[Geriatric surgery or geriatrisation of surgical medicine]. / Gerontochirurgie oder die Geriatrisierung der operativen Medizin.

In the western industrial nations the proportion of old people (according to WHO definition people over 75 years) has been rising for many years and with it the amount of surgical treatment on this group of the population. High age does not automatically mean a risk too high for surgical treatment. Very often the reasons for this age group being high-risk patients are hospital admission in an advanced stage of illness or complications due to the illness. Old people are biologically younger than they were years ago. Often they express their perfectly understandable wish for suitable treatment. New treatments and strategies in surgery such as minimal-invasive surgery, endoluminal techniques for heart and vascular surgery, fast-track-concepts, anaesthetising techniques like spinal anaesthesia or the use of better controllable narcotics, improves alleviation of pain, quick mobilisation and early oral nutrition contribute to a minimisation of the risk. Age-related multimorbidity defines the risks of major operations and requires an individual weighing up of benefit and risk. The decision for or against an operation must take the elderly patient's wishes into account. The most important aspect is not only to help the people survive but to enable them to participate in life. In this paper we try to give an overview of geriatric surgery with all its aspects relevant to insurance.

[From guilt and shame to professional handling of mistakes--risk management in surgical medicine]. / Von Schuld und Scham zu einem professionellen Umgang mit Fehlern--Risikomanagement in der operativen Medizin.

Medical advances in diagnosis and therapy, especially in medical technology, lead to differenciated and more complex strategies in therapy with higher risks. Patients show higher expectations concerning the results of a therapy and claim more often that a mistake in treatment has been made. This makes patients turn to arbitration boards more often. They may also want to bring civil action against physicians and hospitals, claiming for compensation and damages. Personal liability insurances have to pay more for damages. Medical insurances have more recourse demands due to mistake in treatment. Hospital and especially operative medicine do have high chances of risks and mistakes. The implementation of a modern risk management system in the hospitals is becoming more and more important, for patients as well as for the surgical departments. A structured reporting system of critical incidents can produce indicators of potential sources of mistakes, which appears to be a successful approach to reduce or avoid typical risks and mistakes in medical treatment. Risk management in medical treatment must be more than just a trendy word, because its roots are in the medical principles of "primum nihil nocere". It is a challenge to today's and tomorrow's medicine. This article is a general overview of current strategies for avoiding mistakes: It is meant to be the basis of a new culture of mistake avoidance as a part of a future quality competition.

[Quality assurance by routine data (QAR)--a new dimension in quality management of inpatient treatment?]. / Qualitätssicherung mit Routinedaten (QSR)--eine neue Dimension im Qualitätsmanagement der stationären Behandlung?

Patients, admitting doctors and payers want to have more and more valid information about the medical results in hospitals really are. The quality of medical care in hospitals is demonstrated in the quality reports through structure and process data, data of volume about the most common main diagnoses and procedures and, in the current version, also through data of external quality assurance. For patients and payers, this means that it may be difficult to obtain sufficient information on relevant quality criteria for different therapies in hospital departments. It may also mean that it is difficult to choose between hospitals. The project "Quality assurance of inpatient treatment by routine data" (QAR) is a new and extended attempt in quality management. By changing the reimbursement procedures of hospitals to DRG, one receives data from which one can easily deduce marks of quality. For special treatment the QAR marks of quality provide patients, insurance companies and the internal quality management of hospitals with information on the quality of the hospitals and their departments. In this paper, the opportunities and prospects of quality assurance by using routine date will be discussed.

[Surgery on the fast track--"fast track" concepts in abdominal-/pediatric surgery and urology]. / Operative Medizin auf der Schnell- oder Uberholspur--"Fast Track" Konzepte in Chirurgie, Kinderchirurgie und Urologie.

