[Clinical risk management in german hospitals - does size really matter?]. / Strukturiertes Risikomanagement in Krankenhäusern - kommt es doch auf die Größe an?

PURPOSE: In the last years, German hospitals have implemented different measures to increase patient safety. Special importance has been attached to near miss reporting systems (critical incident reporting system, CIRS) as instruments for risk identification in health care, instruments that promise high potential for organisational learning. To gain insight into the current status of critical incident reporting systems and other instruments for clinical risk management, a survey among 341 hospitals was carried out in 2009. Questions covered a process of six steps: from risk strategy to methods for risk identification, to risk analysis and risk assessment, to risk controlling and risk monitoring. MATERIAL AND METHODS: Structured telephone interviews were conducted with 341 German hospitals, featuring in their statutory quality reports certain predefined key terms that indicated the concluded or planned implementation of clinical risk management. The main objective of those interviews was to check the relation between status/organisation of self-reported risk management and both operator (private, public, NPO) and size of hospital. RESULTS: The implementation of near miss reporting systems (CIRS) in German hospitals has been constantly rising since 2004: in 2009, 54 % of the interviewed hospitals reported an implemented CIRS; of these, 72 % reported the system to be hospital-wide. An association between CIRS and private, public or NPO-operator could not be detected (Fisher p = 1.000); however, the degree of CIRS implementation was significantly increasing with the size of the hospital, i.e., the number of beds (Fisher p = 0.008): only 38 % of the hospitals with less than 100 beds reported CIRS implementation against 52 % of those between 100 to 500 beds, and 67 % of those with more than 500 beds. While 62 % of the hospitals interviewed reported the maintenance of a risk management committee, only 14 % reported the implementation of risk analysing techniques. As to clinical risk management, 92 % of the hospitals see potential for internal improvement; 44 % have already communicated with external consultants. CONCLUSION: While identification of clinical risks with near miss and other incident reporting systems meets increasing acceptance, the learning potential based on incident reporting is not yet appropriately being used. There is a deficit regarding systematic and comprehensive risk assessment and controlling; this will have to be met by improving the organisational framework for clinical risk management.

[Low molecular weight heparins after orthopedic and traumatologic operations in geriatrics]. / Niedermolekulare Heparine nach orthopädischen und traumatologischen Operationen in der Geriatrie.

Deep vein thrombosis and pulmonary embolism are common complications after orthopedic and trauma surgery. To prevent these complications, the use of low-molecular-weight heparins (LMWH) as prophylaxis is well proved and accepted. We reviewed 203 patients undergoing geriatric rehabilitation in our hospital after orthopedic and trauma surgery. Despite a prophylaxis with LMWH, 23 (11.3%) of these patients were diagnosed with having a clinically apparent and sonographically confirmed thromboembolic event. The average age of all patients was 81.8 years; the time between surgical or orthopedic intervention and thrombembolic event was on average 29.4 days. Using evidence-based medicine, a search of the literature showed 34 clinical trials concerning the prophylaxis of thrombembolic events with LMWH after orthopedic or trauma surgery. All studies have been reviewed for age of patients and for duration of prophylaxis with LMWH. The average age of all patients involved is 65.8 years. There are only 4 trials with an average age of 75 years or more, with a total number of less than 250 patients. The mean duration of prophylaxis with LMWH is 12.5 days. Only 6 trials concern thromboprophylaxis given longer than 3 weeks after surgical intervention. We conclude that there are no clear data about safety, efficiency and optimal duration of prophylaxis with LMWH in geriatric patients undergoing orthopedic or trauma surgery.

[Current status of primary and secondary prevention of cerebral apoplexy]. / Aktueller Stand der Primär- und Sekundärprävention der zerebralen Apoplexie.

There exists quite a number of risk factors for primary and secondary prevention of stroke. Only in a synopsis with different etiologies and with different personal data one can define their dignity.

Mental practice of motor skills used in poststroke rehabilitation has own effects on central nervous activation.

In the last years it has been shown that the use of the EMG triggered electrical myostimulation (ETEM) brings good results in poststroke rehabilitation. It has been hypothesized that the relearning effects obtained by means of ETEM are due to the reinstatement of proprioceptive feedback. However, the technique is most powerful if imagination of motor acts (the so called mental practice) is used as an initial part of ETEM. Since mental practice in healthy people leads to central nervous activation processes as well as to an improvement of motor skills, we investigated the effects of mental practice alone on central nervous activity by means of EEG in stroke patients. Twelve left-sided hemiplegic patients who underwent a specific poststroke rehabilitation treatment were requested to perform a simple arm movement sequence. In the following mental practice period the patients were requested to imagine the same sequence without any real movement. EEG background activity was recorded during baseline and imagination periods. After the calculation of z-transformed power values within the alpha and beta-1 band, differences between rest and imagination periods were evaluated for significance. Stroke patients showed significant decreases of alpha as well as beta-1 power during mental practice in comparison to the rest period. These changes are similar to those obtained in healthy subjects. Central alpha power diminished only during imagination of the contralateral arm. This phenomenon as well as the decrease of beta-1 power in central derivation were also obtained during real motor performance and might indicate an activation of the sensorimotor cortex. In accordance with the hypothesis of internal feedback mechanisms, this activation is a necessary prerequisite for motor learning during mental practice. We conclude that mental practice of motor skills might have own effects in poststroke rehabilitation.

