The career expectations of medical students: findings of a nationwide survey in Germany.

BACKGROUND: Demographic change, technical progress, and changing patterns of service use influence the future demand for physicians in the German health care system. The attitudes of medical students towards their later work in the health system is important for current health care planning. For that reason a nationwide survey aimed to identify major trends in preferred specialty, workplace characteristics (regional location, hospital) and perceived hindrances for clinical work. METHODS: A questionnaire consisting of 34 closed questions was developed at the University of Mainz in 2009 and administered over the Internet in June and July 2010 to all medical students in Germany. The questions addressed the students' intentions regarding specialty training, location of practice, workload, and regional preference, as well as potential reasons why they might choose not to practice clinical medicine in the future. RESULTS: 12 518 web-based questionnaires were filled in (approx. 15.7% of all medical students in Germany in 2010). The mean age was 24.9 years, with 64% female and 36% male. Favored specialties were internal medicine (42.6%), family medicine (29.6%), pediatrics (27.0%) and surgery (26.8%). Nearly all respondents (96%) stated that they attached importance to compatibility of work and family life. Working in a salaried position (92.2%) was preferred to working in private practice (77.7%). General practice, in particular in rural locations, was significantly less favored than work as a specialist in cities. CONCLUSION: Although the coming generation of physicians anticipate working in clincial settings in the future, shortfalls in the areas of primary care and in rural locations are likely if medical students adhere to their preferences stated in the questionnaire.

Extraosseous uptake with DPD (Teceos(®)).

OBJECTIVE: During a short period of 10 days, four patients presented with intense extraosseous uptake of a technetium-labelled bone-seeking agent, three in the heart and one in the liver at our hospital. During the next 6 weeks, identical heart uptake was found in another two patients. Two patients were re-examined, with identical uptake on the second occasion. A search for a possible cause was initiated. METHODS: Bone scintigraphy with Teceos(®) was performed after labelling the kit as described in the Summary of Product Characteristics [IBA, http://www.iba-molecular.com/sites/default/files/spcT1901E.pdf (in french, 29/3/2011)]. On two occasions, the kit used was retrospectively analysed, without any apparent abnormality. Two patients were re-examined 1 month later, with identical cardiac and liver uptake on repeat examination. Contact with referring physicians and blood test screening did not show any consistent reason for these extraosseous uptakes. Additionally, five cases at other hospitals in Norway have been brought to our attention. RESULTS: In at least ten patients, intense cardiac uptake has been recorded, all in relatively old patients, and one young patient had massive liver uptake. No abnormalities in labelling or composition of 3,3-diphospho-1,2-propanedicarboxylic acid were found. DISCUSSION: Liver and cardiac uptakes of bone-seeking agents have been described in amyloidosis, and for the heart, after myocardial infarction. We have ruled out any possible contamination by interfering radiopharmaceuticals and cannot find any reason for these findings. Eleven patients with amyloidosis seem one of several hypotheses that is highly improbable.

Elevated serum osteoprotegerin levels measured early after acute ST-elevation myocardial infarction predict final infarct size.

BACKGROUND: Increased serum osteoprotegerin has been shown to be associated with increased mortality and heart failure development in patients with acute coronary syndromes. The aim of the present study was to elucidate a possible association between serum osteoprotegerin measured acutely in patients with ST-elevation myocardial infarction (STEMI) and final infarct size. METHODS Serum osteoprotegerin was measured in fasting blood samples from 199 patients with acute STEMI, sampled at a median time of 16 h after primary percutaneous coronary intervention (PCI). After 3 months, final infarct size (in percentage of left ventricular mass; LVM) was assessed by single-photon emission CT. The outcome variable final infarct size was dichotomised using the 75th percentile as the cutoff value (large infarct size ≥ 29.0%). A multivariable analysis was performed adjusting for multiple clinical and biochemical covariates. RESULTS: Median (IQR) osteoprotegerin concentration was 1.4 (1.0, 2.1) ng ml⁻¹ and patients with high osteoprotegerin level (> median) at baseline had larger infarct size at 3 months compared with patients with low osteoprotegerin levels (< median) (25 (8, 40) vs 6 (0, 19)% of LVM, respectively, p < 0.0001). A high osteoprotegerin level was also associated with an approximately sevenfold increase in the odds of developing a large myocardial infarct (OR 7.0; 3.2, 15.5, p < 0.001). After adjustment for potential confounders including peak troponin T, the adjusted OR was 5.2 (2.0, 13.1) p < 0.001. CONCLUSION: High levels of circulating osteoprotegerin measured the first morning after a PCI-treated acute STEMI were strongly associated with final infarct size.

[Medical service centres: are they really the future of ambulatory care in Germany?]. / Medizinisches Versorgungszentrum--Ausnahmefall oder Regelversorgung der Zukunft? Eine Bestandsaufnahme.

