[Blended learning in continuing medical education. Evaluation of an innovative curriculum "bipolar and bipolar spectrum disorders"]. / "Blended learning" in der ärztlichen Fortbildung. Evaluation eines innovativen Fortbildungszyklus "Bipolare Störungen und verwandte Erkrankungen".

BACKGROUND: In this article a blended learning concept in continuing medical education is evaluated over a broad range of ages, as there is little data on this topic so far. The aims of this study were to document the blended learning concept, to evaluate the subjective gain of knowledge, as well as didactic and virtual means. Finally the actual usage and accreditation are reported. MATERIAL AND METHODS: The curriculum referred to the topic of bipolar disorder, combined episodes of face-to-face instruction and individual web-based learning over a period of 3 months. RESULTS: The didactic concept was very well accepted by the participants (N=346) and was evaluated as very user-friendly. The most appreciated dimensions were "subjective gain of knowledge" and "support by media tutor". Nearly 80% participated in both face-to-face as well in both web-based episodes. The component of web-based learning was accredited by the responsible institution (State Medical Association) with increasing number of credits over a period of 3 years. CONCLUSION: Blended learning is a useful didactic concept in continuing medical education of psychiatrists independent of the age of the participants.

Fully Automated Surveillance of Healthcare-Associated Infections with MONI-ICU: A Breakthrough in Clinical Infection Surveillance.

OBJECTIVE: Expert surveillance of healthcare-associated infections (HCAIs) is a key parameter for good clinical practice, especially in intensive care medicine. Assessment of clinical entities such as HCAIs is a time-consuming task for highly trained experts. Such are neither available nor affordable in sufficient numbers for continuous surveillance services. Intelligent information technology (IT) tools are in urgent demand. METHODS: MONI-ICU (monitoring of nosocomial infections in intensive care units (ICUs)) has been developed methodologically and practically in a stepwise manner and is a reliable surveillance IT tool for clinical experts. It uses information from the patient data management systems in the ICUs, the laboratory information system, and the administrative hospital information system of the Vienna General Hospital as well as medical expert knowledge on infection criteria applied in a multilevel approach which includes fuzzy logic rules. RESULTS: We describe the use of this system in clinical routine and compare the results generated automatically by MONI-ICU with those generated in parallel by trained surveillance staff using patient chart reviews and other available information ("gold standard"). A total of 99 ICU patient admissions representing 1007 patient days were analyzed. MONI-ICU identified correctly the presence of an HCAI condition in 28/31 cases (sensitivity, 90.3%) and their absence in 68/68 of the non-HCAI cases (specificity, 100%), the latter meaning that MONI-ICU produced no "false alarms". The 3 missed cases were due to correctable technical errors. The time taken for conventional surveillance at the 52 ward visits was 82.5 hours. MONI-ICU analysis of the same patient cases, including careful review of the generated results, required only 12.5 hours (15.2%). CONCLUSION: Provided structured and sufficient information on clinical findings is online available, MONI-ICU provides an almost real-time view of clinical indicators for HCAI - at the cost of almost no additional time on the part of surveillance staff or clinicians.

Learning from Worked-Out Examples: The Effects of Example Variability and Elicited Self-Explanations

It was investigated to what extent example variability and the elicitation of sophisticated self-explanations foster the acquisition of transferable knowledge by learning from worked-out examples. In addition, it was asked whether the effects of these factors are moderated by the learners' levels of prior topic knowledge. To this end, we had 56 apprentices from a bank learn calculation of compound interest and real interest. They were randomly assigned to the four conditions of a 2 x 2-factorial design (factor 1: uniform vs. multiple examples; factor 2: spontaneous vs. elicited self-explanations). The learning results were measured by a post-test comprising near-transfer problems and far-transfer problems. It was found that the acquisition of transferable knowledge can be supported by eliciting self-explanations. In the case of near transfer, especially learners with low levels of prior topic knowledge profited from the elicitation procedure. On the whole, the findings underline the "causal" relevance of the quality of self-explanations for knowledge acquisition by learning from worked-out examples. The assumption that multiple examples foster transfer performance, at least when sophisticated self-explanations are elicited, was not supported. Copyright 1998 Academic Press.

[CASUS model trial. A computer-assisted author system for problem-oriented learning in medicine]. / Modellversuch CASUS. Ein computergestütztes Autorensystem für die problemorientierte Lehre in der Medizin.

