[Staff Satisfaction within Duty Hour Models: Longitudinal Survey on Suitability and Legal Conformity at a Surgical Maximum Care Department]. / Mitarbeiterzufriedenheit im Arbeitszeitmodell: Längsschnittstudie zu Praxistauglichkeit und Gesetzeskonformität in einer chirurgischen Klinik der Maximalversorgung.

Background Between the conflicting requirements of clinic organisation, the European Working Time Directive, patient safety, an increasing lack of junior staff, and competitiveness, the development of ideal duty hour models is vital to ensure maximum quality of care within the legal requirements. To achieve this, it is useful to evaluate the actual effects of duty hour models on staff satisfaction. Materials and Methods After the traditional 24-hour duty shift was given up in a surgical maximum care centre in 2007, an 18-hour duty shift was implemented, followed by a 12-hour shift in 2008, to improve handovers and reduce loss of information. The effects on work organisation, quality of life and salary were analysed in an anonymous survey in 2008. The staff survey was repeated in 2014. Results With a response rate of 95% of questionnaires in 2008 and a 93% response rate in 2014, the 12-hour duty model received negative ratings due to its high duty frequency and subsequent social strain. Also the physical strain and chronic tiredness were rated as most severe in the 12-hour rota. The 18-hour duty shift was the model of choice amongst staff. The 24-hour duty model was rated as the best compromise between the requirements of work organisation and staff satisfaction, and therefore this duty model was adapted accordingly in 2015. Conclusion The essential basis of a surgical department is a duty hour model suited to the requirements of work organisation, the Working Time Directive and the needs of the surgical staff. A 12-hour duty model can be ideal for work organisation, but only if augmented with an adequate number of staff members, the implementation of this model is possible without the frequency of 12-hour shifts being too high associated with strain on surgical staff and a perceived deterioration of quality of life. A staff survey should be performed on a regular basis to assess the actual effects of duty hour models and enable further optimisation. The much criticised 24-hour duty model seems to be much better than its reputation, if augmented by additional staff members in the evening hours.

[Economic Analysis of Treatment Courses for Patients Over the Age of 80 Years at a Surgical Maximum Care Centre]. / Ökonomische Analyse des Behandlungsverlaufs bei über 80-jährigen Patienten an einer Klinik der chirurgischen Maximalversorgung.

BACKGROUND: The demographic change in Germany with an aging population and the resulting necessity of adequate surgical care for older patients was lately discussed with concern. One major aspect is the estimated higher treatment costs in the care of the elderly. MATERIALS AND METHODS: InEK data from all cases of patients over the age of 80, who were treated and discharged from 2008 to 2012 as inpatients at the Department of General, Visceral, Vascular and Thoracic Surgery at the Charité - Universitätsmedizin Berlin, Campus Mitte, were analysed. Of a total of 13,612 patients 626 patients were over the age of 80. Their lengths of stay, mode of discharge and discharge management as well as costs and reimbursements according to the relevant diagnosis-related groups were analysed. RESULTS: Cases of elderly patients amounted to a stable 5 % of all cases from 2008 until 2012. Their mean length of stay was 14 (median, 9), range, 1-129 days. 80 % of patients could be regularly discharged, 9 % died, 8 % were transferred to another hospital, 2 % discharged into a nursing home and 1 % into a rehabilitation centre. The elderly patients had a patient clinical complexity level of mean 2.84. Costs per day amounted to a mean 778 (median: 627) €, range: 306-7740 €, total costs to 10,686 (median: 5140) €, range: 368-186,059 €. The mean deficit was 491 (median: 176) € per patient, range: - 30,470-75,144 €. The discharge management was significantly different in comparison to patients under the age of 80 with respect to avoidance of discharge at the weekend. CONCLUSION: Patients over the age of 80 are a relevant group in surgery. They have an increased perioperative risk, but patients should not be denied surgery solely because of their age. The perioperative management of the elderly has to be of maximum standardised quality. From an economic perspective it can be stated that elderly patients currently pose no exceptional financial risk to a surgical department, but contribute relevantly to the turnover, whereby special attention has to be paid to an early structured discharge management.