Due to governmental regulation in 2004 new options to establish ambulatory care facilities have become available and are widely used by healthcare providers. Medical service centres (Medizinische Versorgungszentren, MVZs) are characterised by the obligation for interdisciplinary teams of physicians, extended options for the employment of physicians and finally by flexible avenues of investment regarding the establishment of medical service centres. Medical service centres aim to improve ambulatory healthcare provision via an integrated service approach and offer opportunities for hospitals and third-party payers to set foot into the ambulatory healthcare sector. The rise of MVZs has therefore been closely and quite sceptically watched by the medical profession. The spread of MVZs is constant but limited to a modest growth rate. 250 MVZs are set up annually; in summer 2009 a total number of about 1300 had been reached, which is fairly small compared to 92,000 individual and group practices. The prominent specialities include general medicine, internal medicine, and surgery. The majority of MVZs are located in urban and suburban areas. Especially hospitals have, however, been using this approach to establish and operate ambulatory care centres with employed physicians. It remains to be seen whether and to what extent MVZs will improve service provision to the benefit of patients or mainly represent a new business model compromising existing structures. Continuous evaluation of trends is therefore essential for the further development of new ambulatory care structures.

Scintigraphic demonstration of myocardial perfusion and ischaemia associated with coronary artery bypass grafting.

OBJECTIVES: To assess if myocardial perfusion scintigraphy (MPS) at rest can be of value in elucidating myocardial perfusion, ischaemia and perioperative myocardial infarction (PMI) associated with coronary artery bypass graft (CABG) surgery. DESIGN: This was a prospective randomized study of patients undergoing elective CABG. Forty-eight patients in the control group underwent serial ECG recordings and measurements of CK-MB and cTnT. Fifty-four patients in the study group were additionally examined with MPS preoperatively and 2-4 days and 6 weeks postoperatively. RESULTS: The study showed a highly significant (p < 0.001) improvement in myocardial radionuclide uptake from preoperatively to 2-4 days postoperatively. Judged from ECG and enzymatic changes, two control patients and one study patient only had PMI and no additional cases of PMI were demonstrated by MPS. CONCLUSION: MPS at rest showed that CABG significantly improved myocardial perfusion, by demonstrating an increase in radionuclide uptake. In diagnosing PMI, we found that MPS provided no additional information beyond cardiac biochemical markers and ECG changes.

Intracoronary injection of mononuclear bone marrow cells in acute myocardial infarction.

BACKGROUND: Previous studies have shown improvement in left ventricular function after intracoronary injection of autologous cells derived from bone marrow (BMC) in the acute phase of myocardial infarction. We designed a randomized, controlled trial to further investigate the effects of this treatment. METHODS: Patients with acute ST-elevation myocardial infarction of the anterior wall treated with percutaneous coronary intervention were randomly assigned to the group that underwent intracoronary injection of autologous mononuclear BMC or to the control group, in which neither aspiration nor sham injection was performed. Left ventricular function was assessed with the use of electrocardiogram-gated single-photon-emission computed tomography (SPECT) and echocardiography at baseline and magnetic resonance imaging (MRI) 2 to 3 weeks after the infarction. These procedures were repeated 6 months after the infarction. End points were changes in the left ventricular ejection fraction (LVEF), end-diastolic volume, and infarct size. RESULTS: Of the 50 patients assigned to treatment with mononuclear BMC, 47 underwent intracoronary injection of the cells at a median of 6 days after myocardial infarction. There were 50 patients in the control group. The mean (+/-SD) change in LVEF, measured with the use of SPECT, between baseline and 6 months after infarction for all patients was 7.6+/-10.4 percentage points. The effect of BMC treatment on the change in LVEF was an increase of 0.6 percentage point (95% confidence interval [CI], -3.4 to 4.6; P=0.77) on SPECT, an increase of 0.6 percentage point (95% CI, -2.6 to 3.8; P=0.70) on echocardiography, and a decrease of 3.0 percentage points (95% CI, 0.1 to -6.1; P=0.054) on MRI. The two groups did not differ significantly in changes in left ventricular end-diastolic volume or infarct size and had similar rates of adverse events. CONCLUSIONS: With the methods used, we found no effects of intracoronary injection of autologous mononuclear BMC on global left ventricular function.

Total-body irradiation--role and indications: results from the German Registry for Stem Cell Transplantation (DRST).

BACKGROUND AND PURPOSE: Total-body irradiation (TBI) is a key part of the conditioning regimen before hematopoietic stem cell transplantation (HSCT). The exact role of TBI as part of the conditioning regimen is largely unclear. In order to determine the relevance of TBI, the status of TBI utilization was analyzed on the basis of a nationwide registry. MATERIAL AND METHODS: 14,371 patients (1998-2002) documented in the German Stem Cell Transplantation Registry (DRST) were analyzed regarding TBI utilization prior to autologous or allogeneic transplantation, underlying disorder, type of donor, stem cell source, and size of the treatment center. RESULTS: For autologous HSCT approximately 10% of the patients (873/8,167) received TBI, with chronic lymphocytic leukemia (CLL, approximately 80%, 171/214) and low-grade non-Hodgkin's lymphoma (l-NHL, approximately 35%, 330/929) being the most important disorders. In the allogeneic setting 50% of the patients (2,399/4,904) received TBI, with acute lymphocytic leukemia (ALL, 85%, 794/930), acute myeloid leukemia (AML, 45%, 662/1,487) and chronic myeloid leukemia (CML, 49%, 561/1,156) being the key indications. The type of donor, stem cell source and center size did not strongly influence the use of TBI. CONCLUSION: TBI has only a limited role for the conditioning prior to autologous HCST. For allogeneic HSCT TBI is widely accepted with no major changes over the observation time. The use of TBI is generally accepted for ALL, whereas approximately half of the patients with CML or AML received TBI. Although a considerably large database was analyzed, no clear determinants for the use of TBI could be distinguished.