[Center formation, registries, and quality assurance : Economic impact on training and quality of care]. / Zentrenbildung, Register und Qualitätssicherung : Ökonomische Auswirkung auf Ausbildung und Versorgungsqualität.

BACKGROUNDS AND OBJECTIVE: The increasing tendency toward formation of centers and expansion of quality assurance has had a clear effect on medical education and quality of care in Germany in recent years. On the background of the German diagnosis-related groups (DRG) system and the significant devaluation of DRG codes, this issue should be addressed, particularly in the field of orthopedic endoprostheses. METHODS: The effects of center formation and quality assurance on education and quality of care were evaluated based on a middle-sized clinic. In particular, we highlighted the number of training interventions in recent years on the background of the EndoCert initiative. RESULTS: The costs of complete certification of a hospital according to the KTQ or ISO standard, the expenses for the EndoCert certifications and the EPRD, as well as the continuously increasing personnel demands for registries, quality assurance, and education centers represent an immense economic burden. An improvement in the quality of care can be assumed for the EndoCert Initiative, but this remains without consequence for the revenues situation of the respective cases. DISCUSSION: In light of the lack of medical students and in terms of the quality of care in Germany, it must be discussed as to what extent a training-adapted remuneration of clinics is possible. We stress that medical training doesn't only take place in the operating theater and, up until now, has often not been awarded a high priority in the everyday practice of middle-sized clinics across Germany. Since refinancing is not available in the DRG system, in the absence of remuneration of medical education and the different medical center systems, we can expect that affected clinics, particularly those under economic strain, will no longer be able to meet the high demands of modern initiatives.

[Extended lateral gastrocnemius transposition flap for reconstruction of open knee extensor disruption]. / Rekonstruktion eines offenen Quadrizepssehnendefekts mit dem erweiterten lateralen Gastrocnemiussehnenlappen.

We describe a modified technique to reconstruct a damaged knee extensor mechanism after infected patellar fracture. After resection of infected soft tissue and quadriceps tendon a compound suprapatellar defect existed. Due to compromised tissue on the medial aspect of the calf, we used this flap, which consists of the lateral gastrocnemius muscle with parts of the adjacent Achilles tendon. After a follow-up period of several months the range of movement is 0-0-120°.

Effects on evaporation rates from different water-permeable pavement designs.

The urban water balance can be attenuated to the natural by water-permeable pavements (WPPs). Furthermore, WPPs have a 16% higher evaporation rate than impermeable pavements, which can lead to a better urban climate. Evaporation rates from pavements are influenced by the pavement surface and by the deeper layers. By a compared evaporation measurement between different WPP designs, the grain size distribution of the sub-base shows no influence on the evaporation rates in a significant way. On the contrary, a sub-base made of a twin-layer decreases the evaporation by 16% compared to a homogeneous sub-base. By a change in the colour of the paving stone, 19% higher evaporation rates could be achieved. A further comparison shows that the transpiration-effect of the grass in grass pavers increases the evaporation rates more than threefold to pervious concrete pavements. These high evapotranspiration rates can not be achieved with a pervious concrete paving stone. In spite of this, the broad field of application of the pervious concrete paving stone increases the importance in regard to the urban climate.

Urban evaporation rates for water-permeable pavements.

In urban areas the natural water balance is disturbed. Infiltration and evaporation are reduced, resulting in a high surface runoff and a typical city climate, which can lead to floods and damages. Water-permeable pavements have a high infiltration rate that reduces surface runoff by increasing the groundwater recharge. The high water retention capacity of the street body of up to 51 l/m(2) and its connection via pores to the surface lead to higher evaporation rates than impermeable surfaces. A comparison of these two kinds of pavements shows a 16% increase in evaporation levels of water-permeable pavements. Furthermore, the evaporation from impermeable pavements is linked directly to rain events due to fast-drying surfaces. Water-permeable pavements show a more evenly distributed evaporation after a rain event. Cooling effects by evaporative heat loss can improve the city climate even several days after rain events. On a large scale use, uncomfortable weather like sultriness or dry heat can be prevented and the urban water balance can be attenuated towards the natural.

Social appearance anxiety and self-esteem in women: could body mass index have a mediating role? / Ansiedad por la apariencia social y autoestima en mujeres: ¿podría tener el índice de masa corporal un papel mediador?

