Impact of New Shift Models for Doctors Working at a German University Hospital for Gynaecology and Obstetrics Four Years After Implementation. Can They Meet the European Working Time Directive Without Increasing Costs?

Background: The impact of the European Working Time Directive and subsequent collective wage agreements for doctors from 2006 onwards were substantial. So far, no systematic evaluation of their application in Germany has been performed. We evaluated the impact four years after implementation of new shift models in a University Hospital for Gynaecology and Obstetrics (UHGO). Methods: A new shift model was created together with doctors of Tübingen UHOG in 2007 and implemented in 2008. Documentation of working hours has hence been done electronically. Adherence to the average weekly working time limit (AWTL) and the maximum of 10 h daily working time (10 h-dwt) was evaluated, as well as staffing costs in relation to case-weight points gathered within the German DRG (diagnosis related groups) System. Results: Staff increased from a mean of 44.7 full time equivalent (FTE) doctors in 2007 to 52.5 FTE in 2009, 50.8 in 2010, and 54.5 in 2011. There was no statistically significant difference of the monthly staff expenditures per case-weight between the years 2009 or 2010 vs. 2007. 2011, however, was significantly more expensive than 2007 (p = 0.02). The internal control group (five other departments of the university hospital) did not show an increase during the same period. AWTL were respected by 90, 96, and 98 % in 2009, 2010, and 2011, respectively. Of all shifts 10 h-dwt was exceeded by 7.4 % in 2009, 1.3 % in 2010, and 2.6 % in 2011, with significant differences between 2009 and both, 2010 and 2011 (p < 0.001), and between 2010 and 2011 (p = 0.02). Discussion: AWTL and 10 h-dwt could be continuously respected quite well after implementation of the new shift model without increasing the cost/earnings ratio for the first two years. However, in 2011 the ratio increased significantly (p = 0.02).

[A new working shift model for anesthesiologists: an analysis 3 years after implementation]. / Neues Dienstzeitenmodell für Ärzte in der Anästhesie : Eine Analyse 3 Jahre nach Implementierung.

OBJECTIVE: The aim of this study was to assess the efficacy, appropriateness and cost-effectiveness of a new working shift model for anesthesiologists complying with the European working time directive (EWTD) at the University Hospital of Tübingen (UKT), Germany 3 years after implementation BACKGROUND: Applying the standards of the EWTD is challenging for university hospitals as doctors must comply with the challenge of combining patient care, research and teaching. So far there have been no data available for German university hospitals on how these requirements can be met. As the department of anesthesiology is also a service-providing department it is essential not to increase staffing costs with a new shift model. METHODS: In 2007 a new working shift model for the department of anesthesiology was designed and introduced in 2008. Shift planning and documentation of working hours were implemented electronically. The calculated number of doctors to run this model was 87.6 full time equivalents (FTE). For 2009 and 2010 the compliance with the EWTD parameters was checked for 1) average weekly working time limit (AWWTL) and 2) compliance to the maximum daily working time limit of 10 h (10 h DWTL). Furthermore, staffing costs for doctors in 2010 were compared to 2007. To check for the time spent in patient care the period of anesthetic attendance (PAA) was chosen, i.e. the total time of patient contact by anesthesiology staff. Data were analyzed descriptively for AWWTL and for 10 h DWTL. FTE, staff costs and PAA were evaluated by one-way ANOVA. RESULTS: The new shift model allowed 84.4 % of all doctors to comply with the individual AWWT limits of 54 h and 48 h in 2009 (81/96) and 76.0 % in 2010 (79/104). In 2009 61.5 % of anesthesiologists voted for opt-out (59/96) and 53.8 % did so in 2010 (56/104). The 10 h DWTL was respected by 84.0 % in 2009 and by 85.9 % in 2010. The mean number of anesthesiologists rose significantly from 78.4 FTE in 2007 to 82.5 FTE in 2009 and 84.6 FTE in 2010 (p < 0.001 for 2010 vs. 2007, p = 0.004 for 2009 vs. 2007 and was not significant for 2010 vs. 2009). Staff costs per FTE increased from 7,524.79 /month to 7,800.66 /month and 7,966.11 /month in 2007, 2009 and 2010, respectively with the differences being non-significant. The PAA increased significantly from a mean of 6,124 h/month in 2007 to 6,581 h/month in 2009 and 6,872 h/month in 2010 (p < 0.001 for 2010 vs. 2007, whereas 2009 vs. 2007 and 2010 vs. 2009 were not significant). Thus, labour costs increased from 96.59 /h PAA in 2007 to 98.53 /h in both 2009 and 2010, the differences being not significant. CONCLUSIONS: The newly designed shift model allowed a fair compliance with the EWTD in respect to AWTL and 10 h DWTL, although the calculated number of doctors to run the shift model could not be met in 2009 and 2010. Violations of the 10 h DWT limits were stable in 2009 and 2010; however the number of doctors exceeding the AWWT limits appeared to increase. The compliance with opt-out decreased from 2009 to 2010 and a high proportion of AWWTL violations resulted from the group of non-opt-out voters. The staff costs per hour PAA after implementation of the new shift model did not differ significantly from the year before although staffing costs increased by 7.2 % between 2007 and 2010. Costs increased by 162,454 /year for all PAA hours in 2010. Further evaluation of staff satisfaction with the new shift models is needed and already under way.

