analyzed on immunoblots for their proteinase K (PK) resistance, and in hamster bioassays for their infectivity. Samples pressurized under initially neutral conditions and containing native PrP Sc were negative on immunoblots after PK treatment, and a 6-7 log reduction of infectious units per gram was found when the samples were pressurized in PBS of pH 7.4 for 2 h. A pressure-induced change in the protein conformation of native PrP Sc may lead to less PK resistant and less infectious prions. However, opposite results were obtained after pressurizing native infectious prions at slightly acidic pH and in PBS of higher concentration. In this case an extensive fraction of native PrP Sc remained PK resistant after pressure treatment, indicating a protective effect possibly due to induced aggregation of prion proteins in such buffers.

A procedure to define natural groundwater conditions of groundwater bodies in Germany.

Commissioned by Germany's Working Group of the Federal States on Water Problems (LAWA) the authors developed a procedure to define natural groundwater conditions from groundwater monitoring data. The distribution pattern of a specific groundwater parameter observed by a number of groundwater monitoring stations within a petrographically comparable groundwater typology is reproduced by two statistical distribution functions, representing the "natural" and "influenced" components. The range of natural groundwater concentrations is characterized by confidence intervals of the distribution function of the natural component. The applicability of the approach was established for four hydrochemically different groundwater typologies occurring throughout Germany. Based on groundwater monitoring data from 7920 groundwater monitoring stations, 15 different hydrochemical parameters were evaluated for each groundwater typology. For all investigated parameters the range of natural groundwater concentrations has been identified. According to the requirements of the EC Water Framework Directive (article 17) (WFD) this study is a basis for the German position to propose criteria for assessing a reference state for a "good groundwater chemical status".

Molecular characterization of myosin IB from the lower eukaryote Entamoeba histolytica, a human parasite.

The complete amino acid sequence of the Entamoeba histolytica unconventional myosin IB (Eh-myosin IB) is reported. Sequencing of overlapping cDNA fragments reveals a single open reading frame which predicts a 130 kDa protein of 1049 aa. Eh-myosin IB presents the three characteristics domains of myosins I subclass 1. This protein presents homology with myosins IB from other amoebae, but striking homologies with vertebrate unconventional myosins were also observed. The predicted actin and ATP-binding sites are located in the head domain. The heavy chain phosphorylation region is homologous to metazoan myosins I with an acidic residue present at the phosphorylation site. In the neck domain, an IQ motif indicates potential binding of calmodulin to the myosin I heavy chain. In the tail of Eh-myosin IB the three characteristic regions of myosin I are found. A putative membrane binding domain a very short domain rich in alanine and proline we demonstrate to be functional for actin binding, and the src-homology 3 domain. The Entamoeba histolytica myosin IB is the first unconventional myosin so far described in a lower eukaryote.

Neuron labeling by extracellular delivery of horseradish peroxidase in vivo: a method for studying the local circuitry of projection and interneurons at physiologically characterized sites.

An anatomical method is described that yields individual neurons with continuously labeled dendrites and axons following the extracellular deposition of horseradish peroxidase (HRP) at neurophysiological recording sites in vivo. The method is a logical evolution of previous methods for iontophoretic delivery of HRP: Parameters critical to the ultimate concentration of HRP at the labeling site are reduced by an order of magnitude relative to standard practice. In successful cases one neuron or two in the immediate vicinity (50 microns) of recording sites is/are labeled. Labeling of other processes traversing the injection site, if any, is subliminal at highest light microscopic magnification. Due to the labeling of so few cells and the absence of other labeled processes, dendritic trees and local axonal arbors can be reconstructed without ambiguity. In addition to recovering neurons at sites characterized with physiological (e.g., sensory) stimuli, the method offers the further advantage of being fully compatible with subsequent electron microscopy. Both large (> 20 microns) and small (approximately 8 microns) neuron types and glia have been labeled.

A two-channel action-potential generator for testing neurophysiologic data acquisition/analysis systems.

A 2-channel action-potential generator system was designed for use in testing neurophysiologic data acquisition/analysis systems. The system consists of a personal computer controlling an external hardware unit. This system is capable of generating 2 channels of simulated action potential (AP) waveshapes. The AP waveforms are generated from the linear combination of 2 principal-component template functions. Each channel generates randomly occurring APs with a specified rate ranging from 1 to 200 events per second. The 2 trains may be independent of one another or the second channel may be made to be excited or inhibited by the events from the first channel with user-specified probabilities. A third internal channel may be made to excite or inhibit events in both of the 2 output channels with user-specified rate parameters and probabilities. The system produces voltage waveforms that may be used to test neurophysiologic data acquisition systems for recording from 2 spike trains simultaneously and for testing multispike-train analysis (e.g., cross-correlation) software.

