[Curriculum "patient safety" for undergraduate medical students at the department of surgery, University of Greifswald]. / Curriculum "Patientensicherheit" im Blockpraktikum Chirurgie an der Universität Greifswald.

BACKGROUND: Risk reducing measures like the surgical checklist have been proven to reduce effectively adverse events and improve patient safety and teamwork among surgical staff members. Nevertheless, many physicians still refuse to use even simple safety tools like the WHO checklist. A progress in patient safety can only be achieved by changing the operating proceedings and mentality of medical students. This is best performed by teaching patient safety already very early in the medical education. METHOD: The present study demonstrates the implementation and evaluation of the curriculum "patient safety" for undergraduate medical students in the 4th year of medical school at the Department of Surgery, University of Greifswald. 141 students evaluated a total of six lectures from April to October 2011. RESULTS: The results indicate that young medical students show great enthusiasm in safety matters and are willing to adopt the principles. Especially the importance of the issue and the didactic design were evaluated as being very high. CONCLUSION: The curriculum "patient safety" as part of the training program in medical school is a powerful and effective educational tool that is able to raise the student's awareness of patient safety affairs. Thereby it is crucial to start early within medical education during the phase of socialisation. We recommend the general implementation of a patient safety curriculum in medical school.

[A new treatment method in severe fecal incontinence in children]. / Eine neue Behandlungmethode bei schwerer Stuhlinkontinenz im Kindesalter.

We report a case of successful operative therapy of a 12-year-old child with fecal incontinence (Kelly-Holschneider score: 2 points). In the german-speaking area it was the first implantation of an artificial bowel sphincter in a child. The operative procedure, clinical results and anorectal measurements are described.

Urethral pressure profile measurements in children.

After a brief representation of the physiological processes during micturition in the region of the bladder-urethra junction, the pathological changes in neurogenic micturition dysfunctions leading to an increase of the infravesical flow resistance are considered. A suitable procedure for determining exactly the dysfunction is the registration of a urethral pressure profile. The construction is based on pressure measurement by means of a catheter with a lateral eye, with constant slow perfusion. Measuring errors had to be determined in preliminary trials. Examples of investigations in children with various subvesical urinary dysfunctions demonstrates different points concerning this method.

[Rectoanal perfusion manometry--methods and results in healthy persons]. / Rektoanálna perfúzna manometria--metodika a výsledky u zdravých osôb.

The authors elaborated a method of rectoanal perfusion manometry as part of the objective examination of the functional state of continence structures. They describe in detail the examination method and manometric equipment. In a group of 10 volunteers, 8 incontinent patients and 23 subjects after operations causing improved continence they draw attention to the great sensitivity and specificity of the examination as well as to the correlation of manometric results with results of Holschneider's evaluation by a point system. This method should be used in departments concerned with rectoanal surgery.

