[Statutory provisions, aims, motives, attitudes and thinking on the outpatient operation profile of general and abdominal surgery]. / Vorgaben, Zielvorstellungen, Motive, Haltungen und Denken zum ambulanten Operationsprofil der Allgemein- und Viszeralchirurgie.

AIM: The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery. METHOD: Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. RESULTS (KEY POINTS): - In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with § 115b Social Security Code (SGB) V (Germany). - The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, a special industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether a paid service is provided on an outpatient or inpatient basis. - According to § 115b SGB V, whether a hernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5­530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over a period of 14 years. - Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. - Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals. CONCLUSION: The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be a starting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery.

Successful year-round mainstream partial nitritation anammox: Assessment of effluent quality, performance and N2O emissions.

For two decades now, partial nitritation anammox (PNA) systems were suggested to more efficiently remove nitrogen (N) from mainstream municipal wastewater. Yet to date, only a few pilot-scale systems and even fewer full-scale implementations of this technology have been described. Process instability continues to restrict the broad application of PNA. Especially problematic are insufficient anammox biomass retention, the growth of undesired aerobic nitrite-oxidizers, and nitrous oxide (N2O) emissions. In this study, a two-stage mainstream pilot-scale PNA system, consisting of three reactors (carbon pre-treatment, nitritation, anammox - 8 m3 each), was operated over a year, treating municipal wastewater. The aim was to test whether both, robust autotrophic N removal and high effluent quality, can be achieved throughout the year. A second aim was to better understand rate limiting processes, potentially affecting the overall performance of PNA systems. In this pilot study, excellent effluent quality, in terms of inorganic nitrogen, was accomplished (average effluent concentrations: 0.4 mgNH4-N/L, 0.1 mgNO2-N/L, 0.9 mgNO3-N/L) even at wastewater temperatures previously considered problematic (as low as 8 °C). N removal was limited by nitritation rates (84 ± 43 mgNH4-N/L/d), while surplus anammox activity was observed at all times (178 ± 43 mgN/L/d). Throughout the study, nitrite-oxidation was maintained at a low level (<2.5% of ammonium consumption rate). Unfortunately, high N2O emissions from the nitritation stage (1.2% of total nitrogen in the influent) were observed, and, based on natural isotope abundance measurements, could be attributed to heterotrophic denitrification. In situ batch experiments were conducted to identify the role of dissolved oxygen (DO) and organic substrate availability in N2O emission-mitigation. The addition of organic substrate, to promote complete denitrification, was not successful in decreasing N2O emission, but increasing the DO from 0.3 to 2.9 mgO2/L decreased N2O emissions by a factor of 3.4.

[Assessment of chronic obstructive eustachian tube dysfunction : Evaluation of the German version of the Eustachian Tube Dysfunction Questionnaire]. / Beurteilung der chronisch-obstruktiven Tubenfunktionsstörung : Evaluation des "Eustachian Tube Dysfunction Questionnaire" in der deutschen Übersetzung.

BACKGROUND: Eustachian tube dysfunction can cause middle ear diseases and impair quality of life. Sufficient diagnostic tools for chronic obstructive eustachian tube dysfunction are lacking and not reliable enough. PATIENTS AND METHODS: The Eustachian Tube Dysfunction Questionnaire (ETDQ-7) was published by McCoul et al. in 2012 as an instrument to evaluate eustachian tube function. They demonstrated the reliability und validity of their questionnaire. The cut-off point for the diagnosis of eustachian tube dysfunction is ≥ 14.5 at 100 % sensitivity and 100 % specificity. We translated the ETDQ-7 into German and used it on 100 healthy subjects and 43 patients with chronic obstructive eustachian tube dysfunction. RESULTS: The results in the English questionnaire were confirmed by our examinations with the German version of the questionnaire. The mean ETDQ-7 score was 8.67 in the healthy subjects and 24.7 in the patients with chronic obstructive eustachian tube dysfunction. The area under the curve in ROC analysis was 98.8 % (p < 0.0001). CONCLUSION: We recommend the ETDQ-7 as an addition to patient history in the examination of eustachian tube dysfunction. It may as well be valuable in follow-up examinations to monitor treatment success.

Genotoxic, antigenotoxic and phytochemical assessment of Terminalia actinophylla ethanolic extract.

Terminalia actinophylla has been used for anti-diarrheic and haemostatic purposes in Brazil. The fly spot data obtained after exposure of marker-heterozygous Drosophila melanogaster larvae to T. actinophylla ethanolic extract (TAE) in the standard (ST) and high bioactivation (HB) crosses revealed that TAE did not induce any statistically significant increment in any spot categories. Differences between the two crosses are related to cytochrome P450 (CYPs) levels. In this sense, our data pointed out the absence of TAE-direct and indirect mutagenic and recombinagenic action in the Somatic Mutation and Recombination Test (SMART). When the anti-genotoxicity of TAE was analyzed, neither mitomycin C (MMC) nor ethylmethanesulfonate (EMS) genotoxicity was modified by the post-exposure to TAE, which suggests that TAE has no effect on the mechanisms involved in the processing of the lesions induced by both genotoxins. In the mwh/flr(3) genotype, co-treatment with TAE may lead to a significant protection against the genotoxicity of MMC and a weak but significant effect in the toxic genetic action of EMS. The overall findings suggested that the favorable modulations by TAE could be, at least in part, due to its antioxidative potential.