In surgical medicine there are traditions, myths, rites and dogmas which define concepts of treatment and strategies. Upheld and passed on without being examined or confirmed in further studies, these concepts and strategies include preoperative intestinal lavage and fasting, postoperative long-term drainage, tubes und catheters, long-term relaxation of the intestine after abdominal surgery or immobilisation for some days. New techniques and procedures in surgery and anaesthesia, including postoperative pain management like laparoscopic surgery and partial anaesthesia, reduce the need for surgery and minimize morbidity of treatment. For more than ten years now, the Copenhagen abdominal surgeon Henrik Kehlet and his team have systematically dealt with the question of how to reduce perioperative stress and improve postoperative conditions of recovery. The resulting concepts of an "enhanced recovery after surgery" (ERAS) seek to overcome handed-down myths und fix new clinical pathways. In current prospective studies of elective surgery, the clinical use of these fast track concepts have been confirmed in colon surgery, pediatric surgery and urology. Here, examples of some of these studies are discussed together with problems like general complications and length of stay, while aspects of insurance are also taken into consideration.

[Vestibular paroxysmia. A rare but important differential diagnosis]. / Vestibuläre Paroxysmie. Eine seltene, aber wichtige Differenzialdiagnose.

The diagnosis and treatment of vertigo are very common in ear nose and throat medicine and neurology. As our case report demonstrates, an interdisciplinary approach is often useful for finding the correct diagnosis. Diagnosing disabling positional vertigo now seems uncomplicated using special MRI. More important is the history of frequent, short-term vertigo, sometimes accompanied by tinnitus. In analogy to trigeminal neuralgia, treatment should be started with carbamazepine or similar drugs. If unsuccessful, microvascular decompression as a neurosurgical intervention is recommended.

Possible role of MDR1 two-locus genotypes for young-age onset ulcerative colitis but not Crohn's disease.

BACKGROUND: The role of the single nucleotide polymorphisms (SNPs) on positions 2677G>T/A and 3435C>T of the multi-drug-resistance gene 1 (MDR1) in inflammatory bowel disease (IBD) remains unclear. AIMS: To further elucidate the potential impact of MDR1 two-locus genotypes on susceptibility to IBD and disease behaviour. PATIENTS AND METHODS: Three hundred eighty-eight German IBD patients [244 with Crohn's disease (CD), 144 with ulcerative colitis (UC)] and 1,005 German healthy controls were genotyped for the two MDR1 SNPs on positions 2677G>T/A and 3435C>T. Genotype-phenotype analysis was performed with respect to disease susceptibility stratified by age at diagnosis as well as disease localisation and behaviour. RESULTS: Genotype distribution did not differ between all UC or CD patients and controls. Between UC and CD patients, however, we observed a trend of different distribution of the combined genotypes derived from SNPs 2677 and 3435 (chi(2) = 15.997, df = 8, p = 0.054). In subgroup analysis, genotype frequencies between UC patients with early onset of disease and controls showed significant difference for combined positions 2677 and 3435 (chi(2) = 16.054, df = 8, p = 0.034 for age at diagnosis >or=25, lower quartile). Herein the rare genotype 2677GG/3435TT was more frequently observed (odds ratio = 7.0, 95% confidence interval 2.5 - 19.7). In this group severe course of disease behaviour depended on the combined MDR1 SNPs (chi(2) = 16.101, df = 6, p = 0.017 for age at diagnosis >or=25). No association of MDR1 genotypes with disease subgroups in CD was observed. CONCLUSIONS: While overall genotype distribution did not differ, combined MDR1 genotypes derived from positions 2677 and 3435 are possibly associated with young age onset of UC and severe course of disease in this patient group.

The value of Ems Mineral Salts in the treatment of rhinosinusitis in children. Prospective study on the efficacy of mineral salts versus xylometazoline in the topical nasal treatment of children.