[Malpractice in the treatment of fractures and dislocations of the elbow joint in children--experience of the arbitration office of the North German Medical Boards]. / Schlichtungsverfahren bei Kindern mit Frakturen und Luxationen des Ellenbogengelenks--Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the arbitration office of the North German Medical Boards show that 30% of all panel proceedings confirm medical malpractices. In panel proceedings concerning the treatment of fractures in children, the percentage rose to 60% with significant differences in the individual fracture localisations. METHODS: Between the years 2000 and 2010, the arbitration office dealt with 257 panel proceedings regarding the fracture treatment of children. This study evaluates the decisions of 53 proceedings concerning the treatment of fractures and dislocations of the elbow joint. RESULTS: All cases except one concerned the following surgical specialities: 1. orthopaedics/traumatology, n = 14; 2. general surgery, n = 13; 3. paediatric surgery, n = 5. On 7 occasions 2 treatment facilities were involved in the same proceeding. The following types of fractures/dislocations were present (each with the number of proceedings [p] and the confirmed malpractices [m]): fracture of the radial humeral condyle and transcondylar Y-fractures, p = 12, m = 11; fracture of the ulnar epicondyle, p = 2, m = 2; sole dislocation of the radial head as well as in combination with Monteggia lesion, p = 19, m = 17; displaced fracture of the radial head and radial neck, respectively, p = 8, m = 4; fractures of the olecranon, p = 3, m = 2; fracture of the coronoid processus, p = 1, m = 1; dislocations and dislocation fractures of the elbow joint without Monteggia lesion, p = 8, m = 5. DISCUSSION: 42 of these cases (79 %) confirmed malpractice of which 27 (64%) resulted in permanent restriction of the elbow joint mobility. Due to the diversity of injuries, the types of treatment errors were also very variable. In most cases the treatment errors were initiated through the false interpretation of X-ray findings which resulted in false and inadequate therapy measures, for example, the overlooked and not reduced dislocation of the radial head. Three transcondylar Y-fractures were missed on both the X-ray findings and during the operation. In cases where the dislocation of the radial head was not diagnosed in the first instance but operated on within four months (n = 3), a satisfactory result was still achieved. However, if the operation took place at a later time (in our cases 9 months to 8 years after the injury, n = 14) there was no improvement achieved and in many cases the elbow joint mobility deteriorated significantly. In three cases of dislocation of the elbow joint, an intraarticular entrapment of the disjointed ulnar epicondyle was overlooked and therefore not corrected which resulted in deleterious effects on the joint movement. There were five cases with a dislocation combined with a displaced fracture of the radial neck (Mason IV). This fracture was insufficiently reduced/stabilised on two occasions and in one instance the reconstruction of the disrupted joint ligaments was not carried out which resulted in permanent instability of the elbow joint and subluxation. In five casuistic representations the final decision of the arbitration board on the basis of expert reports is illustrated. CONCLUSION: From a traumatological point of view, the elbow region of a child constitutes a distinct problem zone due to the rarity and diversity of the fractures and dislocations in this area. Relevant experiences in diagnostics and therapy of injuries in this region cannot always be expected. Every doctor who happens to come across a case in which a child suffers from such injuries should be responsible for the timely referral to a treatment facility that has the relevant experience to treat such cases.

[Malpractice in the treatment of diaphyseal fractures in children - experience of the Arbitration Office of the Northern German Medical Boards]. / Fehler bei der Behandlung diaphysärer Frakturen der langen Röhrenknochen bei Kindern - Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the Arbitration Office of the North German Medical Boards for extrajudicial claim resolution show that nearly 30 % of all panel proceedings confirm medical malpractice. In proceedings concerning fractures in children the percentage rises to 63 % with significant differences in various fracture localisations. METHODS: Between 2000 and 2011 the Arbitration Office dealt with 272 panel proceedings regarding the fracture treatment in children. In this study 83 proceedings concerning the treatment of diaphyseal fractures of the long bones are evaluated. RESULTS: The claims were related to the following specialities (p = number of proceedings, m = number of malpractices): orthopaedics/traumatology p = 46, m = 38; general surgery p = 17, m = 21; paediatric surgery p = 16, m = 13; anaesthesia p = 1, m = 1; general practitioner p = 2, m = 2. In 7 cases concerning obstetrics (4) and paediatrics (3) no malpractices could be established. In 5 cases two facilities/doctors were included in the same proceeding. On 17 occasions, 2 errors were made that were unrelated to each other. The overall frequency of malpractice was 69 % with no significant differences between the involved facilities. The diaphyseal fracture locations were: humerus p = 5, m = 2; radius and/or ulna (Monteggia fractures excluded): p = 29, m = 20; femur p = 29, m = 20; tibia (with or without fracture of the fibula): p = 20, m = 14. In conservative fracture treatment the following negligent adverse events were confirmed: severe skin lesions owing to either plaster extension or removal of the cast (11), omitted or insufficient reduction followed by consolidation in intolerable malposition (8), no inducement of corrective measures after consolidation in intolerable displacement (11). Following malpractices in the surgical treatment were classified as: no indication for surgical treatment (2), no osteosynthesis in spite of clear indication (3), technical failures in primary osteosynthesis (16), technical failures in repeated osteosynthesis (4), aspiration pneumonia due to missed intubation (1). The applied methods of osteosynthesis were intramedullary nailing, mainly ESIN p = 24, m = 12; plate p = 24, m = 5; fixateur externe p = 7, m = 5. The results of maltreated diaphyseal fractures were altogether moderate: transitional impairment due to delayed or repeated therapeutic measures with prolonged fracture healing, no functional loss 70 %, slight deformation of the forearm, minimal loss of mobility 21 %, remarkable deformation of the forearm with considerable impairment of mobility, especially pronation/supination, deformation of the radio-ulno-carpal joint unit 7 %. DISCUSSION: There are three main categories in the maltreatment of diaphyseal fractures: 1) Omission of fracture reduction with or without internal stabilisation in cases of relevant axial deviation by unjustified expectation of "spontaneous correction". 2) Omission of fracture reduction in cases of unmotivated or neglected secondary displacement. 3) Technical failures in performing of osteosynthesis resulting in instability or the creation of intolerable malposition requiring re-osteosynthesis. The high number of plate osteosyntheses in our series (44 %) is not representative for the general treatment of children's fractures in Germany. Most cases of plate osteosynthesis are related to corrective measures with clear indication. In nine casuistic representations the errors in treatment are explained. CONCLUSION: The evaluation of malpractice in the treatment of diaphyseal fractures in children confirms the consensus: correct assessment of fracture type, early adequate treatment and fracture control, early corrective measures after insufficient primary reduction or secondary dislocation, lead to fracture healing without any anatomic or functional deficiency. Reverse argument: fracture healing leading to anatomic and/or functional loss gives a very probable indication of malpractice.