The CASUS-project, a three year publicly funded effort to improve the quality of continuing medical education in Germany, has one major goal: The development and evaluation of an easy-to-handle author-system for problem-oriented learning in medicine. On the theoretical basis of the cognitive apprenticeship-approach, the concept of a teaching and learning database as a hypermedia system was built. The student should learn to manage authentical problems in the form of authentical clinical cases. The step-by-step learning process is expert-guided by the clinical authors of each case. The creation of various differential diagnoses by the learner is strongly supported in the process. The structure of the program can also be used for case-based examinations. In parallel to the technical development, a case-selection process for medical students students in internal medicine was initiated. About 120 relevant diseases were identified to be represented in the CASUS-case library. Prevalence, transferability of knowledge, treatability, urgence of treatment and preventive aspects were used as selection criteria. The system will be evaluated during the implementation of test cases and will then be available to be used by authors and students on a routine basis in 1997.

[Clinical and electroneurographic results following surgical treatment of the ulnar nerve sulcus syndrome]. / Klinische und elektroneurographische Ergebnisse nach operativer Behandlung des Sulcus nervi ulnaris-Syndromes.

The sulcus of the elbow-joint represents a bottleneck which may cause compression of the ulnar nerve. We studied clinical and electroneurographical results in 26 patients after operation of the sulcus ulnaris-syndrome. The influence of the duration of compression as well as additional illnesses was evaluated on the postoperative result. The surgical treatment was an anterior transposition of the nerve in a subcutaneous layer combined with external neurolysis. Due to the symptoms and the electroneurographical results after operation the patients were divided into three groups. The best results were obtained in cases with a short period of preoperative complaints (below 1 year). Although heavy work had a positive effect on the manifestation of a sulcus ulnaris-syndrome, it had no adverse effect if started again after operation. Anterior subcutaneous transposition is the operative procedure of choice in cases of sulcus ulnaris-syndrome.

[Late results following surgical correction of syndactyly and symbrachydactyly]. / Spätergebnisse nach operativer Korrektur von Syndaktylien und Symbrachydaktylien.

Growth and the type of surgical treatment of the hand play an important role in the results of surgery in children. 29 patients have been operated on because of syndactyly and symbrachydactyly and were controlled. The following parameters were assessed: kind of incision and skin graft, functional results, x-ray to examine the skeleton and the depth of the commissure, colour of the skin graft and use of the hand. After operation of syndactyly all patients were able to use their hands normally, although full extend of flexion and extension was achieved only in 20 of 22 hands. In 5 divided pairs of fingers there was recurrence of syndactyly. In all cases except one, a split thickness skin graft has been used. After operative treatment of symbrachydactyly and complex syndactyly, full extent of flexion was achieved in 13 of 19 hands, in 6 hands the range of flexion was incomplete because of skeleton abnormalities. Recurrence occurred in 9 divided pairs of fingers; in 7 cases, a split thickness skin graft had been used. Despite this, all patients were able to use their hands normally. The use of split thickness skin grafts resulted in a 60% recurrence rate, whereas the use of full thickness skin graft led merely to 7.5% recurrence rate. Our results show the advantage of the full thickness skin graft. As a consequence, full thickness skin graft should be used in all cases. Furthermore, the operation should be performed at an early age, if fingers of unequal length have to be separated. Zig-zag incision should be used in all cases.

[Reconstruction of deformities of the external ear]. / Die Rekonstruktion äusserer Ohrmissbildungen.

Microtia is a rare malformation. Reconstruction of microtia is not a routine operation because of its rarity of occurrence and the complex deformity. In this paper the indication for surgical treatment, technique, results and complications are discussed. Two different operation methods were used in our patients. A multiple-stage and a single-stage reconstruction procedure. We used autogenous rib cartilage. Five of the seven treated patients came to the follow-up examination. Reconstruction was performed 2 years ago in two cases and between 4 and 12 years ago in three cases. Our patients were content with the result in so far as they would be prepared to undergo treatment again. Carefully built rib framework is an essential prerequisite for a successful postoperative result. Microtia represents a greater psychological problem than a cosmetically imperfect result after reconstruction.

Inadequacy of conventional computerized tomography scans for treatment planning of tangential breast (chest wall) fields.