[Perioperative nutrition - a nationwide web-based survey of German surgery departments]. / Perioperative Ernährung aus Sicht von Chirurgen - Eine deutschlandweite Online-Umfragen.

BACKGROUND: Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany. METHODS: In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery. RESULTS: From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents. CONCLUSION: The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany.

Reduction of heart rate variability after colorectal resections.

BACKGROUND: Heart rate variability (HRV) is a sensitive marker of altered sympathetic-parasympathetic function and is reduced in inflammation, illness, and trauma. The effect of major abdominal surgery on the course of HRV parameters is still an issue requiring further investigation. MATERIALS AND METHODS: A prospective, observational study including 40 consecutive patients undergoing elective colorectal surgery under "fast-track" perioperative management. Time and frequency domain parameters of HRV were measured 1 day prior to operation and on days 1-5 postoperatively. General and surgical complications as well as the course of leucocytes and C-reactive protein (CRP) were documented and correlated to the HRV measurements. RESULTS: Time domain parameters of HRV showed a significant decrease compared to the preoperative values on postoperative day 1 and returned to baseline on day 2, demonstrating impaired autonomic regulation in the early postoperative period. No correlation to complications or course of leukocytes or CRP was significant in our study. CONCLUSIONS: Colorectal resections significantly influence the HRV course. The autonomic regulation is reduced in the early postoperative time and all parameters return to baseline until the third day.

Initial results after implementation of a multimodal treatment for peritoneal malignancies.

INTRODUCTION: Peritoneal carcinomatosis represents a clinical condition with a limited perspective concerning long term survival. The combination of surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) represents a complex multimodal therapeutic management concept with promising results for prolongation of survival. For the identification of pitfalls during implementation of the HIPEC procedure into clinical practice an observational study was conducted. METHODS: Between 2005 and 2009 data from all patients treated with cytoreductive surgery and HIPEC for peritoneal carcinomatosis was prospectively collected and analysed. RESULTS: During the observational interval a total of 42 patients underwent surgical treatment for peritoneal carcinomatosis. In 34 patients the complete procedure with surgical cytoreduction and HIPEC was performed. Perioperative mortality (6%) and morbidity (35%) was similar to other reported series. Twenty-five patients (76%) survived the 18 months follow-up period after complete procedure. CONCLUSION: The multimodal therapeutic treatment concept of surgical cytoreduction and following HIPEC leads to promising results for patients suffering from peritoneal carcinomatosis. However this treatment concept is afflicted with a relevant risk of postoperative complications.

[Reduced preoperative fasting periods. Current status after a survey of patients and colleagues]. / Verkürzte präoperative Nüchternheit. Erhebung eines Istzustands nach Analyse von Patienten- und Mitarbeiteraussagen.

BACKGROUND: Since October 2004 German Anaesthesiology Societies have officially recommended a decreased fasting period of 2 h for clear fluids and 6 h for solid food before elective surgery. A survey of patients and health care workers was carried out in our university clinic to assess the implementation of the new fasting recommendations. METHODS: Surgical patients (n=865) as well as physicians and nurses specialized in anaesthesia and surgery (n=2,355) were invited to complete a written questionnaire. The survey inquired about prescribed and practiced duration of fasting, attitudes towards reduced preoperative fasting and knowledge of the new guidelines. RESULTS: Data from 784 patients (91%) and 557 health care workers (24%) were analysed. Patients reported mean fasting times of 10+/-5 h for fluids and 15+/-4 h for solid food. Of the patients 52% and 16% would have preferred to drink and eat before surgery, respectively and 10% were informed about the new recommendations of shorter preoperative fluid and solid fasting. Such patients reported significantly reduced fasting times for fluids compared with those who were recommended to fast for the traditional longer periods (8+/-6 versus 12+/-4 h, p<0.001). Preoperative fasting advice remembered by the patients significantly differed from the prescribed recommendations (2 h fluid fasting, 22 versus 53%, p<0.001). Anaesthesiologists were significantly more knowledgeable of the new guidelines (90 versus 32-42%, p<0.001) and significantly more willing to recommend the new short preoperative fasting times (75 versus 15-19%, p<0.001) than other health care workers. Of all health care workers 82% and 32% reported patients' frequent desire to drink and eat before surgery, respectively, 92% considered reduced preoperative fasting to be positive, 76% feared increased risks for patients and 42% expected a decreased flexibility in their daily work. CONCLUSION: The current guidelines for preoperative fasting have not been widely implemented. Besides a knowledge discrepancy, remarkable concerns remain regarding higher risk for patients which may be important barriers to implementation. Nevertheless, health care workers are aware of patients' desire for shorter preoperative fasting. If the new guidelines are recommended patients will make use of them. Further training of staff and adequate implementation tools are needed.