[Malpractice in the treatment of supracondylar humeral fractures in children - experience of the arbitration office of the Northern German Medical Boards]. / Fehler bei der Behandlung suprakondylärer Humerusfrakturen bei Kindern - Erfahrungen der Norddeutschen Schlichtungsstelle.

INTRODUCTION: Arbitration offices ("Schlichtungsstellen") in Germany are expert panels for the extrajudicial resolution of malpractice claims. The performance of arbitration panel proceedings ("Schlichtungsverfahren") is based on the German medical and insurance jurisdiction. In Germany, and in the United States likewise, malpractice claims involving children concern in most cases fracture treatment followed by appendicitis. Out of 242 panel proceedings with the background of fracture treatment in children malpractice was confirmed in 144 cases (60%). The overall ratio: number of confirmed malpractices to number of all proceedings is 30%. There are remarkable differences between the natural occurrence of the different fracture localisations and the fracture localisation related claims. This ratio amounts for example: clavicula 7 : 1, forearm 2 : 1, femur 1 : 5, elbow region (articular) 1 : 5, humerus supracondylar 1 : 3. METHOD: 32 arbitration panel proceedings concerning alleged malpractice in the treatment of supracondylar humeral fractures in children were evaluated in regards to diagnosis of fracture type and degree of dislocation, conservative and operative fracture treatment, complications, and malpractice related permanent disabilities. RESULTS: In 20 cases (63%) malpractice was confirmed. The different failures could be classified in: 1) Incorrect interpretation of the X-ray findings, classified as fractures without or with minimal displacement, no reduction, healing with intolerable dislocation; n = 3. 2) Insufficient closed or open fracture reduction, stabilisation and healing with intolerable dislocation; n = 10. 3) Correct primary closed or open reduction, unstable osteosynthesis (loss of pin fixation of the ulnar epicondylus), secondary postoperative rotatory dislocation, cubitus varus; n = 3. 4) Delayed detection of a compartment syndrome of the forearm, no or delayed fasciotomy; n = 3, in two cases resulting in severe Volkmann's contracture. 5) Extensive skin necrosis caused by uncontrolled tourniquet under operation. All malunited fractures, except one, led to cubitus varus, often combined with a restriction (extension/flexion) of the mobility of the elbow joint. No cubitus valgus was found in our series. In eight cases a cubitus varus was treated by valgus osteotomy later on. In other cases this procedure was planned. Adverse events which could not be proven as caused by malpractice, included fracture consolidation in minimal tolerable displacement, n = 3; delayed recurrence of the normal mobility of the elbow joint, n = 2; traumatic cubitus varus caused by primary damage of the humero-ulnar epiphysis, n = 3; pin track infection, n = 1; nerve injuries, n = 10. The concomitant nerve injuries concerned: n. medianus 3, n. ulnaris 2, n. radialis 1, nn. radialis and ulnaris 3, nn. medianus and ulnaris 1. In all these cases the claim was based only or together with other reproaches on the nerve injury, but in no case could a malpractice be confirmed. However it should be mentioned that in some cases a iatrogenic nerve injury could not be excluded definitively. Therefore we always recommend the exploration and documentation of the function of the arm nerves at admittance and immediately after treatment. The applied methods of osteosynthesis were pin fixation, crossed or unilateral radial, n = 30; radial screw, n = 1; elastic stable intramedullary nailing fixation (ESIN), n = 1; fixateur externe (reoperation), n = 1. In no case the method of osteosynthesis was proven as inapplicable or as the cause for the adverse event. Permanent disabilities were considered to be slight in 12 cases (deficient mobility of the elbow joint) and severe in two cases (Volkmann's contracture). Physiotherapy was not found to be beneficial for the restitution of normal mobility of the elbow joint after supracondylar fracture. In at least 7 cases painful physiotherapy was applied, although the X-ray films clearly demonstrated the displaced fracture as the cause of the restricted mobility. In 5 casuistic representations of adverse events after treatment of a supracondylar humeral fracture, the final decision of the arbitration board on the basis of expert reports is illustrated. CONCLUSION: The results are discussed in order to avoid mistakes in the treatment of supracondylar humeral fracture in children. The appropriate treatment requires exact assessment of the degree and direction of the fracture dislocation, clear definition of the cases in which active treatment, i.e. closed or open reduction and stabilisation, is obligatory, and experience in the operative treatment. A beginning compartment syndrome of the forearm should be detected early by the initial symptoms and immediately treated by fasciotomy.