Freeze-thawing of breast milk does not prevent cytomegalovirus transmission to a preterm infant.

Freezing human milk is recommended to inactivate cytomegalovirus (CMV). A case of a preterm infant exclusively receiving frozen breast milk from his CMV seropositive mother showed that storage of breast milk for two months at -20 degrees C did not prevent symptomatic postnatal CMV infection.

[Breast feeding of very preterm infants of HCMV-seropositive mothers]. / Muttermilchernährung der sehr unreifen Frühgeborenen von HCMV-seropositiven Müttern -- Stellungnahme.

Preterm infants can be infected with human cytomegalovirus (HCMV) transmitted via breast milk of their HCMV-seropositive mothers, 96 % of whom reactivate the virus during lactation. 38 % of exposed VLBW infants become infected, with 48 % of these developing at least one symptom. Whether priority should be given to the multiple advantages of breast milk feeding or to the avoidance of a possible HCMV infection by exclusive formula feeding still cannot be decided due to insufficient data on the long-term outcome of infected infants. Inactivation of HCMV in breast milk can be achieved safely only via heat treatment, but the clinical consequences resulting from the use of pasteurized breast milk are unknown. Given the above situation, the authors decided to continue breast-feeding of VLBW and ELBW infants in their units after obtaining informed parenteral consent, until data for an evidence-based decision become available.

Cytomegalovirus infection of extremely low-birth weight infants via breast milk.

In addition to seroprevalence and transmission rate, the clinical symptoms of postnatal cytomegalovirus (CMV) infection in infants with a very low birth weight (VLBW; <1500 g; <32 weeks gestational age at birth) were assessed in a 3-year prospective study. CMV monitoring included serologic testing (of the mother and child) and virus culture and PCR (of samples of both breast milk and the infant's urine). Within 3 weeks of the initial virus detection in the infant, clinical and laboratory parameters were evaluated. Of 170 infants, no CMV transmission was found in the 80 infants of seronegative mothers and in the 3 infants of seropositive mothers who did not shed CMV DNA into breast milk. Transmission occurred in 33 of the 87 CMV-exposed infants, 16 of whom presented with such symptoms as hepatopathy, neutropenia, thrombocytopenia, and sepsis-like deterioration. Low birth weight and early postnatal virus transmission were risk factors for symptomatic infection. VLBW infants of CMV-seropositive mothers are at high risk of acquiring a symptomatic CMV infection postnatally via breast milk.

Metabolic reaction after concentric and eccentric endurance-exercise of the knee and ankle.

PURPOSE: Power training plays an essential part in many sport disciplines. The importance of eccentric power training remains a matter of controversial discussion. The objective of this study was therefore to investigate the difference in metabolic reaction between eccentric and concentric stress in comparable work. METHODS: Sixty-four men between 22 and 60 yr of age performed maximum isokinetic 1-min endurance tests of the knee and ankle each in concentric (180 degrees.s-1) and eccentric (60 degrees.s-1) modes with comparable total area of contraction-time curve (NS). Higher strength values (mean peak torque, P < 0.01), lower fatigue (fatigue index, P < 0.001), lower increase in lactate (P < 0.01), and lower ammonia production (P < 0.01) were found in eccentric than in concentric exercise, independent of the joint. The eccentric form of stress showed lower decrease and thus age-dependence in maximum strength and in fatigue than the concentric form. RESULTS: The results permit the conclusion that eccentric exercise leads to less fatigue and lower lactate and ammonia reaction than concentric exercise in comparable work levels. Variable visco-elastic properties of the muscle fibers themselves with additive passive strength in eccentric mode is considered as the cause. CONCLUSIONS: It remains uncertain whether the lower metabolic stress might be useful during the training process. A greater scope of training and increased number of training stimuli might be applied in primarily eccentric forms of exercise.

Epidemiology of transmission of cytomegalovirus from mother to preterm infant by breastfeeding.

BACKGROUND: Breastfeeding practices strongly influence the epidemiology of human cytomegalovirus infection. By contrast with term neonates, few data are available on transmission of infection from mothers to preterm infants during breastfeeding. METHODS: 151 mothers and their 176 preterm infants (gestational age at birth <32 weeks or birthweight <1500 g) were prospectively screened for cytomegalovirus infection by serology, virus culture, and PCR. The roles of cell-free and cell-associated cytomegalovirus excretion during lactation were analysed longitudinally in relation to transmission, by maximum-likelihood estimates. FINDINGS: Of the 69 seronegative breastfeeding control mothers, none had detectable cytomegalovirus DNA in breastmilk and none of their 80 infants shed the virus in urine. The proportion of cytomegalovirus reactivation in seropositive breastfeeding mothers was 96% (73 of 76). The early appearance of viral DNA in milk whey (median 3.5 days post partum in transmitters; 8 days in non-transmitters; p=0.025) and infectious virus in milk whey (10 days and 16 days, respectively; p=0.005) were risk factors for transmission. The cumulative rate of transmission was 37% (27 of 73 mothers; 33 infants). The infection of the neonates had a mean incubation time of 42 days (95% CI 28-69). About 50% of the infected infants had no symptoms, but four had sepsis-like symptoms. INTERPRETATION: The proportion of cytomegalovirus reactivation during lactation almost equals maternal seroprevalence. Breastfeeding as a source of postnatal cytomegalovirus infection in preterm infants has been underestimated and may be associated with a symptomatic infection.