UNLABELLED: The treatment of rhinosinusitis seen in the light of uncertain pathogenesis and variable symptoms is under discussion and ranges from the administration of antibiotics, decongestants and anti-allergic agents to no treatment. In this randomized, prospective, double-blind and controlled study the effect of a 14-day treatment (1-2 sprays into each nostril t.d.) with either isotonic Ems Mineral Salts (EMS) solution (Siemens & Co., Bad Ems, Germany) or xylometazoline solution (0.05%) was tested in children (n=66) aged 2-6 years. MAIN OUTCOMES: the degree of mucosal inflammation, nasal patency, general state of health, condition of the middle ear, auditory function as well as an assessment of complaints by the parents. With the exception of the hearing defects, all parameters showed a clear improvement in both treatment groups at the end of the observation period (p>0.001). The hearing defects showed only a trend towards improvement. At the end of the study no differences between the treatment groups could be determined. However, at the intermediate examination after the first 7 days of treatment more favourable results were seen in the group treated with EMS. No undesired medicinal effects were observed, although in 7 out of 34 cases the nasal spray was improperly used in the group treated with xylometazoline. The results of the study show that there is no difference in efficacy between an exclusive treatment by EMS solution in children aged 2-6 years and a treatment with xylometazoline, but with the distinction that with EMS the length of use was not restricted, there were not the potential side effects of nasal decongestants, and there was no contraindication in the newborn and infants.

Fatty acids in colostrum from mothers of children at high risk of atopy in relation to clinical and laboratory signs of allergy in the first year of life.

BACKGROUND: It remains controversial whether fatty acid (FA) composition of breast milk relates to development of atopy in the infant. This study evaluates FA in colostrum from mothers of children at high risk of atopy in association with atopy at the age of 1 year. METHODS: The FA of colostrum were analyzed for 218 children (60 with low birth weight between 1500 and 2500 g, 84 with a history of maternal atopy, and 74 with an elevated cord blood immunoglobulin (Ig)E of >0.9 IU/ml). Total lipids were extracted, methylated and separated by gas-liquid chromatography. Laboratory screening for allergic sensitization and clinical examination took place within the Leipzig Allergy Risk Children's Study (LARS). RESULTS: Low birth weight was correlated with low percentage levels of 20:2n-6, 22:2n-6, and 22:3n-3 (r = 0.14, P < 0.05; r = 0.14, P < 0.05 and r = 0.20, P < 0.01, respectively) and low gestational age at birth was correlated with low 22:3n-3 (r = 0.15, P < 0.05). There was no association between FA and atopic eczema at the age of 1 year. However, high linoleic acid (LA, 18:2n-6) was linked to high specific IgE against cow's milk protein (P < 0.05), and low docosapentaenoic acid (DPA, 22:5n-3) was associated with elevated total serum IgE (P < 0.05) at the age of 1 year, respectively. CONCLUSIONS: The polyunsaturated fatty acid composition of colostrum in a high risk newborn population shows associations with atopic sensitization at the age of 1 year and may be predictive for later atopic disease.

[Improvement of functional deficits, physical mobility and cognitive function by treatment in a geriatric day hospital]. / Verbesserung von grundlegenden Alltagsfunktionen, Mobilität und kognitiver Leistungsfähigkeit durch Behandlung in einer geriatrischen Tagesklinik.

OBJECTIVES AND METHODS: Several studies showed the efficacy of inpatient geriatric treatment. Different outcomes were reported for geriatric patients treated in outpatient facilities. To analyze the course of rehabilitation, 312 patients (62.2% female) with a mean age of 77.2 years (SD = 7.4) in a geriatric day hospital were evaluated regarding a) changes of functional deficits and mobility, b) cognitive function and c) depression. Patients were examined with a geriatric assessment including activities of daily living, Tinetti, Timed-up and go, Mini Mental State Examination (MMSE), Clock Completion Test, Handgrip Strength-Test, Money-Counting Test and Geriatric Depression Scale (GDS) at admission and discharge. RESULTS: All examined parameters had changed significantly after treatment. A clear decrease in the portion of patients with disability-related outcomes in the examined parameters (Barthel Index, Tinetti, Timed-up and go, MMSE, GDS) was demonstrated: a) the proportion of patients with a Barthel Index under 75 had decreased by 26.5%, the proportion of patients with an increased risk of falls was reduced by 27%, b) the proportion of patients with a MMSE Score less than 24 was decreased by 14.8% and c) mild effects were achieved in depression. CONCLUSIONS: Day hospital geriatric treatment leads to an improvement of functional deficits, mobility and mental health of patients. The results contrast to other studies in day hospital treatment.

[Age dependence of laboratory parameters in a health study--attempt at calculating a laboratory index for assessing biological aging]. / Altersabhängigkeit von Laborparametern in einer Gesundheitsstudie--Versuch der Berechnung eines Laborindexes zur Einschätzung des biologischen Alters.