[New physiological aspects of the human urinary bladder (author's transl)]. / Neue Aspekte der Harnblasenphysiologie.

With respect to the new electrophysiological, morphological, histochemical, pharmacological and urodynamical investigations of the function of the urinary bladder, the common aspect of the existence of a smooth sphincter on one hand and a striated sphincter on the other hand, an alternate function of the parasympathetic and sympathetic nervous system in filling of the bladder and in micturition can no more be accepted. A new own concept of the mechanism, which is in action at the bladder neck closure, is demonstrated. This concept goes out from the existence of two systems of smooth musculature in the outlet of the bladder. The first one with mainly longitudinally laying strips is standing under parasympathetic control. Its activation in the beginning of voiding opens the bladder neck. The second one consists of more circulary strips. Its activation is alpha-adrenergic. The contraction of this part of the musculature causes the closure of the bladder neck. Certainly the striated musculature does not play an important role of the continence in normal persons resting conditions. However, in some pathological conditions, it must be taken into consideration. It must be noted, too, that the striated urethral musculature and the pelvic floor do not act synchronous.

[Experiences in the diagnosis and therapy of neurogenic disorders of bladder emptying]. / Erfahrungen in der Diagnostik und Therapie neurogener Blasenentleerungsstörungen.

Today extensive urodynamic investigations are indispensable for diagnosing and for an on-target treatment of neurogenic bladder dysfunction. Classifications and forms used according to functional aspects are explained. Possible treatment methods are commented in respect of own experiences, especially with regard to chemotherapy, intermittent catheterisation, transurethral electrostimulation, biofeedback therapy and supravesical urinary diversion.

[Clinical course and therapy of fecal incontinence in children]. / Klinik und Therapie der Stuhlinkontinenz bei Kindern.

Among the operative techniques for correction of anal incontinence the transplantation of small striated muscles, which has to be denervated before, is hopeful. In the conservative treatment biofeedback techniques are of great interest. New diagnostic procedures (combined manometric and electromyographic readings of the anal sphincter pressure) allow a better understanding of the individual type of anal incontinence. There are a lot of technical proposals aimed at overcoming anal incontinence. Among them the free transplantation of autogenous muscle can be regarded as a step in the forward direction. As far as conservative treatment is concerned the biofeedback treatment seems to be of interest.

[Measuring scheme for the determination of residual energy of the urinary stream]. / Messanordnung zur Bestimmung der Residualenergie des Harnstrahls.

A measuring arrangement is described for the measurement of the urinary jet pressure on the urethral external meatus in male individuum. The residue energy can be calculated by means of simultaneous urinary flow measurement.

[Urodynamic data]. / Urodynamische Messgrössen.

This paper gives a survey of urodynamic data that may be used for evaluating functional aspects of the bladder and its excretory tract. The different parameters are physically defined. Units of the International System are used in the dimensional formulae, which facilitates the establishment of relations between these parameters. The so-called urethral drag can be derived from the pressure law of Blasius. The calculation is as follows: urethral drag = vesical pressure/(maximum urethral discharge). This value is proportional to the true vesical resistance in a physical sense.