La ansiedad por la apariencia social se ha asociado con muchos conceptos, especialmente con la imagen corporal y la autoestima, y tienen un nivel de comorbilidad muy alto. Nuestro objetivo fue evaluar la relación entre el índice de masa corporal (IMC), la percepción corporal, la ansiedad por la apariencia social y la autoestima entre las mujeres, con especial interés en el posible efecto mediador del IMC entre la ansiedad por la apariencia social y la autoestima. Participaron voluntariamente 1344 mujeres. Las puntuaciones de la escala de autoestima diferían significativamente según la imagen corporal, el IMC y la frecuencia de pesaje. Se encontró que la ansiedad por la apariencia social estaba inversamente relacionada con la autoestima y esta relación siguió siendo significativa cuando se ajustó por el IMC como parámetro mediador. En consecuencia, pensamos que mejorar la percepción corporal de las mujeres y reducir la ansiedad por la apariencia social son las principales intervenciones que pueden aumentar la autoestima de estas mujeres. (AU)

Social appearance anxiety has been associated with many concepts, especially body image and self-esteem, and has a very high level of comorbidity. We aimed to examine the relationship between body mass index (BMI), body perception, social appearance anxiety and self-esteem among women, with a particular focus on the possible mediating effect of BMI regarding the relationship between social appearance anxiety and self-esteem. We included 1344 volunteer women in this study. The self-esteem scale scores of women differed significantly according to body image, BMI, and weighing frequency. Social appearance anxiety was found to be inversely associated with self-esteem, and this relationship remained significant when adjusted for BMI as a mediating parameter. As a result, it is expected that improving women's body perception and reducing social appearance anxiety are the foremost interventions to increase the self-esteem of these women. (AU)

Multicentre approach to epidemiological aspects of craniosynostosis in Germany.

We know of no current published data on the prevalence of craniosynostosis in Germany, so our objective in this study was to contribute to the limited knowledge of its epidemiology by assessing time trends, the frequency of prenatal diagnosis, and the timing of diagnosis and treatment. Data were collected in Saxony-Anhalt during the period 2000-17, and we designed a retrospective multicentre cohort study. The prevalence was 4.8 cases of craniosynostosis/10 000 births, and did not increase during that time. We compared the data of 91 patients with those of 273 controls. There were 75 boys and 16 girls (ratio 4.7:1). Fifty-one children had isolated craniosynostosis, consisting of 46 with a single-suture, and five with a multisuture, synostosis. Twenty-nine were associated with other congenital malformations, and 11 were syndromic. Three cases had been diagnosed prenatally, and 34 had skull deformities diagnosed immediately after birth at a mean (SD) age of 3.4 (4.7) months. The mean (SD) age at the time of first admission to hospital in one of the three surgical centres of Saxony-Anhalt was 5.9 (5.5) months, and 65 patients were operated on at a mean age of 9.1 (6.3) months. In contrast to published reports we found a prevalence of 4.8 cases of craniosynostosis/10 000 births that did not increase during the period 2000-16. Although we found a low prenatal detection rate, the diagnosis and treatment in this cohort study seemed timely.

Storm water runoff concentration matrix for urban areas.

The infrastructure (roads, sidewalk, commercial and residential structures) added during the land development and urbanisation process is designed to collect precipitation and convey it out of the watershed, typically in existing surface water channels, such as streams and rivers. The quality of surface water, seepage water and ground water is influenced by pollutants that collect on impervious surfaces and that are carried by urban storm water runoff. Heavy metals, e.g. lead (Pb), zinc (Zn), copper (Cu), cadmium (Cd), polycyclic aromatic hydrocarbons (PAH), mineral oil hydrocarbons (MOH) and readily soluble salts in runoff, contribute to the degradation of water. An intensive literature search on the distribution and concentration of the surface-dependent runoff water has been compiled. Concentration variations of several pollutants derived from different surfaces have been averaged. More than 300 references providing about 1300 data for different pollutants culminate in a representative concentration matrix consisting of medians and extreme values. This matrix can be applied to long-term valuations and numerical modelling of storm water treatment facilities.

[Is DRG Coding too Important to be Left to Physicians? - Evaluation of Economic Efficiency by Health Economists in a University Medical Centre]. / Ist die Kodierung im Krankenhaus zu wichtig, um sie Ärzten zu überlassen? ­ Evaluation der betriebswirtschaftlichen Effizienz von Gesundheitsökonomen an einem Zentrum der Maximalversorgung.