A statistically based method to generate response maps objectively.

One scheme to classify the physiological response properties of single units in the cochlear nucleus is based on the average discharge rate of the unit and is reflected in the distribution of excitatory and inhibitory regions in a frequency-level map (response map) that spans the unit's receptive area (e.g., Evans and Nelson, 1973; Young and Brownell, 1976; Young and Voigt, 1982; Shofner and Young, 1985, Spirou and Young, 1991). Typically, discharge rate versus level curves are acquired at many frequencies and the investigator determines that a unit is excited or inhibited at a given level if the driven rate is above or below a spontaneous rate estimate by a specified criterion (for example, 20%). The investigator then encloses regions of excitation and inhibition where responses over adjacent frequencies and levels are consistent. In the present report, we describe an objective 3-step computer-based method to generate response maps: raw driven and spontaneous rate estimates are smoothed with a low-pass spatial filter; a unit is said to be excited or inhibited at a given level if the filtered driven rate is above or below the mean filtered spontaneous rate for that frequency by a specified criterion (percentage or statistical); and resultant response maps are median spatial filtered to eliminate spurious regions. The results shown here demonstrate that use of a statistical criterion provides a more reliable detection of excitation and inhibition than a 20% criterion, particularly when the variance of the rate estimates is high. Further, the statistically based method permits unit classification based on response map data that are more rapidly acquired with shorter duration stimuli (32 vs. 200 ms). Although this method is applied to units recorded in the dorsal cochlear nucleus, the technique may be applicable to studies of receptive fields and their plasticity in other systems.

A simple device for the computer quantification of depth measurements in thick light microscope sections.

The use of computerized techniques to characterize quantitatively the anatomy of individual neurons has been increasing. One difficulty has been the quantification of the z-axis or depth measurements within thick light microscopic sections. In the present report we describe a simple device which employs an incremental optical encoder to transduce the movements of the focusing knob of the microscope so that depth information can be recorded directly by a computer. A resolution of 0.13 micron over a range of approximately 8.5 cm is achieved. The mechanical interface to the microscope is simple and applicable to a wide variety of microscopes. Interfacing circuits which allow the optical encoder to be used with an IBM-PC compatible computer are presented and described. The accuracy of the depth measurements is limited only by the mechanical tolerances of the focusing mechanism and by the optics of the microscope.

Repeated low-dose treatment of rats with pilocarpine: low mortality but high proportion of rats developing epilepsy.

Systemic administration of pilocarpine in rats can result in a chronic behavioral state that is similar to human temporal lobe epilepsy. The pilocarpine model of epilepsy is widely used for studying the factors that contribute to the development of epilepsy as a consequence of status epilepticus (SE). For this purpose, pilocarpine is either administered alone at a high systemic dose or in combination with lithium, which markedly potentiates the convulsant effect of pilocarpine. Both experimental protocols, however, are associated with high mortality rates. In the present study, we evaluated whether mortality rate in rats can be decreased by repeated administration of low doses of pilocarpine. The time the rats spent in SE was limited by diazepam. Preliminary experiments in lithium-free rats indicated that repeated low-dose administration of pilocarpine is too time-consuming to produce SE compared to single high-dose administration. All subsequent experiments were performed in lithium-pretreated rats. Single-dose injection of 30 mg/kg pilocarpine produced SE in approximately 70% of the animals, but 45% of the rats died although SE was interrupted by diazepam after 90 min. Repeated i.p. administration of 10 mg/kg pilocarpine at 30-min intervals resulted in SE after 2-4 injections; the mean dose of pilocarpine needed to induce SE was 26 mg/kg. When SE was interrupted after 90 min, mortality rate was below 10%, which was significantly lower compared to the protocol with one single administration of 30 mg/kg pilocarpine. In contrast to mortality rate, the development of spontaneous recurrent seizures did not differ between experimental protocols. Almost all rats which had experienced a SE of at least 60 min developed chronic epilepsy. Average latency to the first spontaneous seizure was approximately 40 days. The frequency and severity of spontaneous seizures was not significantly different between protocols, although animal groups with repeated low-dose treatment tended to have higher frequencies of spontaneous seizures compared to single-dose administration. The present study demonstrates that systemic treatment of lithium-pretreated rats with several low doses of pilocarpine efficiently produces SE and chronic epilepsy with much lower mortality rates than single-dose pilocarpine.

Impact of regional chemotherapy for melanoma metastases.