Activation processes during mental practice in stroke patients.

In healthy subjects, mental practice is known to improve motor performance. It is also known to be accompanied by a higher central nervous activity. Since such effects seem to be desirable for rehabilitation, we investigated the possibility of detecting changes in central nervous activity by means of EEG in stroke patients, and whether these changes were similar to those observed in healthy subjects. 12 left-sided hemiplegic patients who underwent a specific post-stroke rehabilitation treatment were requested to perform a simple arm movement sequence. In the following mental practice period the patients were requested to image the same sequence without any real movement. EEG background activity was recorded during rest and imagination periods. After the calculation of z-transformed power values within the theta, alpha, and beta-1 band, differences between rest and imagination periods were evaluated for their significance. Stroke patients show significant decreases of theta, alpha, as well as beta-1 power during mental practice in comparison to the rest period. These changes are similar to those obtained in healthy subjects. Theta power decreases in central and parietal leads. Central alpha power diminishes only during imagination of the contralateral arm. This phenomenon as well as the decrease of beta-1 power in central derivation were also obtained during real motor performance and might indicate an activation of the sensorimotor cortex. In accordance with the hypothesis of internal feedback mechanisms, this activation is a necessary prerequisite for motor learning during mental practice.

[Conceptual basis of rehabilitation of patients with stroke]. / Die konzeptionelle Basis der Rehabilitation von Patienten mit zerebrovaskulärem Insult.

The authors describe the basis of the current concept of rehabilitation of patients with stroke. This concept is based on recent neurophysiological findings about the processes of information, learning, and memory. This indicates that the plasticity of cerebral structures depends especially on the possibilities either to rebuild or to compensate for destroyed structures with programs of rehabilitation. A comparison is given of 101 stroke patients rehabilitated according to a conventional program and the better results for 295 stroke victims rehabilitated according to a more modern rehabilitation program. Another investigation showed, as an example of the Babinsky phenomenon, that stroke patients can develop the ability to suppress. The results and dynamics of rehabilitation of stroke are an encouragement to continue researching new ways for more effective rehabilitation.

[Rehabilitation in cerebrovascular stroke--experiences and results of a treatment concept based on modern neurophysiology knowledge]. / Die Rehabilitation des zerebrovaskulären Insults--Erfahrungen und Ergebnisse einer Behandlungskonzeption auf der Basis moderner neurophysiologischer Erkenntnisse.

The modern concept of rehabilitation of patients with stroke is based on new neurophysiological investigations about processes of movements, learning and memory. Therefore the rehabilitation is multidimensional. The complete patterns of symptoms must be considered. The training of cognitive functions has the same importance as the treatment of disorders of movements. The effects of this concept are investigated in 295 patients in accordance with self-activities and ability of walking. The results have been compared with 101 patients without consideration of all gnostic defects. The results of the modern rehabilitation concept were better. Patients with aphasia having similar good results but patients with diminished ability to cooperation having unfavourable prognosis of rehabilitation.

Use of biotinylated DNA probes in screening cells obtained from cervical swabs for human papillomavirus DNA sequences.

A nonradioactive DNA-detection procedure using biotinylated DNA probes in the screening of cells from cervical swabs for DNA sequences homologous to human papillomavirus (HPV) DNA was tested. This alternative DNA-detection method yielded results comparable to those obtained with radioisotope-labeled DNA probes in 32 cases tested. This procedure obviates the special precautions required for radioisotope materials. Accordingly, this technique can be made available to many laboratories, and conclusive evidence as to the relation of HPV infection to cervical cancer may thus be accumulated.

[Social sequelae and problems following apoplexy]. / Soziale Folgen und Probleme nach Apoplexie.

162 patients with stroke (cerebrovascular accident) were investigated of some social problems. The patients were treated in two internal clinics or in a rehabilitation center for stroke-patients. The assessments were accomplished in 30 months after clinical treatment. The average of age was 69 years. The percentage of women was 61%. The majority of patients lives in own flats, 12% in a nursing home. The furniture of flats, was often not approximated for disabled persons. The care almost was undertaken through relatives. More institutional support could be helpful in few cases. Help was wished in according to conditions of flats, meals on wheels, programs for self-activities, references to nursing, technical helpings and transportation services. These investigations suggest that the families are an important factor in rehabilitation of stroke. They need social and psychological support. The attitude of family determinated essential the prognosis of rehabilitation.