Transmission of cytomegalovirus infection through breast milk in term and preterm infants. The role of cell free milk whey and milk cells.

We investigated the reactivation of cytomegalovirus during lactation and analysed the role of human milk whey and milk cells in mother-to-child-transmission. In contrast to term infants, preterm infants may be infected symptomatically by breastfeeding. Human milk whey is the material of choice for detection of maternal DNAlactia and virolactia, whereas milk cells not necessarily have to be infected in transmitters.

Evaluation of protein S-100 serum concentrations in healthy newborns and seven newborns with perinatal acidosis.

UNLABELLED: We measured Protein S-100 serum levels in 66 healthy newborns during the first week of life and in 7 newborns with perinatal acidosis. Normal values (n = 66) constantly ranged between 0.66 and 3.33 microg/l (2.5 and 97.5 percentiles) during the evaluation period. CONCLUSIONS: Newborns with signs of hypoxic-ischaemic encephalopathy (HIE) after perinatal acidosis showed elevated Protein S-100 serum levels, whereas newborns without these signs had normal concentrations. S-100 might thus be a marker of central nervous system damage in newborns. Key words: Asphyxia, brain damage, neonate

The influence of age on isokinetic torque of the upper and lower leg musculature in sedentary men.

While strength patterns in aging for the knee joint have been well investigated in the concentric mode, few data are available about the behaviour in the eccentric mode and for either modus in the ankle. The purpose of this study was to compile reference data for the lower extremities in untrained men between 20 and 60 years of age to determine the influence of age, especially in the eccentric work mode. Sixty-four male subjects between 20 and 60 years were divided into four age groups. Using a LIDO ACTIVE dynamometer, maximum torque was tested for the knee between 90 degrees to 0 degrees and for the ankle between 30 degrees to -10 degrees at velocities 60, 180, 240, 300 degrees/s concentric, 60 and 120 degrees/s eccentric and isometric with angles 15 degrees, 30 degrees, 45 degrees, 60 degrees, 75 degrees for the knee and 30 degrees, 20 degrees, 10 degrees, 0 degrees , -10 degrees for the ankle. Individual parameters for age-dependence were checked using linear correlation calculation with p < 0.01 set as significant. The peak torque (PT) of the knee extensors and flexors showed a typical course with the highest values in the eccentric and isometric mode and a decrease in the concentric mode with increasing angular velocity. In the concentric mode there was a significant negative correlation between PT and age at all angular velocities, but none for isometric and eccentric mode. The greatest maximum torque in the ankle was attained in the eccentric mode at 60 degrees/s. The difference to the knee was smallest in this mode compared to isometric and concentric. The plantar flexion showed age-dependence at all concentric velocities, less in eccentric and none in isometric mode. There was no correlation in dorsiflexion. The influence of loss of muscle fiber and degeneration in the course of aging has thus less influence in eccentric measurements than in the concentric mode. On the contrary, it must be assumed that the high eccentric tensions which are possible due to the quasi-elastic structures in the muscle, are maintained by the increase in stiffness of the connective tissue.

The cardiocirculatory reaction to isokinetic exercises in dependence on the form of exercise and age.

Although isokinetic training is gaining in importance in prevention and rehabilitation, even for older patients, there is hardly any information available on the extent of cardiocirculatory stress. This study was aimed, therefore, at examining the cardiocirculatory reaction to various isokinetic forms of exercise in dependence on age. Sixty-four subjects between 22 and 60 years of age were assigned to four age groups and the maximum torque measured in concentric and eccentric exercises with various angle accelerations. Moreover, all subjects underwent 1-min concentric and eccentric endurance stress and an isometric test. The cardiocirculatory reaction as reflected in heart rate and blood pressure patterns was determined, as well as the plasma catecholamines adrenaline and noradrenaline measured. The eccentric maximum torque was significantly above the concentric maximum torque; there was a significant inverse relationship to age only in the concentric mode of exercise (r = -0.48; p < 0.01). The cardiocirculatory reaction in endurance stress and isometry, like the behavior of heart rate, blood pressure, and plasma catecholamines, was greatest in concentric exercise, although the maximum strength values were lower, followed by eccentric exercise and isometry. Exercise values such as those attained in maximum ergometric forms of exercise were not reached. It is concluded that no special precautionary measures are required in isokinetic forms of exercise.