Influence of pre-operative fluid infusion on volume status during oesophageal resection--a prospective trial.

BACKGROUND: Perioperative fluid therapy is controversially debated in surgery. In malnourished and hypovolaemic patients, a restrictive fluid regimen may lead to hypoperfusion and increased incidence of complications. The present prospective cohort study was performed to assess whether pre-operative i.v. fluid administration improves intraoperative cardiac preload in patients undergoing oesophageal resection. METHODS: Intraoperatively, the intrathoracic blood volume index (ITBVI) was monitored in 44 consecutive patients undergoing elective oesophagectomies with the transthoracic thermodilution technique. Twenty-two of these patients received a pre-operative i.v. fluid loading with a balanced crystalloid solution (1 ml/kg/h over 48 h). RESULTS: After induction of anaesthesia ITBVI was low but not different between the groups [767 (512-1314) vs. 775 (531-1200) ml/m(2), P=0.81]. In the intervention group, the extravascular lung water increased above normal levels during the operation. The groups did not differ in cardiac output, blood pressure, heart rate and central venous pressure. Post-operative morbidity was not different between the cohorts. CONCLUSION: Pre-operative i.v. fluid loading with crystalloid solutions could not be shown to improve the intraoperative volume status and cardiac function in this study. Randomised trials with other volume replacement techniques are recommended.

[Problem-based learning for surgery. Increased motivation with less teaching personnel?]. / Problemorientiertes Lernen in der Chirurgie. Erhöhte Lernmotivation bei geringerem Personalaufwand?

BACKGROUND: Traditional teacher-centred education strategies often do not meet the needs and student abilities of adult learning. The introduction of small learning groups requires considerable increases in staff. Problem-based learning could increase the motivation to acquire knowledge but without being as staff-intensive. METHODS: Medical students (n=98) in their fourth clinical semester were randomly assigned to either a structured course (SC) or problem-based learning (PBL) for surgery. Their motivation and acceptance of the courses were recorded at the end of term in anonymous questionnaires using Likert scales, with scores ranging from 1 (very good) to 6 (unsatisfactory). RESULTS: Both course structure and the teachers received much better ratings from the PBL students (P<0.01 each). The motivation of students to deal with surgical problems beyond the course material was significantly higher after PBL, with 1.8 (0.7), than after the structured course with 3.1 (1.2) (P<0.01). The overall rating was substantially worse for the structured course, with 3.1 (1.2) than for PBL at 1.4 (0.6) (P<0.01). CONCLUSIONS: Problem-based learning in the surgical curriculum increases student acceptance and motivation with little demand on staff. It should be increasingly implemented.

"Fast-track"-rehabilitation in surgery, a multimodal concept.

The rates of postoperative local surgical complications (e.g. wound-infection, abscess, anastomotic leakage) and the postoperative mortality have markedly decreased over the past decades. However the occurrence of general medical complications (e.g. cardio-pulmonary or renal dysfunction, nosocomial infections, thromboembolism) after abdominal surgery is still frequent with an incidence of 20-60% (1-6). "Fast-track"-surgery, also called "Fast-track"-rehabilitation or "ERAS" (enhanced recovery after surgery) programme, is a combination of different pre- and intraoperative measures, which have been mainly validated in elective colonic surgery, but they can be principally employed in all surgical settings. With this approach it is possible to accelerate the postoperative convalescence and reduce the rate of general complications markedly (4, 7-10).