Background: We investigated and evaluated the cost effectiveness of coding by health care economists in a centre for orthopaedics and trauma surgery in Germany, by quantifying and comparing the financial efficiency of physicians with basic knowledge of the DRG-system with the results of healthcare economists with in-depth knowledge (M.Sc.). In addition, a hospital survey was performed to establish how DRG-coding is being performed and the identity of the persons involved. Material and Methods: In a prospective and controlled study, 200 in-patients were coded by a healthcare economist (study group). Prior to that, the same cases were coded by physicians with basic training in the DRG-system, who made up the control group. All cases were picked randomly and blinded without informing the physicians coding the controls, in order to avoid any Hawthorne effect. We evaluated and measured the effective weighting within the G-DRG, the DRG returns per patient, the overall DRG return, and the additional time needed. For the survey, questionnaires were sent to 1200 German hospitals. The completed questionnaire was analysed using a statistical program. Results: The return difference per patient between controls and the study group was significantly greater (2472 ± 337 €; p < 0.05); the overall return was raised by 494,500 €. The mean additional time needed was 11.32 ± 0.8 min per case, resulting in an increase in proceeds of 218 ± 38 € per minute. 2.5 % of all cases had to be devaluated by the health economist after the initial coding by the control group. Returned sheets of 60 hospitals were evaluated. The median level of DRG case reports was 1277 (2500-62,300). Coding was performed in 69 % of cases by doctors, 19 % by skilled specialists for DRG coding and in 8 % together. Overall satisfaction with the DRG was described by 61 % of respondents as good or excellent. Conclusion: Our prospective and controlled study quantifies the cost efficiency of health economists in a centre of orthopaedics and trauma surgery in Germany for the first time. We provide some initial evidence that health economists can enhance the CMI, the resulting DRG return per patient as well as the overall DRG return. Data from the survey shows that in many hospitals there is great reluctance to leave the coding to specialists only.

Development and investigation of a pollution control pit for treatment of stormwater from metal roofs and traffic areas.

Source control by on-site retention and infiltration of stormwater is a sustainable and proven alternative to classical drainage methods. Unfortunately, sedimentary particles and pollutants from drained surfaces cause clogging and endanger soil and groundwater during long-term operation of infiltration devices. German water authorities recommend the use of infiltration devices, such as swales or swale-trench-systems. Direct infiltration by underground facilities, such as pipes, trenches or sinks, without pretreatment of runoff is generally not permitted. Problems occur with runoff from metal roofs, traffic areas and industrial sites. However, due to site limitations, underground systems are often the only feasible option. To overcome this situation, a pollution control pit was developed with a hydrodynamic separator and a multistage filter made of coated porous concrete. The system treats runoff at source and protects soil, groundwater and receiving waterways. Typically, more than 90% of the pollutants such as sedimentary particles, hydrocarbons and heavy metals can be removed. Filters have been developed to treat even higher polluted stormwater loads from metal roofs and industrial sites. The treatment process is based on sedimentation, filtration, adsorption and chemical precipitation. Sediments are trapped in a special chamber within the pit and can be removed easily. Other pollutants are captured in the concrete filter upstream of the sediment separator chamber. Filters can be easily replaced.

Metal concentrations in soil and seepage water due to infiltration of roof runoff by long term numerical modelling.

The qualitative effects of stormwater infiltration on soil and seepage water are investigated with long term numerical modelling. The retention behaviour of different soils and materials used in infiltration devices is determined with batch and column tests. Results of the laboratory tests are adsorption isotherms which represent input data for numerical transport modelling. The long term simulations are performed with combinations of different solutions (types of roof runoff) and infiltration devices (swale and trench) under different hydrogeological conditions. The presented results contain the infiltration of low polluted roof runoff, runoff from a roof with zinc sheets and from a roof with copper sheets concerning the heavy metals zinc, copper and lead. The increase of concentrations in the infiltration body is high. For the infiltrated water, the results show a migration to groundwater only for the low adsorbing soil.

A modified ROC analysis for the selection of cut-off values and the definition of intermediate results of serodiagnostic tests.