The laboratory analyses of 404 participants of the health study GUNDULA, 201 men and 203 women between 30 and 80 years old, were performed to evaluate the variables for the determination of biological age. From the more than 70 laboratory variables resulting from clinical-chemical and hematologic tests and from urinalysis, less than 40 are significantly age-dependent. About half of these variables were examined by regression analysis to evaluate whether they are useful for the estimation of biological age by a laboratory index. Considerable sex differences were observed. The laboratory indexes for the participants altogether (resulting from 13 parameters) and separated for women (10 parameters) and men (8 parameters) show more variations than the biological age estimated by non-invasive parameters. In men only, there exists a significant but inverse correlation between laboratory index and relative aging rate, the difference between biological and chronological age. The results of some striking variables (e.g. dehydroepiandrosterone sulfate and others) and the results of an explorative factor analysis with regard to possible interconnections between variables and chronological age will be discussed.

The exon 3-retaining and the exon 3-deleted forms of the growth hormone-binding protein (GHBP) in human serum are regulated differently.

Recently, two isoforms of the growth hormone-binding protein (GHBP), which is identical with the extracellular domain of the growth hormone receptor (GHR), have been described. One isoform contains the exon 3 (E3+GHBP) and one excludes the exon 3 (E3-GHBP). The distribution of both isoforms in peripheral blood and their functional relevance is so far unknown. To study the molecular distribution of both species we have analysed sera of 141 subjects with average weight, overweight and obesity by newly developed immunoassays. The relationship between the different molecular forms of GHBP and specific parameters of body composition as well as risk factors of metabolic disturbances, were then examined. The extracellular domain of the exon 3-retaining and -deleted isoforms of the GHR are released as E3+GHBP and E3-GHBP into the peripheral circulation. Furthermore, both molecular species do not show any correlation to each other (r = 0.67) and their relative proportion in blood is gender-dependent with a higher E3-GHBP proportion in females (P < 0.01). E3+GHBP appears to have a considerably stronger correlation to indicators (BMI, fat mass, waist circumference) and metabolic risk factors (fasting insulin, uric acid, triglycerides, apolipoprotein B, diastolic blood pressure) of adiposity than E3-GHBP, indicating differences in their functional significance. The availability of assays for the determination of GHBP isoforms may be very important for the study of the GH receptor and its soluble extracellular domain, GHBP.

Eight novel LDL receptor gene mutations among patients under LDL apheresis in Dresden and Leipzig.

LDL apheresis is highly efficient in reducing elevated plasma cholesterol. Due to strict indications only patients with severe, refractory hypercholesterolemia are treated with this method. Mutations in the LDL receptor gene are major genetic causes for severe hypercholesterolemia. Screening the entire gene in LDL apheresis patients from Saxony should determine whether an increased frequency of defined mutations is responsible for the atherogenic hypercholesterolemia in this group. 31 unrelated patients (15 male, 16 female, age 33-71 yrs.) were included in the analysis. The LDL-R gene was screened using SSCP and/or automated sequencing. The familial defective apolipoprotein B-100 (FDB) mutation was genotyped using established PCR techniques. Nineteen of 31 patients were carriers of an LDL-R mutation. Ten missense and two nonsense mutations, three insertions and two deletions were detected. The mutations C74S, C74R, T87M, 660delC, 662insCCCCG, 680insGGACAAATCTGA, 1428insC and 2167delG have not been previously described. One patient was compound heterozygous for two missense mutations. Two further patients were heterozygous for FDB. No mutations were found among controls. A genetic background for hypercholesterolemia in the LDL-R could be established in about 61% of the patients examined. Therefore, methods of DNA analysis allow to recognize and adequately treat a large portion of high-risk individuals at an early stage.

[Soluble leukocyte adhesion molecules in vegetarians of various ages]. / Lösliche Leukozytenadhäsionsmoleküle bei Vegetariern unterschiedlichen Alters.