Detection of HMGI-C in the peripheral blood of breast cancer patients.

The human high mobility group (HMG) protein (HMGI-C) belongs to the HMG family of architectural transcription factors which are expressed only during embryonic development, and not in normal adult tissues. Considerable interest has recently been shown in HMGI-C and its expression in a variety of neoplastic tissues, whereas no expression could be found in normal tissue adjacent to the tumour. So far, no data is available on the expression of HMGI-C in the peripheral blood of patients with solid tumours. In this study we analysed the expression of HMGI-C in peripheral blood samples of 61 patients with breast cancer and 35 healthy donors using a haemi-nested reverse transcriptase-polymerase chain reaction (RT-PCR) technique. No HMGI-C could be detected in any of the healthy donors' samples. In the three prognostic groups according to the Nottingham Prognostic Score, the proportion of patients expressing HMGI-C differed significantly (P=0.001). The worse the prognosis was, the more patients expressed HMGI-C. This is the first report on the expression of HMGI-C in the peripheral blood of patients with breast cancer and our data suggest that this expression is correlated with a poor prognosis.

The comparability of quality of life scores. a multitrait multimethod analysis of the EORTC QLQ-C30, SF-36 and FLIC questionnaires.

This study investigates whether similarly named subscales of three quality of life questionnaires, the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the Medical Outcome Study Quality of Life Questionnaire Short Form 36 (SF-36) and the Functional Living Index Cancer questionnaire (FLIC) assess similar aspects of the patients' quality of life. A multitrait multimethod analysis on the answers of 234 cancer patients showed that subscale correlations as indicators of convergent validity significantly exceed corresponding correlations of discriminant validity in five of the seven dimensions analysed (physical functioning, emotional functioning, pain, fatigue/vitality and nausea/vomiting). The results of the social functioning and overall health subscales are less clear. Content analysis of the social functioning scales reveals that this domain is differently operationalised in the three questionnaires. Linear regressions of the overall health subscales suggest that patients interpret overall health questions of the three questionnaires differently. The results show that overall health subscales of these three questionnaires cannot be equated, while most specific subscales provide valid results.

Novel approaches to the treatment of primary amyloidosis.

Primary (AL, amyloid light-chain) amyloidosis is a plasma cell disorder in which deposits of amyloid light-chain protein cause progressive organ failure. It is important to recognise that amyloidosis is a dynamic process and chemotherapy-induced reduction of the activity of the plasma cell clone reduces the supply of the amyloid precursor protein and can result in a major regression of the deposits. The most common target organ is the kidney and renal amyloidosis manifests as proteinuria or nephrotic syndrome. Proteinuria is seen in three quarters of patients. Amyloid related nephrotic syndrome and renal failure are potentially reversible. Fatigue, congestive heart failure, hepatomegaly, peripheral neuropathy, orthostatic hypotension, carpal tunnel syndrome and macroglossia are other common features. The median survival is one to two years. Conventional-dose melphalan as standard treatment can prolong the median duration of survival by about ten months, but the clinical response rates with improvement of impaired organ function are low. Up-front high-dose chemotherapy with autologous peripheral blood stem cell transplantation is much more effective and can result in a major improvement in the clinical condition of patients. However, the toxicity related to this treatment can be relevant due to impaired organ function. Conventional-dose chemotherapy consisting of vincristine, doxorubicin and dexamethasone or high-dose dexamethasone or interferon-alpha are other possible approaches to treatment. The improvement of patient condition with an effective conventional-dose chemotherapy may increase the tolerability of high-dose chemotherapy and reduce transplantation related problems.

CD99 positivity and EWS-FLI1 gene rearrangement identify a breast tumor in a 60-year-old patient with attributes of the Ewing family of neoplasms.