A total number of 50 sera from clinically confirmed cases of canine Borrelia (B.) burgdorferi infection and 44 negative control sera were tested with a B. burgdorferi specific antibody ELISA. The data were submitted to the 'two-graph receiver operating characteristic' (TG-ROC) analysis which is a plot of the test sensitivity (Se) and specificity (Sp) against the threshold (cut-off) value assuming the latter to be an independent variable. Thus, in contrast to the conventional ROC analysis, valid pairs of Se and Sp can be read for pre-assigned threshold values directly from the TG-ROC plots. A cut-off that realises equal test parameters (Se = Sp = theta 0 (theta-zero)) can be obtained as the intersection point of the two graphs. Since the value for theta 0 is below a preselected accuracy level (95% or 90%), two cut-off values are selected that represent the bounds of an 'intermediate range' (IR). IR can be considered as a 'borderline' range for the clinical interpretation of test results. The proportion of the measurement range (MR) that gives unambiguous test results can be expressed using IR as the 'valid range proportion' (VRP = (MR-IR)/MR). VRP and theta 0 are useful parameters for test comparison since they do not depend upon the selection of a single cut-off point. In addition, the selection of cut-off values is supported by graphical displays of efficiency, Youden's index and likelihood ratios which can be considered as functions of the pre-assigned cut-off value. TG-ROC was derived as a user-defined template for a commercially available spreadsheet programme (MS-EXCEL, Microsoft).

Predominant site of airway resistance in chronic obstructive pulmonary disease.

The purpose of the present clinical research was to establish the major site of resistance and obstruction in patients with severe, symptomatic chronic obstructive pulmonary disease. We used a noninvasive technique by measuring airflow in a plethysmograph after patients breathed air and after breathing a mixture of 80 percent helium and 20 percent oxygen. In group 1 were 14 patients (mean age, 63 +/- 7 years [+/- 1 SD]) with bronchitis. The ratio of their forced expiratory volume in one second over the vital capacity (FEV1/VC) was 43 +/- 10 percent (mean +/- 1 SD), and their single-breath carbon monoxide diffusing capacity (Dsb) was normal (125 +/- 41 percent of the predicted value). In group 2 were 13 patients with emphysema (mean age, 60 +/- 10 years), whose FEV1/VC was 33 +/- 11 percent and Dsb was 55 +/- 14 percent of predicted. All patients had abnormally low increases in the maximum expiratory flow at midvital capacity after breathing the helium-oxygen mixture. The range in group 1 was -11 percent to +14 percent and in group 2 was -10 percent to +15 percent. Normal subjects in our laboratory show increases of at least +24 percent. This indicates that the limitation of airflow occurs primarily in the small (less than 2 mm in internal diameter) and not the large airways.

The protective effect of ketotifen in bronchial asthma.

Thirty-six patients with confirmed allergic bronchial asthma were divided into 3 parallel groups and treated with ketotifen 1 mg b.i.d. (Group I), ketotifen 2 mg b.i.d. (Group II), and clemastine 1 mg b.i.d. (Group III) respectively for 6 months. Nine out of 12 patients in Group I and 10 out of 12 in Group II experienced a statistically significant improvement in dyspnoea and in pulmonary function (Tiffeneau test). Likewise there was a marked reduction in the number, severity and average duration (minutes per week) of asthmatic attacks. By the 12th week, 8 out of 12 patients in the clemastine group had dropped out because of inefficacy. Ketotifen was very well tolerated by all the patients. In both ketotifen groups pathological eosinophil counts returned to normal during treatment. It can be concluded that ketotifen is effective in the long-term prophylaxis of bronchial asthma.

Alimentary tract duplications in infants and children.

This is a review of 30 duplications of the alimentary tract in 28 patients treated at the Surgical Unit of the Children's Department of the Medical University of Pécs, Hungary, and at the Department of Pediatric Surgery of the Medical Academy of Dresden, Germany, from 1964 to 1989. The ages of patients ranged from 1 day to 13 years, 80 percent were less than 2 years of age at initial presentation. There were 6 thoracic, 20 abdominal and 2 thoraco-abdominal duplications. Distended abdomen, vomiting, bowel obstruction and palpable abdominal mass were most frequently encountered. Plain thoracic and abdominal x-rays, ultrasonography, barium esophagogram, barium meal and enema were the most common diagnostic procedures. Emergency operative intervention was required in 18 patients. One infant died of an unrelated disease. Twenty-three duplications were cystic and 3 tubular. One patient had an appendiceal duplication, and another patient a flat lumenless duplication located on the perineum close to the anal opening. The surgical procedure--removal of the duplication--should not be more radical than necessary to eliminate the potential complaints and prevent recurrence. During surgery the common blood supply shared between the duplication and the native bowel must be carefully protected to avoid undue sacrifice of normal bowel.

Minimally invasive repair of pectus excavatum--the Nuss procedure. A European multicentre experience.