[New trends in diagnosis and therapy in pediatric surgery]. / Neue Trends der Diagnostik und Therapie in der Kinderchirurgie.

The advent of new and improved diagnostic methods has had favourable bearings on therapeutic achievements in paediatric surgery. Ultrasonography, computer tomography, manometry, and endoscopy are major examples of relevance. Prenatal diagnostic ultrasonography has been assuming a growing role in prenatal detection of malformations. Postnatal corrective surgery can thus be properly planned and performed under conditions which are optimum for mother and child. Many examples are given to demonstrate that in today's paediatric surgery possibilities for diagnosis and therapy have substantially improved, last but not least, owing to efficient interdisciplinary cooperation.

[Pediatric urologic guidelines]. / Kinderurologische Leitlinien.

Because of the enormous progress of science and technology and increasing possibilities in diagnostics and therapeutics guidelines are also necessary in pediatric urology. Guidelines must have the non-committal character of recommendations in order not to reduce the freedom of medical action in diagnosis and therapy to the detriment of patient interests. The special premises and conditions of guidelines must be defined. Due to the large variety of diseases and disturbances in pediatric urology, it is important to limit the number of guidelines.

[Subvesicular obstruction in the girl and in the women. 1. Etiology, forms, diagnosis]. / Subvesikale Obstruktionen beim Mädchen und bei der Frau. 1. Atiologie, Formen, Diagnostik.

An account is given of aetiological and pathophysiological peculiarities related to various forms of subvesical obstructions in girls and women. There are obstructions with morphologically visible background, but great importance should be attributed also to neuromuscular functional disorders. Clinical symptoms reflect secondary pathological mechanisms of function. On top of endoscopy, radiography, and urethral calibration, closest attention should be given to urodynamic approaches to the diagnosis of subvesical obstructions. Measurement of bladder pressure and urine flow together with calculation of urethral flow resistance, and preparation of pressure-flow diagrams should be undertaken simultaneously for better assessment of the functional extent and severity of subvesical obstruction in the patient concerned. This will provide information needed for compensation or decompensation of the disorder.

[Etiology and therapy of peritonitis in childhood]. / Ursachen und Therapie der Peritonitis im Kindesalter.

The causes of peritonitis in childhood, particularly in infancy, were found to differ substantially from those in adult age. An overall account is given in this paper of general and differential diagnosis of extra-abdominal diseases which may be potentially mistaken for peritonitis. Clinical diagnosis is of crucial importance in childhood. Perforated appendicitis was the absolutely major cause of peritonitis in 119 children who received surgical treatment in the course of 18 years. An initial antibiotic combination of gentamicin with ampicillin, and metronidazole together with immune treatment have proved to be an effective therapeutic approach to this form of peritonitis.

[Studies following bladder reconstructions in cystoschisis]. / Untersuchungen nach Blasenrekonstruktionen wegen Blasenspalte.

The question how to perform the best surgical repair of bladder exstrophy is still being discussed. By various urodynamic investigations following bladder reconstruction we came to the conclusion that the new built bladder and its outlet tract can function normally.

[Clinical course and therapy of acquired anal incontinence]. / Klinik und Therapie der erworbenen Analinkontinenz.

43 patients suffering from anal incontinence underwent surgical correction. The late results up to 14 years after surgery are described. Continence was evaluated by inquiries and by manometric readings of the recto-anal stress profile. Prevailing surgical procedures were reconstruction of the anal sphincter (n = 23) and pedicled transplantation of the M. gracilis (n = 10). Both methods yielded satisfactory late results.

[Neurogenic bladder dysfunction in childhood. I. Diagnosis]. / Zur Problematik der neurogenen Blasenentleerungsstörungen im Kindesalter. Teil I: Diagnostik.

The diagnostic demands of the neurogenic disturbances of the voiding of the bladder in patients with myelodysplasia are summarized in tabulated form. It is reported in detail on own experiences of the authors with urodynamic measuring methods and with the electromyography of the striated musculature of the floor of the pelvis. At present the two methods are not yet used everywhere and they are a considerable enrichment of the diagnostics.