Rearrangements of the EWS gene with ETS transcription factor genes as a result of chromosomal translocation and high expression levels of CD99MIC2 characterize the Ewing family of tumors (EFT). This group of rather undifferentiated neoplasms affects bone and soft tissue in children and young adults mostly between 5 and 30 years of age (median, 15 years). This study reports a case of a CD99MIC2 positive small round cell tumor in the breast of a 60-year-old woman in whom a t(11;22)(q24;q12) chromosomal aberration was identified by cytogenetic analysis. Reverse transcriptase (RT)-polymerase chain reaction (PCR) followed by sequence analysis revealed expression of a chimera transcript in which EWS exon 10 was fused to FLI1 exon 6. Previously, this gene fusion has been reported to occur in approximately 3% of EFT. The specific gene rearrangement of EWS intron 10 was confirmed on Southern blot of genomic DNA. This study further contributes to the growing list of unusual neoplasms in adults that carry genotypic and phenotypic traits of the EFT.

[Hyperthermic intraperitoneal chemotherapy in the German DRG system. Analysis of case cost calculations of a maximum care university]. / Hypertherme intraperitoneale Chemotherapie im G-DRG-System. Analyse der Fallkostenkalkulationen eines universitären Maximalversorgers.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) offers patients with peritoneal cancer of various origins the chance of a relevant increase in life expectancy. These cases are very complex from a medical viewpoint and very expensive from an economical aspect. An analysis of case cost calculations was performed to find out whether this procedure can on average be carried out cost-effectively by a maximum care university. MATERIALS AND METHODS: All cases from 2008 in which HIPEC was carried out were analyzed. The types of main diagnosis, secondary diagnoses, procedures, times from incision to suture and hospital stay were analyzed. On the basis of the case costs the proceeds and marginal returns were calculated from the diagnosis-related groups (DRGs) and additional remuneration when applicable. The causes of positive and negative marginal returns were explained using the InEK cost matrix. RESULTS: In 18 patients there were 9 different main diagnoses and 7 different "main procedures" (from a surgical perspective the most resource intensive procedures) and a total of 10 different DRGs were identified in the grouping algorithm. With an average of 2 operations (range 1-7) per patient the summed incision-to-suture time was 423 min (170-962 min). The patients stayed on average 6.4 days (1.3-17.6 days) in intensive care. The average case cost was 21,072€ (range 8,657-55,904€) and the proceeds 20,474€ (6,333-37,497€). Each case had on average a debit balance of 598€ (range from 11,843€ profit balance to 18,407€ debit balance) with an assumed base rate of 2,786€. The causes for positive or negative marginal profits were mostly operating times, incision-to-suture times and duration of intensive care. CONCLUSIONS: The proceeds showed on average a deficit of only 3% compared to the costs. The operating times must be decreased by optimization particularly of the preoperative approach. Interventions should be carried out in one stage only and the intraoperative connecting and waiting times should be reduced in order to reduce the incision-to-suture times.

["Fast-track" rehabilitation to enhance recovery after ileostomy closure--a prospective clinical trial]. / "Fast-track"-Rehabilitation zur Beschleunigung der Rekonvaleszenz nach Ileostomarückverlagerung--eine prospektive kontrollierte Studie.

BACKGROUND AND AIMS: After colorectal resections, concepts for early recovery (ERAS or fast-track) could reduce the length of the hospital stay. Whether or not such a multimodal treatment can shorten the hospitalisation after loop ileostomy closure was investigated in the present study. PATIENTS AND METHODS: All patients admitted for elective closure of a loop ileostomy were prospectively investigated. The first group (n = 20) was postoperatively treated in a conventional manner. In the other group (n = 20), a concept for "fast-track" rehabilitation including early oral feeding, early mobilisation and abandonment of opioid analgesia was used. RESULTS: Oral feeding with liquids and solid food was tolerated in the "fast-track" group earlier than after conventional treatment. There was no increase in the incidence of postoperative complications. Patients of the "fast-track" group could be discharged 3 days earlier on average (p = 0,01). CONCLUSION: "Fast-track" rehabilitation can shorten the length of hospitalisation after elective ileostomy closure.