The use of transverse tomography treatment-planning scans, which have to be taken in the exact treatment position of the patients, is essential for precision radiotherapy of breast cancer. Transverse tomography scans give all necessary informations for an optimal isodose distribution within the target volume for the individual patient, and maximal sparing of normal tissues (e.g. lung) is achieved. The exact topography of internal mammary nodes may also be incorporated in the planning scan with the help of lymphoscintigraphy. Conventional computerized tomography (CT) scanners have too small gantry openings (50-70 cm) to allow for proper positioning of the patients under treatment conditions. Using such treatment-planning scans for patients in the actual treatment position would cause an underdosage in excess of 5% within the target volume, when 60Co fields are used. Also, a much larger volume of normal tissues (mainly lung) would unnecessarily be irradiated. Treatment-planning scans obtained by TAT (transverse analog tomography) do not have the crucial positioning problems of conventional CT scanners and enable the precise transformation of a valid isodose distribution to each patient. In addition, positioning wedges (with adjustable wedge angles) may be placed under the patient to achieve the optimal treatment position. A useful alternative of TAT scanning for precise treatment planning of patients with breast cancer would be a CT scanner with a wide enough gantry opening to allow for any patient positioning under actual treatment conditions.

[Comparative study of primary and secondary management of flexor tendon injuries]. / Vergleichende Studie von primär und sekundär versorgten Beugesehnenverletzungen.

In 1974 a replantation service started at the authors' department. Before that time the treatment of flexor tendon injuries was mainly performed secondarily. Therefore, the authors had the opportunity to compare patients after primary and secondary surgery. In 52 primarily and 22 secondarily treated patients the technique of Kleinert was used. Following issues were investigated: functional results, decrease of grip strength, influence of early mobilization on sensibility restoration in cases of nerve injury, relation between sensitivity to cold and vessel and nerve injuries, duration of physiotherapy and disability. The damage of only one finger might lead to decrease of grip strength. Primary surgery was superior to secondary surgery. Early mobilization in cases of additional nerve injuries did not affect sensibility restoration. Poor sensibility increased the chance of cold sensitivity. The duration of physiotherapy and of disability depended on the need for second procedures such as tenolysis which was more common in the group of secondarily treated patients.

[Determination of the integral dose in computer tomography of the neurocranium]. / Bestimmung der Integraldosis bei der Computertomographie des Neurokraniums.

The amount of exposure of the cranium is calculated on the basis of the measured dose distribution in craniocaudal direction and on the axial planes of the Alderson phantom. The integral dose of the cranium and the local dose at sensitive organs are used as a measure of radiation exposure.

[Reconstruction of grip function in cases of a fingerless or missing hand]. / Rekonstruktion einer Greiffunktion in Fällen von fingerloser oder fehlender Hand.

In two cases a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient all fingers of the left hand were amputated at the metacarpo-phalangeal joint level. The second and the third finger were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. The distal and middle phalanx of the transplanted third toe had to be re-amputated because of mummification two weeks after the transplantation and was covered with a groin flap. Good function of the newly formed grip could be demonstrated. The second patient was a 21-year old man with amputation of both hands. Grip reconstruction in the right lower arm was performed by transplantation of the second toe of each foot together with a metatarsal bone and a dorsalis pedis flap. One year after the operation the follow-up study demonstrated good function of the newly formed hand. The patient is able to use his two new fingers during daily life mainly to hold small objects. The sensation and the range of movement of the newly formed right hand are demonstrated and discussed.

[Percutaneous measurement of oxygen partial pressure as an evaluation method of free flaps]. / Die perkutane Messung des Sauerstoffpartialdruckes als Beurteilungsmethode freier Lappen.

Transcutaneous, polarographic pO2-measurement can be used to estimate and monitor the circulation in free tissue transfers. Our experience in this field using a modified Clark's electrode is reported by presenting some examples. Its value in intraoperative and postoperative monitoring and for the early diagnosis of a critical reduction of blood flow in free flaps with microvascular anastomoses is assessed in the light of our early experience with this technique.

Grip reconstruction by double-toe transplantation in cases of a fingerless hand and a handless arm.

In two cases, a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient, all fingers of the left hand were amputated at the metacarpophalangeal joint level. The second and third fingers were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. Although the distal and the middle phalanx of the transplanted third toe had to be amputated because of mummification 2 weeks after the transplantation and was covered with a groin flap, good function of the newly formed grip can be demonstrated. The second patient is a 21-year-old man with amputation of both hands at the wrist. A grip formation on the right lower arm was performed by transplantation of the second toe of each foot together with the metatarsal bone and a dorsalis pedis flap. Both metatarsal bones were fixed to the ulna and radius with metal plates, and tendons and nerves, together with a vascular supply, were reconstructed. One year after the operation, a follow-up study demonstrates good function of the newly formed "hand." The patient is able to use his two new "fingers" during daily life, mainly to hold small objects. A myoelectric prosthesis has been placed on the patient's left arm, and the patient uses this to hold bigger objects. Restoration of sensation and the range of movement of the newly formed right "hand" are demonstrated and discussed.