Assessment of genotoxicity of Lidocaine, Prilonest and Septanest in the Drosophila wing-spot test.

The scope of this study was to characterize the likely interaction Lidocaine, Prilonest and Septanest have with DNA, with a view to quantitatively and qualitatively establishing mutagenic, clastogenic, and/or recombinagenic activity of those compounds. The wing somatic mutation and recombination test in Drosophila melanogaster, which detects simultaneously point and chromosomal mutations as well as recombination induced by the activity of genotoxins of direct and indirect action, was used. Each of the anesthetics was tested at different concentrations, administered orally for 48 h to 3rd-stage larvae, in two independent experiments, with concurrent negative controls. The results obtained revealed that only Prilonest exhibits genotoxic activity in somatic cells, being able to induce exclusively homologous recombination. Additionally, it was possible to conclude that the genotoxic effect attributed to Prilonest is not related to metabolites produced via the P450-type enzymes. However, both Lidocaine and Septanest are unable to induce either events related to gene and chromosomal mutation, or reciprocal recombination.

Interleukin-10 expression is induced by increase of intracellular calcium levels in the monocytic cell line U937.

The regulation of interleukin-10 (IL-10) expression after treatment with a high, exponential, electric pulse was investigated in the monocytic cell line U937. Recently, we showed IL-10 protein production in the monocytic cell lines U937 and THP-1 after exposure to a single, high exponential electric pulse [Lehmann MH, Höffken K, Berg H (1996) Bioelectrochem. Bioenerg. 41: 227-229]. In the present study, the specificity of this process was proven by semiquantitative reverse-transcriptase polymerase chain reaction. It was found that the presence of calcium in the culture medium during the pulse is essential for IL-10 protein production. Only a small amount of IL-10 protein was produced in calcium free medium. The calcium specific chelator EGTA prevented IL-10 protein production induced by the electric pulse in a dose-dependent manner. Additionally, IL-10 mRNA transcription could be induced in U937 cells without pulse application by means of the calcium ionophore ionomycin. No IL-10 protein could be detected by ELISA. However, down-regulation of TNF-alpha mRNA levels after ionomycin stimulation provided an indirect proof that IL-10 protein production occurred.

Assessment of chronic rejection in permanent accepted renal allografts in anti-CD4 treated rats.

In rats, transient prophylactic anti-CD4 therapy with the nondepleting mAB RIB5/2 prevents acute rejection of MHC-mismatched allografted kidneys and induces long-lasting unresponsiveness. However, little is known about long-term benefits of this prophylactic anti-CD4 regimen. Here we report experimental results of permanently accepted rat renal allografts after prophylactic anti-CD4 treatment in regard to signs of chronic rejection. Kidneys from Wistar Furth donors were orthotopically grafted into bilateral nephrectomized BDIX recipients under the cover of anti-CD4 treatment (20 mg/kg b.w). Kidney function was serially monitored by measurement of serum creatinine and urine protein excretion. After 100 or 300 days respectively renal allografts were harvested, histologically and immunohistologically assessed and intragraft cytokine gene expression determined. Serum creatinine increased in few allografted rats. 30% of the 300-day-old grafts had an increased proteinuria and higher degrees of glomerular sclerosis. In these grafts cellular infiltration was more pronounced. However, no activated leukocytes (IL-2 receptor positive) were detected. Correspondingly, intragraft gene expression of CD3, IL-10 and IFN gamma was low. The results of our study indicate that a prophylactic anti-CD4 regimen diminishes chronic rejection to a level comparable to isografted or naive mass-reduced or ischemic kidneys. Thus, the signs of chronic rejection observed seem to be mainly caused by alloantigen-independent processes.

[Evaluation of anesthetic activity in the operating room. Use of beta relative cost index]. / Evaluation de l'activité anesthésique au bloc opératoire. Utilisation de l'ICR bêta.

OBJECTIVE: To evaluate the anaesthetic activity in the operating rooms using the newly reconstructed RCI beta, or relative cost index beta, a specific tool for analysis of anaesthetic activity and the linked cost. STUDY DESIGN: Prospective multicentric survey. METHODS: All scheduled anaesthetic procedures performed in March 1995 were collected. RCI beta items were entered in a standardized data base. Gender, age group, time of admission to the operating room, time of incision, time of exit from the operating room, and the code number of the surgical or radiological procedure were added on request of the steering committee. RESULTS: Complete responses were obtained from 35 out of the 37 contacted departments. A total of 31,391 procedures were analysed. Only 14% of patients were of ASA class over 2. Anaesthetic practices were comparable between institutions. Only the incidence of special circumstances and techniques was higher in University hospitals. General anaesthesia was the most widely used technique (76.58%). A large proportion (19%) of anaesthetics were given for endoscopy and radiology. More than 87% of patients were monitored postoperatively in recovery areas. There was a lower correlation between the theoretical standard duration and median actual duration of the perioperative period than the operative period (r = 0.54 vs r = 0.81). DISCUSSION: Part of our activity could be described with RCI beta. The obtained data allow a comparison of anaesthetic activity in the operating rooms of different hospitals, departments and units. Further analysis of these data will also provide information about the types of surgical procedures and the level of global activity.