[Cytomegalovirus infections after kidney transplantation and passive immunization]. / Zytomegalievirusinfektionen nach Nierentransplantationen und passive Immunisierung.

Cytomegalovirus infection after renal transplantation impairs the survival rate of patient and graft. An incidence of 24 to 92% of CMV infections after renal transplantation is reported, but only 15 to 77% of these patients show clinical symptoms. Contaminated donor organs, blood transfusions and reactivation by immunosuppression are the main causes of this infection. Active immunisation cannot prevent the reactivation of the infection, but also antiviral agents can hardly influence the course of the disease. Passive immunisation showed promising effects in bone-marrow transplantation and is now also tried in renal transplantation. The first results of a randomized study do not allow a final conclusion, but show less clinical symptomatic CMV infections, and statistically significant less herpes simplex infections in the group receiving anti CMV IgG prophylaxis.

[Segmental chlamydia proctitis]. / Die segmentale Chlamydien-Proktitis.

A case report is given of a 28 year old homosexual suffering from segmental proctitis caused by Chlamydia. The patient had watery diarrhea and fever since 3 weeks. Stool specimen testing was negative in regard to Salmonella, Shigella and worm eggs. Infection with N. gonorrhoea, Herpes simplex virus, Toxoplasma gondi, Yersinia and M. tuberculosis could be excluded. Serological testing yielded results suggestive of an old lues infection successfully treated. On histological examination typical reticulocytary suppurating granuloma were found. Therapy of choice of Chlamydia-proctitis is tetracyclines.

[Prognosis and epidemiology of acute hepatitis B infection]. / Prognose und Epidemiologie der akuten Hepatitis-B-Infektion.

44 patients with acute hepatitis B virus (HBV) infection were observed until recovery and formation of anti-HBs or in case of development of chronic infection for up to 18 months. With the exception of 3 patients the infection resolved clinically within 3 to 16 weeks, HBs and HBe antigen were eliminated. Anti-HBs and anti-HBe formation could be demonstrated in 39 patients. An accurate prognosis of the course of the disease could be predicted in 42 out of 43 patients by comparison of the serum HBs antigen concentrations at the beginning of clinical symptoms with those after 4 weeks. Inclusion of HBe antigen demonstration enabled predictability in all patients. In 15 patients with acute HBV infection the risk of infection (occupational exposure, transfusion etc.) was known. By investigation of contact persons (family members, sex partners etc.) of the remaining patients HBs antigen und partly HBe antigen in serum could be demonstrated in 11.8% of these persons (11 out of 93). In contrast, in contact persons of patients with known risk of infection HBs antigen could be demonstrated in only one case (1 out of 36). No one of the HBs antigen positive contact persons was aware of the possibility of infectiousness. They did not perceive any connection between their own chronic infection and acute HBV infection occurring around them.

[Indications for special rehabilitation programs for cerebrovascular strokes]. / Zur Indikation für spezielle Rehabilitationsprogramme bei zerebrovaskulärem Insult.

The rehabilitation of patients with stroke was a long time a neglected problem. Meanwhile there are several hospitals with comprehensive rehabilitation services with physical, occupational, speech, psychological and social assessments. The effectiveness were investigated in 296 stroke patients. 195 patients from two internal hospitals were compared with 101 patients from a hospital rehabilitation unit. Both groups were very similar according of age, sex, nature of stroke and the most of other factors. The effect were evaluated on the basic of ADL-classes (activities of daily living) at the time of discharge. The success of the special rehabilitation was better in patients with aphasia, flaccid and strong spastic hemiparesis, complicated diseases, lower motivation and mild or moderate psychoorganic syndromes. Absent of ability to cooperate limited the rehabilitation outcomes. In mild and severe followings of stroke were found same results in both groups. High age of life alone are not decreased the prognosis.

Comparison of four different methods for detection of rubella IgM antibodies.

Four different tests for detection of rubella-specific IgM antibodies were compared: two Ig separation methods (centrifugation and chromatography) with subsequent haemagglutination inhibition test and two commercially available ELISA tests. The 114 sera tested had been sent to the diagnostic laboratory, mostly with insufficient clinical histories. Agreement between the centrifugation method and one of the ELISA tests was good (2 divergent results with 107 sera tested), while the other ELISA test yielded more positive (partly perhaps non-specific) results. The chromatographic method did not separate the Ig classes as reliably as the centrifugation method, but because of its simplicity it may be useful, if adequate test controls are performed. The divergent results are discussed. It is postulated that in cases with pending induced abortion, two independent tests should be performed.