[Bridging a lymphatic vessel defect using vein interposition (an experimental study)]. / Uberbrückung eines Lymphgefässdefektes mittels Veneninterposition.

By means of improved microvascular surgery 10-15 mm long vein grafts were interposed into the lymphatic vessels in the groin area of 12 dogs. 6-12 weeks later a histological, clinical and radiological reexamination was performed. In 8 cases out of the 12 the interposed veins were patent, in 4 cases the lumina were occluded by fibrotic tissue. The clinical application of lymphatic vessel-defects in cases of lymphedemas is discussed.

[Microsurgical reconstruction of lymphatic system defects]. / Experimentelle Untersuchungen zur mikrochirurgischen Rekonstruktion von Lymphgefässdefekten.

In a group of eighteen dogs (1977-79) artificially interrupted lymphatics have been bridged by suitable small vein grafts. Patency was controlled by different methods: by clinical microscopical control, by microlymphangiography and by histological examinations. The patency rate in this group was 61.1 per cent. So for the first time it could be shown experimentally that it is possible to restore interrupted lymphatics by grafting. This might be the basis for a causal therapy of secondary lymphedema by reconstruction of interrupted or occluded lymphatics. In a further group of fifteen dogs different autologous grafts have been compared. Each five lymphatic, venous and arterial grafts have been interposed in lymph collectors of 0.3 to 0.6 mm in diameter by the same surgeon applying the same microsurgical and atraumatic technique. The grafts varied from 8 to 25 mm in length. While all the lymphatic grafts remained patent, one of the five venous and all arterial grafts were occluded. There could not be found any correlation of patency rate to length of the grafts. Light microscopical and electron microscopical examinations of the harvested vessels showed heavy pathological findings of the arterial walls. In the venous grafts the intima was thickened to different extent. This could be explained by the lack of blood supply from the lumen. Very likely the occlusion of all arterial grafts seems to be explained by the disturbance of the vessel wall blood supply. The lymphatic grafts histologically showed nearly no pathological damage. There was complete reendothelialization at the suture line of all patent grafts. From these experimental results it is concluded that arteries are not suitable for interposition in order to restore lymph drainage. It could be shown that veins and lymphatics are equally usable for this purpose. Therefore these two structures have been used clinically in cases of therapy resisting lymphedemas for reconstruction of the destroyed lymph paths.

[Plastic surgery after extensive tumor surgery of the scalp]. / Defektdeckung nach ausgedehnten Tumorresektionen an der Schädeldecke.

Extensive resections of tumors of the scalp penetrating into the bone and the brain often require the use of free flaps for coverage as the only possibility. Four cases are reported and the specific problems of these microsurgical operations in this region are discussed.

[Microsurgical intervention in a case of Raynaud's gangrene]. / Mikrochirurgische Intervention bei einem Fall von Raynaud'scher Gangrän.

In a case of typical Raynaud's gangrene a microsurgical therapeutic intervention has been tried. To interrupt the periarterial sympathetic nerve network, 1,5-2 cm of both collateral arteries of the affected right index finger were excised and replaced by two venous grafts. In addition both collateral nerves were dissected and reanastomosed for elimination of sensation and pain for some time. In the early postoperative time the patient was free of pain and started using the finger during daily life. 6 weeks after the operation a control-angiography was performed and since that moment the patient complained again of severe pain in the affected finger. The angiography had led to vascular spasm with consequent thrombosis of the patent ulnar venous graft. Because of the severe pain in the finger we were forced to amputate the finger.

[Evaluation criteria for the functional determination after replantation in the hand region]. / Bewertungskriterien für die funktionelle Beurteilung nach Replantationen im Handbereich.

A method of recording the functional results of replantations in the hand is presented, supplying reproducible results of sufficient accuracy by simple means and within a reasonable time. The following criteria are evaluated: fitness for work, usefulness of the hand, mobility, sensibility, circulation and trophic changes, esthetics, perspiration and the retrospective attitude of the patient to replantation and pain. The several parameters are evaluated according to their relevancy and graded according to a scale of values. The total of these values gives the final result. The different results are classified as excellent, good, functionally sufficient and poor. This method of recording the results of digital replantation was evaluated in a series of 28 follow-up examinations with 33 replanted parts. The method of evaluation and the results are discussed in detail.