LapSim virtual reality laparoscopic simulator reflects clinical experience in German surgeons.

BACKGROUND AND AIMS: The aim of this study was to analyze the ability of a training module on a virtual laparoscopic simulator to assess surgical experience in laparoscopy. METHODS: One hundred and fifteen participants at the 120th annual convent of the German surgical society took part in this study. All participants were stratified into two groups, one with laparoscopic experience of less than 50 operations (group 1, n=61) and one with laparoscopic experience of more than 50 laparoscopic operations (group 2, n=54). All subjects completed a laparoscopic training module consisting of five different exercises for navigation, coordination, grasping, cutting and clipping. The time to perform each task was measured, as were the path lengths of the instruments and their respective angles representing the economy of the movements. Results between groups were compared using chi(2) or Mann-Whitney U-test. RESULTS: Group 1 needed more time for completion of the exercises (median 424 s, range 99-1,376 s) than group 2 (median 315 s, range 168-625 s) (P<0.01). Instrument movements were less economic in group 1 with larger angular pathways, e.g. in the cutting exercise (median 352 degrees , range 104-1,628 degrees vs median 204 degrees , range 107-444 degrees , P<0.01), and longer path lengths (each instrument P<0.05). CONCLUSION: As time for completion of exercises, instrument path lengths and angular paths are indicators of clinical experience, it can be concluded that laparoscopic skills acquired in the operating room transfer into virtual reality. A laparoscopic simulator can serve as an instrument for the assessment of experience in laparoscopic surgery.

Expression of high-mobility-group-protein HMGI-C mRNA in the peripheral blood is an independent poor prognostic indicator for survival in metastatic breast cancer.

HMGI-C belongs to the high-mobility-group-protein (HMG) family of architectural transcription factors and considerable interest has recently been shown in its expression in neoplastic tissues and apparent involvement in tumorigenesis. We could previously demonstrate an expression of HMGI-C mRNA in the peripheral blood of breast cancer patients for the first time. In this prospective study, we evaluated the independent prognostic power of HMGI-C mRNA expression in the peripheral blood of an unselected cohort of 69 patients with metastatic breast cancer using a hemi-nested reverse transcriptase polymerase chain reaction (RT-PCR) followed by sequence analysis of the resulting PCR products. Multivariate analysis was performed using the Cox regression model. HMGI-C mRNA was detected in peripheral blood from 21 out of 69 (30%) patients with metastatic breast cancer. Median survival was 15.9 months in patients expressing HMGI-C, while in the group of patients without HMGI-C expression the median survival had not been reached yet after a median follow-up of 24.7 months and 85.4% were still alive in this group. Disease-specific survival was significantly worse for patients positive for HMGI-C in comparison to those not expressing HMGI-C (P=0.0001). In a multivariate regression analysis, HMGI-C remained an independent prognostic factor for overall survival (P=0.001) besides oestrogen receptor status (P=0.024) and presence of metastases in liver and lungs (P=0.029). HMGI-C expression in the peripheral blood of patients with metastatic breast cancer is a powerful independent indicator for poor overall survival and this is the first study to demonstrate its prognostic relevance in univariate and multivariate analysis.

Eosinophilia during fludarabine treatment of chronic lymphocytic leukemia.

Although eosinophilia has been reported as a side effect of purine analogues, there is no report on fludarabine-induced eosinophilia in chronic lymphocytic leukemia (CLL). During chemotherapy with fludarabine and cyclophosphamide, we observed two cases of significant eosinophilia. A 67-year-old patient with CLL developed bone marrow and peripheral blood eosinophilia up to 7.9x10(9)/l, the highest eosinophil count ever reported during treatment with a purine analogue. The eosinophilia persisted for 33 days. Another patient developed bone marrow eosinophilia without eosinophilia in the peripheral blood. These are the first documented cases of fludarabine-induced eosinophilia in CLL, and this side effect may conceivably be more common than previously recognized.