Metastatic malignant melanoma requires sophisticated delineation of therapeutic approaches in order that palliation of the disease should be managed effectively. To date, systemic chemotherapy for melanoma metastases appears to be of only limited benefit, since tumoricidal drug levels can hardly be achieved in a way to overcome primary or secondary drug resistance of melanoma cells. With respect to topographically defined patterns of metastasis, therapeutic approaches introducing regional chemotherapy have recently promised improved palliation in the management of advanced solid tumors including melanoma. Among these approaches, isolated limb perfusion has become a well-established procedure in the treatment of melanoma which has metastasized to the extremities. The adjuvant setting of this technique is currently under investigation, and suggests a beneficial outcome in perfused high-risk patients. Intraarterial infusion techniques with or without regional venous drug hemofiltration might provide high cytotoxic tissue levels at the target region, thus subsequently leading to enhanced cell kill rates evidenced in terms of clinical responses. Angioocclusive approaches using persistent (chemoembolization) or transient (microspheres, liposomes) blocking techniques with subsequent reduction of the arterial/arteriolar blood flow may optimize the pharmacological advantage of regional drug delivery. In addition to cytoreductive surgery and systemic chemotherapy, the above-mentioned approaches of regional chemotherapy offer a new perspective in the palliative management of metastatic melanoma.

Angioocclusive chemotherapy in melanoma: rationale and technical considerations.

To date, systemic chemotherapy for melanoma metastases appears to be of only limited benefit since tumoricidal drug concentrations can hardly overcome primary or secondary drug resistance of melanoma cells. Recently, intraarterial infusion techniques with or without regional venous drug hemofiltration have been shown to provide high cytotoxic levels at the target region, thus subsequently using persistent (chemo-embolization) or transient (microspheres, liposomes) blocking techniques may optimize the pharmacological advantage of regional drug delivery. In a pilot series in metastatic liver cancer a significant increase of drug concentration within the target tissue could be achieved while systemic levels were found to be reduced during angio-occlusion. The rationale of angio-occlusive approaches in melanoma offers the possibility of focusing the anti-tumor action directly at the target so that improved response rates can be expected.

Response properties of type II and type III units in dorsal cochlear nucleus.

Type II and type III units in the dorsal cochlear nucleus (DCN) of unanesthetized (decerebrate) cats are those with excitatory responses to best frequency (BF) tones at all levels above threshold. They are distinguished from type IV units which give predominantly inhibitory responses to tones. Type II and type III units are distinguished from one another by their rates of spontaneous activity. Type II units have low rates of spontaneous activity (below 2.5 spikes/s), whereas type III units are spontaneously active at rates up to 95 spikes/s. In this paper we show that segregation of units according to spontaneous activity produces a segregation of several other properties as well. A typical type II unit responds vigorously to BF tones (median maximum rate of 242 spikes/s), has slightly nonmonotonic rate versus level function, and responds weakly or not at all to broadband noise. These units tend to be located in the deep layer of the DCN. Type III units tend to respond to BF tones at moderate rates (median maximum driven rate of 124 spikes/s), have monotonic or nonmonotonic rate versus level functions, and respond to noise at rates comparable to their tone rates. They are distributed somewhat more uniformly in all DCN layers, but a majority were found in the fusiform cell and molecular layers. Most evidence indicates that type II units are recorded from inhibitory interneurons in the DCN.

Response map properties of units in the dorsal cochlear nucleus of barbiturate-anesthetized gerbil (Meriones unguiculatus).

The response map scheme introduced by Evans and Nelson (1973) and modified by others, including Davis et al. (1996) for use with gerbils, has been used primarily for classifying units recorded in the cochlear nucleus of unanesthetized decerebrate preparations. Units lacking spontaneous activity (SpAc) have been classified as either type I/III or type II units based on the relative strength of their responses to broad-band noise compared to their responses to best-frequency (BF) tones. The relative noise index (rho), a ratio of these responses after SpAc is subtracted out, provides a convenient measure of this relative strength. In this paper, responses of 320 units recorded in the dorsal cochlear nucleus (DCN) of barbiturate-anesthetized gerbils to short-duration BF tones and broad-band noise were recorded. Since 87.5% of these units lacked SpAc, their response maps resembled those of type II and type I/III units. Units were characterized by rho and the normalized slope (m) of a best line fit to the BF rate versus level plot starting from the sound level corresponding to the first inflection point of the rate curve (typically its maximum value or the start of its sloping saturation). The distributions of rho and m values do not form distinct clusters as they do for units in the decerebrate preparation. Thus, the criteria developed for classifying DCN units in the decerebrate preparation do not appear appropriate for units in the barbiturate-anesthetized preparation. Deposits of horseradish peroxidase were used to locate 52 units. Most of the low SpAc units, 56% with poor noise responses (5/9) and nearly 70% with strong noise responses (25/36), and nearly all of the high SpAc units (6/7), were located either within or below the fusiform cell layer.