OBJECTIVES: Upregulation of leukocyte adhesion molecules under atherogenic conditions is accompanied by the release of soluble forms of adhesion molecules into the bloodstream. Vegetarians have a favorable cardiovascular risk profile. The aim of the present study was to assess the levels of circulating E-selectin (cE-selectin), circulating intercellular adhesion molecule-1 (cICAM-1), and circulating vascular adhesion molecule-1 (cVCAM-1) in both vegetarians and subjects of the average population and furthermore to evaluate the age dependence of cell adhesion molecules. METHODS: 24 male and 59 female vegetarians (mainly members of the German Society of Vegetarians) and 124 male and 179 female control subjects (volunteers, of the ILSE study Leipzig = Interdisciplinary Long Time Study of Health Adult Age and the Lipid-Study Leipzig), 18-89 years old were included in the study. The serum levels of circulating cell adhesion molecules were determined using monoclonal antibody-based ELISA assays (R & D Systems, Abingdon, Europe Ltd.). RESULTS: Vegetarians were characterized by a favorable lipid profile and a low prevalence of common risk factors for atherosclerosis. This group showed a tendency towards lower cICAM-1 levels in comparison with control subjects. Furthermore, significantly lower cE-selectin levels were found in the group of vegetarians. An age-dependent increase of cVCAM-1 and cICAM-1 levels was found both in the group of vegetarians and control subjects. No significant differences were noted regarding the gender of the subjects included in the study. CONCLUSION: Low cE-selectin levels of vegetarians may reflect the favorable cardiovascular risk profile of this group. Furthermore, the present data indicate that cVCAM-1 and cICAM-1 are age-dependent parameters independent of risk for atherosclerosis.

Amino acid sequence, crystallization and structure determination of reduced and oxidized cytochrome c6 from the green alga Scenedesmus obliquus.

Cytochrome c6from the unicellular green alga Scenedesmus obliquus was sequenced, crystallized in its reduced and oxidized state and the three-dimensional structure of the protein in both redox states was determined by X-ray crystallography. Reduced cytochrome c6crystallized as a monomer in the space group P 21212, whereas the oxidized protein crystallized as a dimer in the space group P 3121. The structures were solved by molecular replacement and refined to 1. 9 and 2.0 A, respectively. Comparison of the structures of both redox states revealed only slight differences on the protein surface, whereas a distortion along the axis between the heme iron and its coordinating Met61 residue was observed. No redox-dependent movement of internal water molecules could be detected. The high degree of similarity of the surfaces and charge distributions of both redox states, as well as the dimerization of cytochrome c6as observed in the oxidized crystal, is discussed with respect to its biological relevance and its implications for the reaction mechanisms between cytochrome c6and its redox partners. The dimer of oxidized cytochrome c6may represent a molecular structure occurring in a binary complex with cytochrome b6f. This assembly might be required for the correct orientation of cytochrome c6with respect to its redox partner cytochrome b6f, facilitating the electron transfer within the complex. If the dimerization is not redox-dependent in vivo, the almost identical surfaces of both redox states do not support a long range differentiation between reduced and oxidized cyt c6, i.e. a random collision model for the formation of an electron transfer complex must be assumed.

Structural analysis at 2.2 A of orthorhombic crystals presents the asymmetry of the allophycocyanin-linker complex, AP.LC7.8, from phycobilisomes of Mastigocladus laminosus.

An electrophoretically purified allophycocyanin-linker complex, AP. LC7.8, from phycobilisomes of Mastigocladus laminosus has been crystallized in the orthorhombic space group P212121. Cryocrystallographic x-ray measurements enabled the structural analysis of the complex at a resolution of 2.2 A. The asymmetric unit contains two side-to-side associated "trimeric" (alphabeta)3 allophycocyanin complexes comprising the linker polypeptide in a defined orientation inside the trimer. The linker representing a protein fold related to the prosegment of procarboxypeptidase A is in contact with only two of the three beta-subunits and directly interacts with the corresponding chromophores of these proteins. In addition to a modulation of the chromophores' spectral properties, the linker polypeptide attracts the alphabeta-subcomplexes, thereby bringing the beta-chromophores closer together. These results will enable interpretations of energy-transfer mechanisms within phycobiliproteins.