Since the first description in 1998, the minimally invasive repair of pectus excavatum has gained increasing acceptance. The aim of this survey is to report on the experiences of eight European centres with this technique. 172 patients with a mean age of 15.1 (+/- 4.6) years were treated and evaluated, 35.5 % were symptomatic. 45.3 % of the patients had an asymmetric configuration of the chest, 74.3 % had a CT index above 3.25. Mean duration of the operative procedure was 76 minutes. Major complications, including dislocation of the bar or stabiliser, pneumonia, atelectasis, local infection, pleural and pericardial effusion and liver injury occurred in 11.1 % of the patients. Minor complications, such as self-resolving pneumothorax, atelectasis and subcutaneous emphysema were reported in another 8.1 %. Early cosmetic results were excellent or good in 81.5 %. Although the surgical procedure is simple, blood-sparing and short, consideration of some important technical details, proper patient selection and knowledge of the limitations is of vital importance. Long-term results are still lacking.

[Duplication of the alimentary canal in infants and children]. / A tápcsatorna kettözetei csecsemökben és gyermekekben.

This is a review of 30 duplications of the alimentary tract in 28 patients treated at the Surgical Unit of the Children's Department of the Medical University of Pécs, Hungary and at the Department of Pediatric Surgery of the Medical Academy of Dresden, Germany, from 1964 to 1989. The ages of patients ranged from 1 day to 13 years, 80 per cent were less than 2 years of age at initial presentation. There were 6 thoracic, 20 abdominal and 2 thoracoabdominal duplications. Distended abdomen, vomiting, bowel obstruction and palpable abdominal mass were most frequently encountered. Plain thoracic and abdominal X-rays, ultrasonography, barium esophagogram, barium meal and enema were the most common diagnostic procedures. Emergency operative intervention was required in 18 patients. One infant died of an unrelated disease. Twenty-three duplications were cystic and 3 tubular. One patient had an appendiceal duplication, and another patient a flat lumenless duplication located on the perineum close to the anal opening. The surgical procedure--removal of the duplication--should not be more radical than necessary to eliminate the potential complaints and prevent recurrence. During surgery the common blood supply shared between the duplication and the native bowel must be carefully protected to avoid undue sacrifice of normal bowel.

[Is surgical education associated with additional costs? A controlled economic study on the German DRG System for primary TKA]. / Kostet operative Ausbildung Geld? Eine kontrollierte gesundheitsökonomische Studie auf Grundlage des deutschen DRG-Systems am Beispiel der primären Knieendoprothetik.

AIM: Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedic surgery, the cost of surgical training has as yet not been quantified. In a pilot study, we investigated the economic impact of surgical training under DRG system influences, analysing the cost-proceeds structure in surgical training for orthopaedic residents. METHODS: Consecutive TKAs were performed by the most educated surgeon (Group A) having implanted ≥ 1000 TKAs, another attending (Group B) with ≥ 200 TKAs and a resident (Group C) having assisted in 25 TKAs (n = 30 patients per Group A-C). All patients were embedded in a standardised clinical pathway. By analysing the costs parameters such as numbers of blood transfusions, the operating time and the length of stay in the hospital we investigated the health care-related costs matched to the DRG-based financial refunding. Data were analysed after undergoing a analysis of variance followed by a post-hoc Scheffé procedure. RESULTS: On the one hand the resident generated additional costs of 1111,7 ± 97 € in comparison to the Group A surgeon and 1729,8 ± 152 € compared to the attending Group B (p > 0,05), these were generated by longer stay in hospital, longer operation time and higher need of resources. On the other hand there were significantly higher proceeds of the Group C in comparison to the attending Group B and also to Group A: 474,78 ± 82 € vs. A and 150,54 ± 52 € vs. Group B (p < 0,05). This was generated both by a higher patient clinical level of complexity (PCCL) and increased complication rates resulting in a consecutively augmented profit by grouping these patients to a more lucrative DRG. Overall the deficit per patient treated by the resident is 637 ± 77 € vs. Group A and 1579,3 ± 137 € vs. Group B (p > 0,05). CONCLUSION: The German DRG matrix results in higher profits accounted to the learning surgeon by increased PCCL relevant status and grouping the case to a more profitable DRG. Hereby, the additional costs are only partly redeemed. Surgical education of residents is associated with additional costs for the hospital. These costs have to be redeemed to allow good surgical training for hospitals having good teaching conditions.